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Japan Journal of Nursing Science (2015) 12, 113–123
doi:10.1111/jjns.12055
ORIGINAL ARTICLE
Adherence to diet and fluid restriction of individuals on hemodialysis treatment and affecting factors in Turkey Dilek EFE1 and Semra KOCAÖZ2 1 Department of Medical Nursing, School of Health, Bozok University, Yozgat and 2Department of Nursing, Nigde Zubeyde Hanim School of Health, Obstetric and Women’s Health Nursing, Nigde University, Nigde, Turkey
Abstract Aim: This study was conducted to determine adherence to diet and fluid restriction in hemodialysis-treated individuals and the affecting factors in Turkey. Methods: This descriptive study was conducted between 15 October 2010 and 15 January 2011 in subjects who voluntarily agreed to participate in the study from three dialysis centers in a city located in the Central Anatolia Region of Turkey. One hundred and twenty-one individuals treated with hemodialysis made up the study sample. The data were collected using a questionnaire consisting of 41 questions and the Dialysis Diet and Fluid Non-adherence Questionnaire. The data were evaluated with percentage, median, Mann–Whitney U-test, Kruskal–Wallis test, Student’s t-test in independent samples and Spearman’s rank correlation coefficient. Results: The authors found that 98.3% of the individuals experienced non-adherence to diet and 95.0% with fluid restriction. The authors found a weak and negative relationship between calcium levels and non-adherence to fluid restriction, a weak relationship between phosphorus levels and diet non-adherence frequency and degree and the fluid non-adherence frequency scores, and a moderate positive relationship between phosphorus levels and fluid restriction non-adherence degree scores (P < 0.05). Conclusion: Based on these results, regular training and information regarding diet and fluid restriction must be provided to individuals aged 21–35 years with no one in the family to help with their care, those who consumed salted food, or had interdialytic weight gain of 4.5 kg or more. Key words: adherence, diet, fluid restriction, hemodialysis, nursing.
INTRODUCTION Chronic renal failure is an irreversible and progressive renal dysfunction that may eventually lead to end-stage renal disease (ESRD). Hemodialysis (HD) is the most common method used for the treatment of individuals diagnosed with ESRD (Akoglu & Suleymanlar, 2005).
Correspondence: Dilek Efe, Bozok Üniversitesi Türkiye Odalar ve Borsalar Birlig˘i Sag˘lık Yüksekokulu Bozok Üniversitesi Erdog˘an Akdag˘ Kampüsü, 66100, Yozgat/ Türkiye. Email: [email protected] This study was presented as a poster presentation at the 14th National Internal Medicine Congress, 3–7 October 2012, Antalya, Turkey. Received 13 November 2013; accepted 26 May 2014.
The CREDIT study conducted in 2009 with the contribution of the Turkish Nephrology Association found that 15.7% of Turkish adults (∼7.5 million people) have chronic renal disease at various stages and 78.5% of this group is undergoing HD (Suleymanlar et al., 2011). HD treatment enables individuals to deal with ESRD symptoms but can cause severe physical, psychological, social, and economic problems (Kaba et al., 2007; Kammerer, Garry, Hartigan, Carter, & Erlich, 2007). Such problems experienced during HD treatment increase the emotional pressure on individuals and make adherence to treatment difficult by disturbing the mental state (Kara, 2007; Ozturk, Altuntas, Ozsan, & Gunduz, 2009). The 2003 World Health Organization (WHO) report defines adherence as “a measure of the
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
D. Efe and S. Kocaöz
Japan Journal of Nursing Science (2015) 12, 113–123
individual’s behavioral change according to the recommendations of the health care team regarding medication use, diet and lifestyle change” (World Health Organization, 2003). As in all chronic diseases, individuals diagnosed with ESRD who continue HD treatment should adapt to the drug treatment and diet and fluid restrictions to maintain their health (Denhaerynck et al., 2007; White, 2004). The adherence of HD patients to diet and fluid restriction is evaluated with subjective and objective measurement tools. Subjective measurements are made through the verbal statements of the patients and healthcare workers’ opinions, while objective measurement is made with biological and biochemical values such as phosphorus, albumin, interdialytic weight change, and sodium and fluid intake (Kara, Çaglar, & Kılıc, 2007). The adherence of ESRD patients to their treatments and the diet and fluid restrictions is difficult due to their physiological and psychological problems (Kaba et al., 2007). The non-adherence of HD-treated individuals to diet and fluid restrictions is reported to cause fluid–electrolyte imbalance and malnutrition together with increased mortality rates (Ovayolu, Ucan, Pehlivan, & Yildizgordu, 2007). Studies have demonstrated that many factors such as lack of social support (Yokoyoma et al., 2009), smoking, sex, age, HD duration, the presence of other chronic disorders (Kara, 2007; Kutner, 2001), the perception of the chronic disease follow up and treatment, health beliefs, cultural characteristics, and satisfaction with the healthcare system play an important role in the non-adherence of HD patients to diet and fluid treatment (Kara, 2007; WHO, 2003). The non-adherence to treatment rate of HD patients varies according to the definition used and the measurement tools (Kutner, Zhang, McClellan, & Cole, 2002). It is reported that approximately 86% of dialysis patients have adherence problems with one or several aspects of the treatment (Loghman-Adham, 2003). Kugler, Vlamick, Haverich, and Maes (2005) found that 81.4% of HD patients showed non-adherence to diet and 74.6% to fluid restriction. A study from the authors’ country found these rates to be 58.1% and 68.1%, respectively (Kara et al., 2007). Determining the status of non-adherence to diet and fluid restrictions before and during HD and taking measures to eliminate it are reported to significantly increase the effectiveness of the treatment (Kutner, 2001). Cooperation between the members of a multidisciplinary team is required to ensure adherence of HD-treated individuals to their treatment. The nurses
