Patients’ Concerns at Their Admission in Hospital and Its Related Factors in Kermanshah, Iran

Although concerns result in dissatisfaction of peoples, average levels of concern are almost advantageous as people keep plans for the future to remove their concerns; however, excessive and uncontrollable concerns can hurt people (1). Research on concern is quite recent and, due to the lack of comprehensible studies on this issue, the content of concern is not clearly defined and there is no reliable measurement on it (2). In general, concern has been defined as an attempt to solve mental problems with unknown results and one or a few possible negative consequences (3). In another study, concern was defined as an attempt to solve a problem where the danger is constantly recurring and there is no solution. Generally speaking, theorists agree that concern is a cognitive concept that is uncontrollable, and potentially changeable to future events and disasters (3-5). The concern could be explained as being worried about the future and negative events which result in a negative and severe mental verbal reaction (6). Sickness and hospitalization could be stressful experiences for patients and their families, and may cause various concerns about each event from admission to discharge (7). Most patients admitted to hospitals are afraid of being confronted with an unfamiliar hospital environment, surgery room, and ICU equipment (8). Also, they worry about surgical complications, less physical strength, lack of playing their roles and responsibilities in the family or community; and due to facing negative emotions associated with these factors, patients find themselves stressed and anxious (8-10). It is known that stress could be helpful in moderation (11), though severe stress and concern in patients may interrupt diagnosis procedure, and lead to incomplete and complicated therapeutic tasks. Furthermore, it may increase the Patients’ Concerns at Their Admission in Hospital and Its Related Factors in Kermanshah, Iran Soraya Siabani1,2,3 ID , Leila Solouki3* ID , Afshin Almasi3 ID , Sina Siabani1 ID , Motahareh Khaledi1 ID , Elaheh Sepehri3 ID , Maryam Almasi3 ID

need for sedative medications and their complications (12), which can cause further problems. These concerns and anxieties create a defective cycle for the patient and increase the time of hospitalization, frequent visits to the hospital, and higher rates of in-hospital mortality, and even after discharge (4). Illness is not the only reason for concern in patients admitted to the hospital; therefore, concern and stress are not limited to anxiety disorders or diseases such as cancers (13,14).
Various studies reported different causes for concern and anxiety in patients, including ignoring patients' physical and psychological needs (7), facing diagnostic procedures (15), lack of effective remedies to recover, lack of empathy of nurses, waiting for services (16), lack of information on medical procedures, and fear of pain during diagnostic treatments (17). It is important to control high concerns during examinations, since the concern may increase the duration of treatment and increase the possibility of side effects (18). There are no definite borders for the concern and it is not limited to patients with anxiety disorders (14) or cancer (13). The concerns in patients with heart failure are similar to those reported by cancer patients. (19,20). Knowing the major concerns of patients admitted to hospitals can lead to a better understanding of the problems related to hospitalization, as well as the personal and family problems influencing their recovery process. Therefore, it is essential to develop effective interventions to reduce stress factors and modify the influence of this experience on patients and, as a result, facilitate the improvement of patients (21,22). Accordingly, the present study addressed the types of concerns and the associated factors patients face during admission to hospitals.

Materials and Methods
This descriptive-analytic study was conducted on adult patients admitted to different educational hospitals affiliated to Kermanshah University of Medical Sciences, Iran in 2016-2017. The number of hospitalized patients was the criterion to calculate the share of each hospital, and random multi-stage sampling was used to select the samples.
Inclusion criteria were being over 18 years old, speaking Persian or Kurdish, having a stable physical condition, having mental health certified by a nurse at the hospital, and written consent to participate in the study.

Participants
Participants included all patients admitted to Imam Ali, Imam Khomeini, Taleghani, and Motazedi hospitals in Kermanshah, Iran . Using a multi-stage sampling method (stratified and then random sampling in each category), a total of 600 patients admitted to different departments of the hospitals were chosen as the participants. The share of each hospital was calculated according to the number of patients admitted to that hospital, and then the name and location of the participants were extracted from the admission list of patients by simple random sampling.

