Tugba Menekli, Sibel ?entürkDepartment of Internal Medicine Nursing, Malatya Turgut ?zal University, Faculty of Health Sciences, Malatya 440, Turkey.Department of Internal Medicine Nursing, Burdur Mehmet Akif Ersoy University, Bucak Health School, Bucak-Burdur 15300, Turkey.

Abstract Objective: This study aims to identify the relationship between the intolerance of uncertainty and the fear of COVID‐19 in patients awaiting kidney transplantation during the COVID‐19 pandemic.Methods: This descriptive and cross‐sectional study was performed with the participation of 355 individuals.The data were collected with a patient information form, the intolerance of uncertainty scale – short form (IUS), and the fear of COVID‐19 scale(FCV‐19S). Results: The mean IUS – short form score of the participants was 53.03 ± 5.11,and their mean FCV‐19S score was 30.62 ± 4.10.A statistically highly significant positive relationship was identified between the FCV‐19S and IUS scores of the participants (r: 0.850;P ＆lt; 0.001).Conclusion: As the patients’ intolerance of uncertainty increased, their fears of COVID‐19 also increased.For patients awaiting kidney transplantation during the COVID‐19 pandemic, which is full of challenges, to cope with fear and uncertainty, it is recommended that patients are provided with care with a multidisciplinary team approach.

Keywords: COVID‐19; intolerance of uncertainty; kidney transplantation; death; fear

Background

COVID‐19 is a highly infectious disease, the outbreak of which was declared by the World Health Organization as a pandemic, which is transmitted between humans through respiratory droplets and physical contact and which affects several human body systems, especially the respiratory system [1–3].Although months have passed since the emergence of COVID‐19 and the development of a variety of vaccines,today, numerous people still get infected with COVID‐19 and lose their lives due to both the restrictions regarding access to vaccines and factors speeding up the spread of the infection, such as COVID‐19 variants identified in the United Kingdom, Brazil, South Africa, and India [3, 4].

The global health crisis that is caused by the rapid spread of COVID‐19 has led to large‐scale disruptions in every domain of health services.Organ transplantation was among the procedures that were the most affected by the COVID‐19 pandemic [5, 6].It is stated that in 2030,the number of people who will survive with dialysis or kidney transplant treatments will reach 5.5 million worldwide.The prevalence of chronic renal failure in Turkey is 15.7%.There are approximately 9 million chronic kidney disease patients [7].Since 2022, 4 thousand 322 organ transplants have been performed in Turkey, and 2,985 of these transplants were kidney transplants.About 17 thousand 594 patients with kidney diseases who want to regain their health with organ transplantation are waiting in line [8].Due to transplant‐related immunosuppression, besides comorbidities such as diabetes mellitus, hypertension, or heart disease, kidney transplant recipients are at a higher risk in terms of contracting COVID‐19 and experiencing COVID‐19 more severely [6, 9].As one of the key barriers to organ transplantation involves infections caught by the transplant recipient or donor, the emergence of COVID‐19 as a pandemic considerably affects transplantation procedures worldwide.It has been stated that the kidney was among the most frequently and severely affected organs during the course of COVID‐19, and by interrupting the transplantation, referral, and listing processes, the COVID‐19 pandemic has led to a decrease in the number of organ transplants [5,6, 9, 10].

Being a key source of social and individual stress besides leading to a quite high number of deaths across the world, the COVID‐19 pandemic exerts negative psychological, social, and economic effects on the lives of patients awaiting kidney transplantation [9, 10].Individuals who have panic and fear, along with an increase in the perception of threat as a consequence of this infectious disease, may exhibit behaviors diverging from those they usually do [10, 11].While the COVID‐19 pandemic leads to a decrease in the number of organ transplants in most countries, it may lead most transplant candidates on waiting lists to suffer from uncertainty and fear [5, 6].It was put forward that regarding the post‐transplantation period, 63.1% of transplant candidates on waiting lists had uncertainty about what sort of a medical prognosis they would have if they contracted COVID‐19 infection, and 36.9% of them had a fear of catching COVID‐19 from other patients [11].Due to such factors, the COVID‐19 pandemic has led to an increase in the mortality rates of patients on waiting lists.In the United States of America, it was observed that mortality rates increased 2.2 folds in patients on waiting lists in states with the heaviest COVID‐19 burden [5, 11].