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play a key role in this team by ensuring adherence of the individuals to the treatment, and participating in their monitoring and evaluation, as they have maintained long-term communication with HD patients (Kammerer et al., 2007; Kara, 2007). The nursing services provided at HD centers in the authors’ country focus mostly on physical care. Nurses are unable or unwilling to fulfill their roles and responsibilities in the care of patients on HD treatment with a holistic approach (Kara et al., 2007). The adherence of HD-treated patients to diet and fluid restriction has been reported to increase and some adverse events to be prevented or reduced when effective nursing interventions are applied (Denhaerynck et al., 2007). It is important for nurses to provide training to HD patients to facilitate their adherence to diet and fluid restrictions. Such training needs to include information on diet and fluid restriction, medication use (e.g. vitamin D preparation, erythropoietin, iron support), coping methods for the family and individual, and adaptation to lifestyle changes (Kammerer et al., 2007). These should also cover the pre-dialysis period, be continuous, and repeated according to individual requirements (Baraz, Parvardeh, Mohammadi, & Broumand, 2010; Durna, Akin, & Ozdilli, 2009). It has been reported that 49.1% of subjects do not receive pre-dialysis training in Turkey TSN, 2013 (Turkish Society of Nephrology, 2013). This indicates that nurses do not adequately meet their responsibilities as trainers that would facilitate their supporting behavioral changes that protect and improve the health of the patients and their families. Despite the presence of many international studies on the adherence of ESRD subjects to the diet, treatment protocols, and fluid limitations (Baraz et al., 2010; Denhaerynck et al., 2007; Kugler et al., 2005; Kutner, 2001; Lee & Molassiotis, 2002), only a few studies have been published from Turkey (Kara et al., 2007; Ovayolu et al., 2007). The authors therefore believe that determining the factors that influence adherence to the allimportant diet and fluid restrictions in ESRD treatment would help increase the awareness of nurses working in HD centers in the authors’ country and would also contribute to the planning of the training and nursing interventions to be provided to subjects undergoing HD treatment.
Aim of the study This study has been conducted to determine the HD-treated individuals’ adherence to diet and fluid restriction and the influencing factors in Turkey.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 113–123
METHODS Design This study was designed as a descriptive survey.
Study population This descriptive study was conducted with individuals who presented between 15 October 2010 and 15 January 2011 at one state-owned and two private dialysis centers in a city in the Central Anatolia Region of Turkey to receive HD treatment. All dialysis centers in this province were included in the study. There was a total of 154 registered ESRD patients for HD treatment at these dialysis centers during study period. No sample was chosen and all subjects that accepted participation and met study inclusion criteria were included in the sample. Inclusion criteria were: (i) age of 18–65 years; (ii) to have undergone HD treatment for at least 6 months; (iii) to be able to respond to the survey questions; (iv) not to be included in the preliminary administration; and (v) accept participation in the study with verbal and written consent. There were 33 subjects that did not meet the inclusion criteria (10 subjects were included in the preliminary administration, four subjects had been on treatment for less than 6 months, one subject could not respond to verbal questions, 11 subjects were older than 65 years, five subjects were away from the province, one subject was receiving cancer treatment, and one refused to participate), leaving 121 subjects for the study.
Setting There were 21 subjects receiving HD treatment at the dialysis center of the state hospital, and 91 and 42 for a total of 154 at the two private dialysis centers. Nurses and physicians with a HD certificate provided service 5 or 6 days a week at these centers. Nutritional education cannot be provided to individuals treated with HD in these centers due to the absence of a dietitian. However, the questions of the individuals receiving HD treatment are answered by nurses and doctors working in these centers. In addition, information about diet and fluid restriction based on specific values are provided by doctors when changes occur in the laboratory results of individuals receiving HD treatment.
Adherence to diet and fluid restriction
Department of Nutrition and Dietetics and screening the published work (Baysal, Bozkurt, & Ozsoy, 2002; Denhaerynck et al., 2007; Kammerer et al., 2007; Kara, 2007, 2009), and with the Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) (Vlaminck, Maes, Jacobs, Reyntjens, & Evers, 2001). The questionnaire form was administered to the patients receiving HD treatment after any required adjustments were made. The data were collected by the investigator by using the face-to-face interview method. The interviews lasted approximately 30 min. Weight and laboratory values of the individuals were obtained from the medical records in the dialysis centers.
Questionnaire form The questionnaire consisted of 41 questions divided into four parts: (i) sociodemographic characteristics such as age, educational level, occupation, height, weight, and social security (13 questions); (ii) disease characteristics such as years of HD treatment, HD duration, HD frequency, presence of other chronic disorders, symptoms experienced (eight questions); (iii) family support including the presence of an individual for home care and treatment, and with whom to share experiences and feelings (two questions); and (v) diet and fluid intake history of the individuals receiving HD treatment as regards fluid consumption (tea, soft drinks, coffee, ready-made fruit juice), daily water consumption, salt usage in meals, frequency of consumption of meals with potassium or phosphorus, and reasons for nonadherence to diet or fluid restriction (18 questions). The weight of the subjects was evaluated according to the dry weight in the patient folder as determined by the healthcare professionals at the dialysis center. The height of the subjects on HD treatment was measured by the investigator with a tape measure. The body mass index (BMI) was calculated according to the height and dry weight values. The BMI values were classified according to WHO criteria as thin ( 0.05) (Tables 1,2).
