The Role of Family Support in Stress and Anxiety Conditions in The Elderly with Chronic Kidney Disease Underwent Hemodialysis Therapy

Abstract


INTRODUCTION
Chronic kidney disease (CKD) is a disease condition that attacks the kidneys which is characterized by the body's inability to maintain metabolic abilities and electrolyte-fluid balance so that uremia occurs (Asriani, 2013). According to Kurniawati (2019) in her research of 130 nurses in several hospitals in Central Java Province, nurses tend to prioritize physical care and treatment (Grehenson, 2019). This underlies the importance of conducting research on psychosocial problems in elderly people with chronic diseases, including chronic kidney disease.
People with chronic kidney disease who underwent hemodialysis therapy programs are at great risk of experiencing cognitive impairment, as well as mental health disorders such as emotional disturbances, anxiety, and stress, so they need support from their families (K. Agustina & Dewi, 2013). In our preliminary study at Bhayangkara Kediri Hospital, there were 93,3% of 30 patients who underwent hemodialysis got good enough family support, but we also found that 53,3% of them tend to have stress conditions. They said that they were stressed by their many lifestyle prohibitions due to their illness (researcher primary data, 2022). Family support for ill people can help increase one's self-esteem and abilities. Families can provide support for their families member which has illness by giving encouragement, approval of opinions, empathy, knowledge, and advice (Kartikasari, 2015;D. O. . Puspita & Nurchayati, 2021). This study aims to determine the effect of family support on stress and anxiety levels in the elderly with chronic kidney disease undergoing hemodialysis therapy.

RESEARCH METHODS
This study is quantitative research with a cross-sectional approach, which analyzes 3 variables including the independent variable, that is family support, and 2 dependent variables, namely the level of stress and anxiety. Respondents who participated in this study were elderly (age > 60 years) with chronic kidney disease who underwent hemodialysis at Bhayangkara Hospital, Kediri. Patients were selected based on certain criteria, that is patients underwent hemodialysis within > 6 months. The sampling technique used in this study was accidental sampling where the patients who were respondents were patients who came to undergo a hemodialysis program during the study, totaling 42 respondents. An ethical review was carried out for this study through the Research Ethics Commission of the Bhakti Wiyata Kediri Institute of Health Sciences. The statistical test used is the Spearman rho test to determine the effect of family support on and to determine the effect of family support on the anxiety of the elderly.
The instruments used in the study for both Family Support, Stress Levels, and Anxiety Levels for the Elderly were a questionnaire. Family support which is a variable in this study uses the perspective of the elderly as measured using a questionnaire. The Family Support Questionnaire used consists of 20 ports consisting of favorable and unfavorable ports and has been tested for validity and reliability with a Cronbach value of α = 0.862. The stress level variable was measured using a questionnaire which was prepared by involving 3 stress-triggering factors, namely Physical -Biological Stress, Psychological Stress, and Social Stress and its validity was tested, as well as a reliability test with a Cronbach value of α = 0.891. The questionnaire for assessing stress consists of 20 statements. The next variable is the Anxiety Level of the Elderly which is measured using the Geriatric Anxiety Scale questionnaire. This questionnaire was developed by Daniel L. Segal which is used to determine the scoring of the elderly who experience anxiety.  Table 1 shows that more than half of the respondents are male (52.4%), although the proportion and number are not far adrift with the number of elderly women (47.6%). This is 9 that the proportion of patients with kidney disease underwent hemodialysis between men and women is not much different even though the number of men tends to be more than women.   Table 3 we can see that the respondents in this study had a percentage that was not much different between ≤12 months and those who had underwent hemodialysis for >12 months. Even so, it appears that fewer elderly respondents who have been >12 months underwent hemodialysis compared to those underwent hemodialysis ≤12 months.  Table 5 provides information on the respondents' employment data, where more than half of the respondents are not working (61.9%), and the rest are still doing their previous jobs such as farming and trading. Respondents who do not work consist of retired state apparatus and also those who have not carried out their previous jobs, for example factory workers, other non-state civil apparatus jobs, and housewives. More than half of the respondents felt that they did not receive support from their families while underwent hemodialysis. This can be seen from table 6 which shows that the family support in the Less category has a percentage of 59.5% and there is no Good category in terms of family support.  Table 7 shows that the elderly who were participated in this study had an average level of Severe and Moderate stress with the same percentage of 42.9%. 14,4 Table 9 shows that most of the elderly in this study felt the lack of family support and were under severe stress (38%). Elderly with moderate levels of stress who feel that their family support is sufficient, shows the same percentage as the elderly with less family support. This is indicated by the same percentage of 21.45%.  Table 10 shows an overview of the level of anxiety with family support obtained by the elderly. The table provides information that most respondents have a moderate level of anxiety and feel a lack of family support (31%). -0,399 The results of data analysis using the Spearman's Correlation test both on family support for stress levels and family support for anxiety levels show a value of ρ≤0.05. The significance value for family support on stress levels is 0.000, while for family support on anxiety levels is 0.009. This means that family support has an influence on stress levels and also on anxiety levels in elderly people with CRF who are underwent hemodialysis therapy. In addition to the significance value, different correlation coefficient values can be obtained between family support for stress and family support for anxiety levels. The correlation coefficient value of family support on stress levels is -0.603 which indicates a strong correlation between family support and stress levels. Different things were obtained in family support with anxiety levels which showed a correlation between the two, but this correlation was low. It is known from the value of the correlation coefficient between family support and anxiety level is -0.399.