Topics such as when the COVID‐19 pandemic will come to an end,when ideal and definitive treatment methods can be developed for COVID‐19, or for how long the effects of the COVID‐19 pandemic will continue to create uncertainty worldwide [12, 13].In this context, the intolerance of uncertainty is a factor that is significant to the effects of the fear of COVID‐19 on the health of patients awaiting kidney transplantation.Fear and uncertainty make people feel stressed,worried, and weak [12, 14].It is stated that this situation affects both the physical and psychological health of patients awaiting kidney transplantation negatively.Identifying the factors affecting the fear and uncertainty intolerance levels of patients and to the extent of the effects of these factors on the fear and uncertainty intolerance levels of patients is of importance to the measures to be taken and the interventions to be implemented during the COVID‐19 pandemic [14,15].This study examines how the COVID‐19 pandemic, which is a major source of uncertainty, affects the uncertainty intolerance and COVID‐19 fear levels of patients.It is considered that the data collected in the study will guide patients in terms of lowering their fear levels,enhancing their tolerance of uncertainty, facilitating their coping with potential problems, and managing their treatment and therapy processes during the COVID‐19 pandemic.

Objective

This study aims to identify the relationship between the intolerance of uncertainty and the fear of COVID‐19 in patients awaiting kidney transplantation during the COVID‐19 pandemic.

Methods

The population of this descriptive and cross‐sectional study comprised patients who were awaiting kidney transplantation and presented to the outpatient clinic of the Kidney Transplantation Center of Inonu University Medical Center in Malatya from 10 November 2021 to 10 January 2022.The sample included patients who presented to the aforementioned outpatient clinic to attend their follow‐ups and satisfied the inclusion criteria of the study.The sample size required for the study was calculated by power analysis.According to the calculation made with an effect size of 0.30, a margin of error of 0.05,a confidence interval of 0.95, and a statistical power of 0.95, the sample size was identified as a minimum of 350 participants.In this regard, a total of 355 patients were included in the study.

Inclusion criteria

1.Being 18 years old or older.

2.Not having any communication barriers and/or perceptual disorders.

3.Agreeing to participate in the study.

Exclusion criteria

1.Being under the age of 18.

2.Non‐Turkish speakers, having communication barriers and/or perceptual disorders.

3.Not agreeing to participate in the study.

Data collection

The data were collected with a patient information form that was developed by the researchers based on their review of the relevant literature [1, 5, 10, 12], the intolerance of uncertainty scale (short form), and the fear of COVID‐19 scale.Before the study, a pilot study was performed with five eligible patients who awaited kidney transplantation, and hence, the final version of the survey form was created as the data collection tool.The survey form was applied to the patients using the face‐to‐face interview technique in full compliance with mask‐wearing, hygiene, and social distancing rules.Before the survey form was applied to the patients, information on the research objective and the survey form was given to the patients, and the patients were asked to consent to participate in the study verbally and in writing.Applying the survey form to each patient took approximately 10–15 minutes.

Patient information form.This form had 13 questions designed to identify the characteristics of the patients (age, sex, marital status,education level, place of residence, employment status, perceived income level, smoking status, alcohol consumption status, duration of being diagnosed with chronic kidney disease, comorbidities, duration of undergoing hemodialysis, and duration of being wait‐listed for kidney transplantation).

Intolerance of uncertainty scale – short form (IUS-12).Carleton,Sharpe and Asmundson (2007) developed IUS‐12 [16], and Sar??am,Erguvan, Ak?n and Ak?a (2014) adapted it to Turkish [17].IUS‐12 has 12 items and two subscales, namely, prospective anxiety (items 1, 2,3, 4, 5, 6, and 7) and inhibitory anxiety (items 8, 9, 10, 11, and 12).Designed as a five‐point Likert‐type scale (1: not at all characteristic of me; 2: a little characteristic of me; 3: somewhat characteristic of me;4: very characteristic of me; 5: entirely characteristic of me), IUS‐12 is a self‐report measure designed for adults.IUS‐12 does not contain any inversely scored item.The total score to be obtained on IUS‐12 ranges from 12 to 60 points.A high total IUS‐12 score points to a high level of intolerance of uncertainty.In this study, Cronbach’s alpha coefficient of the scale was calculated as 0.91.