A statistically significant relationship was found between hemoglobin, hematocrit, potassium (entry), sodium, albumin, creatinine (entry), and Kt/V values and the scores of four items of the DDFQ (P > 0.05). A weak and negative relationship was found between the calcium (Ca++) level and FFN scores (P < 0.05). No statistically significant relationship was found between individuals’ Ca++ levels and FDN, DDN, and DFN scores (P > 0.05). The authors found a weak relationship between phosphorus levels and FDN, DDN, and FFN scores, and a moderate, positive, and significant
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 113–123
Adherence to diet and fluid restriction
Table 1 Distribution of diet non-adherence mean scores and medians of individuals included in the study Frequency of diet non-adherence (0–14 days) Mean ± SD
Median
Min.
Degree of diet non-adherence (0–4)
Max.
Mean ± SD
Median
Min.
Max.
Characteristics
N
Sex Female Male
46 75
6.0 ± 4.7 4.0 0.0 14.0 6.1 ± 4.3 5.0 1.0 14.0 MW-U = 1677.000, P = 0.796
1.9 ± 0.9 2.0 ± 0.8
Age, years 21–35 36–50 61–65
16 27 78
9.4 ± 5.3 12.0 1.0 6.2 ± 4.8 4.0 0.0 5.3 ± 3.8 4.0 1.0 KW = 7.532, P = 0.023
14.0 14.0 14.0
2.6 ± 1.0 3.0 1.0 2.0 ± 0.8 2.0 0.0 1.8 ± 0.8 2.0 0.0 KW = 7.800, P = 0.020
4.0 4.0 4.0
37 76
5.9 ± 4.2 5.9 ± 4.5
4.0 4.5
1.0 0.0
14.0 14.0
2.1 ± 0.8 1.9 ± 0.8
2.0 2.0
0.0 0.0
4.0 4.0
8
8.5 ± 4.9
8.5
1.0
14.0
2.2 ± 0.2
2.0
1.0
3.0
Educational level Not educated Primary school graduate High school graduate and above
KW = 2.273, P = 0.321 Marital status Married Single
2.0 0.0 2.0 1.0 t = 0.326, P = 0.745
4.0 4.0
KW = 4.202, P = 0.122
100 21
5.9 ± 4.3 4.0 0.0 14.0 6.7 ± 4.8 6.0 1.0 14.0 MW-U = 957.500, P = 0.213
1.9 ± 0.8 2.0 0.0 2.2 ± 1.0 2.0 1.0 MW-U = 881.500, P = 0.213
4.0 4.0
Someone in the family who helps with care and treatment Yes No
97 24
5.4 ± 4.0 4.0 0.0 14.0 8.8 ± 5.1 9.0 2.0 14.0 MW-U = 712.500, P = 0.003
1.9 ± 0.8 2.0 0.0 2.4 ± 0.9 2.0 1.0 MW-U = 805.500, P = 0.012
4.0 4.0
Someone who shares the problems Yes No
82 39
5.5 ± 4.1 4.0 0.0 14.0 7.2 ± 5.0 6.0 1.0 14.0 MW-U = 1316.500, P = 0.114
1.9 ± 0.8 2.2 ± 0.8
4.0 4.0
Salt consumption habit in meals Salted Normally salted Less salted Without salt
40 29 43 9
8.1 ± 4.8 8.0 2.0 5.6 ± 4.3 4.0 0.0 4.9 ± 3.6 4.0 1.0 4.0 ± 3.9 2.0 1.0 KW = 12.890, P, P = 0.005
14.0 14.0 14.0 10.0
2.2 ± 0.9 2.0 1.0 2.0 ± 0.8 2.0 0.0 1.9 ± 0.8 2.0 0.0 1.4 ± 0.7 1.0 1.0 KW = 6.922, P = 0.074
4.0 4.0 4.0 3.0
Interdialytic weight gain 0–1.4 kg 1.5–2.9 kg 3.0–4.4 kg ≥4.5 kg
16 37 50 18
4.5 ± 3.8 3.0 1.0 4.6 ± 3.6 4.0 0.0 6.4 ± 4.5 5.0 1.0 9.4 ± 4.6 10.0 3.0 KW = 16.109, P = 0.001
14.0 14.0 14.0 14.0
1.7 ± 0.5 2.0 1.0 2.0 0.0 1.8 ± 0.8 2.0 ± 0.9 2.0 1.0 2.5 ± 0.8 3.0 1.0 KW = 11.148, P = 0.011
2.0 4.0 4.0 4.0
2.0 0.0 2.0 1.0 t = 2.169, P = 0.032
KW, Kruskal–Wallis test; MW-U, Mann–Whitney U-test; SD, standard deviation; t, Student’s t-test independent groups.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Japan Journal of Nursing Science (2015) 12, 113–123
Table 2 The distribution of fluid non-adherence mean scores and medians of individuals included in the study Frequency of fluid non-adherence (0–14 days) Characteristics
N
Sex Female Male
46 75
Age, years 21–35 36–50 61–65
16 27 78
Educational level Not educated Primary school graduate High school graduate and above
Mean ± SD
Max.
