Post-Traumatic Growth, Mindfulness, and Quality of Life in Liver Transplant Recipients: A Cross-Sectional Study

Abstract

Purpose: This study aimed to examine post-traumatic growth, mindfulness, and quality of life in recipients after liver transplantation. Design and Methods: This study employs a descriptive and cross-sectional design. We collected data in an organ transplant center affiliated with a research and application hospital in Eastern Turkey. The sample in our study included a total of 292 liver transplant recipients. We collected data using a personal information form, the Post-Traumatic Growth (PTG) Inventory, the Mindfulness Scale (MS), and the Quality of Life Questionnaire (QoL) Short Form (SF-36). We performed data analysis using descriptive statistical methods and one-way analysis of variance. Results: Of the liver transplant recipients, 72.6% were between 45 and 64 years of age, 72.3% were female, and 56.5% had undergone liver transplantation more than 1 year prior. Liver transplant recipients scored between 64.89 and 97.85 on the negative subscales. Recipients scored between 32.70 and 44.72 on the positive subscales in QoL SF-36. The PTG and MS mean scores were 62.43 ± 20.31 and 62.35 ± 7.14, respectively. There was a positive correlation between positive QoL sub-dimensions and MS and PTG (p < 0.05). Conclusions: We found a positive and strong relationship between PTG and mindfulness; in addition, we found that an increase in both had the effect of improving QoL. We recommend developing strategies that increase PTG, and that mindfulness be performed to improve QoL among patients following liver transplantation.

1. Introduction

Serious physiological and psychological problems are observed in patients with end-stage liver failure due to dysfunction, increased toxicity, and impaired homeostasis. As an effective surgical treatment option for end-stage liver failure, liver transplantation is performed with the goal of higher survival rates and a better quality of life (QoL) [1,2,3]. Transplantation surgery aims to improve the health and life satisfaction of recipients, help them adapt to social life, and ensure they are as healthy as possible [4]. However, liver transplantation is a complex, challenging, and major surgical operation with serious postoperative complications [5,6,7]. Patients may have negative experiences due to possible complications and adverse events after liver transplantation [8]. Studies have reported that negative patient experiences decrease QoL and increase stress [9,10].

Post-traumatic growth (PTG) refers to positive changes resulting from coping with a traumatic event [11]. As a result of coping with difficult and traumatic life crises, a person can experience a spiritual gain and positive life experiences. An individual with PTG may establish more meaningful relationships with others, appreciate life more, become spiritually stronger, and experience spiritual enrichment [11,12]. Individuals with liver transplantation are exposed to several traumas during the perioperative process. Waiting for an organ transplant makes the patient fear death, experience psychological fatigue due to stress, and experience burnout, causing them to lose hope over time. Meanwhile, a traumatized individual may develop suicidal ideation. After a proper organ is found, the patient goes through a difficult transplant process. The recipient may also experience post-transplant problems, including the burden of postoperative care and potential complications. Therefore, liver transplantation causes patients to have a challenging and traumatic experience until it is concluded [13].

Mindfulness refers to the awareness of one’s thoughts, feelings, and bodily sensations [14]. People with mindfulness have high insight and can focus all their attention on themselves [15]. Avoiding and ignoring negative emotions can lead to significant problems. Mindfulness enables individuals to accept difficulties without self-judgment. This acceptance not only reduces the impact of physical pain and stress but also increases resilience against the disease [16]. Studies have reported that increased mindfulness can reduce pain and anxiety and increase sleep quality in individuals with osteosarcoma [17], reduce the severity of depression and anxiety in cancer patients [18], and lower the frequency of attacks in people with major depressive disorders [19].

We consider that elevated mindfulness and PTG will improve QoL in liver transplant recipients. QoL can be defined as one’s satisfaction with living conditions, being satisfied with existing opportunities, and feeling good [20,21]. Liver transplant recipients undoubtedly need to feel good and stay motivated. Thus, they can gain the strength to cope with complications, undesirable events, and a serious care burden after liver transplantation. In this study, we aimed to examine the levels of PTG, mindfulness, and QoL in liver transplant recipients.

