International Urology and Nephrology (2005) 37:595–602 Ó Springer 2005

DOI 10.1007/s11255-005-0397-8

Quality of life in Turkish haemodialysis patients

Arzu Acaray1 & Rukiye Pinar2

1
Mihaliccik Government Hospital, Eskisehir; 2Marmara University College of Nursing, Istanbul, Turkey

Abstract. The aim of the study was to assess quality of life (QOL) in Turkish haemodialysis patients and to
identify related socio-demographic and clinical variables. To measure QOL 100 patients completed SF-36
during regularly scheduled haemodialysis. We found that patients’ QOL was substantially impaired. Age
was negatively related to physical components of QOL. Duration of haemodialysis was negatively corre-
lated with most of QOL dimensions. EPO treatment, education on disease and haemodialysis, and com-
pliance to prescribed diet had great positive effects on QOL. Among the factors we have found to be related
with the QOL in this study, probably the most important were education on disease and haemodialysis, and
compliance to prescribed diet, in which we have influence, as nurses, on improving the QOL in patients
receiving haemodialysis. The priority of renal nursing services should therefore be addressed to provide
support in these areas.

Key words: Haemodialysis, Quality of life

Introduction Literature review

According to World Health Organization (1948),
health is defined as ‘‘a state of complete physical,
psychological and social well-being and not merely
the absence of disease or infirmity’’. This defini-
tion of health has influenced the criteria for
evaluating many medical and nursing interven-
tions [1].
Chronic haemodialysis (HD) is a very effective
medical technology, and the ability of such
technology to sustain lives is of unquestioned
significance. However, considerable doubt con-
cerning the objective success of dialysis was
raised when it was demonstrated in the USA that
only 25% of hospital dialysis patients were
capable of doing little more than caring for
themselves [2].
It is now widely accepted that, goals of dialysis
therapy are not only to improve survival, but also
to improve quality of life (QOL), [3–7]. Investi-
gation of patient QOL may provide useful infor-
mation to set up standards for process of medical
and nursing care [5].
End Stage Renal Disease (ESRD) is a rather
common health problem in our country. Accord-
ing to the year 2000 data of the Turkish
Nephrology Association (TNA), the incidence of
ESRD as for Turkish population is 118.5 per
million, with a total of 19015 ESRD patients. HD
is the most preferred method for ESRD [8].
According to TNA’s year 2000 report, 6594 new
patients began undergoing HD therapy in Turkey
in 2000 [8]. As stated in the year 2001 report of the
Ministry of Health, the total number of patients
under HD therapy program is 12196 [9].
Patients having regular HD therapy have to
deal with the symptoms, have to follow special diet
schedules, have to adapt to the changes in their
whole lives and in their body images, have to be
prepared for indefinite progress of the disease, and
have to reconsider their personal, social and pro-
fessional objectives. Therefore, HD has negative
influences on patient’s QOL and social, economi-
cal, psychological dimensions of life. In other
words, HD affects patient’s whole life [6, 10, 11].
596
The aim of the present study was to learn about
QOL in patients receiving HD treatment in Turkey
and to evaluate the impact of demographic and
clinical variables on QOL.
Methods
Sample
This study recruited from three hospitals in Bursa,
Turkey between August 2002 and December 2002.
The sample of the research was chosen among
patients who met the eligibility criteria specified as
(1) aged above 18; (2) able to read and write
Turkish; (3) diagnosed as End Stage Renal Dis-
ease; (4) being at least 6 months under the HD
treatment programme; (5) not having any psychi-
atric conditions; and (6) being conscious and
cooperative. Of the 150 patients that met eligibility
criteria, 50 patients refused to participate due to
fatigue, time limitations, and such factors, and 100
patients were included in the study. Thus 66.7% of
eligible patients were included to the study. Before
the initiation of the study, ethical approvals of the
Hospital’ Ethical Review Board and informed
consent from all patients were obtained.
Instruments
The data on demographic and clinical character-
istics of the patients were gathered by using a
descriptive form. Demographic variables studied
were gender, age, education, marital status,
employment status, and income. Clinical charac-
teristics comprised primary renal disease, duration
of HD, structured education on the disease and
HD, compliance to prescribed diet and medica-
tion, and use of erythropoietin.
The Medical Outcomes Study-36 Item Short
Form Health Survey (SF-36) was used to evaluate
QOL. The SF-36, which was developed by Ware
and colleagues, assesses eight health concepts:
physical functioning (PF), role limitations due to
physical problems (RP), social functioning (SF),
role limitations due to emotional problems (RE),
mental health (MH), vitality (VT), bodily pain
(BP) and general health perception (GH). Nor-
malized scores representing overall physical func-
tioning and mental functioning are calculated
from the individual scales and are presented as the
physical component scale (PCS) and mental com-
ponent scale (MCS). The PCS includes the
dimensions of PF, RP, BP, GH and VT. The MCS
is composed of the SF, RE, MH, GH and VT. The
scales VT and GH are parts of both dimensions.
All raw scale scores are linearly converted to a 0
(worst possible health status or QOL) to 100 (best
possible health status or QOL). The score of the
subgroups as well as the final global score of the
SF-36 changes between 0 and 100, respectively
[12]. Different language versions of the SF-36
including Turkish are available. Pinar has done
SF-36’s validation into the Turkish HD patients
(1995). In her study test–retest correlation was 0.94
and cronbach alpha value was 0.92 [13]. In the
present study Chronbach’s alpha coefficients for
the eight subscales of the SF-36 ranged from 0.88
to 0.95 (PF ¼ 0.94, RP ¼ 0.95, SF ¼ 0.93,
RE ¼ 0.94, MH ¼ 0.91, VT ¼ 0.93, BP ¼ 0.88,
GH ¼ 0.89), supporting the internal consistency of
the subscales. Patients were given a brief expla-
nation of the SF-36 and were asked to complete it
during regular scheduled HD therapy.
Statistical analysis
All data analyses were run on SPSS, Version 10.0.
Descriptive statistics and summary statistics,
including means, ranges, SDs, and frequencies
were used to summary patients’ demographics,
clinical characteristics, and QOL scores. The sta-
tistical significance for differences between groups
was tested with t-test and one-way ANOVA test,
or, when appropriates, their non-parametric
equivalents. To study the correlations between
SF-36 scores and continuous variables Pearson’s
Product Moment Correlation was used. Signifi-
cance in all statistical analysis were defined to be
P < 0.05.
Results
Table 1 lists demographic and clinical variables of
the patients. The majority of the patients were
males (61%) and married (47%) with a mean age
of 41 years. Fifty percent of them were secondary
or high school graduates and most of them (78%)
were unemployed. Primary disease causes of 39%
of the subjects were unknown. Among the known
causes, glomerulonephritis took the first place with
 597