Mean ± SD
7.0 ± 5.3 6.0 0.0 14.0 6.4 ± 4.7 4.0 0.0 14.0 MW-U = 1676.000, P = 0.792
2.1 ± 1.1 2.2 ± 1.0
Median
Min.
10.6 ± 4.3 12.0 2.0 8.6 ± 5.3 10.0 0.0 5.2 ± 4.3 3.5 0.0 KW = 17.756, P = 0.0001
Median
Min.
2.0 0.0 2.0 0.0 t = 0.148, P = 0.883
Max. 4.0 4.0
14.0 14.0 14.0
2.9 ± 0.9 3.0 1.0 2.3 ± 1.0 3.0 0.0 1.9 ± 1.0 2.0 0.0 KW = 12.549, P = 0.002
4.0 4.0 4.0
37 76
6.6 ± 4.9 6.6 ± 5.0
6.0 4.0
0.0 0.0
14.0 14.0
2.2 ± 1.2 2.1 ± 1.0
3.0 2.0
0.0 0.0
4.0 4.0
8
7.5 ± 5.3
8.5
1.0
14.0
2.1 ± 0.8
2.0
1.00
3.0
KW = 0.100, P = 0.951 Marital status Married Single
Degree of fluid non-adherence (0–4)
KW = 0.860, P = 0.650
100 21
6.5 ± 4.9 4.0 0.0 14.0 7.3 ± 5.2 8.0 0.0 14.0 MW-U = 964.500, P = 0.555
2.1 ± 1.0 2.0 0.0 2.5 ± 1.1 3.0 0.0 MW-U = 836.000, P = 0.128
4.0 4.0
Someone in the family who helps with care and treatment Yes No
97 24
6.0 ± 4.7 4.0 0.0 14.0 9.4 ± 5.2 10.0 1.0 14.0 MW-U = 755.500, P = 0.007
2.02 ± 1.1 2.0 0.0 2.7 ± 0.9 3.0 1.0 MW-U = 775.000, P = 0.008
4.0 4.0
Someone who shares the problems Yes No
82 39
5.9 ± 4.9 4.0 0.0 14.0 8.1 ± 4.8 10.0 1.0 14.0 MW-U = 1190.500, P = 0.022
1.9 ± 1.1 2.6 ± 0.9
Salt consumption habit in meals Salted Normally salted Less salted Without salt
40 29 43 9
8.1 ± 5.0 8.0 1.0 6.0 ± 4.8 4.0 0.0 6.2 ± 4.9 3.0 0.0 4.5 ± 4.6 3.0 0.0 KW = 7.183, P = 0.066
14.0 14.0 14.0 14.0
2.5 ± 0.9 3.0 1.0 2.1 ± 1.0 2.0 0.0 1.9 ± 1.1 2.0 0.0 1.5 ± 1.0 1.0 0.0 KW = 10.792, P = 0.013
4.0 4.0 4.0 3.0
Interdialytic weight gain 0–1.4 kg 1.5–2.9 kg 3.0–4.4 kg ≥4.5 kg
16 37 50 18
4.5 ± 4.6 3.0 0.0 5.0 ± 4.3 3.0 0.0 6.8 ± 4.9 5.0 0.0 11.6 ± 3.0 12.0 4.0 KW = 24.817, P = 0.0001
14.0 14.0 14.0 14.0
1.6 ± 1.1 1.5 0.0 1.9 ± 1.1 2.0 0.0 2.2 ± 1.0 2.0 0.0 3.1 ± 0.7 3.0 1.0 KW = 20.597, P = 0.0001
4.0 4.0 4.0 4.0
2.0 0.0 3.0 1.0 t = 3.485, P = 0.001
4.0 4.0
KW, Kruskal–Wallis test; MW-U, Mann–Whitney U-test; SD, standarddeviation; t, Student’s t-test independent groups.
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© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 113–123
Adherence to diet and fluid restriction
Table 3 Relationship between laboratory results of individuals included in the study and Dialysis Diet and Fluid Non-adherence Questionnaire Frequency of diet non-adherence Laboratory findings Hemoglobin, g/dL Hematocrit, % K+, mmol/L (input) Na+, mmol/L Ca++, mg/dL Phosphorus, mg/dL Albumin, g/dL BUN, mg/dL (input) Creatinine, mg/dL (input) Kt/v
Degree of diet non-adherence
Frequency of fluid non-adherence
Degree of fluid non-adherence
rs
P
rs
P
rs
P
rs
P
−0.06 −0.12 −0.09 0.07 0.01 0.23 0.12 0.12 0.16 −0.02
0.538 0.211 0.343 0.431 0.952 0.013 0.203 0.193 0.090 0.871
−0.08 −0.10 −0.17 0.10 0.05 0.18 0.05 0.14 0.11 −0.02
0.414 0.298 0.067 0.259 0.600 0.044 0.624 0.120 0.253 0.833
−0.08 −0.12 −0.14 0.01 −0.22 0.24 0.06 0.12 −0.0.01 −0.01
0.395 0.195 0.130 0.934 0.017 0.007 0.534 0.203 0.949 0.898
−0.12 −0.15 −0.11 0.05 −0.12 0.28 0.12 0.20 0.03 0.07
0.184 0.113 0.253 0.624 0.177 0.002 0.175 0.031 0.763 0.478
Bold text indicates statistical significance. BUN, blood urea nitrogen; rs, Spearman’s rank correlation coefficient.