Fear of COVID-19 Scale (FCV-19S).Ahorsu et al.developed the FCV‐19S in 2020 [18] and tested it for validity and reliability in Turkish by Bakio?lu, Korkmaz, and Ercan (2020) [19].FCV‐19S is a five‐point Likert‐type scale.The total score to be obtained from FCV‐19S ranges from 7 to 35 points.The scale has no inversely scored item.A high FCV‐19S score implies that the respondent feels a high level of fear of COVID‐19.In this study, Cronbach’s alpha coefficient of the scale was found as 0.89.

Data analysis

The collected data were analyzed by using the Statistical Package for the Social Sciences 24.0.Descriptive statistics were calculated for the data, and the Kolmogorov‐Smirnov test was utilized to determine whether the data were normally distributed.The Cronbach’s alpha coefficient was calculated in the context of the reliability analysis.Independent‐samples t‐test and one‐way analysis of variance were used for the normally distributed data.The Bonferroni test as a post hoc analysis method, was employed to identify the source of the statistically significant difference identified in previous tests.Additionally, Pearson’s correlation and linear regression analyses were conducted.The level of statistical significance was identified as aP‐value below 0.05 (P＆lt; 0.05).

Ethical aspect of the study

Before the study, ethical approval was obtained from the Non‐Invasive Clinical Trials Ethics Committee of Burdur Mehmet Akif University(No.GO 2021/375), and permission to perform the study was received from the Kidney Transplantation Center of Turgut Ozal Medical Center of Inonu University where the research would be conducted (2021‐306/52).After patients awaiting kidney transplantation were informed about the study, they were asked to consent to participate in the study verbally and in writing.This study was performed in full compliance with the principles of the Declaration of Helsinki.Lastly, written permission was received from the developers of the two scales that would be used in this study.

Results

It was determined that the mean age of the patients was 32.19 ± 6.90 years, their mean duration of being diagnosed with chronic kidney disease was 7.97 ± 2.44 years, their mean duration of undergoing hemodialysis was 5.96 ± 1.05 years, and their mean duration of awaiting kidney transplantation was 2.62 ± 0.87 years.The sociodemographic characteristics of the patients are presented in Table 1.

There were statistically significant differences in the mean FCV‐19S scores of the patients based on the variables of sex, the status of having another chronic disease, and the duration of being diagnosed with chronic kidney disease (P＆lt; 0.05).There were also significant differences in the mean IUS‐12 scores of the patients based on the variables of marital status, education level, and duration of being diagnosed with chronic kidney disease (P＆lt; 0.05) (Table 1).

The mean FCV‐19S score of the patients was 30.62 ± 4.10.The answers given by the patients to the items on FCV‐19S are presented in Table 2.

The mean total IUS‐12 score of the patients was 53.03 ± 5.11, whiletheir mean prospective anxiety subscale score was 30.28 ± 2.83, and their mean inhibitory anxiety subscale score was 22.45 ± 2.97.The answers given by the patients to the items on IUS‐12 are presented in Table 3.

Table 1 Mean FCV-19S and IUS-12 scores based on patient characteristics (n = 355)

Table 1 Mean FCV-19S and IUS-12 scores based on patient characteristics (n = 355)

Table 2 Responses of patients to the fear of COVID-19 scale items (n = 355)

A statistically highly significant positive correlation was found between fear of COVID‐19 and intolerance of uncertainty (r: 0.850;P＆lt; 0.001).Likewise, fear of COVID‐19 had highly significant positive correlations with prospective anxiety (r: 0.790,P＆lt; 0.001) and inhibitory anxiety (r: 474,P＆lt; 0.001).Next, fear of COVID‐19 had highly significant positive correlations with the variables of age and duration of being diagnosed with chronic kidney disease, whilst intolerance of uncertainty had a highly significant positive correlation with the variable of duration of being diagnosed with chronic kidney disease (P＆lt; 0.001) (Table 4).

Table 3 Responses of patients to the intolerance of uncertainty scale (short form) items (n = 355)

Table 4 Correlations between FCV-19S scores, IUS-12 scores, and certain variables

The intolerance of uncertainty variable had a highly significant effect on the fear of COVID‐19 (β = ?0.601, t = 8.12,P＆lt; 0.001),where the intolerance of uncertainty accounted for 43% of the total variance in fear of COVID‐19 (R2=0.43, F = 46.90,P＆lt; 0.001) (Table 5).