Table 1. Demographic and clinical variables of the patients

Gender (%) Female/male 39/61

Age (mean ± SD) (range) 41.1 ± 13.7 (range = 18–72)
Education (%) No formal education 6
Primary school 32
Secondary/high school 50
University 12
Marital status (%) Married 47
Single 31
Widowed/divorced 22
Employment status(%) Full-time employed 3
Part-time employed 19
Unemployed 78
Income (%) Poor/good 45/55
Primary kidney disease (%) Unknown 39
Glomerulonephritis 22
Chronic pyelonephritis 8
Diabetes mellitus 16
Hypertension 6
Acute kidney failure 4
Cystic kidney 5
Duration of HD (mean months ± SD) (range) 57.7 ± 47.8 (range = 6–180)
Being educated on the disease and HD (%) Yes/no 48/52
Compliance to prescribed diet (%) Yes/no 47/53
Compliance to prescribed medication (%) Yes/no 86/14
Erythropoietin (%) Yes/no 58/42

a rate of 22%. The mean duration of HD was
57.7 months. It was defined that 52% of the
patients did not receive any education on the
disease and HD, and that 53% of them were not
following the prescribed diet, while 86% of the
subjects were defined to regularly follow pre-
scribed medication. Fifty-eight percent received
EPO treatment.
The mean SF-36 scores are shown in Table 2.
As shown in the table, the least score defined by
the patients among domains of QOL refers to VT,
while the highest score refers to SF.
Our study showed that gender was not influen-
tial on QOL. It is noted that PF (P < 0.01), GH
(P < 0.05) and PCS (P < 0.05) significantly de-
creased as ages increased, while there was no sta-
tistically significant correlation between age and
sub scores in MH, and MCS. Most of QOL
domains in the SF-36 and PCS, MCS and overall
QOL increased as educational status increased.
This increasing was significant in PF (P < 0.05).
Among eight scales of the SF-36, PF (P < 0.05), BP
(P < 0.05) and overall QOL score (P < 0.05) was
significantly higher in single patients when com-
pared with that of married and the widowed or
divorced patients. Patients with better incomes had
slightly higher scores in overall QOL than patients
with poor incomes (P < 0.05) (Table 3).
We defined in our study that as the duration of
HD therapy increased, scores of most SF-36