relationship between phosphorus levels and DFN scores (P < 0.05). A weakly positive significant relationship was found between pre-dialysis blood urea nitrogen (BUN) levels and DFN (P < 0.05). No statistically significant relationship was found between BUN levels and FDN, DDN, and FFN scores (P > 0.05) (Table 3). Frequency of diet non-adherence and DFN score medians of those who consumed salted food were higher than those who did not (P < 0.05) but with no statistically significant difference between DDN and FFN score medians (P > 0.05). FDN, DDN, FFN, and DFN score medians of those who had 4.5 kg or more interdialytic weight gain were higher than those who gained less weight (P < 0.05) (Tables 1,2).
Factors affecting non-adherence Frequency of diet non-adherence, DDN, FFN, and DFN score medians in HD-treated individuals in the 21–35 year age group were found to be higher than in the other age groups (P < 0.05). No statistically significant difference was found between the sex of the HD-treated individuals and the FDN and FFN score medians and DDN and DFN score means (P > 0.05). No statistically significant difference was found between marital status and education level and the FDN, DDN, FFN, and DFN score medians (P > 0.05) (Tables 1,2).
DISCUSSION Non-adherence to diet and fluid restriction Chronic renal failure (CRF) is a disease that affects eating and drinking habits and preferences and causes
many metabolic, physiological, and psychological changes in individuals (Ovayolu et al., 2007). Patients have difficulties complying with CRF treatment due to the changes they experience (Kara, 2007). Material and spiritual losses, becoming dependent on someone else, treatment side-effects, changes in the lifestyle of an individual and their family, and diet and fluid restriction are among these changes that make adherence difficult (Kara, 2007; Ovayolu et al., 2007; Ustun & Karadeniz, 2006). When adherence to diet and fluid restriction is ensured, the side-effects of the treatment decrease, the caregiver’s burden decreases, the quality of life of the patient increases, psychosocial health problems decrease, and expected life duration increases. Adherence to diet and fluid restriction is therefore important (Kara, 2007; Kutner, 2001). According to Hansen (2001), each individual experiences the problem of non-adherence to treatment to a certain degree. The authors found that 98.3% of their HD-treated individuals to experience nonadherence to diet and 95.0% to fluid restriction. Kugler et al. (2005) reported that 81.4% of HDtreated individuals experienced non-adherence to diet and 74.6% to fluid restriction. Kara et al. (2007) reported 58.1% of HD-treated individuals to be noncompliant with their diet and 68.1% with fluid restriction. The present authors found higher rates of nonadherence to diet and fluid restriction compared to other studies (Kara et al., 2007; Kugler et al., 2005). This difference may stem from the characteristics of the place the study was carried out and the individuals in the sample.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Japan Journal of Nursing Science (2015) 12, 113–123
Perceived family support The presence of someone in the family helping with the care and treatment and sharing the problems or the presence of social support are factors that facilitate adherence to HD treatment (Kara et al., 2007). The absence of social support causes stress, anxiety, and psychological changes. Such changes affect the immune system, potentially leading to other problems and death (Thong, Kaptein, Krediet, Boeschoten, & Dekker, 2007). Studies (Kugler et al., 2005; Kara et al., 2007) emphasize the importance of social and family support in adherence to diet and fluid restriction. The authors found that FDN, DDN, FFN, and DFN score medians were higher in patients with no one in the family to help with care and treatment (P < 0.05) (Tables 1,2). In addition, DDN and DFN score means and the FFN score median of those with no one to share problems with were also higher than in those who had someone (P < 0.05) (Tables 1,2). Ozturk et al. (2009) reported that CRF patients who had always been supported by their family and relatives received significantly less psychiatric support and found it easier to accept the disease. Thong et al. (2007) found HD-treated individuals who struggled with uncertainties in treatment and diet regime to accept the changes in lifestyle more easily when they had the support of friends and family. The results of these studies (Kara et al., 2007; Kugler et al., 2005; Ozturk et al., 2009; Thong et al., 2007) are similar to the present authors’ research findings in showing that having family and social support increases adherence to treatment.