Table 5 Predictors of FCV-19S based on the regression analysis (n = 355)

Discussion

The COVID‐19 pandemic has created widespread fear and anxiety among patients awaiting kidney transplantation.The failure to find an effective treatment method for COVID‐19 aggravates these negative feelings even further and creates uncertainty about where the process is headed [20, 21].The results of this study showed a relationship between the intolerance of uncertainty and fear levels in patients awaiting kidney transplantation.In this study, the mean FCV‐19S score of the patients was found as 30.62 ± 4.10.Considering that the maximum score to be obtained by a respondent on FCV‐19S is 35 points, it may be stated that the patients who participated in this study felt a high level of fear of COVID‐19.Among studies conducted with the participation of patients awaiting kidney transplantation, it has been discerned that patients have high levels of fear of COVID‐19 [22,23].

In this study, a statistically highly significant positive relationship was identified between age and fear of COVID‐19 in the patients, and as their age increased, their fear of COVID‐19 also increased.Age has been known as a risk factor since the beginning of the COVID‐19 pandemic.In various studies performed on the topic, it has been put forward that older individuals are more at risk during the COVID‐19 pandemic [24–26].Accordingly, the initial COVID‐19 restrictions were mostly targeted at older individuals [27, 28].It may be considered that all these circumstances led older individuals to feel higher levels of COVID‐19‐related fear than young adults.Various restrictions implemented to stop the spread of the COVID‐19 pandemic may have been a factor directly or indirectly affecting the COVID‐19‐related fears of older individuals.For instance, due to restrictions such as the lockdown measures put in effect for individuals aged above 65 years,older individuals have been exposed to bullying and disrespectful behaviors on social media and in social life [27, 29].Older individuals are at a higher risk in the context of the COVID‐19 pandemic because COVID‐19 has a poorer prognosis as age increases, and older individuals have higher hospitalization and mortality rates than young individuals [24, 25, 29].Thus, it is expected the situation to find that the fear of COVID‐19 increases along with older age.

In our study, it was found that the female patients had higher levels of COVID‐19‐related fear than the male patients.Reactions given to the COVID‐19 pandemic vary depending on sex differences.It was reported that women felt higher levels of anxiety and fear in this context [30, 31].In the cross‐sectional study conducted by Inbar and Shinan‐Altman (2021) with 1,085 adults, it was found that most participants were worried (77.4%), scared (62.8%), or stressed out(55.3%).In the same study, it was also seen that women had higher emotional reaction scores than men, and emotional reactions were highly prevalent among women and older individuals [32].In the cross‐sectional study performed in the state of Parana in Brazil, with the participation of 3,495 women and 1,143 men, it was found that women had higher levels of COVID‐19 fear than men [33].From a psychosocial perspective, it may be asserted that in many societies,women are expected to assume more roles and responsibilities than men in both their home and business lives.Due to all these circumstances, in comparison to men, women have a quite high likelihood of being exposed to stress.On the other hand, women are more successful in adapting to these stressors.However, in general, as women are physically sensitive and fragile, they get sick more frequently than men.The fact that women get sick more frequently than men may explain why women have higher levels of COVID‐19‐related fear than men.Besides, the fact that masculinity culturally symbolizes power, courage, and fearlessness may have tempted men to avoid expressing their fears [30, 31, 33].

It was discerned that the patients in this study who had chronic diseases besides chronic kidney disease had higher levels of COVID‐19 fear.Numerous studies have demonstrated that COVID‐19 has a poorer prognosis in individuals with comorbidities, and individuals with comorbidities have higher hospitalization and mortality rates [34, 35].This high risk carried by individuals with comorbidities was emphasized by all sources of information during the COVID‐19 pandemic, was frequently brought to the agenda, and continues to remain on the agenda, particularly in news sources.The likelihood that individuals with chronic diseases feel more defenseless against COVID‐19 than healthy individuals and think that they are more at risk of death due to their chronic diseases may be a significant source of fear[36].

