Sociodemographic factors and health conditions associated with the resilience of people with chronic diseases: a cross sectional study

ABSTRACT Objective: to investigate the association between resilience and sociodemographic variables and the health of people with chronic kidney disease and / or type 2 diabetes mellitus. Method: a cross-sectional observational study performed with 603 people with chronic kidney disease and / or type 2 diabetes mellitus. A tool to collect socio-demographic and health data and the Resilience Scale developed by Connor and Davidson were applied. A descriptive and multivariate analysis was performed. Results: the study participants had on average 61 years old (SD= 13.2), with a stable union (52.24%), religion (96.7%), retired (49.09%), with primary education (65%) and income up to three minimum wages. Participants with kidney disease showed less resilience than people with diabetes. Conclusion: the type of chronic illness, disease duration, body mass index and religious beliefs influenced the resilience of the study participants.


Introduction
The changes that chronic disease brings are not always addressed properly, which may cause difficulties in the care and control of this disease, causing stress and bringing suffering to those persons and their families. However, it is realized that some of these people manage to overcome these difficulties keeping adherence to treatment and coping with their illness as something to be overcome, even if they often have many other problems in the different areas of their life.
This may be related to the concept of resilience.
Resilience is still an understudied construct in the scientific literature in the field of nursing. However, in health care, it is being explored with studies, especially with traumatic situations and, more recently, studies of people with chronic health conditions (1)(2)(3)(4) . to be a dynamic process (5) . When it comes to illness, resilience appears as a possibility of change, being understood as a person's ability to cope with illness, accepting the limitations imposed by the condition, with due adherence to treatment, seeking to adapt to the situation and live positively (6) . Resilience can enable some control over the negative impact of the physical, social and economic consequences, and the emotional consequences perceived in the disease (7) .
In this sense, the use of the concept of resilience can also be seen as a possibility to promote the acceptance of the indicated modifications and easier adaptation to the new health habits. Tackling chronic disease and adapting to the new lifestyle takes effort, dedication and to overcome the situation. Thus, resilience has proven to be a concept that can contribute to the control of chronic disease (1,3,(8)(9) . However, few studies have addressed the association of resilience, sociodemographic aspects and health condition of people with chronic diseases (7)(8)(9) . To show these variables in association with resilience can contribute to the development of a theoretical model that shows how resilience is expressed in chronic disease in order to collaborate in health care, indicating elements to promote better coping with the situation.
In this sense, we sought to know how resilience is expressed in these people and what aspects could influence it. Thus, it was defined as objective of the study: To assess the association between resilience and sociodemographic and health conditions of people with chronic kidney disease and / or type 2 diabetes mellitus.

Results
The study participants had on average 61 years old (SD = 13.2). Regarding gender 493 (81.8%) women and 110 (18.2%) men participated. Table 1 presents the sociodemographic characteristics, and Table 2 the health conditions for the total sample and by disease group.
We emphasize that the variable "individual monthly income of the person" was answered by 368 people, considering the value of the minimum wage in the year of data collection; and the BMI variable was obtained from 577 people, since 26 did not accept and / or had not physical condition to perform this measurement.

