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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2020  |  Volume : 31  |  Issue : 1  |  Page : 150-159
Effectiveness of interventions based on lazarus and folkman transactional model on improving stress appraisal for hemodialysis patients in Tehran

1 Aging Health Department, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Environmental and Occupational Hazards Control Research Center, Tehran, Iran
3 Departments of School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 Department of Medical Psychology, Health Promotion, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
5 Department of Urology, Health Promotion, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
6 Department of Health Education, Health Promotion, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

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Date of Submission02-Feb-2019
Date of Decision08-Apr-2019
Date of Acceptance11-Apr-2019
Date of Web Publication3-Mar-2020


Today, we witness an increase in the prevalence of chronic kidney disease, which is a very stressful process. In order to cope with the stress caused by this disease, the first step is to appraise the stressful situation correctly. Therefore, the present study was conducted with the aim of investigating the effect of training on the basis of Lazarus and Folkman transactional model on stress appraisal for hemodialysis (HD) patients. The present quasi-experimental study was conducted on 116 filed HD patients in two dialysis centers in Tehran. The patients were randomly divided into two groups: experimental and control groups. The data were collected using a researcher-made questionnaire whose validity and reliability were confirmed. After performing the intervention, the primary and secondary appraisals’ scores were investigated before and three months after the intervention. The data were analyzed using independent /?-test, paired /-test, and covariance at a significant level of 0.05 using software Statistical Package for the Social Sciences version 16.0. The mean age of participants in the study was 52.86 years. In this study, the difference between the mean score of the primary appraisal and substructure of perceived susceptibility, motivational relevance, self-blame (casual focus), and secondary appraisal and self-efficacy substructure after the intervention was significant in the experimental group. However, these differences were not significant in the control group. According to the study results, it can be concluded that the use of training based on Lazarus and Folkman tran- sactional model can be useful for improving the correct appraisal of individuals for stressful situations.

How to cite this article:
Morrowati Sharifabad MA, Ghaffari M, Mehrabi Y, Askari J, Zare S, Alizadeh S. Effectiveness of interventions based on lazarus and folkman transactional model on improving stress appraisal for hemodialysis patients in Tehran. Saudi J Kidney Dis Transpl 2020;31:150-9

How to cite this URL:
Morrowati Sharifabad MA, Ghaffari M, Mehrabi Y, Askari J, Zare S, Alizadeh S. Effectiveness of interventions based on lazarus and folkman transactional model on improving stress appraisal for hemodialysis patients in Tehran. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Apr 7];31:150-9. Available from: http://www.sjkdt.org/text.asp?2020/31/1/150/279935

   Introduction Top

Chronic renal failure is associated with progressive degeneration of renal function, with impaired metabolism of the body water and electrolytes, which the main treatment is hemodialysis (HD).[1] Dialysis is associated with a series of dietary and life restrictions that severely affect the life and physical and mental well-being of patients.[2]

During recent years, many studies have been conducted to understand the relationship between physical health and psychological factors deeply that led to the formation of a new field called health psychology. One of the most important areas of research in this category is the study of the relationship between different types of diseases and stress.[3] Chronic kidney disease (CKD) is a life- threatening disease and its burden is increasing in the world.[4],[5] These patients face a number of problems with dialysis treatment, including system-dependent life, financial problems, and limited treatment-related activities and problems, all of which can lead to psychological problems for these patients.[6]

Stress is the physiological response of the body to any kind of change, threat, or internal and external pressure that causes the person’s mental imbalance, and stress is an inevitable event in the life of all individuals. The term stress is a general meaning, its definition is very difficult, and it is complex because it has different meanings for different individuals in different places and times.[7]

For coping with psychological stress, specialists have recommended new methods, such as having proper nutrition, having proper physical activity, relaxation methods, and time management, many of which including positive thinking have been reported effective in the face of stress and anxiety.[8]

In this regard, health professionals can also help patients to change their unhealthy behaviors by selecting and applying appropriate models. Lazarus and Folkman transactional model is an established tool to models to reduce stress and create appropriate behaviors.[9]

