Psychological status and intervention strategy of maintenance hemodialysis patients in COVID-19 epidemic

Background An outbreak of novel coronavirus disease 2019 (COVID-19) is a newly discovered contagious disease, which rst broke out in China.Based on the psychological state, maintenance hemodialysis (MHD) patients might bear psychological problemsunder the COVID-19epidemic situation.To evaluate the psychological health of MHDpatients and explore the corresponding intervention strategies. Methods Acluster sampling approach was employed to obtain a sample of 206 MHD patients from two hospitals in Yunnan province: a COVID-19-designated hospital and a non-COVID-19-designated hospital. Post-traumatic stress disorder (PTSD) checklistwas used to assess the psychological status,while Kidney Diseaseand Quality of Life --Short Form(KDQOL-SF)was applied to assess the quality of life(QOL). The factorsinuencing thepsychological status in MHD patients were employed by binary logistic regression. Results Among MHD participants (age 53.4 ± 15.3 years), 61 cases showed mild to moderate positive PTSD, and 72 casespresented severe positive PTSD.The level of education, capital income, hospital, depressive tendency, and QOL were the inuence factors for the occurrence of PTSD. Moreover, the PTSD was negatively correlated with QOL and positively correlated with COVID-19-designated hospital and the depressive tendency. which prompt psychological and from staff to ensure timely treatment of patients.


Background
In late 2019, an outbreak of novel coronavirus disease 2019 (COVID-19) is a newly discovered contagious disease caused by SARS-CoV-2 virus, which rst broke out in China, primarily manifesting as severe respiratory illness and human-to-human transmission, but can affect multiple organs, such as kidney, digestive tract, heart, and blood system.It is rapidly spreading worldwide has raised global concerns [1,2].
After 7 months, we are still experiencing a devastating pandemic with local outbreaks across all continents. By the end of June 2020, the World Health Organization (WHO) reported more than 10,000,000 con rmed COVID-19 cases and 500,000 deaths across 210 countriesand regions. The infection has developed into a world emerging health threat [3].
In order to contain the spread of this disease, scientists from various countries have focused their efforts on the study of its epidemiology, clinical features, modes of transmission, and the management of COVID-19. Although with the advanced medical science and resources, the impact on the public was direct and realistic with prolonged duration and wide coverage; also, it might cause a series of psychological problems [4].
Reportedly, viral RNA has been identi ed in both kidney tissue and urine; moreover, infectious SARS-CoV-2 was successfully isolated from semen and urine of a COVID-19 patient [5]. Also, maintenance hemodialysis (MHD) patients developed COVID-19 infection in hemodialysis (HD) centers [6][7][8]. An HD center is the unit with concentrated population and high mobility. MHD patients need to go to the HD centers for HD 3 times a week for 4 h each time. During the frequent trips between the HD center and home, the risk of COVID-19 infection could be high. Moreover, these patients are accompanied by various complications [9]. Based on the psychological state, MHD patients might bear more psychological problemsunder the epidemic situation than the normal population.
Thus, the present study evaluated the psychological health level of MHD patients under the COVID-19 epidemic situation in order to provide emergency psychological intervention strategies.

Methods
Study area, population, and sampling techniques A cross-sectional survey was conducted in May 2020. Acluster sampling approach was employed to extract a sample of 206 MHD patients. The COVID-19-designated hospitalisresponsible for uni ed screening of suspected COVID-19 patients and treating con rmed COVID-19 patients, whilethe non-COVID-19-designated hospitalis not responsible for screening and treating COVID-19 patients. The First A liated Hospital of Kunming Medical University is the COVID-19-designated hospital, whileKunming TongrenHospital is thenon-COVID-19-designated hospital. The inclusion criteria were as follows: patient'sglomerular ltration rate < 15 mL/min.1.73 m 2 ; receive HD three times/week for 4 h each time over a period longer than 3 months; aged ≥ 18 years. The exclusion criteria were as follows: the induction period of hemodialysis, recent major surgery,dottiness, malignant tumors, and patients who were unwilling to cooperate.