Non-adherence and biochemical and biological values Increased phosphorus levels decrease the Ca++ level and a relationship has been found between these low levels and non-adherence to diet and fluid restriction (Altiparmak, 2009; Baysal et al., 2002). The authors found a weak and negative relationship between the Ca++ level and FFN scores (P < 0.05) (Table 3). There was a weak relationship between phosphorus levels and FDN, DDN, and FFN scores, and a moderate, positive and significant relation between phosphorus levels and DFN scores (P < 0.05) (Table 3). Kara et al. (2007) found a significant relationship between phosphorus level and adherence to diet and fluid restriction in HD-treated patients. These results support the present authors’ study findings. Informing subjects that increased consumption of foods containing phosphorus will decrease Ca++ levels
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and cause health problems and informing them regarding solutions will be beneficial in maintaining the balance of these ions. Restriction of salt from the diet and restriction of fluid intake are important in the prevention of cardiovascular diseases in HD-treated individuals (Baysal et al., 2002; Welch, Bennett, Delp, & Agarwal, 2006). When individuals do not restrict salt in their diet, they become thirsty and this leads to drinking more water (Welch et al., 2006). Only 5.0% of the individuals treated with HD in the present study complied with the fluid restriction. A study from the present authors’ country has reported that all family members consume tea, most commonly black tea, in all seasons, with a monthly tea consumption per family of 2.33 kg (Sayili & Gozener, 2013). The authors found that such tea-drinking habits leads to difficulty with fluid restrictions in HD-treated subjects. In addition, the present study found that the FDN, DDN, FFN, and DFN score medians of those with an interdialytic weight gain of 4.5 kg or more to be significantly higher than who gained less weight (P < 0.05) (Tables 1,2). Increased interdialytic weight gain causes problems such as shortness of breath, muscle cramps, anxiety, pulmonary edema, and hypertension in individuals (Denhaerynck et al., 2007). The recommended interdialytic weight gain for HD-treated individuals is 2.5 kg (Molaison & Yadrick, 2003). Kara et al. (2007) and Kugler et al. (2005) found HD-treated patients with high interdialytic weight gain to experience more non-adherence to diet and fluid restriction, similar to the present study. These results indicate that teaching alternative methods to decrease thirst, such as putting an ice cube into the mouth, could be effective in decreasing non-adherence of individuals to fluid restriction. Hypertension and left ventricular hypertrophy may develop when subjects are non-compliant to diet salt and fluid restriction (Welch et al., 2006). The SALTURK study from Turkey has reported a daily individual salt consumption of 18.01 g (Erdem et al., 2010). The present authors found that 33.1% of the individuals on HD treatment consumed their food with salt. FDN and DFN score medians were found to be higher in those who consumed their meals with salt than those who did not in the present study (P < 0.05) (Tables 1,2). Providing information on how high salt consumption may affect the health and checking salt consumption habits when patients come for their HD session are considered to be effective in promoting adherence to diet and fluid restriction.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 113–123
Factors affecting non-adherence Adherence of HD-treated individuals to diet and fluid restriction is affected by many factors such as sex, age, sociocultural characteristics, health status, knowledge of existing disease, and familial and environmental conditions (Kammerer et al., 2007; Kara, 2007; WHO, 2003). One of the factors that affects adherence to HD treatment is age (Kammerer et al., 2007). In the present study, FDN and DDN median scores of HD-treated individuals in the of 21–35 year age group was higher than in the other age groups, and the FFN and DFN score medians of the 51–65-year age group was significantly lower than the 36–50 year age group (P < 0.05) (Tables 1,2). Leggat et al. (1998) found HD-treated individuals in the 20–39-year age group to experience more non-adherence to treatment than the 40–59-year age group. Young people are reported to experience intense feelings of being independent and therefore not wanting to accept being dependent on the HD machine and diet and fluid restrictions (Kara et al., 2007Kutner, 2001). Non-adherence to treatment is therefore more common in younger patients (Kara, 2007; Kugler et al., 2005). The results the authors obtained in the present study are similar to those found in the Leggat et al. study (1998) and other articles (Kara, 2007; Kugler et al., 2005). Based on these results, performing studies investigating adherence to diet and fluid restriction in young people and using nursing interventions and providing training according to the results obtained should be effective in increasing adherence.
CONCLUSION In conclusion, the authors found high levels of nonadherence to diet and fluid restriction in the subjects of the present study. The authors also found the Cronbach alpha value for the scale used to determine nonadherence to diet and fluid restriction to indicate a moderately reliable tool. Nurses need to be more aware that the adherence of HD patients to diet and fluid restriction is influenced by many factors such as age, family support, nutritional status before the disorder, and cultural habits. The adherence can change over time and it is therefore necessary to collect data related to the adherence of patients on HD to diet and fluid restrictions at regular intervals, and nursing interventions related to the factors influencing adherence should be planned and used. The authors recommend developing new scales with high validity
Adherence to diet and fluid restriction
and reliability to evaluate the non-adherence of patients to fluid restriction and conducting new studies on the subject.
Study limitations Some data in the study were obtained through the verbal statements of the subjects included in the sample. The reliability of the results therefore depend on the responses of these individuals. Another limitation was that the subjects were included according to meeting the inclusion criteria and only if they were residents of the province the study was conducted in. It is therefore possible to generalize the authors’ results only to individuals receiving HD treatment in that province.
ACKNOWLEDGMENT The authors are grateful to all the participants in the study.
CONFLICT OF INTEREST The authors declare no conflicts of interest with respect to the authorship and/or publication of this article.
FUNDING This research was not supported by any institution.
AUTHOR CONTRIBUTION D. E. performed the statistical analyses and drafted the manuscript, was involved in the study design, made contributions to the manuscript and the data for the analyses available, prepared the data for the analyses, read and approved the final manuscript, and was responsible for critical revisions for important intellectual content. S. K. drafted the manuscript, was involved in the study design, made contributions to the manuscript, prepared the data for the analyses, read and approved the final manuscript, and was responsible for important intellectual content.
