Attachment style predict compliance, quality of life and renal function in adult patients after kidney transplant: preliminary results

Abstract

Aim: Aim of this study was to evaluate the association between attachment style, compliance, quality of life and renal function in adult patients after kidney transplantation. Methods: A total of 43 adult patients who received a kidney transplant more than 3 months before were enrolled and were asked to complete two Self-Report questionnaires: Attachment Style Questionnaire (ASQ-40) and Short Form Health Survey (SF-36). Also compliance was measured using appropriate questions. Results: Linear regression analysis showed associations between the confidence in relationships (ASQ-40) and compliance [beta = −0.37; B = −0.02; t(41) = −2.51; p = 0.02]; aspects of anxious attachment style (ASQ-40) and creatinine levels [beta = 0.3; B = 0.13; t(41) = 2.03; p = 0.04]; aspects of avoidant attachment style (ASQ-40) and compliance [beta = −0.37; B = −3.15; t(41) = −2.35; p = 0.02]. Patients who exhibited avoidant attachment had a significantly better perception of their own general health than patients with anxious [F(2,37) = 6.8; p < 0.05] or secure attachment; however, they had a worse perception regarding role limitations due to emotional problems, compared to patients with anxious attachment [F(2,37) = 6.4; p < 0.05]. Discussion: The results of this study suggest that the evaluation of the attachment style in adult kidney transplant patients can contribute to plan a goal-directed psychological support program for these patients, in order to increase their compliance. The association between aspects of anxious attachment style and creatinine level needs more investigations.

• Adherence to treatment
• attachment
• kidney transplantation
• quality of life
• renal function

Introduction

Many patients with chronic kidney disease requiring dialysis treatment report severe psychological distress, high burden of somatic symptoms and impaired quality of life.1 It is generally accepted that kidney transplant is the optimal treatment with better quality of life (QoL), reduced medical expenses and prolongation of life.2 Approximately 40% of the adult kidney transplanted patients show low compliance to immunosuppressive therapy, increasing the risk of organ rejection2 and poor recovery of mental and post-operative physical QoL.3 Attachment theory, the medical-patient relationship, has increasingly been applied to understand disease and chronic illness.4 Attachment style has been found to be a critical psychological aspect, antecedent to the development of the doctor-patient relationship which indirectly influences patient compliance to medical treatment.4 Compliance has been found to be extremely variable and related to different aspects, as social support, behavior and perception on illness, and doctor-patient relationship.5 Aim of this study was to evaluate the association between attachment style, compliance, quality of life and renal function in adult patients after kidney transplantation.

Methods

Following local Ethical Committee approval, 43 adult patients who underwent kidney transplant were enrolled into the study. The inclusion criteria of recipients were: age between 18 and 70 years, level of education at least primary school, at least 3 months post-transplantation and absence of psychopathological diagnoses. Patients were asked to complete two self-reported questionnaire: Short Form Health Survey (SF-36) and Attachment Style Questionnaire (ASQ-40). The Short Form Health Survey (SF-36) contains 36 questions which assess eight aspects of QoL: physical functioning (PF), role-physical functioning (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional functioning (RE) and mental health (MH). Each question is given a score from 0 to 100. Two items and a Vas Scale were administered to patients to measure compliance: (Q1) “In the past four weeks, how many times did you fail to take your prescribed dose?”; Q2: “Do you remember if in the past four weeks have you taken your anti-rejection drugs two or more hours before or after than the prescribed time?”. Patients initially responded indicating “YES” or “NO". If the answer was “YES", they had to indicate the frequency they had performed the behavior, using a range from 1 to 5. Vas Scale with the question “How would you rate the level of compliance to your therapy from 0 to 100?”, was aimed to express the subjective experience of compliance. The Attachment Style Questionnaire (ASQ) is a 40-item self-report measure of adult attachment. Items are rated on a 6-point Likert-type scale (1 = totally disagree, 6 = totally agree). The five subscales of the ASQ include the following item: Confidence ASQ_1; Need for Approval ASQ_2; Preoccupation with Relationships ASQ_3; Relationships as Secondary ASQ_4 and Discomfort with Closeness ASQ_5. Creatinine and blood urea nitrogen were dosed during the follow-up visit.

Statistical techniques

Correlation analyses (Pearson’s r) were conducted in order to evaluate the relationship between gender, age, distance from transplant, subscales of ASQ-40 and subscales of SF-36, compliance’s questions and biochemical factors. ANOVA (Fisher’s F) was done in order to test differences between patients with secure attachment, insecure anxious attachment and insecure avoidant attachment. Linear regression models were carried out in order to evaluate the effect of possible psychological predictors on the levels of compliance and biochemical factors. Statistical analyses were performed using Statistica Version 5.1 software (StatSoft, Tulsa, OK).

Results

Forty-three patients (female/male = 19/24; mean age 50.50 ± 15.10, mean transplant follow up 101 ± 89 months) were enrolled in the present study. As regard to patients’ attachment style, 42% showed an insecure avoidant attachment style, 30% showed an insecure anxious style, 21% showed a secure attachment style and just 7% showed a disorganized attachment style. The answers to compliance test were the following: 41% of patients responded they do not delay the schedule of drugs. Mean value of VAS was 95.93 ± 8.75. Correlations among gender, age, distance from transplant, subscales ASQ-40 and adherence, subscales SF-36, creatinine. Pearson r and p value are shown in Table 1. The analysis of variance revealed that patients with insecure avoidant attachment (n = 18) had significantly better perception regarding their own general health (GH) [F(2,37) = 6.8; p ≤ 0.01] than patients with anxious (n = 13) or secure (n = 9) attachment. However, they had worse perception regarding role limitations due to emotional problems compared to patients with anxious attachment F(2,37) = 6.4; p < 0.05. The linear regression analysis showed three significant associations. The first one reports the association between the confidence in relationships and compliance [beta = −0.37; B = −0.02; t(41) = −2.51; p = 0.02]; the second one reports the association between aspects of avoidant attachment style and compliance’s perception [beta = −0.37; B = −3.15; t(41) = −2.35; p = 0.02]; the last association is between aspects of anxious attachment style (ASQ_AN) and creatinine levels [beta = 0.3; B = 0.13; t(41) = 2.03; p = 0.04].