Based on stress transactional model, two intermediate processes occur in response to stress: (1) the primary appraisal that the person understands the susceptibility and severity to stressors. At this stage, the motivational relevance occurs with the stressor, which means that can stressors influence the goals and cause of stress? Therefore, reducing the actual value for health hazards may reduce the motivation to apply and adopt health behaviors such as discontinuation of smoking and diet control.[10] The primary appraisal relates to the motivational factors of stressors, during which the person suffers from certain mental stress or anxiety and may be more concerned and sinful if the person is responsible for creating stress. Therefore, the most important aspect of the appraisal of the cause of the disease may be the answer to the question that these factors have caused the disease.[10],[11],[12]

The second stage is the secondary appraisal, which is to examine the resources and options of individual compatibility with stressors. The main focus of the secondary appraisal is on stressors’ change, which includes perceived control of a health threat, perceived ability to manage emotional responses to a health threat, and self-efficacy.[13],[14],[15]

In a study by Mosavinasab et al, the variable of stress appraisal and coping methods played an important role in mental health of indi- viduals.[16] Furthermore, Glazer and Liu in a study mentioned that stress management interventions focused on individuals’ appraisal of job stressors as a threat or challenge for individuals to deal with stressors.[17]

The results of some studies also indicate that with changing the appraisal of individuals, the response of a person can be changed in the face of the stressor.[16],[18] The fact that how a person perceives a situation as stressful depends on the degree of stressfulness of that situation. A completely identical event can be appraised by the two individuals completely different.[19]

Since appraisals are important determinants of coping strategies for individuals,[16] and given the above, it is very important for HD patients to be able to properly appraise the stressful situation of their disease, since some of the situations perceived by HD patients as potential stressful perhaps are not the case, and with modifying the way of individuals’ appraisal, many stresses surrounding dialysis can be prevented. One of the important strategies in this field is training how to correctly appraise the stressful situation for HD patients. Therefore, the present study for the first time studied the effect of training based on the transactional model of Lazarus and Folkman on how to appraise stress in patients undergoing HD in Tehran.

   Materials and Methods Top

Study design and population

This was an interventional study conducted in the summer of 2018 aimed to investigate the effect of training on the basis of Lazarus and Folkman transactional model on stress appraisal for HD patients in Tehran. The study population included all patients undergoing HD in Tehran. The sampling method was that at first, two dialysis centers of the east of Tehran were selected randomly that were close to each other in terms of social, cultural, and economic characteristics, one of them as the experimental group and the other as the control group. The centers were separated from each other so that the experimental group could not provide information to the control group, and then, randomly, the sample was selected among them. In order to determine the sample size, considering the error of the first type 5%, the test power was 90% with 95% confidence with respect to the mean and standard deviation values of stress score as 36.2 ± 9.47[20] and 64.12 ± 17.64 according to previous studies, the sample size was n = 52 in each group, and with a 10% drop in the study, the sample size was n = 116 that each of the experimental and control groups had n = 58.

Inclusion and exclusion criteria

The study inclusion criteria include CKD, Tehran resident, HD, having a case at the dialysis center, having at least reading and writing skills, ability to attend training sessions, and having no history of chronic psychological disease, and the study exclusion criteria include psychiatric treatment, reluctance to participate in the study, and having a history of relevant training.


A researcher-made questionnaire was used to collect data prepared based on the transac- tional model of Lazarus and Folkman. The questionnaire consisted of demographic questions and 44 questions for measuring the primary and secondary appraisals of the transactional model. The number of questions in each substructure included the following: perceived susceptibility (11 questions), perceived severity (8 questions), motivational relevance (4 questions), casual focus (6 questions), perceived control over outcomes (6 questions), perceived control over emotions (5 questions), and self-efficacy (5 questions).

How to score all questions on 3-option Likert scale of I agree (1), I have no idea (2), and I disagree (3). The inverse questions of this questionnaire included 38, 35, 22-27, 20, and 1-18. The range of scores for each field was set 0-100, with higher scores in all phrases indicating higher stress.

