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Health promotion through lifestyle improvement is an important topic that has received considerable attention from the scientific community worldwide. This study aimed to determine the effect of Pender's health promotion model on self-efficacy and treatment adherence behaviors of hemodialysis patients in Shahrekord, Iran, in 2018–2019.
This quasi-experimental study was performed on 70 hemodialysis patients who were attending routine hemodialysis sessions in Hajar hospital in Shahrekord. Individuals were selected by simple random sampling and randomly assigned to two groups of control and intervention. In the preintervention stage, all patients completed a questionnaire that was prepared to collect demographic information and measure health-promoting behaviors, self-efficacy, and treatment adherence. The intervention group participated in eight sessions of a health promotion model-based education program. Both groups were asked to complete the questionnaire again immediately after the intervention and also 2 months later.
Considering the positive effects of the program on patients undergoing hemodialysis, it is recommended to use the program to promote the well-being of these patients without time restrictions.
Keywords: Hemodialysis patients, Pender's health promotion model, self-efficacy, treatment adherenceChronic renal failure is a progressive, irreversible disorder that impairs the ability of the kidney to remove metabolic waste and maintain fluid and electrolyte balance; an impairment that ultimately leads to uremia and several other severe conditions.[1,2] This disease is a public health problem worldwide.[3] The global prevalence of the condition is about 242 cases per million people, which increases by about 8% every year.[4] The incidence and prevalence of renal failure are increasing even in advance countries such as the United States, where the number of people who have undergone or are undergoing dialysis has increased from 340,000 in 1999 to 651,000 in 2010.[3] In Iran too, the statistics show that the incidence of chronic renal failure has been increasing for many years. In a study by Kazemi et al., the number of patients covered by dialysis centers in Iran was estimated at 11,000. Furthermore, the number of end-stage renal disease (ESRD) patients in 2008, when the country had a population of about 70 million, was estimated to 36,000, a figure that was estimated to grow by 12% annually.[5] Since ESRD is a lifelong medical condition, the survival of ESRD patients depends on their adherence to medical instructions and treatment. Further, nonadherence to treatment can worsen the condition and cause frequent hospitalization, which, in turn, can impose significant burdens on the health-care system.[6] Undergoing hemodialysis treatment completely changes the patient's life, as it requires regular attendance in dialysis sessions, adherence to medications, and major changes in diet.[7] There are generally four therapeutic recommendations for ESRD patients: Limiting fluid consumption, taking dietary precautions (e.g., eating low salt, low potassium, and low phosphorus foods), adhering to medication, and adhering to dialysis sessions.[7,8,9] Nonadherence to these four behaviors has profound impacts on the clinical outcomes of ESRD patients.[10] However, ESRD patients who receive hemodialysis face many challenges in adhering to treatment.[11]
The devastating impact of chronic kidney failure on the life of hemodialysis patients forces them to make fundamental changes in their lifestyle and requires them to adopt necessary strategies to manage their chronic illness. A person with a high degree of self-efficacy is likely to be more involved in self-care activities, which in turn has an impact on their quality of life and can reduce their mental disorders.[12] Perceived self-efficacy is a person's belief in their abilities to control their own actions and performance levels and the events that affect their lives.[13] People with low self-efficacy are less likely to attempt new health behaviors or change the behaviors to which they are accustomed. Self-efficacy can influence people's motivation and stimulates them to strive and persist in positive behaviors, an attitude that is very important for the treatment of chronic diseases.[14,15] In a quasi-experimental study, performed on 62 dialysis patients in Taiwan, the results showed that increased self-efficacy led to increased adherence to certain therapeutic behaviors such as diet restriction.[16] Health promotion through lifestyle change is an important topic that has received much attention from the global scientific community. Health promotion can be described as the science or art of helping people change their lifestyle to move toward a state of optimal health, a goal that can be achieved through concerted effort to raise awareness, change behaviors, and create an environment that promotes healthy behaviors.[17] One of the prominent models developed in this area is the health promotion model introduced by Pender in 1982, which is focused on empowering people to achieve higher levels of well-being. Pender has defined health promotion as an enhancement in health and well-being that requires a change in lifestyle, with lifestyle described as a set of behaviors aimed at disease prevention and health promotion. The health promotion model is a theoretical framework for analyzing the factors of health and their relationship with health-promoting behaviors that contribute to the movement toward enhanced wellbeing and quality of life. This model is a guide for understanding the complex biopsychosocial processes that compel people to engage in health behaviors that result in health promotion.[18] Numerous studies have extensively demonstrated the effectiveness of health promotion model-based programs on lifestyle and its associated factors, including self-efficacy, perceived barriers, and perceived benefits to behaviors.[19,20,21]
Despite the great attention paid by the Global Scientific Community to health promotion through lifestyle change and the enormous investments made in this area and also the especial importance of this subject for hemodialysis patients, there is still no single-organized comprehensive program based on a specific educational model for educating hemodialysis patients. As a result, most hemodialysis patients do not acquire the ability to absorb necessary information regarding their condition, which leaves them wondering what programs to follow and how to follow them. Considering that Pender has also provided a tool for measuring health-promoting behaviors, this concept can be used to develop a comprehensive rehabilitation program based on an educational model for hemodialysis patients. The present study aimed to evaluate the effect of the six dimensions of Pender's health promotion model (responsibility, physical activity, nutrition, interpersonal relationships, stress management, and spiritual growth) on self-efficacy and adherence behaviors of patients undergoing hemodialysis in the city of Shahrekord (Iran) in 2018–2019.