2. Materials and Methods

In this study, we investigated the levels of PTG, mindfulness, and QoL in recipients after liver transplantation. The prospective method was used to collect the data for this study. Data collection was carried out between January and June 2022. Patients who had undergone liver transplantation in the hospital where the study was conducted were taken to a private interview room by the researchers during their routine outpatient clinic visits. Liver recipients with informed consent were asked to fill out the questionnaires. It took an average of 15 minutes to fill out the questionnaire for each recipient.

2.1. Study Design and Participants

This is a descriptive and cross-sectional study. This study was conducted in an organ transplant unit of a research and practice hospital in Eastern Turkey. The purposive sampling method was used in the sample selection. We calculated the sample size using the G*Power-3.1.9.2 software, a 0.05 margin of error, and a 95% confidence interval. As a result of power analysis, we determined that n = 140 recipients should be included in the study. All liver transplant recipients who met the inclusion criteria and agreed to participate in the study were allowed to be included in the sample. Thus, the sample of the study consisted of n = 292 liver transplant recipients. The following criteria were used to decide which liver transplant recipients to include and exclude from the study.

2.2. Sampling Inclusion Criteria

• Having had a liver transplant and being over 18 years old;
• Having no communication or language problems;
• Agreeing to participate in the study;
• Not having received training on mindfulness and PTG before.

2.3. Sampling Exclusion Criteria

• Not having had a liver transplant and being under 18 years old;
• Having communication or language problems;
• Not agreeing to participate in the study;
• Having previously received training on mindfulness and PTG.

2.4. Data Collection Method and Tools

We collected data using a personal information form, the Post-Traumatic Growth Inventory, the Mindfulness Scale, and the QoL Questionnaire Short Form-36.

2.5. Personal Information Form

This form included questions about the personal characteristics of liver transplant recipients, such as their gender, age, and marital status, as well as the liver transplantation process.

2.6. Post Traumatic Growth Inventory

The Post-Traumatic Growth Inventory (PTGI) was introduced by Tedeschi and Calhoun (1996) [22]. It is used to report one’s own inner growth after experiencing a negative and traumatic event. This is a 6-point Likert-type scale, consisting of 21 items. The Turkish validity and reliability study of the PTGI was performed by Kagan et al. [23]. The total scale score ranges from 0 to 105. A higher score indicates a higher level of PTG. The PTGI consists of three dimensions: changes in self-perception, changes in philosophy of life, and changes in relationships. In the Turkish version of the PTGI, the internal consistency coefficients for the dimensions of changes in self-perception, changes in relationships, and changes in philosophy of life were reported to be 0.88, 0.77, and 0.78, respectively [24]. In this study, the total internal consistency coefficient of the PTGI was determined as 0.89.

2.7. Quality of Life Questionnaire Short Form-36

The Rand Corporation developed this scale to assess QoL [25]. The Turkish version of the Quality of Life Short Form (SF-36) has been translated, and a study to ascertain its validity and reliability has been conducted. It is a self-assessment scale with a generic criterion feature. It consists of 36 items and eight dimensions. (i) Physical function measures the effects of role limitations due to physical health problems arising from working hours or daily activities; (ii) role limitations due to physical problems measure the limitation of physical activities due to health problems (limitations on daily activities such as carrying things, climbing stairs, and walking); (iii) role limitations due to emotional problems measure the effect of role limitations (such as depression or anxiety in work or daily activities) due to emotional problems; (iv) vitality measures energy and fatigue; (v) mental health measures general mental health in terms of psychological distress and well-being; (vi) social function measures the limitations in social activities due to physical and emotional issues (such as obstacles to visiting friends and relatives); (vii) bodily pain measures how pain affects severity and working power; and (viii) general health includes one’s own understanding of their general health (feelings about own health). The Likert scale is useful in QoL assessment except for some items, considering the last four weeks before measurements. The positive subscales (physical function, vitality, mental health, social functioning, and general health) of the QoL SF-36 questionnaire evaluate related health dimensions on a scale of 0–100, where a higher score indicates a better quality of life. In addition, negative subscales (role limitations due to physical problems, role limitations due to emotional problems, and Bodily pain) in QoL SF-36 evaluates health-related dimensions on a scale of 0–100, where a high score indicates poorer quality of life [25,26].

