The Effect of Educational Program on Improving the Lifestyle of Hemodialysis Patients:  Model of Planned Behavior

INTRODUCTION

Chronic kidney disease is a major cause of death and diseases in the world, that in addition to physical health, also threatens other dimensions of health. The hidden nature of chronic kidney disease in the early stages prevents its early diagnosis, resulting in late diagnosis of disease in end-stage kidney disease and dialysis [1]. According to Iran’s dialysis annual statistics in 2015, the number of patients with end-stage kidney disease in the world was estimated at 3730000, out of which 58000 were in Iran [2].

Despite the extensive use of hemodialysis, it has many problems such as high blood pressure, anemia, dehydration, lack of concentration for a long period, renal osteodystrophy, complications of the reproductive system, arterial tract infections, and long-term complications for patients and these problems gradually decrease the quality of the patients [3]. Various approaches have been proposed to improve the quality of life of hemodialysis patients, the most important of which is to use behaviors that promote health and change the lifestyle. Health-promoting behaviors are the science and the art of changing the lifestyle to achieve maximum health by adopting behaviors such as proper nutrition, regular exercise, avoiding high-risk behaviors, controlling emotions and feelings, resisting stress and complications of the disease, and adapting to disease and developing of independence [4]. In their study, Benner et al. stated that improving nutrition in kidney patients improved their quality of life and had a significant relationship with reducing mortality in these patients [5].

Despite the importance and role of lifestyle in improving the quality of life of hemodialysis patients, evidence suggests that the lifestyle of these patients is not at a good level. The study conducted by Nonoyama et al. (2010) showed that most of these patients had a moderate level of life quality [6].

Therefore, given the undesirable lifestyle of these patients, it is necessary to consider interventions to train and empower them. In this regard, the first step to implement educational programs is using educational models. The educational programs will be effective if they are based on behavior change models. The model of planned behavior is one of the comprehensive models in the area of behavior change. According to this model, an individual is a rational agent, so that s/he processes information before s/he wants to do a behavior, and then, her/his basic beliefs and, consequently, her/his behavior may change [7, 8].

Although various studies have shown the effectiveness of educational programs according to the theory of planned behavior on advancing physical action in adolescents, following a low-salt diet in heart patients, preventing urinary tract infections in pregnant women, adopting anti-aggression behaviors, and promoting physical activity in patients with type 2 diabetes, increased consumption of dairy products in the elderly people, and adopting AIDS-preventive behaviors [9, 10], changing lifestyle in patients with a heart attack [11], weight control of hemodialysis patients [12], reducing of symptoms and signs of the disease in hemodialysis patients [11], nutritional behaviors and physical activity in hemodialysis patients [13], they have not examined all dimensions of lifestyle.

Nurses play a major role in educating the patient because they have more access to the patient and her/his family and spend much time to provide care for them, so they can provide frequent opportunities for educating and can also assess the quality of education. Enhancing the nurses’ knowledge of the role and importance of education to patients improves their performance, leading to a higher level of satisfaction among the patients [14]. Thus, given the role and importance of lifestyle change in improving the life quality of dialysis patients and due to the limited number of studies conducted in this regard, the researchers decided to conduct a study to investigate the effect of training program according to the model of planned behavior on improving the lifestyle of hemodialysis patients.

MATERIALS AND METHODS

This randomized clinical trial study was conducted on 112 hemodialysis patients referring to the dialysis wards of Golestan and Imam hospitals in Ahvaz from October to November. In the present study, to select the samples, the medical files of all patients who were hospitalized up to 3 months before the start of the study with the diagnosis of dialysis were examined. The inclusion criteria of the study included having age above 18 years, being under hemodialysis for at least 3 months, lack of any physical or mental diseases that influence the ability to participate in the study, ability to communicate, having the skill of reading and writing, and ability to participate in education. The exclusion criteria of the study also included patients transferred to intensive care units for any reason, complications during dialysis, and need for medical measures, being absent in more than one session in educational sessions. In this study, individuals were assigned to test (n=56) and control (n=56) groups randomly and by permuted block randomization method and block size of 4 (using a table of random permutations). After randomly selecting and allocating the samples, the pre-test was performed for both groups. After collecting the data, it was analyzed using statistical software and the educational intervention was designed for the test group according to the results of the pre-test data analysis.