Measuring tools
Post-traumatic stress disorder (PTSD) is a psychological disorder characterized by intense fear, helplessness, and avoidance, resulting from exposure to a traumatic event or catastrophic life event. It is clinically manifested with three main syndromes: re-experiencing, avoidance behavior or numbness, and physiological hyperarousal [10,11]. The current study used the post-traumatic checklist scale (PCLS-L) to measure the PTSD of MHD patients. PCLS-L is a brief and self-report questionnaire for evaluating the severity of three main syndromes inPTSD [12]. It encompasses a wide variety of three projects, which is divided into 17 items, such as items 1-5 (re-experiencing), items 6-12 (avoidance), and items 13-17 (hyperarousalsyndrome).Each itemwas subjected to ve-level scoring to accumulate the total score. The range of scores was 17-85; the higher score implied the higher likelihood of suffering PTSD. Normal: the total score is 17-37; mild and moderatePTSD: 38-49; severe of PTSD: 50-85 [13,14].
Kidney Disease and Quality of Life-Short Form (KDQOL-SF) can be de ned as a kidney patient's usual or expected physical, emotional well-being, or social experience that consists a 36-item short form health survey (SF36) and kidney disease target areas (KDTAs). It is a comprehensive assessment of general health status and kidneydisease-related clinical characteristics [15].KDQOL-SF is an overall assessment of QOL in MHD patients.

Data collection
Four doctors and two medical students were educated as interviewers for data collection. The questionnaire included demographic characteristics, the age of onset, complications, the duration of treatment, transportation, educational level, income, PCLS-L,and KDQOL-SFTM. The capital income was adjusted to 2020 values and converted to USD using the o cial conversion rate in2020 ($1.00 = ¥7.13).
Statistical Analysis SPSS 23.0 software was used for statistical analysis. The enumeration data were expressed as percentages. The quantitative data between two groups were expressed as mean ± standard deviation, while the affecting factors ofPTSD wereanalyzed bybinary logistics regression analysis. Statistical signi cance was based on two-tailed P-values, and a P-value of < 0.05 was considered to be statistically signi cant.

Results
A total of 215 MHD participants from two HD centers,one is COVID-19-designated hospital, and the other is a non-COVID-19-designated hospital. Of these, 206 consented, representing a response rate of 95.8%. Consequently, a total of 206 valid questionnaires were collected.
General characteristics of the patients A total of 206 MHD participants, aged ≥ 18 years, underwent MHD, 4 h/session, three times/week. The general characteristics of the patients are presented in Table 1. The cohort consisted of 128 males and 78 females; the ratio of male to female was 1.64, and the average age was 53.4 ± 15.3 (range: 18-90)years-old. About 69% of the MHD participants were from COVID-19-designated hospitals. The patients in the COVID-19-designated hospital had a higher level of education and capital income than patients in the non-COVID-19-designated hospital group (P < 0.05). Moreover, the patients in COVID-19-designated hospital were younger, while the duration of HD in the non-COVID-19-designated hospital was longer (P < 0.01).

PCLS-L in MHD patients
Several studies have suggested that a score of 38 is the critical value in the PCLS-L for PTSD-positive patients [16,17]. Therefore, the score of ≥ 38 points was classi ed as positive PTSD in this study. The higher score implied the higher likelihood of suffering from PTSD, which encompasses a wide variety of three projects: re-experiencing, avoidance, and hyperarousal. In this study, the average PCLS-L score was 42.55 ± 14.51 (range: 27-59). A total of 61 cases showed mild to moderate positive PTSD (29.6%) and 72 cases were severe PTCD (35.0%). Table 2 shows the scores of different dimensions among the three projects in PCLS-L. Participants with higher education level had higher scores of PCLS-L (P < 0.05). In addition, MHD patients with higher capital income had higher scores of PCLS-L (P < 0.01). Conversely, the scores of MHD patients in the non-COVID-19-designated hospital were lower than those in the COVID-19designated hospital(P < 0.01). Also, the scores of patients with depressive tendencies were higher than those without such tendencies (P < 0.01). In uencing factors of PTSD Binary logistics regression was performed with PCLS-L of MHD patients. The dependent variable is the positive PTSD (0 = asymptomatic, 1 = symptomatic), while age (0 = less than 60 years, 1 = exceed 60 years), level of education (0 = below junior school, 1 = high school, 2 = bachelor's degree or above), gender (0 = male, 1 = female), per capita income (0 = less than $3086, 1 = more than $3086), hospital (0 = COVID-19-designated hospital, 1 = non-COVID-19-designated hospital), mode of trip (0 = public transport, 1 = personal motor vehicle ), duration of treatment (0 = less than 12 months, 1 = exceed 12 months), and depressive tendency (0 = no, 1 = yes) were independent variables ( Table 3). The present study revealed that the factors affecting the PCLS-L included hospital (B = 4.331, P < 0.001), depressive tendency (B = 1.639, P < 0.05), and KDQOL-SF (B = 0.076, P < 0.05). The PTSD was positively correlated with COVID-19designated hospital and depressive tendency but negatively correlated with KDQOL-SF.

Discussion
The outbreak of COVID-19 is a rare pandemic. The closing of schools, businesses, sporting events, and meetings is a critical element in "social distancing," a powerful tool to restrict transmission of this disease [18]. Such unprecedented steps create anxiety and uncertainty in humans that is unparalleled in modern history. MHD patients who experience the COVID-19 epidemic situationare vulnerable to emotional pain and other di culties [19]. The current study quantitatively examined the psychological characteristics of HD patients' experiences during this epidemic in addition to the in uencing factors of PTSD.