2.8. Mindfulness Scale

The Mindfulness Scale (MS) was developed by Brown and Ryan (2003) to measure one’s level of mindfulness [27]. This six-point Likert-type scale consists of fifteen items and is evaluated over a single total score. Higher scores indicate greater mindfulness. The internal consistency coefficient and test–retest reliability of the original scale were 0.82 and 0.81, respectively [27]. Ozbeyaz et al. (2011) adapted the scale for use in Turkish populations [28]. The internal consistency coefficient and test–retest reliability of the Turkish scale were 0.80 and 0.86, respectively [28]. In our study, the Cronbach’s alpha coefficient of the scale was found to be 0.89.

2.9. Statistical Analysis

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) 25.0 IBM. The Kolmogorov–Smirnov test was used to check whether the data had a normal distribution. The data were evaluated using descriptive methods (frequency, percentage, mean, and standard deviation) and one-way analysis of variance (one-way ANOVA). Complementary post hoc analysis was used to explore differences between means. Pearson correlation analysis was used to analyze the relationship between the scale scores. The results were evaluated at a 95% confidence interval and p < 0.05 significance level.

2.10. Ethical Considerations

The Institutional Review Board of the Organ Transplant Hospital of Turgut Ozal Research and Application Hospital approved this study. Later, approval was obtained from the Ethics Committee of Selcuk University Faculty of Medicine (Number: 70632468-050.01.04, Date 23 January 2022). Informed consent was obtained from patients who underwent liver transplantation in accordance with the principles of the Declaration of Helsinki. Patients who agreed to participate in this study were included after obtaining their informed consent.

2.11. Results

Table 1. Personal characteristics of liver transplant recipients (n = 292).

Age	n	%
30–44 years	68	23.3
45–64 years	212	72.6
65 years and above	12	4.1
Sex
Female	81	27.7
Male	211	72.3
Marital Status
Single	83	28.4
Married	209	71.6
Education
Literate	32	11.0
Primary education	70	24.0
High school	89	30.5
Associate degree	65	22.3
Bachelor’s degree	36	12.3
Type of Donor
Living donor	271	92.8
Cadaver Donor	21	7.2
Employment Status
Civil servants	80	27.4
Employee	44	15.1
Self-employed	75	25.7
Housewife	43	14.7
Retired	36	12.3
Unemployed	14	4.8
Income Status
Income less than expenses	94	32.2
Income equals expenses	133	45.5
Income more than expenses	65	22.3
Transplant Time
Less than 6 months	32	11
6 months to 1 year	95	32.5
More than 1 year	165	56.5

shows the personal characteristics of liver transplant recipients. Of liver transplant recipients, 72.6% were between the ages of 45 and 64 years, 23.3% were between the ages of 30 and 44 years, 72.3% were women, 71.6% were married, 30.5% were high school graduates, 92.8% received a liver transplant from a living donor, 27.4% were civil servants, and 45.5% had an income equal to their expenditures. When the recipients’ liver transplantation time was examined, 11% had liver transplantation less than 6 months ago, 32.5% between 6 months and 1 year ago, and 56.5% had liver transplantation more than 1 year ago.

Table 2. Liver transplant recipients’ SF-36, PTGI, and MS mean scores (n = 292).

