|Year : 2016 | Volume
| Issue : 2 | Page : 250-255
|Influence of nutritional education on hemodialysis patients' knowledge and quality of life
Hossein Ebrahimi1, Mahdi Sadeghi2, Farzaneh Amanpour3, Ali Dadgari2
1 Center for Health-Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
2 Department of Nursing, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
3 Department of Epidemiology and Biostatistics, School of Public Health, Shahroud University of Medical Sciences, Shahroud, Iran
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|Date of Web Publication||11-Mar-2016|
| Abstract|| |
To determine the effects of educational instructions on hemodialysis patients' knowledge and quality of life (QOL), we studied 99 patients randomly assigned to control and experimental groups after participation in a pretest exam. The two groups were not significantly different in terms of demographic composition. The instrument used in this study was a questionnaire regarding patients' knowledge and the standard questionnaire to assess QOL for end-stage renal disease (ESRD) patients. Then, intervention (nutritional education) was conducted in the experimental group lasting for 12 weeks. After 16 weeks, a post test regarding subjects' knowledge on dietary instructions and their QOL were as conducted. There was no significant difference in QOL score and knowledge score before and after intervention in the control group, but there was a significant difference in the experimental group. In addition, after the intervention, the difference in knowledge and QOL score persisted between the two groups. The results of this study supported the positive effects of educational program on patients' knowledge and QOL among ESRD patients. It is recommended that dietary instruction be included in all educational programs to improve ESRD patients' QOL.
|How to cite this article:|
Ebrahimi H, Sadeghi M, Amanpour F, Dadgari A. Influence of nutritional education on hemodialysis patients' knowledge and quality of life. Saudi J Kidney Dis Transpl 2016;27:250-5
|How to cite this URL:|
Ebrahimi H, Sadeghi M, Amanpour F, Dadgari A. Influence of nutritional education on hemodialysis patients' knowledge and quality of life. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2020 Jan 22];27:250-5. Available from: http://www.sjkdt.org/text.asp?2016/27/2/250/178253
| Introduction|| |
End-stage renal disease (ESRD) is a worldwide health issue.  According to Iranian Nephrology Association, more than 16,600 patients with ESRD are under dialysis treatment in 355 units in scattered areas in Iran. 
Hemodialysis (HD) in an effective modality of treatment; however, management of patients maintained on dialysis is very difficult.  Moreover, quality of life (QOL) among patients under treatment of HD is low, which affect their life style. ,,
In recent years, there has been growing interest in patients' QOL through conducting different educational programs. ,, HD patients express high levels of stress and encounter a variety of physical, psychological, and social problems. , Health professional, especially nurses, can play a key role in the evaluation of QOL in HD patients. 
One of the most important aspects of nursing career is educating HD patients, and this can reflect positively on their QOL. ,,, Improvement of the nutritional status of HD patients is an essential component of nursing intervention to reduce the complications of the disease. , Nurses have close contact with their patients and can instruct them to follow a healthy diet. 
Previous studies in our country revealed controversial results regarding association of diet control and QOL among HD patients. In one study, the investigators found that dietary interventions did not influence QOL;  however, a more recent study showed that nutritional intervention could significantly improve the QOL of HD patients.  The aim of this study was to determine the effects of educational instructions on HD patients' knowledge and QOL.
| Methods|| |
We studied 99 patients undergoing HD treatment at the Imam Hossein Hospital in Shahroud, Semnan Province, IR, Iran. We included patients older than 18 years, maintained on HD treatment during the last 12 months, do not have evident psychoemotional problems and do not receive any psychotropic medications. All the patients and/or their family members were able to read and write or communicate orally and use written instructions. All the patients were compliant to HD treatment at the same hospital and had reliable access to telephone contact at home.
All the patients in the study were informed about the purpose of the study and signed the informed consent form. This study was conducted on approval and close monitoring of university ethics committee in Shahroud University of Medical Sciences.
The instrument used in this study was a questionnaire consisted of 15 demographic questions, a questionnaire regarding subjects' dietary status consisted of 14 questions, and the standard questionnaire to assess QOL for ESRD patients. 
Faculty members, experts in dialysis treatment, assessed and confirmed the content and face validity of the dietary questionnaire. To evaluate the reliability of the questionnaire, testretest method was applied with r = 0.86 between two assessments. Previous investigators had previously assessed and approved the reliability and validity of QOL questionnaire.  The questionnaire had a high internal consistency  and provided wide and deep interpretation of variables in relations with QOL HD patients.  Complementary data were collected from the medical records of the patients.
The investigators considered the possibility of contamination of data between the patients in the control and the experimental groups. Therefore, the patients on HD on even days (Saturday, Monday and Wednesday) were assigned to the experimental group and the patients on HD on odd days (Sunday, Thursday, and Thursday) were assigned to the control group.