Table 1. Correlations among gender, age, distance from transplant, subscales ASQ-40 and adherence, subscales SF-36, CRE and BUN.

	Q1	Q2	VAS	PF	RP	BP	GH	VT	SF	MH	RE	CRE	BUN
Gender	−0.18	−0.25	0.10	0.03	−0.09	−0.02	−0.04	−0.10	0.08	−0.00	−0.08	−0.26	−0.26
	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS
Age	0.13	0.04	−0.04	−0.47	−0.15	−0.50	−0.23	−0.34	−0.19	−0.15	−0.24	−0.14	−0.01
	NS	NS	NS	p = 0.002	NS	p = 0.001	NS	p = 0.026	NS	NS	NS	NS	NS
Time distance	0.13	0.04	−0.15	0.03	0.20	0.01	0.19	−0.05	0.12	−0.16	0.12	−0.04	0.21
	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS
ASQ_1	−0.37	−0.32	0.10	0.13	0.22	0.26	0.32	0.18	0.19	0.08	0.32	−0.28	0.06
	p = 0.016	p = 0.036	NS	NS	NS	NS	p = 0.037	NS	NS	NS	p = 0.038	NS	NS
ASQ_2	0.06	0.24	−0.06	−0.02	−0.09	0.16	−0.08	−0.08	0.03	−0.15	−0.08	0.29	−0.03
	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS	NS
ASQ_3	0.13	0.16	−0.16	−0.00	0.05	−0.06	−0.16	−0.13	−0.20	−0.36	−0.10	−0.21	0.03
	NS	NS	NS	NS	NS	NS	NS	NS	NS	p = 0.019	NS	NS	NS
ASQ_4	0.18	0.22	−0.30	−0.09	−0.27	−0.18	−0.26	−0.33	−0.24	−0.36	−0.38	0.22	0.07
	NS	NS	NS	NS	NS	NS	NS	p = 0.030	NS	p = 0.016	p = 0.012	NS	NS
ASQ_5	0.10	0.03	−0.33	0.16	0.02	−0.05	−0.09	−0.14	−0.11	−0.43	−0.17	−0.02	0.11
	NS	NS	p = 0.030	NS	NS	NS	NS	NS	NS	p = 0.004	NS	NS	NS
ASQ_AN	0.34	0.33	−0.23	−0.08	−0.16	−0.13	−0.30	−0.24	−0.24	−0.31	−0.32	0.30	0.02
	p = 0.025	p = 0.030	NS	NS	NS	NS	NS	NS	NS	p = 0.046	p = 0.032	p = 0.049	NS
ASQ_AV	0.26	0.32	−0.35	−0.04	−0.29	−0.21	−0.31	−0.33	−0.23	−0.41	−0.43	0.03	0.00
	NS	p = 0.038	p = 0.023	NS	NS	NS	p = 0.043	p = 0.032	NS	p = 0.006	p = 0.004	NS	NS

Notes: subscales ASQ-40: confidence (ASQ_1), need for approval (ASQ_2), pre-occupation with relationships (ASQ_3), relationships as secondary (ASQ_4), discomfort with closeness (ASQ_5), aspects of anxious attachment style (ASQ_AN), aspects of avoidant attachment style (ASQ_AV); subscales SF-36: physical functioning (PF), social functioning (SF), role-physical functioning (RP), role-emotional functioning (RE), mental health (MH), vitality (VT), bodily pain (BP), general health perception (GH); (Q1) “In the past four weeks, how many times did you fail to take your prescribed dose?”; (Q2) “Do you remember if in the past four weeks have you taken your anti-rejection drugs two or more hours before or after than the prescribed time?”, VAS Scale “How would you rate your adherence levels from 0 to 100?”; creatinine (CRE), blood urea nitrogen (BUN). NS, not significant.

Pearson r and p values are shown.

Discussion

This is the first study that investigates the association between attachment style, compliance, QoL and renal function in adult patients after kidney transplantation. In this study, we show that the quantitative dimensions of attachment style affected compliance behavior, QoL and creatinine levels. Higher levels of insecure attachment dimensions (anxious or avoidant) were significantly associated with a worse compliance level and low QoL. Moreover, patients with high levels of self confidence have a good perception of their health and do not find difficulty in performing activities due to emotional problems. However, self confidence is considered a key factor in understanding compliance: patients with high levels of self confidence have good compliance, while patients with anxious attachment have worse perception of the role limitations due to emotional problems. In this study, within QoL, patients with high levels of discomfort with closeness, and those who give to the relationship a secondary role, had a lower perception of mental health, vitality and feel rather limited in performing activities due to emotional problems. They also had a lower level of compliance and a lower perception of their compliance. Patients with high levels of avoidant relationship had a low perception of their own mental health. In addition, they reported a worse compliance with higher values of creatinine. This study also shows that increasing age in kidney transplant patients, as well as in patients affected by other chronic pathologies,3 is associated with lower physical activity, higher perception of bodily pain and lower vitality. The results of this study suggest that evaluating the attachment style in adult patients who have received a kidney transplant might contribute to improve the psychological support programs for patients increasing compliance to treatment.6^,7 However, the small sample size and the cross-sectional nature of the study do not allow the generalization of the present findings. Moreover, longitudinal follow-up studies are undoubtedly desirable.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.