Total and Subscales	Number of Items	Items	Score Range	Min.–Max.	Mean ± Sd
QoL SF-36	36	1–36	-	-	-
Physical function	10	3–12	0–100	25–66	44.72 ± 4.02
Role limitations due to physical problems	4	13–16	0–100	32–100	97.85 ± 9.16
Role limitations due to emotional problems	3	17–19	0–100	23–84	70.54 ± 6.95
Vitality	4	23, 27, 29, 31	0–100	20–84	32.70 ± 13.2
Mental health	5	24–26, 28, 30	0–100	4–65	43.6 ± 12.4
Social function	2	20, 32	0–100	4–84	42.76 ± 5.69
Bodily pain	2	21, 22	0–100	15–89	64.89 ± 5.14
General health	6	1, 33–36	0–100	11–45	38.42 ± 6.05
PTGI	21	1–21	0–105	6–105	62.43 ± 20.31
Changes in self-perception	10	5, 10–13, 15–19	0–50	0–50	32.48 ± 10.6
Changes in the philosophy of life	6	1–4 7, 14	0–30	1–30	17.98 ± 6.04
Changes in relationships	5	6, 8, 9, 20, 21	0–25	0–24	11.95 ± 6.45
MS	15	1–15	15–90	39–81	62.35 ± 7.14

shows the QoL SF-36, PTGI, and MS scores of liver transplant recipients. The scores of liver recipients from QoL SF-36 sub-dimensions were role limitations due to physical problems, 97.85 ± 9.16; bodily pain, 64.89 ± 5.14; and role limitations due to emotional problems, 70.54 ± 6.95. Also, the scores of QoL SF-36 from other sub-dimensions were physical function, 44.72 ± 4.02; vitality, 32.70 ± 13.2; mental health, 43.6 ± 12.4; social function, 42.76 ± 5.69; and general health, 38.42 ± 6.05. The PTGI and MS mean scores of liver transplant recipients were 62.43 ± 20.31 and 62.35 ± 7.14, respectively.

Table 3. Liver transplant recipients’ QoL SF-36, PTGI, and MS mean scores by age groups (n = 292).

Total and Subscales	Age Groups (Mean ± Sd)			Test and Sig.
	30–44 Years (1)	45–64 Years (2)	65 Years and Above (3)
QoL SF-36	-	-	-	-
Physical function	46.19 ± 4.12	39.01 ± 4.01	36.24 ± 3.99	F = 0.910 p < 0.001 **
Post hoc				1 > 2,3
Role limitations due to physical problems	68.45 ± 15.12	90.34 ± 12.24	99.01 ± 6.3	F = 2.104 p < 0.001 **
Post hoc				3 > 2 > 1
Role limitations due to emotional problems	78.65 ± 6.99	67.56 ± 7.14	61.05 ± 5.5	F = 0.878 p = 0.047 *
Post hoc				1 > 2 > 3
Vitality	36.69 ± 11.16	33.25 ± 9.63	27.61 ± 11.28	F = 1.566 p = 0.124
Post hoc				1 > 2 > 3
Mental health	39.64 ± 12.1	44.18 ± 9.78	42.26 ± 11.16	F = 1.749 p = 0.176
Social function	46.69 ± 6.1	41.74 ± 4.78	38.54 ± 5.46	F = 0.919 p = 0.029 *
Post hoc				1 > 2,3
Bodily pain	61.63 ± 3.45	65.86 ± 3.58	66.3 ± 3.51	F = 0.636 p = 0.012 *
Post hoc				3 > 1,2
General health	29.18 ± 5.63	34.16 ± 5.84	24.29 ± 4.26	F = 1.866 p = 0.036 *
Post hoc				3 < 1 < 2
PTGI	56.02 ± 22.67	64.12 ± 19.31	68.91 ± 16.4	F = 4.849 p = 0.008 **
Post hoc				1 < 2 < 3
Changes in self-perception	29.61 ± 11.66	33.27 ± 10.17	34.91 ± 9.53	F = 3.446 p = 0.412
Changes in philosophy of life	15.6 ± 6.2	18.75 ± 5.9	18.08 ± 3.96	F = 1.105 p < 0.001 **
Post hoc				1 < 2,3
Changes in relationships	10.8 ± 6.72	12.09 ± 6.36	15.91 ± 5.01	F = 3.442 p = 0.033 *
Post hoc				1 < 2 < 3
MS	62.36 ± 7.14	62.16 ± 7.2	64.75 ± 7.62	F = 3.263 p = 0.616