Families Support
The results of measuring family support obtained by respondents in this study indicated that none of the respondents received good support, but in fact more than half (59.5%) felt that family support was lacking. This can happen because there are several things that affect the acceptance of family support in the elderly with kidney disease who are underwent hemodialysis therapy.
The first thing that can affect the acceptance of family support by the elderly is education. According to Setiadi, one's belief in family support is formed by intellectual variables, one of which is education. This intellectual variable influences a person's way of thinking in understanding the factors that cause problems experienced by a person (E. D. Puspita, 2023) . Another factor that plays a role in the formation of family support that is felt by someone is the age factor. According to Kholifah, someone who is at an advanced age will experience increased attention to his family and a stronger sense of wanting to be close to his family. The elderly also easily experience a decrease in emotional control so they get emotional easily when something is not what they want. This can affect the elderly's acceptance of the support given by their families (Kholifah, 2016). Decreased family support can also occur as a result of decreased family coping. This decrease in family coping can occur in patients who suffer from chronic disease so that this long treatment can cause fatigue in supporting individuals (families) of people who are sick (Herdman, 2014).
The things mentioned above can be factors that result in family support received by the elderly underwent hemodialysis therapy in this study showing the Poor category. The highest percentage of elderly respondents in this study was Elementary School (SD). Only 26.2% of respondents have at least graduated from high school. This can affect the elderly in understanding the health problems they experience and the family's response to their illness. Respondents in this study were all elderly people with a minimum age of 60 years. This is in accordance with Kholifah's opinion (2016) that someone who has entered old age will increase his desire to be close to his family. This is very possible to make the elderly always want to be accompanied by their families, especially when underwent treatment. However, on the other hand, elderly family members may not always be able to accompany the elderly when underwent hemodialysis. The next factor that also appeared in the respondents of this study was that the average period of underwent hemodialysis therapy was 13.67 months. This means that the average elderly has undergone hemodialysis therapy for more than 1 year. This certainly can be at risk of reducing family coping due to the appearance of fatigue in accompanying the elderly to carry out their hemodialysis therapy.

Stress Levels
Assessment of stress levels in the elderly underwent hemodialysis shows that the average elderly experience severe and moderate stress. This is shown by the relatively large percentage in the two categories, each of which has 42.9%. The level of stress experienced by the elderly with hemodialysis therapy can be influenced by various things.
Various studies have been conducted to determine the factors that influence stress levels. According to Mubin et al., one of the factors that influence the stress level of the elderly is socioeconomic factors. This is because the elderly are seen as an economic burden due to the changes that occur to them which result in the elderly being no longer able to make money productively (Mubin et al., 2018).Another factor that affects stress in the elderly is old age itself. Old age itself basically raises the risk of a person experiencing stress. Various changes that occur in someone who is elderly raises the risk of the elderly experiencing stress (HPA, 2023;Kholifah, 2016). Stress can also be influenced by gender. Several studies have stated that women tend to experience stress more easily, and tend to experience more severe levels of stress, as well as experience depression, compared to men (Mumulati et al., 2020;Nasrani & Susi, 2015;Putri et al., 2020).
Half of the respondents in the study did not work, consisting of housewives, as well as those who previously worked but have now stopped working, while the other respondents are retired state apparatus, farmers and traders. The average unemployed respondent said that they did not have income because they did not work, so that the money they earned depended on gifts from their next of kin. A low economy will make sick elderly people need to consider various expenses related to illness and treatment. Even though the majority of the elderly do not incur costs for hemodialysis directly because they have used health insurance, the elderly still need to take into account expenses during treatment, for example transportation costs, costs for administration, as well as food costs which are sometimes unavoidable. This is certainly something that adds to the burden on the minds of the elderly with kidney disease who are underwent hemodialysis.
The age of the respondents in the study were all elderly, namely at least 60 years old. Elderly is the final stage in human life, where at this age various changes occur in life. These changes can be in the form of decreased physical function of the body, psychological changes due to the loss of family members and friends, and changes in economic ability due to not having income or decreasing income after retirement or not working. These changes are stressors experienced by the elderly so it is very likely that stress will occur and the stress level will increase.
The elderly in this study had a gender percentage that was not much different between men and women, namely 52.4% male and 47.6% female. Several studies have stated that women experience stress more easily and experience increased levels of stress and depression. One more factor that has a role in terms of the stress level of the elderly is the family support received by the elderly. Research conducted by Anugrah & Sugiyanto (2018) on the elderly who are in the Tresna Werdha Social Institution (PSTW) Budi Luhur Kasongan Bantul Unit shows that the elderly who receive better family support have lower stress levels compared to the elderly with more family support. Lacking (Anugrah & Sugiyanto, 2018). Similar results were also conveyed by several other studies which also found the fact that family support is needed to reduce stress in the elderly. The better the support the elderly receive from their families, the lower the level of stress experienced, and vice versa (Bella, 2022;Muttaqin, 2017;Permana, 2013) .These things do not rule out the possibility of being factors that contribute to the percentage of stress levels in respondents in the study, the average is in the Moderate and Severe categories.