The content validity of this questionnaire was confirmed by calculating content validity index and content validity ratio (CVR)using expert panel views, which included 12 professors and specialists in the field of health education, psychology, and renal specialist and examined the relevance, simplicity, and clarity of each question. Given that the number of evaluators was 12, the questions with CVR of less than 0.56 were excluded from the test, and thus, the score of 44 items was larger than Lawshe table (0.56).[21] In this study, the value of content validity index calculated using the formula was 0.85, which was an indication of acceptable tool validity.

The reliability of the tool was evaluated using Cronbach’s alpha method, the results of which are given in [Table 1].
Table 1: Results of the reliability of research tool.

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In order to conduct model-based meetings, the educational program and content was designed in accordance with the model structures under the supervision of experts. Before the intervention, the goals of the course were presented to the participants, and informed consent was obtained. Then, the tool was provided to all participants and asked them to respond to tool questions. The pretest was performed in two experimental and control groups. Based on pretest and analysis data, qualitative study results (the results of the qualitative study were presented in a separate paper), intervention design, and appropriate educational content were prepared for the experimental group.


In the following, the experimental group received eight training sessions in groups of five to six people in lecture, group discussion, and question and answer. The content of the training sessions was as follows:

Session 1: Inauguration, familiarity with members, familiarity of members with each other, the expression of logic, the framework and objectives of educational sessions, and understanding stress general (definition of stress and its types).

Session 2: Explain the causes of stress (the physiological, behavioral, and psychological symptoms) and the explanation of the roots and the internal and external factors that caused stress and the impact of stress on health.

Session 3: Explaining the relationship between stress and illness and explaining how stress is making us sick and the effects on organs of the body and explain the misconceptions about stress.

Session 4: Relaxation exercises, exercises to relieve stress, stretching, contraction, and muscle expansion, exercise of self-relieving, deep breathing, progressive relaxation training, and training mental imagery exercise, and the patients were asked to do these exercises each night for 15-20 min before going to the bed. Moreover, 15 min of each session was devoted to the relaxation exercises in the subsequent sessions. The patients also received educational pamphlets with the trained subjects.

Session 5: Define assessments of stressful situations, cite examples of people’s differences in how to assess the same stressful situations, and ask questions about the cause, use of statistics, and the indication of the prevalence of stress in dialysis patients.

Session 6: Explaining the role of self-blaming (casual focus) in generating negative thoughts and stress, defining self-efficacy and its role in controlling stressful situations, mentioning resources for increasing self-efficacy.

Session 7: Definition of coping, types of coping, definition of problem management, training of problem management, definition of emotional regulation, training of skills to control emotions, the correct way to express emotional reactions, training strategies for increasing body potential to deal with stress, and training emotional regulation methods.

Session 8: Reviewing the presented topics, practicing the discussed topics, the use of training sessions for adaptive logical appraisal, reviewing negative thoughts and how to challenge them, and reviewing and explaining individual patient achievements. After completing the training sessions, a booklet containing all the materials presented during the sessions was given to the patients. Since the patients undergoing HD treatment had a long time at the center of dialysis and were not willing to come to another center for inter- vention, the intervention was performed at the center of dialysis, so the dialysis center of the experimental group was divided into several parts, and training was divided into several groups and in all three shifts of the morning, afternoon, and evening for all patients in the dialysis center of the experimental group because there was no possibility of differentiation of the participating and nonpartici- pating subjects in the study for training. Therefore, all experimental group subjects in the dialysis center received the intervention, but the questionnaire was only available to those participated in the study.

The intervention was based on the model in the experimental group and content and time required, and then, the posttest was performed in both the experimental and control groups, and the results were analyzed. The data were collected and analyzed within three months after the intervention. Finally, the effect of intervention was measured in the transactional model framework and compared with that of the control group.

Ethical considerations

Before starting the study, the Ethics Committee of Faculty of Medical Sciences of Yazd provided the permission with an ethics code of R.SSU.SPH.REC.1397.012, related references were provided by Yazd University of Medical Sciences for dialysis centers in Tehran, and the study was registered at Clinical Trials Registration Center with the code of IRCT ID: IRCT20180524039814N1.