Table 2. SF)36 scores (mean ± SD) for the sample

PF RP BP GH VT

60.0 ± 24.0 47.0 ± 32.0 52.5 ± 27.0 39.5 ± 20.5 34.0 ± 15.0
SF RE MH PCS MCS Overall QOL

62.0 ± 26.0 53.0 ± 32.0 52.0 ± 20.0 46.6 ± 18.1 48.0 ± 16.2 47.3 ± 16.3
 598
Table 3. Effects of demographic variables of the patients on SF-36 scores

PF RP BP GH VT SF RE MH PCS MCS Overall

QOL

Gender
Female 57.3±23.2 47.4±33.8 57.2±27.7 43.3±22.5 35.0±15.4 67.8±27.8 55.6±33.6 50.1±21.8 47.1±18.7 49.4±16.4 49.3±16.1
Male 62.4±25.1 46.7±31.8 49.1±25.3 37.2±20.2 33.1±15.2 57.9±24.3 51.4±31.3 52.6±18.6 46.3±17.9 47.0±16.1 45.6±15.3
t 1.01 0.10 01.5 1.41 0.60 1.87 0.63 0.59 0.21 0.71 1.01
Age
r )0.28** )0.13 )0.08 )0.18* )0.10 )0.10 )0.13 0.09 -0.24* )0.15 )0.19
Educational
status
No formal 40.0±17.3 20.8±24.6 53.7±28.5 25.8±14.3 53.7±28.5 44.4±14.0 38.9±44.3 54.0±20.5 33.2±17.3 37.8±13.0 36.0±13.3
education
Primary school 55.0±26.3 43.0±33.1 47.9±25.0 37.5±20.0 47.9±25.0 60.4±25.9 49.0±32.8 50.0±20.6 42.9±18.7 45.6±16.8 44.4±15.6
Secondary school 64.6±23.2 50.0±31.5 55.8±26.4 40.4±20.7 55.8±26.4 65.6±26.5 53.3±30.9 51.1±19.1 49.9±18.7 49.2±15.8 48.4±14.8
University 67.5±20.6 58.3±32.6 49.1±30.5 48.7±26.9 49.1±30.5 58.3±27.3 69.4±26.4 57.0±21.9 52.1±16.7 54.1±16.2 53.5±18.3
Chi-square 8.73* 6.08 2.33 3.69 3.86 3.75 4.65 0.87 7.37 3.99 4.80
Marital status
Married 56.9±24.4 43.6±30.6 53.9±25.1 37.1±21.0 33.0±16.1 61.9±27.5 55.3±32.1 53.1±20.0 45.3±16.4 48.5±15.4 46.1±15.1
Single 69.8±23.7 51.1±34.0 59.5±27.4 48.1±21.2 35.5±14.9 65.6±26.7 53.8±31.8 52.9±20.4 51.9±19.1 50.6±15.5 52.3±14.9
Widowed/divorced 54.5±22.6 49.2±34.4 38.9±23.9 32.9±18.7 33.4±14.3 56.1±21.5 47.0±33.6 46.7±18.7 42.0±19.4 43.0±18.3 41.6±16.2
Chi-square 7.84* 1.19 7.73* 2.63 4.17 1.57 1.00 1.96 4.50 4.06 3.03*
Employment
status
Employed 65.7±26.4 51.1±34.9 46.0±27.9 39.1±21.8 33.4±13.9 56.6±26.1 59.1±27.8 33.4±13.9 55.8±20.6 49.6±16.3 47.4±16.1
Unemployed 58.9±23.8 45.8±31.8 54.1±25.9 39.7±21.2 34.0±15.7 63.3±26.0 51.3±33.4 34.0±15.7 50.5±19.6 47.5±16.2 46.9±15.7
z 1.20 0.68 1.63 0.26 1.16 0.92 0.97 1.17 0.61 0.61 0.01
Income
Good 58.7±24.7 45.0±32.7 51.1±26.8 41.7±19.7 33.8±15.3 66.7±23.3 51.8±31.4 54.3±20.2 45.8±18.3 49.5±16.2 47.9±16.1
Poor 61.8±24.3 48.6±32.4 53.3±26.3 37.9±22.2 33.9±15.3 57.8±27.6 53.9±33.0 49.4±19.4 47.3±18.1 46.8±15.9 46.3±15.4
t 0.64 0.56 0.42 0.88 0.04 1.72 0.32 1.22 0.40 0.81 1.38*

*P < 0.05;**P < 0.01.