Anxiety Levels
There are two categories of anxiety levels that have a high percentage in this study, namely the category of Moderate Anxiety Level (50%) and Severe (33.3%). Several studies have found things that affect a person's anxiety level. Half of the elderly who were respondents in this study had moderate levels of anxiety (50%). Anxiety experienced by the elderly can be influenced by several factors.
Gender in several studies has a relationship with the level of anxiety in a person (Ainunnisa, 2020;Paputungan et al., 2019). The results obtained from the study showed that the percentage of elderly with male sex (52.4%) was almost the same as the percentage of elderly with female sex (47.6%). In general, the percentage of elderly men in this study was greater than that of women. However, the results of the research data tabulation showed that the percentage of elderly women experiencing severe anxiety was higher than that of men. Of the 18 respondents with severe anxiety, 66.7% were women, and the rest were men. According to Sadock & Sadock (2010) this is because women have more sensitive feelings, so they are more emotional in responding to things compared to men (Paputungan et al., 2019).
Another factor that plays a role in the level of anxiety is the family support received by the elderly. This is supported by the research results of a number of researchers who found results in their research that family support has a relationship with the level of anxiety experienced by the elderly (Afifah et al., 2017;Aprilia et al., 2022;Saputra, 2019). Referring to family duties in the health sector according to Friedman (2010), one of them is that the family has the duty to provide care for family members who are sick (Susanto, 2023).This family task describes family support for sick family members. Caring for sick family members can be realized in the form of providing support for sick family members. Elderly who get family support will feel happy, comfortable, and fear that their health condition will decrease. This has a good impact on the elderly, including the elderly who are sick. The elderly will be more excited to face the next treatment process (Nisa et al., 2019).
These factors can explain the results obtained in this study that the average respondent's anxiety level is in the Moderate and Severe categories. These various factors cannot be ignored in efforts to improve the health of the elderly, especially in managing anxiety in the elderly.