   Statistical Analysis Top

In order to analyze the data, central and distribution indicators and independent t-test, paired t-test and Wilcoxon tests were used according to the study objectives. Three months after the completion of the training course, the posttest was performed from both the experimental and control groups, and the data were analyzed using descriptive and inferential tests by software Statistical Package for the Social Sciences (SPSS) version 16.0 (SPSS Inc., Chicago, IL, USA).

   Results Top

According to demographic information, the participants in the study had a mean age of 52.81 years with a standard deviation of 7.71. Most of the subjects were male (51.7%), married (89.7%), and high school (29.3%), and most of them (32.8%) were housewives. Most of the participants (85.3%) reported that there was no history of CKD in their firstgrade family. As shown in [Table 2], according to the Chi-square test, the experimental and control groups are similar in terms of demographic variables at the beginning of the study and have no significant difference. For the gender, 29 women and 29 men were in the experimental group. Twenty-seven women and 31 men were in the control group. No significant difference was found between the two groups (P = 0.42), and for other demographic factors (marital status, education level, occupational status, and history of disease), no significant difference was found between the two groups.

According to paired t-test to compare mean scores of the primary appraisal and its substructures before and three months after the educational intervention between the two groups, significant changes were found in the experimental group in terms of the primary appraisal and perceived susceptibility substructures, motivational relevance, and self- blame. However, these differences are not significant in the control group. According to the independent t-test, no significant difference was found between the mean scores of the primary appraisal variable and its substructures in the experimental and control groups before performing the intervention. These changes are significant after three months of intervention, with difference seen in primary appraisal variable, motivational relevance and casual focus substructures between two groups. According to the results of covariance analysis, a significant difference was found between the two groups on the primary appraisal variable and the motivational relevance and casual focus substructures within three months after the intervention [Table 3].
Table 2: Comparison of participants' demographic variables in intervention and control groups (Chisquare test).

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Table 3: Comparison of mean and standard deviation of primary appraisal scores in intervention and control groups before and 3 months after intervention.

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According to the results of paired t-test significant changes was found in the experimental group regarding the secondary appraisal and self-efficacy substructure, but these differences in the control group are not significant. According to independent t-test, no significant difference was found between the mean scores of the secondary appraisal variable and its its substructures in the experimental and control groups before performing the intervention for self-efficacy substructure changes are significant three months after the intervention. According to the results of covariance analysis with the primary adjustment, a significant difference was found between the two groups in the secondary appraisal variable and perceived control over emotions and self- efficacy substructures three months after the intervention [Table 4].
Table 4: Comparison of mean and standard deviation of secondary appraisal scores in intervention and control groups before and 3 months after intervention.

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   Discussion Top

The present study was conducted with the aim of investigating the effect of training on the basis of the transactional model of Lazarus and Folkman on stress appraisal for HD patients in Tehran. The study results indicated a change in the mean perceived susceptibility score after the intervention in the experimental group. These results are consistent with Fakhri et al study on the anxiety of pregnant nulli- parous women.[22] The perceived susceptibility substructure is important because cognitive distortions and ineffective attitudes are one of the effective factors on the emergence of stress in HD patients. In fact, using Lazarus and Folkman model-based training, HD patients believed that stress was very risky for their health. Using health belief model, they improved compliance with standard precautions in preventing clinical staff working stress in the hospital. A significant increase was found in perceived susceptibility score in the experimental group after the intervention.[23]

No significant difference was found in perceived severity in the present study after the intervention. In a study by Shao et al in title Effect of a Health Belief Model-based education program on patients’ belief, physical activity, and serum uric acid, after the intervention, the mean score of perceived severity increased,[24] the results of the present study were not consistent with the study, and perhaps, the difference is due to the difference in the community studied and characteristics of the sample.