Data Collection
A socio-demographic questionnaire was used to gather the required data including demographic information, current disease, and medical history. A 27item researcher-developed questionnaire was used to collect the required data based on a 5-point Likert scale (1=strongly disagree to 5=strongly agree). The initial framework of the questionnaire was prepared using the contents of several studies in this field (23)(24)(25)(26). The questionnaire was required to check patients' concerns about hospital expenses, family concerns, education and occupation concerns, complete treatment and recovery, concern about unfamiliar hospital environments, concern about medical services, and concern about diagnostic procedures. The validity of the content of the questionnaire was evaluated by consulting six experts in this field and applying the viewpoints in the pilot study. The reliability of the questionnaire was also measured using Cronbach's alpha coefficient (0.81). Descriptive and inferential statistics including mean, median, standard deviation, skewness, Kruskal-Wallis statistical tests, and Mann-Whitney test were used to analyze the data at statistical significance level P <0.05. furthermore, SPSS software version 21 was used to analyze the data.
After obtaining the required permissions from the Ethics Committee of KUMS, explaining the purpose of the research, and getting a consent letter from all subjects, the participants were requested to complete the questionnaire.
Based on the results of the Kruskal-Wallis test, the distribution of concern scores was different in different educational groups (P = 0.012). Limit comparison tests (binary) found women to be more concerned than men (P = 0.83). Also, divorced/widowed showed to be more concerned than other groups (P = 0.93). It was shown that the concern score was associated with educational level, so that illiterate patients reported the highest concern (P = 0.043). The concern scores were higher http://ddj.hums.ac.ir http among workers, farmers, and housewives, respectively (P = 0.230). Regarding income (less than $100, between 100 to $200, between 200 to $300, over $300), it was observed that people with lower incomes had higher concern scores (P < 0.001). According to insurance status, patients with welfare insurance had higher concern scores than other groups (P = 0.073). Also, regarding the length of admission in the hospital, those admitted less than a week showed lower concern compared to those hospitalized for more than a week (P < 0.001). There was a significant difference in the distribution of the concern scores for the groups with the final diagnosis of disease (P < 0.001), so that group 7 (other diseases) showed significantly lower levels of concern compared to the third )neurology) and fourth groups (cancer) ( Table 2).
The results of the concern scores obtained from the questionnaire suggested that the highest concern scores were related to the following items: uncertainty about the duration of hospitalization (score=1462, M=2.44), concern about unsuccessful treatment and total recovery (score=1333, M=2.22), concern about the cost of the hospital (score=1251, M=1.89), concern about being in an unfamiliar environment in hospitals (score=1136, M=1.89), and future re-admission )score=1111, M=1.85).

Discussion
The present study sought to investigate the determinants of concern and its related factors in patients admitted to different wards of educational hospitals of Kermanshah, Iran. Based on the analysis of patients' information on a researcher-developed questionnaire, the present study suggested a significant relationship between variables of income rates, education, length of admission in the hospital, and final diagnosis of the disease with the patient's concern score. Results from the present study were consistent with the following studies on the variables under study and the concern scores. A cross-sectional descriptive study investigated 130 patients with heart failure and reported a significant relationship between age the final diagnosis of disease and length of hospital admission with concern score on future (27). Results from the present study suggested a significant difference between the concern scores among the diagnostically categorized groups so that patients in cancer and neurology groups showed higher levels of concern compared to other groups. Also, patients hospitalized for less than a week were less concerned in comparison to patients admitted to hospitals for a longer period. It could be inferred that since more serious health issues need longer health care, patients with severe health problems have higher concern scores. Another study compared the concern and depression among 300 patients with coronary artery disease admitted to hospitals patients using the standardized Hospital Anxiety and Depression Scale (HADS). Results from the study showed a high prevalence of concern and depression among the patients (28). The current study reported a significant difference in the concern scores among the groups categorized with the final disease diagnosis and suggested higher levels of concern among cancer and neurology groups compared to other groups. In addition, the results reported higher levels of concern in groups suffering from more serious health problems.
Results of a cross-sectional descriptive study on 218 family members of 130 hospitalized patients reported a poor economic status of the families regarding hospital costs and role changes as effective factors on the increase of the anxiety and concern among families (29). The present study also suggested higher concern scores among patients with lower income levels and poor economic conditions compared to others. This condition may result from the poor work condition in Iran where better-paid jobs need higher education at the governmental level. However, the role's change was not found significant in the concern scores in the present study. Also, a cross-sectional study to estimate patient's safety, satisfaction, and quality of hospital care on 61 168 nurses and 130 000 patients in 12 European countries and the United States reported dissatisfaction of quality of hospital care in all countries and suggested improving the hospital's working environment as a relatively low-cost strategy to increase safety and quality of hospital care and, as the result, patients' satisfaction (30). Although the concern scores in the present study generally showed patients' low levels of concern about admission to hospitals, findings from our study were strongly consistent with the results above and clarified the linear relationship between the concern score and length of admission, concern about unsuccessful treatment and total recovery, unfamiliar environments in hospital and, last but not least, concern about re-admission. Therefore, it could be understood that increasing the quality of hospital care and patients' satisfaction may help reduce the patients' concerns during hospital admission. One of the main limitations of this study was the reluctance of patients to participate in completing questionnaires due to the severity of the disease and pain. To resolve this problem, severely ill patients were excluded from the study because they might give unrealistic answers or not answer all questions due to fear of confrontation with the staff. To reduce this limitation, the questioners were trained to assure the confidentiality of patients' information.

Conclusion
The results of the present study indicated a significant relationship between the variables of literacy, average income, length of admission, the final diagnosis of disease, and the level of concern among patients admitted to hospitals, which could help better understand the problems associated with hospitalization experience and introduce effective interventions to control influential factors of the concern. The findings of this study could offer practical suggestions to reduce the patients' concerns while admission to hospitals. That includes training and enhancing the medical team's therapeutic capabilities based on patients' needs, effective communication with patients to support them, reducing stress factors to facilitate the recovery process and improve disability and mortality and reduce treatment and patient costs.