F = ANOVA, one-way analysis of variance, ** p < 0.01, * p < 0.05.

shows the mean scores for the SF-36, PTGI, and MS according to the age group of the liver transplant recipients. We found that the variable of age caused statistically significant differences in the scale scores of liver transplant recipients. Liver transplant recipients aged between 30 and 44 years scored higher on the SF-36 sub-dimensions of physical function, vitality, and social function compared to other age groups (p < 0.05). Liver transplant recipients aged between 30 and 44 years had lower role limitations due to physical problems and higher role limitations due to emotional problems (p < 0.05). Those aged 65 years and older felt more bodily pain (p < 0.05) and had higher PTGI scores than other age groups.

Table 4. Correlation analysis for liver transplant recipients’ MS, PTGI, and QoL SF-36 sub-dimensions scores (n = 292).

		MS	PTGI	PF	RP	RE	VT	MH	SF	BP	GH
MS	Pearson Correlation	1	0.028	0.684	−0.029	−0.022	−0.076	0.470	0.084	−0.013	0.021
	Sig. (2-tailed)		0.004 **	0.024 *	0.007 **	0.711	0.193	0.042 *	0.152	0.031 *	0.718
	N	292	292	292	292	292	292	292	292	292	292
PTGI	Pearson Correlation	0.028	1	0.085	−0.020	−0.964	0.015	−0.086	−0.033	−0.006	0.025
	Sig. (2-tailed)	0.004 **		0.145	0.740	0.002 **	0.796	0.145	0.575	0.918	0.673
	N	292	292	292	292	292	292	292	292	292	292

PF; physical function, RP; role limitations due to physical problems, RE; role limitations due to emotional problems, * p < 0.05, ** p < 0.01. VT; vitality, MH; mental health, SF; social function, BP; bodily pain, GH; general health.

shows the results of the correlation analysis of the MS, PTGI, and SF-36 sub-dimension scores of liver transplant recipients. There was a negative, weak, and statistically significant correlation between the negative subscales of QoL SF-36 [role limitations due to physical problems (r = −0.029, p = 0.007) and bodily pain (r = −0.013, p = 0.031)] and MS. There was a positive, moderate, and statistically significant correlation between the positive subscales of QoL SF-36 (physical function (r = 0.684, p = 0.024) and mental health (r = 0.470, p = 0.042) and MS. There was a positive, weak, and statistically significant correlation between PTGI and MS (r = 0.028, p = 0.004). There was a strong negative and statistically significant correlation between the negative subscale of QoL SF-36, role limitations due to emotional problems, and PTGI (r = −0.964, p = 0.002).

3. Discussion

In this study, we reported that liver transplant recipients’ quality of life was suboptimal, while post-traumatic growth and mindfulness levels were slightly above average. The results obtained in this study were based on the fact that PTG positively increased mindfulness and QoL. The concept of PTG has been in the literature for over 30 years, and remains highly relevant today. It is often inevitable that liver transplant recipients who undergo a complicated process have a variety of positive and negative feelings. Negative emotions can drive treatment and care away from compliance, while positive emotions can increase the motivation of patients to cope with their health condition. PTG can have a positive effect on the mood and sense of power of liver transplant recipients. Studies have found a statistically significant increase in PTG among post-transplant patients [29,30,31,32]. The results of this study support previous studies.