Probable causes of psychological crisis in MHD patients in the COVID-19epidemic
MHD patients constitute a distinct and high-risk group [20], which is often associated with low immunity, decline or even loss the ability of work, substantial economic burden, inability to ful ll family responsibilities and participate in active social life, and suffer from various complications such as, muscle weakness, pruritus, fatigue, diabetic, hypertension, and restless legs. These factors are associated with lower QOL and poor clinical outcomes, leading to a higher risk of psychological crisis in MHD patients than that in the general population [21,22].
Due to the characteristics of novelty, asymptomatic shedding, long incubation period, COVID-19 can be directly transmitted from person to person, spreading rapidly and exhibiting variable manifestations; thus, the outbreak of COVID-19 is a challenge to the existing health systems [23,24].To date, speci c treatment and prevention options, such as targeted antiviral drugs and vaccines, are not available [25]. Hence, the WHO recommended traditional public health outbreak response tactics-quarantine, isolation, social distancing, and community containment [26]. However, in order to obtain hemodialysis, MHD patients need to travel from home to the HD center three times each week for 4 h/session, serving as potential vectors for infection. This same shift of MHD patients should be set in the same closed space in a HD unit, and thus, home isolation cannot be realized. In thisstudy, the risk of PTSD occurrence in COVID-19 designated hospital is higher than that in the non-COVID-19 designated hospital, indicating that MHD patients in COVID-19 designated hospitals were facing more serious psychological stress and more anxious mental health conditions. Moreover, due to the speci city of the HD center, i.e., donning biohazard suits by medical staff managing patients and inquiry into the history of exposure and clinical symptoms, by each shift, which will inevitably bring about strong fear and aggravate the psychological harm in MHD patients [27].
Indubitably, a myriad of incorrect and false information is spread on the Internet. Many citizens express their negative emotions such as anxiety, fear, worry, and tension, through social media, and hence, excessive mass media exposure, including the latest updated epidemic reports, the number of con rmed cases, and increasing death-toll lead to the "information epidemic." The spreading of rumors and di culty in obtaining trustworthy information further aggravates the anxiety and fear of MHD patients. During the dialysis interphase, the MHD patients were isolated at home, resulting in less contact with the outside world, which increased the feelings of loneliness and helplessness, in turn increasing the risk of psychological crisis.

Intervention tactics
Despite the introduction of the psychological rst aid manual (PFA) by the WHO in 2005, there has been a lack of psychological support and counseling model based on local cultural characteristics pertaining to MHD. Thus, the management of MHD patients under the COVID-19 pandemic needs to be under intensive focus, especially the MHD patients in COVID-19 designated hospitals who exhibit depressive tendencies.
Firstly, the COVID-19-related and mental health education of MHD patients is strengthened using bulletin board, phone Application, o cial accountsof WeChat, improving the scienti c understanding of the outbreak, and ensuring that every patient (or families/carers) focuses on the o cial accounts of HD center and join the WeChat group of HD center. The WeChat group and o cial accounts may provide mental health knowledge and COVID-19-related protection information regularly. For example, the questionnaire survey revealed that few patients know diarrhea as one of the symptoms of COVID-19 [28], but have a poor understanding of the correct disinfection methods at home; the education with respect to such situation is strengthened via WeChat.
Secondly, effective psychological monitoring should be carried out by medical teams, especially in COVID-19 designated hospitals. The medical staff in COVID-19 designated hospitals should recognize that adjustment and intervention measuresfor mental disorders should be initiated as early as possible.
The psychological evaluation form and questionnaire identi ed the high-risk patients who were then selected for interviews. Targeted professional psychological support was provided by psychological therapists among patients with unstable emotions or obvious depression and anxiety behaviors. In Ethics approval and consent to participate:The study was conducted in accordance with the Declaration of Helsinki, and the Ethics Committee of Kunming Medical University approved the protocol. All participantshavegiven written informed consent.
Consent for publication:Not applicable.
Availability of data and materials:The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.we con rm that the data on the sample of 206 MHD patients from two hospitals have not been reported in any other submission by us or anyone else.
Competing interests:The authors declare that there are no con icts of interest. Authors' contributions: QL conceived the idea, designed the study, administered theproject, and drafted on the manuscript. JN conducted the eld study and drafted the original manuscript. SZ conducted eld study and investigation. WC conducted theinvestigationand curated the data. YCcollected the data. HW provided critical comments and edited the manuscript. XW conducted theinvestigation. All authors approved the nal version of the manuscript.