 599

domains (PF, BP, GH, VT), PCS, MCS and overall

52.4±14.51
52.7± 15.2
41.8± 14.3

35.9± 14.8
42.2±15.2

48.8±15.1

52.0±14.7
40.1±14.3
QOL significantly decreased. Participants who were

)0.33**

3.70***

4.02***
Overall
educated on the disease and HD produced signifi-

3.42**

2.97**
QOL
cantly higher scores in all domains of SF-36, except
RP, BP and MH than patients who were not

53.5±15.5
53.4±15.8
42.9±14.9

43.1±15.3

49.7±15.6
37.0±15.9

52.0±15.6
42.4±14.9
educated. Compliance to prescribed diet was a

)0.23*

3.42**

3.38**

3.06**
2.47*
MCS
significant predictor of improved QOL in terms of
GH (P < 0.01), VT (P < 0.01), SF (P < 0.05), RE

50.2±18.6
51.1±18.8
42.5±16.7

43.4±17.3

47.8±18.0
39.7±18.5

52.2±17.5
38.9±16.2
(P < 0.01), MCS (P < 0.01), and overall QOL

)0.31**

3.88***
(P < 0.01). Patients who followed the prescribed

2.41*
PCS

1.90

1.26
medication yielded higher scores in all QOL
domains, except VT, which creates statistically