This quasi-experimental study was performed on 70 hemodialysis patients in the city of Shahrekord in 2018–2019. The inclusion criteria were the willingness to participate in the study, having undergone at least 6 months of dialysis, no mental disorder, and no exposure to other methods of education during the study. The exclusion criteria were the withdrawal of consent, traveling, and undergoing renal transplant.
The research goals were achieved with the help of a multi-part instrument for data collection. This instrument was a multidimensional questionnaire prepared to evaluate the effect of dimensions of Pender's health promotion model on self-efficacy and treatment adherence. This instrument consisted of four parts. The first part consisted of three items related to demographic characteristics of hemodialysis patients, which were completed at the beginning of the study. The second part was the Health Promoting Lifestyle Profile II (HPLP II), which consist of 52 items in six dimensions including spiritual growth (9 questions), health responsibility (9 questions), physical activity (8 questions), nutrition (9 questions), interpersonal relationships (9 questions), and stress management (8 questions). These items are scored based on a Likert scale, with scores ranging from 1 (never) to 4 (always), A higher mean score indicates better health condition. This standard questionnaire was developed by Pender et al. in 1996. Walker and Hill-Polerecky reported a Cronbach's alpha of 0.94 for HPLPII and alphas ranging from 0.79 to 0.94 for its six dimensions.[22] In the third part of the instrument, self-efficacy of patients was measured using a tool called the Strategies Used by People to Promote Health. This tool was developed by Lev, and Owen for assessing self-efficacy in the area of self-care and consists of 29 questions, of which 5 are related to coping, 7 to stress reduction, 3 to decision-making, and 14 to positive attitude. These questions measure the extent of a person's confidence in the four aforementioned areas on a 5-point Likert scale from very low (very little) to very high (quite a lot). The scientific validity of this tool has been verified by the internal consistency method (0.93) and by factor analysis (0.81). Other researchers have also confirmed its scientific validity at 0.93.[23] The fourth and final part of the instrument was the ESRD-Adherence Questionnaire (ESRD-AQ) developed by Kim (2009). This 41-item self-report tool measures the patient's adherence to four treatment-related behaviors: hemodialysis attendance, medications, fluid restrictions, and diet prescription. The face validity and construct validity of ESRD-AQ have also been established by the same researchers. The reliability of this tool has been reported to be about 0.83.[24]
After receiving approval for the research design and acquiring authorization, ethics code, and letter of introduction from the Ethics Committee and the Research Department of the Shahrekord University of Medical Sciences, the researcher contacted Hajar Hospital (in Shahrekord) and explained the objectives of the study to the management of the hospital and its dialysis department. After gaining permission from the hospital, the eligible patients were identified and those willing to participate were asked to provide written informed consent. Participants were selected from among eligible patients using the convenience sampling method. Questionnaires of demographic information, self-efficacy, treatment adherence, and health promotion were completed in interviews. Patients were then randomly assigned to two groups, control and intervention, by a random allocation software application [ Figure1 ]. Patients assigned to the intervention group were contacted at the beginning of the education program and were invited in groups to participate in the education process. The sessions were held in one of the rooms of the hospital (intervention was done in the form of group sessions). The program was designed based on the six dimensions of Pender's health promotion theory, namely responsibility, physical activity, nutrition, interpersonal relationships, stress management, and spiritual growth. The program consisted of 45-min sessions held twice a week for 4 weeks [ Table 1 ].