Mindfulness is an important value that affects motivation and improves treatment compliance in liver transplant recipients [33,34]. In addition, several studies have examined the effects of mindfulness on patients who have undergone organ transplantation [35,36]. As recipients perceive liver transplant surgery as the beginning of a new life, this increases their mindfulness and compliance with possible changes in the postoperative period [29]. After liver transplantation, fear of graft rejection, exposure to social isolation due to a suppressed immune system, problems caused by immunosuppressive drugs, poor mental health, pain, and anxiety are important problems in recipients, reducing their QoL [37,38,39]. In this study, liver transplant recipients with higher mindfulness had better QoL. Our study is the first study to examine PTG, mindfulness, and QoL comparatively in post-liver transplant recipients and is a rich source of information in this respect.

Liver transplant recipients are subject to several traumas. A chronic liver disease resulting in transplantation surgery and increased burden of care after liver transplantation causes patients to have several traumas. Post-traumatic growth may occur in this challenging perioperative process, and patients may gain consciousness and awareness [8]. In our study, we observed that liver transplant recipients experienced significant role limitations due to physical problems, along with moderate bodily pain and emotional role limitations. Consequently, the participants perceived their general health status as poor. In a study conducted with liver transplant recipients, it was reported that psychological well-being was worse in those with poor general health and that their general health was mostly poor [40]. Several previous studies have advocated that PTG improves recovery after liver transplantation [29,30,41].

A previous study of QoL after liver transplantation found that liver transplant recipients over 40 years of age had worse physical performance than others, and those under 30 years of age had a greater sense of physical limitation than others. The study also found a correlation between advanced age and bodily pain [4]. In our study, we noted that those aged between 30 and 44 years had the highest physical performance and the lowest bodily pain, and that physical performance decreased and perceived bodily pain increased with advancing age. In our study, it was found that recipients between the ages of 30 and 44 had poorer PTG and mental health compared to other age groups. This indicates that recipients in the 30–44 age group need more psychosocial support.

Mindfulness-based training improved the quality of life related to stress, resilience, depression, anxiety, and health in transplant patients, as reported in the literature [42]. Additionally, mindfulness-based training was found to increase medication compliance following liver transplantation [33,34]. Liver transplant recipients scored between 64.89 and 97.85 (score range, 0–100) on the negative subscales (role limitations due to physical problems, role limitations due to emotional problems, and Bodily pain). Recipients scored between 32.70 and 44.72 on the positive subscales (physical function, vitality, mental health, social function, and general health) in SF-36. The results of this study revealed the need to develop strategies to improve the quality of life of liver transplant recipients.

Mindfulness enables people to observe themselves and gain inner insight. This may be the first step of psychosocial healing and increasing mental resilience. Increased mindfulness can change one’s self-perception, enabling them to find meaning in life. In this way, they experience PTG. One of the obstacles preventing healthcare professionals from cooperating with liver patients after transplantation is the negative emotions in those patients. If liver transplant recipients can cope with negative emotions thanks to mindfulness and PTG, their quality of life improves. This is a single-centered study, which is considered a study limitation.

4. Conclusions

This study examined the quality of life, mindfulness, and post-traumatic growth levels of liver transplant recipients. The majority of liver transplant recipients in the study were women, and aged between 45 and 64. More than half of the recipients had received their liver transplant more than a year ago. Liver transplant recipients scored above the midrange and very close to the top of the QoL SF-36 (between 64.89 and 97.85) on the negative subscales (role limitations due to physical problems, role limitations due to emotional problems, and Bodily pain). Recipients scored below the midrange (between 32.70 and 44.72) on the positive subscales (physical function, vitality, mental health, social function, and general health) of the QoL SF-36. There was a negative relationship between the negative sub-dimensions of quality of life, role limitations due to physical problems and Bodily pain, and mindfulness. We found a positive relationship between physical function and mental health, the positive sub-dimension of quality of life, and mindfulness. Furthermore, an increase in mindfulness was found to be associated with an increase in post-traumatic growth. As post-traumatic growth increased, the positive sub-dimensions of quality of life, physical function, and mental health also increased. There is a limited number of studies that examined the levels of post-traumatic growth, mindfulness, and quality of life separately in recipients after liver transplantation. The results of this study show the positive effect of post-traumatic growth and mindfulness on quality of life.