53.5±19.4
53.2±19.3
50.1±20.3

50.0±20.2

52.6±20.3
28.2±13.4

52.5±20.8
50.5±18.6
significant differences in GH (P < 0.01), SF

)0.06
(P < 0.05), MCS (P < 0.05) and overall QOL

MH

0.78

0.90

1.32

0.50
scores (P < 0.01). We found that all QOL domains,

55.43±31.4
except RP, RE and MH, of the patients receiving

62.4±30.0
60.4±30.5
46.1±32.4

44.6±32.0

45.4±16.2

55.7±31.5
49.2±33.1
erythropoietin (EPO) treatment were statistically

2.85**
)0.13

2.26*

1.88

1.00
higher than those who did not (Table 4).
RE

68.8±24.8
69.2±25.3
54.9±24.9

55.6±25.7

63.8±25.2
49.2±34.6

67.2±25.2
54.2±25.4
2.84**
)0.15

2.61*

1.96*

2.53*
Discussion
SF

38.1±15.0
39.0±14.4
29.1±14.6

30.1±14.6

34.8±15.4
41.3±18.7

37.0±16.1
29.6±13.0
QOL scores
)0.28**

3.39**

2.70**

2.40*
1.37
In our study, the SF-36 scores of the patients were
VT

defined to be low. Findings of various researches

47.1±18.9
47.4±19.8
32.4±20.1

32.9±21.1

42.6±20.4
37.5±27.3

46.6±20.2
29.9±18.7
studying the QOL of ESRD and HD patients [4, 7,
)0.29**

3.75***

4.21***
3.53**

2.74**
14–16] also reflect that the QOL ranged from
GH

medium to low, which are in accordance with the

57.0±28.8
56.5±30.7
48.5±21.3

48.2±23.7

54.1±27.1
21.4±17.4

57.1±28.0
45.8±28.0
findings of our study.
)0.33**

2.15*
Table 4. Effects of clinical variables of the patients on SF)36 scores

1.52

1.67

1.71

Effects of demographical variables on the QOL

BP

47.3±34.3
49.0±33.8
45.2±31.3

46.7±31.0

46.8±32.3
38.1±34.2

51.3±32.9
41.1±31.1

In our study, the SF-36 scores did not significantly

)0.06

vary between the sexes. This finding is in accor-

0.58

0.10

0.20

1.57
RP

dance with some studies [15–19], while negated by

55.65±25.1

others [7, 20–24]. In studies, which support that

64.1±23.8
65.6±22.8

57.1±24.7

61.0±24.6
56.4±23.5

68.2±21.9
49.6±23.8
)0.32**

the QOL of the individuals varied according to the

4.03***
2.09*

sex, physical dimension of QOL is stated to be

1.45

0.66
PF

higher in males [7, 20, 23]. In two studies investi-

*P < 0.05; **P < 0.01; ***P < 0.001.
Compliance to prescribed diet Yes
Yes

Yes

Yes
No

No

No

No

gators found the impact of female sex on physical

z
r

function to be roughly equivalent to the effect of

having diabetes mellitus [23, 25]. The reason for
Compliance to prescribed

this gender difference in different studies remains

Being educated on the

speculative. Possible explanations could include

Duration of HD

biological factors or cultural conditioning, biases

disease and HD

Erythropoietin

in the provision of care according to sex [26], or

medication

the effect of differences in clinician’s attitude to-

ward female patients [27]. This is an area that is
poorly understood and one that needs additional
study.
600
Our study revealed that there was a negatively
significant relation between age and PF (P < 0.01),
GH (P < 0.05) and PCS (P < 0.05). Some studies
reflected a negative relation between age and QOL
[5, 7, 14, 18, 21–23, 28], while other studies set that
there was no such relation (15, 16, 19). Some of the
studies that support a negative relation between
age and QOL define that physical QOL worsened
with the increasing age, which is parallel to our
findings [5, 7, 14, 21–23, 28]. In our study SF, RE,
MH, and MCS in the SF-36 were not significantly
correlated with age. One possibility was that, with
increasing age dialysis patients adjust better to
their illness and treatment. Other possibility was
that, dissociation between physical states and
perceived health-related QOL, which has previ-
ously been observed [14, 29].
According to the results of our study, the PF,
RP, GH, RE, PCS, MCS and overall QOL scores
increased as the educational status of the subjects
increased, although slightly significant difference
was just defined between education and PF
(P < 0.05). This expected finding, in our study, is
supported by many studies [17, 18, 20, 23, 24, 28).
It is commonly accepted that higher levels of
education would positively affect and promote
health behaviours, and that individuals would
volunteer to shoulder the responsibilities of their
own health and thus would learn and employ the
strategies to cope with the sickness and its symp-
toms, leading to an enhanced QOL [21, 23, 30].
Single participants of the study, when com-
pared to the married and widowed or divorced
participants, were seen to have higher scores in all
SF-36 sub domains, except RE and MH, produc-
ing statistically significant differences in PF, BP
and overall QOL. In different studies [4, 15, 17, 19,
24], none of the SF-36 scores differed between
married and unmarried patients. Our result may
be associated with several factors: First, the fact
that the single participants were younger might
have played a role in the result. The relation be-
tween age and the QOL, as defined in our study, is
also supported by the literature [5, 7, 14, 18, 21, 23,
28]. Second, that the single participants had no
children or families to take care may have lead to
decreased levels of psychosocial burdens. Finally,
that their families shouldered the economical
responsibilities of single individuals might also
have prevented their QOL from further influences
that are experienced by others [5].
Employers are usually reluctant to hire workers
with dialysis who have to take regular leave for
medical follow-up [31]. Patients are forced to
either take lower paid jobs or lose their jobs after
going on dialysis [32, 33]. It was shown that
employment status changed dramatically with the
onset of renal replacement therapy. While only
the 24.8% of all patients were not working before
the onset of dialysis, 57.5% of these patients were
not working during their time on dialysis [34]. In a
study in Hong Kong dialysis patients, it was re-
ported that 84% of the haemodialysis patients had
no job [24]. In Turkey, many facilities offer dialysis
treatments during the daytime only, making it
difficult for haemodialysis patients to maintain a
normal working life. As seen in Table 1, 78% of
the participants, in the present study, were unem-
ployed, and 55% of them explained their income
as poor. Overall QOL of the participants with
good incomes is significantly higher than those
with poor incomes. In related studies, significant
relations between the rate of income and the QOL
are defined [4, 16, 23, 31], specifying higher QOL
scores of the individuals with higher monthly in-
comes than those with lower incomes [16, 24].
Effects of clinical variables on the QOL
By univariate analysis, we found that number of
months on haemodialysis had a significant inverse
relationship with the changes in PF, BP, GH, VT,
PCS, MCS and overall QOL scores. This result is
parallel to the results of the study by Mittal et al.
[22]. In another study [4], a statistically significant
decline in the physical QOL overtime was observed
although no overall significant decline in the
mental QOL over time could be demonstrated. In
the present study, time effect was observed in the
MCS, but an inspection of the composing scales
revealed no significant time effect in the SF, RE
and MH scales. Similar to Merkus et al.’s study
[4], there was no relation between duration on
haemodialysis and MCS, except GH and VT in the
present study. It may be that with chronic disease,
the impact on aspects of self-assessed mental
health may become blunted with timely as a useful
psychological adaptation.
Information provision plays an important role
in the enhancement of QOL for dialysis patients.
The QOL scores of the participants who were
educated on the ESRD and HD were higher than