For motivational relevance, after the intervention, a significant change was found in the motivational relevance score of the patients, which indicates the effect of the intervention. Heim and Keil in a study stated that the classification of lecture training is not effective for the development and improvement of behavior only by increasing the motivational relevance.[25]

The mean scores of self-blame of patients regarding stressors after the intervention were significant, indicating the effect of training on this substructure. In various studies, it has been shown that self-blame of those who are affected or injured is more common than normal ones.[26] Sharifibastan et al also stated that those who are optimistic about life do not consider themselves as the disease cause in dealing with life-threatening events such as diseases, and thus, they are not constantly blamed for their own ends and can return to their normal life.[27]

Finally, the study of the primary appraisal structure showed that after the training intervention in the experimental group, there were significant changes in the experimental group. The study results were consistent with the study by Mazloomy Mahmoodabad et al who examined teachers’ stress in Yazd using a transactional model.[28]

The secondary appraisal, which is a measure of resources and options for adaptation to stressors, includes three substructures of perceived control of outcomes, perceived control of emotions, and self-efficacy. No significant change was found in perceived control over outcomes and perceived control over emotions substructures after the intervention, but these changes were significant in terms of self- efficacy. It seems that one of the reasons for this is the condition of dialysis. Because of having dialysis due to the severity of the treatment, one believes that he cannot change the outcome. Therefore, the individual’s belief in controlling his disease is related to be more compatible with existing facts. For self- efficacy, the results indicated an improvement in the self-efficacy of the subjects after the intervention. The results of many studies, including Soltaninejad and He et al, have pointed to the role of training in increasing self-efficacy of individuals.[29],[30] Modanloo et al in a study stated that training along with SMS learning is more effective on improving self- efficacy of HD patients.[31] Madadkar in a study referred to the effectiveness of Jacobson’s relaxation technique on improving self-efficacy of HD patients.[32] Self-efficacy makes individuals believe in their abilities and therefore have high motivations to overcome obstacles by learning different skills; thus, individuals with higher self-efficacy will make more efforts to overcome the problems.[24] In some studies, the role of encouraging participants to achieve behavioral goals has been mentioned.[33],[34] In the present study, by encouraging participants to achieve small successes, and following the achievement of higher behavioral goals, also self-efficacy of patients increased. Bandura also believed that small personal success would increase perceived self- efficacy in individuals.[35] Finally, the study of the secondary appraisal structure showed that after the intervention, changes in this structure were significant in the experimental group, and these results were consistent with the study of Mazloumi Mahmoodabad et al[28] and Gardner et al on occupational stress management of the UK health department staff.[36] In their study, behavioral methodological training did not change the scores of the two primary and secondary appraisals’ scores of subjects for stressors. Perhaps, the reason for the difference in these results is due to the cultural and demographic differences of individuals. In a study on students, Toulabi et al concluded that their intervention improved cognitive appraisal and student achievement behaviors.[37] In a study on patients with breast cancer, Bigatti et al concluded that there is a need for cognitive appraisal when understanding the symptoms of depression in cancer patients.[38]

Unfortunately, the studies found on the primary and secondary appraisal structures of the transactional model of stress are very few, and studies that have been conducted on this subject have not considered the appraisal substructures. Therefore, there were problems in interpreting the results.

The limitation of this study was conducting this study only on patients undergoing HD and in two centers of dialysis centers in Tehran. Furthermore, data collection was based on self-reporting scales that could distort information from patients. It is suggested to investigate the transactional model appraisal structures in other cities and other diseases in order to generalize the results in future studies.

   Conclusion Top

HD patients are often exposed to stressful situations due to the nature of their disease, and this prolonged exposure can negatively affect their lifestyle. One of the useful ways to better understand stressful situations and to perform a proper appraisal of HD patients is to train with appropriate educational models. In this study, the educational intervention program based on Lazarus and Folkman tran- sactional model has a positive effect on the primary and secondary appraisals of HD patients, which will definitely affect the perceived stress of patients.

Conflict of interest: None declared.

   References Top

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Correspondence Address:
Somayeh Alizadeh
Department of Health Education and Health Promotion, Shahid Sadoughi University of Medical Sciences, Yazd
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DOI: 10.4103/1319-2442.279935

PMID: 32129208

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