In this study, it was observed that the patients had a high IUS‐12 mean score.This finding was in a similar vein to other findings in the relevant literature.Such findings may be explained by the fact that the diagnosis and treatment processes of patients have been interrupted during the COVID‐19 pandemic [22, 23].During the COVID‐19 pandemic, the high number of patients awaiting organ transplantation,the low number of organ donations, the anxiety of patients about the future of transplantation, and the current state of uncertainty have created negative effects on patients.At any moment of life, patients awaiting organ transplantation experience a crossroads between dying and having transplantation.The fact that, in the post‐transplantation period, patients can no longer have a life as they used to in the past,and they are confronted with organ losses or the threat of death alongside organ transplantation may lead patients to feel helpless and intolerant of uncertainty [12, 13].

It was found that, as per the variable of education level, there was a statistically significant difference in mean IUS‐12 scores of the respective patient groups.This finding was in parallel with the relevant literature [14, 15].As the education levels of the patients who participated in this study increased, their tolerance of uncertainty also increased.This situation may have been associated with the possibility that individuals could manage to accept the disease and find more effective ways to cope with problems.Besides, in our study, based on the variable of duration of being diagnosed with chronic kidney disease, there was a statistically significant difference in the mean IUS‐12 scores of the respective patient groups.As the duration of being diagnosed with chronic kidney disease increased among the patients,their intolerance of uncertainty also increased.In the aftermath of the initial process in which patients are diagnosed with chronic kidney disease, patients can think over the forthcoming process more and more, and this, in turn, can significantly affect their uncertainty intolerance levels [37, 38].Moreover, in this study, married patients had a higher mean IUS‐12 score than single patients.In the relevant literature, it has also been discerned that married patients have higher levels of uncertainty intolerance [39, 40].This situation can be explained by the possibility that as a consequence of being a spouse,being a parent, and having domestic responsibilities, married patientsmay had a heavier psychosocial burden than single patients.Furthermore, in this study, as age increased, the intolerance of uncertainty among the patients also increased.As an individual with chronic kidney disease gets older, the disease is exacerbated, and accordingly, it is inevitable that their intolerance of uncertainty will increase.

According to the results of this study, there was a statistically significant positive relationship between intolerance of uncertainty and fear of COVID‐19.Besides, the uncertainty intolerance levels of the patients had a statistically significant effect on their COVID‐19 fear levels.As known, people feel more stress and fear in circumstances that they cannot control or foresee.In other words, individuals feel more stress and fear alongside uncertainties about what will happen,when it happens, or what the consequences will be.Uncertainty increases fear, and nowadays, when the fear of COVID‐19 is prevalent,individuals mostly seem worried [37–42].People who are intolerant of uncertainty find uncertainty stressful and frustrating, and they believe that uncertainty has negative connotations and should be avoided.Thus, people experience difficulty in circumstances that create uncertainty.It is known that people experience uncertainty during the COVID‐19 pandemic, and it is considered that these individuals’ COVID‐19‐related fears increase in association with the feeling of uncertainty [41, 43].Moreover, in studies performed with the participation of adults, it has been seen that there is a statistically significant positive relationship between fear of COVID‐19 and intolerance of uncertainty.Likewise, the relevant literature showed that, as the intolerance of uncertainty in individuals increases, their COVID‐19 fears also increase [19, 41, 42].Considering the interactions and predictive relationship between the fear of COVID‐19 and the intolerance of uncertainty, it may be asserted that the results of the aforementioned studies have been in support of the findings of this study.

Limitations

The results of this study do not apply to all patients awaiting kidney transplantation in Malatya.Instead, they are limited solely to patients awaiting kidney transplantation, having examinations at the health facility where this study was performed, and agreeing to participate in this study.

Conclusion

In conclusion, it was determined that the fear of COVID‐19 increases as the intolerance of uncertainty increases in patients awaiting a kidney transplant.To reduce uncertainty and fear levels, taking into account the age, sex, marital status, and education level of the patients,COVID‐19 infection, how the COVID‐19 infection is transmitted to people, what the signs and symptoms of COVID‐19 infection are,education should be given about the methods of prevention from COVID‐19.To reduce the comorbidity rate in patients with additional chronic diseases and a long diagnosis period, awaiting kidney transplantation during the COVID‐19 pandemic, care should be provided by a multidisciplinary team, and psychosocial support should be offered.