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doi:10.1111/jjns.12055
ORIGINAL ARTICLE
Adherence to diet and fluid restriction of individuals on hemodialysis treatment and affecting factors in Turkey Dilek EFE1 and Semra KOCAÖZ2 1 Department of Medical Nursing, School of Health, Bozok University, Yozgat and 2Department of Nursing, Nigde Zubeyde Hanim School of Health, Obstetric and Women’s Health Nursing, Nigde University, Nigde, Turkey
Abstract Aim: This study was conducted to determine adherence to diet and fluid restriction in hemodialysis-treated individuals and the affecting factors in Turkey. Methods: This descriptive study was conducted between 15 October 2010 and 15 January 2011 in subjects who voluntarily agreed to participate in the study from three dialysis centers in a city located in the Central Anatolia Region of Turkey. One hundred and twenty-one individuals treated with hemodialysis made up the study sample. The data were collected using a questionnaire consisting of 41 questions and the Dialysis Diet and Fluid Non-adherence Questionnaire. The data were evaluated with percentage, median, Mann–Whitney U-test, Kruskal–Wallis test, Student’s t-test in independent samples and Spearman’s rank correlation coefficient. Results: The authors found that 98.3% of the individuals experienced non-adherence to diet and 95.0% with fluid restriction. The authors found a weak and negative relationship between calcium levels and non-adherence to fluid restriction, a weak relationship between phosphorus levels and diet non-adherence frequency and degree and the fluid non-adherence frequency scores, and a moderate positive relationship between phosphorus levels and fluid restriction non-adherence degree scores (P < 0.05). Conclusion: Based on these results, regular training and information regarding diet and fluid restriction must be provided to individuals aged 21–35 years with no one in the family to help with their care, those who consumed salted food, or had interdialytic weight gain of 4.5 kg or more. Key words: adherence, diet, fluid restriction, hemodialysis, nursing.
INTRODUCTION Chronic renal failure is an irreversible and progressive renal dysfunction that may eventually lead to end-stage renal disease (ESRD). Hemodialysis (HD) is the most common method used for the treatment of individuals diagnosed with ESRD (Akoglu & Suleymanlar, 2005).
Correspondence: Dilek Efe, Bozok Üniversitesi Türkiye Odalar ve Borsalar Birlig˘i Sag˘lık Yüksekokulu Bozok Üniversitesi Erdog˘an Akdag˘ Kampüsü, 66100, Yozgat/ Türkiye. Email: [email protected] This study was presented as a poster presentation at the 14th National Internal Medicine Congress, 3–7 October 2012, Antalya, Turkey. Received 13 November 2013; accepted 26 May 2014.
The CREDIT study conducted in 2009 with the contribution of the Turkish Nephrology Association found that 15.7% of Turkish adults (∼7.5 million people) have chronic renal disease at various stages and 78.5% of this group is undergoing HD (Suleymanlar et al., 2011). HD treatment enables individuals to deal with ESRD symptoms but can cause severe physical, psychological, social, and economic problems (Kaba et al., 2007; Kammerer, Garry, Hartigan, Carter, & Erlich, 2007). Such problems experienced during HD treatment increase the emotional pressure on individuals and make adherence to treatment difficult by disturbing the mental state (Kara, 2007; Ozturk, Altuntas, Ozsan, & Gunduz, 2009). The 2003 World Health Organization (WHO) report defines adherence as “a measure of the
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individual’s behavioral change according to the recommendations of the health care team regarding medication use, diet and lifestyle change” (World Health Organization, 2003). As in all chronic diseases, individuals diagnosed with ESRD who continue HD treatment should adapt to the drug treatment and diet and fluid restrictions to maintain their health (Denhaerynck et al., 2007; White, 2004). The adherence of HD patients to diet and fluid restriction is evaluated with subjective and objective measurement tools. Subjective measurements are made through the verbal statements of the patients and healthcare workers’ opinions, while objective measurement is made with biological and biochemical values such as phosphorus, albumin, interdialytic weight change, and sodium and fluid intake (Kara, Çaglar, & Kılıc, 2007). The adherence of ESRD patients to their treatments and the diet and fluid restrictions is difficult due to their physiological and psychological problems (Kaba et al., 2007). The non-adherence of HD-treated individuals to diet and fluid restrictions is reported to cause fluid–electrolyte imbalance and malnutrition together with increased mortality rates (Ovayolu, Ucan, Pehlivan, & Yildizgordu, 2007). Studies have demonstrated that many factors such as lack of social support (Yokoyoma et al., 2009), smoking, sex, age, HD duration, the presence of other chronic disorders (Kara, 2007; Kutner, 2001), the perception of the chronic disease follow up and treatment, health beliefs, cultural characteristics, and satisfaction with the healthcare system play an important role in the non-adherence of HD patients to diet and fluid treatment (Kara, 2007; WHO, 2003). The non-adherence to treatment rate of HD patients varies according to the definition used and the measurement tools (Kutner, Zhang, McClellan, & Cole, 2002). It is reported that approximately 86% of dialysis patients have adherence problems with one or several aspects of the treatment (Loghman-Adham, 2003). Kugler, Vlamick, Haverich, and Maes (2005) found that 81.4% of HD patients showed non-adherence to diet and 74.6% to fluid restriction. A study from the authors’ country found these rates to be 58.1% and 68.1%, respectively (Kara et al., 2007). Determining the status of non-adherence to diet and fluid restrictions before and during HD and taking measures to eliminate it are reported to significantly increase the effectiveness of the treatment (Kutner, 2001). Cooperation between the members of a multidisciplinary team is required to ensure adherence of HD-treated individuals to their treatment. The nurses