Families Support and Stress Levels
The results of this study found that the largest percentage of respondents had severe stress levels with less family support (38%). Analysis using the Spearman's Correlation test obtained a value of ρ = 0.000 with a correlation coefficient of -0.603. This shows that family support has a close relationship with the stress level of the elderly with kidney disease underwent hemodialysis. The correlation of this relationship has a negative direction, which means that the better the family support received by the elderly, the lower the level of stress experienced by the elderly.
Several studies have obtained results that are in line with this study. Research conducted by Anugrah & Sugiyanto (2018) on the elderly who are in the Tresna Werdha Social Institution (PSTW) Budi Luhur Kasongan Bantul Unit shows that the elderly who receive better family support have lower stress levels compared to the elderly with more family support. Lacking (Anugrah & Sugiyanto, 2018). Similar results were also conveyed by several other studies which also found the fact that family support is needed to reduce stress in the elderly. The better the support the elderly receive from their families, the lower the level of stress experienced, and vice versa (Bella, 2022;Muttaqin, 2017;Permana, 2013). According to Taylor (2009) support from the family given to the elderly will be able to reduce the stress experienced by the elderly. This family support has a stress reducing effect so that individuals can control their stress levels (Muttaqin, 2017). Family support also has an influence on coping with the elderly which has an impact on the ability of the elderly to manage the stressors they experience. Lack of family support will have an impact on the formation of maladaptive coping in the elderly which results in the difficulty for the elderly to calm down when facing small problems encountered in their life journey (Permana, 2013).
The things above explain the results obtained in this study that elderly people with severe stress are elderly who feel they do not receive enough support from their families. Elderly people who feel they are not getting enough support from their families have decreased their ability to deal with the stressors they receive. Good ability to be able to manage the stressors they face is very important for the elderly with illness, including the elderly with kidney disease who are underwent hemodialysis therapy. According to Smeltzer (2008) hemodialysis therapy is given to patients with kidney disease who have a Glomerular Filtration Rate (GFR) <15 ml/minute, hyperkalemia, failure of conservative therapy, urea levels > 200 mg/dl (Munawar, 2017). Hemodialysis therapy must be carried out routinely according to the schedule given by the doctor. Hemodialysis lasts a lifetime because this procedure functions to replace the role of the kidneys which cannot carry out their functions due to damage to these organs. This procedure is continuous with a duration of approximately 4 hours for each hemodialysis with a frequency of 2-3 hemodialysis in one week (Munawar, 2017). The condition of the elderly who experience pain accompanied by therapeutic procedures that must be carried out for life becomes a stressor for the elderly, causing the elderly to experience stress. Such conditions require support from the family so that the elderly can manage the stressors they encounter during their journey to deal with their illness. Lack of family support will result in the elderly having unadaptive coping, difficulty managing the stressors they experience so that the stress they experience will increase.

Families Support and Anxiety Levels
Family support also has a relationship with the anxiety level of the elderly who suffer from kidney disease and undergo hemodialysis therapy. These results were obtained by researchers in this study in accordance with the results of the Spearman's Correlation test obtained by a value of ρ = 0.009 with a correlation coefficient of -0.399. In contrast to the correlation between family support and stress levels which shows a strong relationship, the correlation between family support and anxiety levels has a low correlation coefficient.
According to research conducted by previous researchers obtained results that support the results of this study. Previous studies have found that family support has a relationship with the anxiety level of the elderly (Afifah et al., 2017;Aprilia et al., 2022;Saputra, 2019). The role of the family in reducing the anxiety of the elderly is related to the feeling of pleasure, security and comfort felt by the elderly from their families. These feelings have a positive impact on the enthusiasm of the elderly to attend the next care process (Nisa et al., 2019)s.Family support also makes the elderly braver to face the fear they experience (A. Agustina & Oxyandi, 2018).
The results of this study are in line with the previous research. Family support felt by the elderly affects the fear felt by the elderly during the management of their illness. Family support that can be realized, for example by accompanying the elderly when carrying out hemodialysis therapy, will be able to provide a sense of security for the elderly. The elderly will feel that they are always accompanied so they don't need to worry that something bad will happen to them, because their family is with them. This will make the elderly feel less anxious.
The correlation coefficient which shows a low strength relationship can be influenced by the receipt of information about health that has been received by the elderly while underwent hemodialysis. The results of sharing with respondents during this research found the conclusion that while undergoing illness and hemodialysis, the elderly also obtained information about the description of the illness and hemodialysis therapy they were undergoing. These results are supported by several studies that have been conducted previously, that knowledge can improve the anxiety of the elderly (Daha et al., 2021;Ernawati et al., 2022). The existence of these factors has a good impact on the anxiety of the elderly. So even though family support is proven to have a significant relationship with anxiety levels, the correlation is low.

CONCLUSIONS
This study provides us with the fact that there is a significant effect of family support on both stress levels and anxiety levels in the elderly with kidney disease underwent hemodialysis therapy. This study also provides information that the better family support will be able to reduce stress levels and anxiety levels in the elderly. This is certainly expected to be able to enable families who have family members who are sick, especially the elderly with acute kidney disease who are underwent hemodialysis therapy, to be able to continue to provide their best support to the elderly. Good family support can have a positive impact on improving stress and anxiety levels so that in the future it is expected to be able to improve the health quality of the elderly as much as possible.
The results of this study can provide evidence of the importance of family support in the psychological health of the elderly, especially stress and anxiety levels. The results of this study confirm that the elderly, especially those with chronic kidney disease who are treated with hemodialysis, need support from their families in order to maintain their psychological stability. Health workers, especially nurses, are expected to be able to obtain scientific references to provide education to families of patients with chronic kidney disease so that they always try to provide their best support for their elderly family members with chronic kidney disease who are underwent hemodialysis therapy.