The intervention included training according to the model of planned behavior, which was performed individually and face-to-face for the subjects in 8 sessions of 20 minutes (daily). A post-test was carried out using statistical tests and statistical software for the 2 groups one month after the intervention, and the data was analyzed. In this study, the researcher did not perform any educational intervention for the control group, and to observe the ethical principles and standards in the research, an educational pamphlet was submitted to the control group after performing the post-test. Data collection tools in this study included three questionnaires, including a demographic information questionnaire, a model of planned behavior questionnaire, and a lifestyle questionnaire. The questionnaire of demographic information involved questions on age, gender, education, job and income, number of hemodialysis sessions per week, duration of disease, current smoking, history of smoking, and history of dialysis in other family members. Questionnaire-based model of planned behavior structures: In order to prepare and develop this questionnaire, after review of literature based on the desired model, items to determine the level of attitude (9 questions), subjective norms (15 questions), perceived behavioral control (9 questions), behavioral intention (4 questions) were designed. The total questionnaire includes 37 items, scored on a 5-point Likert scale, ranging from I completely agree (5), I agree (4), I have no idea (3), I disagree (2) and I completely disagree (1). Item 3 is scored reversely (I completely agree (1), I agree (2), I have no idea (3), I disagree (4), I completely disagree (5)), the score of each subject in each of the subscales is obtained from the sum of scores of the items of the same subscale. In this questionnaire, the subscale of attitude is scored from 9 to 45, the subscale of subjective norms is scored from 15 to 75, the subscale of perceived behavioral control is scored from 9 to 45, and the subscale of behavioral intention is scored from 4 to 20. Higher scores in each of the sub-scales indicate a more desirable status.

The lifestyle questionnaire includes 52 questions and 6 subscales of nutrition, physical activity, health responsibility, stress management, interpersonal relationships, and self-actualization. Each question is scored on a 4-point Likert scale, ranging from never (1), sometimes (2), most often (3), and always (4). The total score varies between 52 and 208. It is calculated separately for each dimension of lifestyle so that the score of each subscale is obtained from the scores of the answers given to the questions of the same subscale, and the total score of the subject in the health promotion lifestyle is a score obtained from the subject’s answer to 52 questions. Higher scores indicate a healthier lifestyle. In each subscale and the whole questionnaire, a score of less than or equal to 49% of the total score indicates a poor status, a score of 50 to 74% indicates a moderate status, and a score of 75 or higher indicates a good status in that dimension of lifestyle or the general lifestyle.

In this study, quantitative variables were reported as mean, standard deviation, minimum and maximum, and qualitative variables were reported as frequency (percentage). The normality of quantitative variables was assessed using the Shapiro-Wilk test. To investigate the relationship between qualitative variables, the Chi-square test (Fisher's exact test) was used, and to compare quantitative variables between two independent groups (intervention and control), independent t-test, or its non-parametric equivalent one (Mann-Whitney test) was used. A significant level of less than 0.05 was considered in the present study. Data was analyzed using SPSS version 22 software.

RESULTS AND DISCUSSION

In the present study, 112 hemodialysis patients referring to Golestan Hospital and Imam Hospital of Ahvaz participated. Their mean age was 53.67 ± 13.90 years in the treatment group and 52.17 ± 16.96 years in the control group. No significant difference was found between the two groups in terms of age using an independent t-test. In addition, there was no meaningful difference between control and experimental groups with regard to gender, marital status, education, job status, dialysis family history, current smoking, previous history of smoking, and disease other than kidney disease based on chi-square test (Table 1).

Table 1. The Comparison of Similarity between Experimental and Control Groups with regard to Demographic Characteristics

By the use of t-test, a comparison of mean lifestyle scores between the 2 groups indicated that though there was no meaningful difference between the 2 groups before the intervention, a meaningful difference was observed between the 2 groups after the intervention (p <0.05). In the comparison of mean scores of intragroup lifestyle dimensions, the findings of the paired t-test showed a meaningful difference in the test group (p <0.05); however, no significant difference was observed in the control group (Table 2).

Table 2. The Comparison of Mean Scores of Lifestyle Dimensions and its Dimensions in Two Groups of Test and Control before and after the Intervention

^* t- test, ^**paired t-test, significancy < 0.05

The findings indicated that there was not any significant difference between the mean attitude scores in the two groups before the intervention according to a statistical test of the t-test (p = 0.69), but there was a significant difference between the two groups after the intervention (p <0.001). p). In addition, in comparing the mean scores of intragroup attitude, the statistical results obtained from a paired t-test showed that there was a statistically meaningful difference between the mean scores of attitude before and after the intervention (p <0.001), but it was not significant in the control group (p = 0.39).

There was also a significant difference between the mean scores of subjective norms and perceived behavioral control in the two groups before and after the intervention. There was a statistically meaningful difference in the test group (p <0.05), but no significant difference was found in the control group. However, the behavioral intention scores in the two groups before and after the intervention showed a significant difference, and intragroup comparison of mean scores of behavioral intention based on the Wilcoxon and Mann-Whitney statistical tests showed that there was no statistically significant difference in the test group (p > 0.05), but a meaningful difference was observed in the control group (Table 3).

Table 3. The Comparison of Mean Scores of Planned Behavioral Pattern Structures in the Two Groups of Test and Control before and after the Intervention

^* t- test, ^**paired t-test, significancy < 0.05

* Wilcoxon, Mann-Whitney