The intervention in the experimental group consisted of face-to-face educational sessions lasting 30-40 min followed by 10-15 min time to answer the questions. The face-to-face method is a common educational strategy in clinical settings, since it provides better possibility to evaluate the behavioral changes. ,
Moreover, all family members of the patients were asked to support them using the materials. The educational material was a pamphlet including information regarding the importance of adherence to a healthy diet, avoiding harmful consequences of poison accumulation in blood and tissues, and a list of food restriction and limitations in fluid intake. The educational instructions were delivered twice a week lasting for 12 weeks and each session lasted 40-60 min. Four weeks after complementing the program, a post test evaluation regarding patients' knowledge on dietary instructions and their QOL was done in both the control and the experimental groups.
| Statistical Analysis|| |
Analysis was done using the SPSS software, version 19.0 (IBM Corp., Armonk, NY) One-way ANOVA, Student's t-test and paired t-test were applied to compare the means, and Chi-square test was used for comparison of proportions in both groups.
| Results|| |
The mean age of the patients was 50.92 ± 10.98 years. Of all patients of the study 38 (38.4%) were females and 61 (61.6%) were males. Baseline demographic data are presented in [Table 1]. The patients of the study showed no significant difference in variables such as age, sex, educational level, employment status, history of dialysis treatment (years), and adequacy of dialysis treatment (per-week) between the experimental and the control groups.
|Table 1: Sociodemographic and clinical data of the patients undergoing hemodialysis.|
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The comparison of the results pertaining to patients' knowledge indicated that there were no significant differences between pre-and post-results in the control group (P = 0.22); however, in the experimental group, the comparison showed a significant difference between the pre-and post-results (P = 0.00). Furthermore, the comparison of patients' knowledge between the two groups after the intervention, indicated a significant difference between the experimental and control groups (P = 0.00) [Table 2].
|Table 2: Comparisons of mean knowledge score in hemodialysis patients in the experimental and the control groups.|
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The comparison of the mean QOL score in the two groups before the intervention showed no significant difference (P = 0.24) whereas after the intervention, the mean QOL score significantly increased in the experiment group compared with the control group (P = 0.00) [Table 3]. In addition, the QOL score showed no significant difference before and after the intervention in the control group (P = 0.43). However, a significant difference was observed in the experimental group before and after the intervention (P = 0.00).
|Table 3: Comparisons of mean QOL score in hemodialysis patients in the experimental and the control groups.|
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| Discussion|| |
Inappropriate diet was associated with low QOL and increased complications among chronic HD patients.  In addition, these patients, having specific dietary needs and treated with a variety of medications, require constant education to cope with the ever-changing needs both in physical and emotional aspects. 
In our study, the patients' mean score of knowledge of the dietary needs significantly increased after condensed dietary instructions. This finding is in accordance with previous studies which supported the positive effects of dietary education on patients' knowledge regarding their daily diet. ,,, Ford et al found that properly instructed patients showed significant improvement in their knowledge on food and diet.  Hasanzadeh et al showed a positive and significant improvement of dietary education on HD patients' knowledge in Iranian HD population. 
According to previous studies, limited health literacy is associated with poor QOL. Improving health literacy is a major step to improve the health outcomes of HD patients. , Moshtagh et al. found that dietary educational intervention for HD patients improved their health status including mental health. Moreover, in accordance with the findings of present study, the subjects of the study demonstrated significant improvement in their physical and social performance, reduction of anxiety and depression after participate in program.  Thomas et al found that patient's counseling could postpone their needs to HD and increase their QOL. They also concluded that dietary instructions should be included as an important component of any educational intervention.  Rahimi et al found that the continued care model could improve many dimensions of QOL (general and specific) among HD patients. 
In contrast to our findings, Aghakhani et al found that dietary instruction program could be effective only in the physical health dimension of QOL.  This diversity of results may be due to the confounding variables such as older age and lower level of education among subjects of those studies.
Since our results support the positive effects of educational intervention on patients' knowledge, QOL, and the different dimensions of health, it can be concluded that education as a whole and dietary educational intervention as a specific approach can facilitate patients' health status, reduce the consequence of disease, and improve patients' QOL.
However, there are some limitations for this study, such as some confounding variables including subjects' personal emotional characteristics, cultural, and social background, interpersonal relationships, economic diversities, and different level of driving and deterrent forces among subjects of the study, which could affect their learning. Moreover, there was a possibility of data contamination by transferring information between groups by dialysis ward personnel and patients. To minimize this, they were informed to avoid contamination of the data.
We conclude that our study findings suggest that educational intervention on diet for chronic HD patients improved both knowledge and QOL. Nurses are in proper position to facilitate patients' leaning in order to promote health and QOL.
| Acknowledgments|| |
It is a pleasure to acknowledge all nursing staff of HD ward in Imam Hossein Hospital in Shahroud, Semnan Province. This study would not be able to achieve its goals without the patients who actively participated in it. This study was sponsored by the Vice Chancellor for research at Shahroud University of Medical Sciences (research grant no. 9116).
Conflict of Interest
Authors declare that they have no conflict of interest.
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Department of Nursing, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud
[Table 1], [Table 2], [Table 3]
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