those who were not educated, displaying statisti-
cally significant differences in all domains of SF-
36, except RP, BP and MH. Studies conducted in
our country; researching the effects of education
on the QOL of HD patients, state that the edu-
cation given was not influential on the QOL of the
patients (35, 36). In these studies, evaluation was
carried out in 2 weeks [35] and 4 weeks [36] after
education. Considering the fact that cognitive
functions of HD patients are reduced due to the
medical condition, we are in the opinion that
individuals would not be able to gain behavioural
changes in such a short period and that education
should be assessed in longer terms. The purpose of
an educational activity, as well known, is to have
individuals obtain desired behavioural changes,
and a minimum of 6 months is required for such
purposes. We believe that prospective studies using
mentioned criteria would provide better under-
standing on the subject, that being educated would
help individuals prevent symptoms resulting from
the sickness or dialysis and enable them to cope
with the symptoms more effectively, and that they
may better adapt to their medical conditions, and
may better adhere to their scheduled diet and
medications thus enhancing the QOL.
Our study showed that following the prescribed
diet was influential on the QOL. A scan of the
literature revealed a limited number of related
studies. Tasci in her study defines that following
the prescribed diets was not influential on QOL
scores. We derived from the results of our study
that the metabolic control of the patients following
the prescribed diets would be controlled easier, less
frequency of sickness/dialysis complications re-
lated with overweight would be experienced, and
therefore, QOL would be better in these patients.
We believe that adaptation to the medication
leads to a less perception of the distress of the
symptoms, positively affecting the QOL perceived
by the patients. In this study, following the pre-
scribed medication was defined to significantly
affect GH, SF, MCS and overall QOL. Another
study in Turkey has also demonstrated a rela-
tionship between adherence to the treatment
protocol and better QOL [19].
It has recently become clear that the use of
recombinant human erytropoietin to treat anae-
mia associated with chronic renal disease signifi-
cantly improves QOL [3, 19, 37–39]. A study
conducted by the Canadian EPO group (1990) also
601
shows that the EPO treatment, compared to
placebo, significantly affected physical symptoms,
fatigue, relationships, depression, and physical and
overall QOL scores as in Karnofsky Index and
Sickness Impact Profile (SIP) [40]. The results of
the study by Tasci reveal that the well-being
dimension of QOL of the patients undergoing
EPO therapy was significantly higher [19].
We found that all QOL domain scores in the
SF-36, except RP, RE and MH, of the participants
receiving EPO treatment were statistically higher
than those who did not. This result was similar to
that of other studies mentioned above. We are in
the opinion that, because it cures anaemia, reduces
physical symptoms resulting from anaemia
including exhaustion, fatigue and reluctance, and
regulates sexual functions, EPO therapy improves
physical functions, which in turn, we believe, have
positive affects on the QOL of the patients.
Conclusions
It is important to emphasize that among the factors
we have found which relate to the QOL in this
study, education on disease and HD and compli-
ance to prescribed diet are probably the most
important in which we have influence, as nurses, on
improving the QOL in patients on HD. Random,
long-term studies are needed to determine if these
variables can influence patient’s QOL.
One possible limitation of the study is the rel-
atively small sample size. Hence, generalization of
the results of the study may be somewhat limited.
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Address for correspondence: Rukiye Pinar, Ph.D., Tutuncu
Mehmet Efendi Cad, Kaptan Ihsan Sk, Seniha Apt, No: 6/1,
Goztepe, 34730, Istanbul, Turkey
Phone: +90-216-360-6326; Fax: +90-216-330-3033
E-mail: rukiyepinar@yahoo.com