Discussion
From the adjusted multivariate analysis it was found that, among the socio-demographic factors, only religion influenced the resilience. Few authors relate resilience with religiosity, faith or spirituality. Religious belief is identified as a source of support to face difficult situations (7) . The other sociodemographic variables presented in our study -age, sex, marital status, labor activity, education and income -have not been identified as factors that influence resilience. With regard to age, in two other studies, one of them also developed with people with DM (8) and another with nurses (11) , a relationship between this variable and resilience was also not identified (8,11) .
It is realized that living with chronic disease requires adjustment both for those living with diabetes (12) and for those living with CKD (13) . In this study, the influence of resilience scores were related to health factors, such as type of chronic illness, disease duration and BMI.
In regards to the type of disease, diabetes is related to better resilience, which can be explained because it is a disease, often silent, which does not require sharp changes in people's lives. It does not present itself with physical and emotional manifestations, such as those caused by kidney disease, particularly for people who are undergoing hemodialysis. This specific way in how disease affects the lives of people with CKD may be the reason for the lower scores of resilience in those people (14)(15) . Furthermore, depression, frequent in individuals with CKD, is a variable that can affect resilience (16)(17) . This finding indicates the need for further research exploring resilience with other variables, such as depression.
Disease duration negatively influenced resilience in two periods: those participants presenting six to 10 years of disease, as well as those over 16  mostly do not focus on the relationship with the duration of the disease. However, the increase of these diseases and complications arise from non-adherence over the years (12)(13)(14) . This means that the longer the time living with the disease, the larger the impact on people's lives, leading to lower resilience scores, as was obtained in our study.
As for the BMI, people with CKD maintained their weight within the normal parameter, which is associated with weight loss, one of the characteristic manifestations of this disease in its terminal stages (18) . One of the factors contributing to the weight loss is the necessity of the diet to which people on hemodialysis are submitted (18) .
Conversely, people with DM2 have low adherence to dietary restrictions, as well as this disease having obesity as one of its causes (19) . That means that overweight and obesity are common among people with DM. A previous study showed the prevalence of low adherence to the diet and physical inactivity in people with diabetes (20) .
Also, it was found in another study that 55.78% of the women studied did not diet and 61.22% did not exercise, showing that specific care recommendations are not always followed (12) .
Regarding the association between resilience, marital status and sex, the findings obtained corroborate other studies, which also showed no significant correlation between these variables (10,(21)(22) . We believe that these variables should be explored in future studies.
Regarding the variable education, we observed that resilience scores do not seem to be related to education, as even those who never studied have similar scores, meaning that being resilient is independent of the level of education as the other studies show (11,23) .
People who worked scored higher in resilience; however, the adjusted analysis demonstrated no influence of this variable in resilience, as well as income.
Another study showed a different situation, with income significantly related to resilience (8) . There are few studies that relate resilience to economic status. However, one author states that having a low socioeconomic status does not prevent the development of resilience (1) .
Studies of people with DM and that used the CD-RISC to analyze the resilience found average scores ranging from 74.9 (SD = 14.8) and 83.1 (SD = 8.5) (22)(23) . In another study, also with people with diabetes, but using a different resilience scale (RS from Wagnild and Young), findings showed that more than half of the participants (66.4%) were classified as highly resilient, through the mean and standard deviation found in the study (8) . These findings also concur with the results of the present study, stressing that people with diabetes have shown high scores of resilience, i.e. very close to those of healthy people (10) .
Despite the fact that the research on resilience of people with CKD are scarce, what we have observed is that the findings refer to smaller resilience scores for this population, as presented in the study that applied the Wagnild and Young's Resilience Scale (24) . Studies done with the CD-RISC that found lower scores for resilience, approaching those found in people with CKD, were those in people with depression, psychiatric anxiety disorders and schizophrenia and those that suffered some kind of trauma. The scores in those studies were between 46.1 (SD = 18.7) and 68.0 (SD = 15.3) points (10,25) .
The differences between the two groups may be considered a limitation of the study, especially due to the fact that one study was conducted only with women with DM2. However, this limitation can be relativized by the fact that comparing the groups in regards to sociodemographic data was not a goal of the study, but it was rather to verify the association between resilience and sociodemographic and health conditions of people with chronic kidney disease and/or diabetes mellitus type 2. In addition, the adjusted analysis identified no difference between men and women's resilience scores.

Conclusions
The study revealed that resilience is associated with the type of chronic disease, i.e., people with CKD on hemodialysis have lower resilience scores than people with DM. Along with the type of disease, the duration of disease, BMI and having a religion were also factors that influence the resilience of people with these chronic diseases.
Given the undeniable need to find options to help to better control chronic diseases and to achieve a more harmonious relationship with them, the concept of resilience emerges as a possibility still needing further studies, exploring the association with other variables, as well as the evaluation of strategies for promoting resilience.