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play a key role in this team by ensuring adherence of the individuals to the treatment, and participating in their monitoring and evaluation, as they have maintained long-term communication with HD patients (Kammerer et al., 2007; Kara, 2007). The nursing services provided at HD centers in the authors’ country focus mostly on physical care. Nurses are unable or unwilling to fulfill their roles and responsibilities in the care of patients on HD treatment with a holistic approach (Kara et al., 2007). The adherence of HD-treated patients to diet and fluid restriction has been reported to increase and some adverse events to be prevented or reduced when effective nursing interventions are applied (Denhaerynck et al., 2007). It is important for nurses to provide training to HD patients to facilitate their adherence to diet and fluid restrictions. Such training needs to include information on diet and fluid restriction, medication use (e.g. vitamin D preparation, erythropoietin, iron support), coping methods for the family and individual, and adaptation to lifestyle changes (Kammerer et al., 2007). These should also cover the pre-dialysis period, be continuous, and repeated according to individual requirements (Baraz, Parvardeh, Mohammadi, & Broumand, 2010; Durna, Akin, & Ozdilli, 2009). It has been reported that 49.1% of subjects do not receive pre-dialysis training in Turkey TSN, 2013 (Turkish Society of Nephrology, 2013). This indicates that nurses do not adequately meet their responsibilities as trainers that would facilitate their supporting behavioral changes that protect and improve the health of the patients and their families. Despite the presence of many international studies on the adherence of ESRD subjects to the diet, treatment protocols, and fluid limitations (Baraz et al., 2010; Denhaerynck et al., 2007; Kugler et al., 2005; Kutner, 2001; Lee & Molassiotis, 2002), only a few studies have been published from Turkey (Kara et al., 2007; Ovayolu et al., 2007). The authors therefore believe that determining the factors that influence adherence to the allimportant diet and fluid restrictions in ESRD treatment would help increase the awareness of nurses working in HD centers in the authors’ country and would also contribute to the planning of the training and nursing interventions to be provided to subjects undergoing HD treatment.
Aim of the study This study has been conducted to determine the HD-treated individuals’ adherence to diet and fluid restriction and the influencing factors in Turkey.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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METHODS Design This study was designed as a descriptive survey.
Study population This descriptive study was conducted with individuals who presented between 15 October 2010 and 15 January 2011 at one state-owned and two private dialysis centers in a city in the Central Anatolia Region of Turkey to receive HD treatment. All dialysis centers in this province were included in the study. There was a total of 154 registered ESRD patients for HD treatment at these dialysis centers during study period. No sample was chosen and all subjects that accepted participation and met study inclusion criteria were included in the sample. Inclusion criteria were: (i) age of 18–65 years; (ii) to have undergone HD treatment for at least 6 months; (iii) to be able to respond to the survey questions; (iv) not to be included in the preliminary administration; and (v) accept participation in the study with verbal and written consent. There were 33 subjects that did not meet the inclusion criteria (10 subjects were included in the preliminary administration, four subjects had been on treatment for less than 6 months, one subject could not respond to verbal questions, 11 subjects were older than 65 years, five subjects were away from the province, one subject was receiving cancer treatment, and one refused to participate), leaving 121 subjects for the study.
Setting There were 21 subjects receiving HD treatment at the dialysis center of the state hospital, and 91 and 42 for a total of 154 at the two private dialysis centers. Nurses and physicians with a HD certificate provided service 5 or 6 days a week at these centers. Nutritional education cannot be provided to individuals treated with HD in these centers due to the absence of a dietitian. However, the questions of the individuals receiving HD treatment are answered by nurses and doctors working in these centers. In addition, information about diet and fluid restriction based on specific values are provided by doctors when changes occur in the laboratory results of individuals receiving HD treatment.
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Department of Nutrition and Dietetics and screening the published work (Baysal, Bozkurt, & Ozsoy, 2002; Denhaerynck et al., 2007; Kammerer et al., 2007; Kara, 2007, 2009), and with the Dialysis Diet and Fluid Nonadherence Questionnaire (DDFQ) (Vlaminck, Maes, Jacobs, Reyntjens, & Evers, 2001). The questionnaire form was administered to the patients receiving HD treatment after any required adjustments were made. The data were collected by the investigator by using the face-to-face interview method. The interviews lasted approximately 30 min. Weight and laboratory values of the individuals were obtained from the medical records in the dialysis centers.
Questionnaire form The questionnaire consisted of 41 questions divided into four parts: (i) sociodemographic characteristics such as age, educational level, occupation, height, weight, and social security (13 questions); (ii) disease characteristics such as years of HD treatment, HD duration, HD frequency, presence of other chronic disorders, symptoms experienced (eight questions); (iii) family support including the presence of an individual for home care and treatment, and with whom to share experiences and feelings (two questions); and (v) diet and fluid intake history of the individuals receiving HD treatment as regards fluid consumption (tea, soft drinks, coffee, ready-made fruit juice), daily water consumption, salt usage in meals, frequency of consumption of meals with potassium or phosphorus, and reasons for nonadherence to diet or fluid restriction (18 questions). The weight of the subjects was evaluated according to the dry weight in the patient folder as determined by the healthcare professionals at the dialysis center. The height of the subjects on HD treatment was measured by the investigator with a tape measure. The body mass index (BMI) was calculated according to the height and dry weight values. The BMI values were classified according to WHO criteria as thin ( 0.05) (Tables 1,2).
A statistically significant relationship was found between hemoglobin, hematocrit, potassium (entry), sodium, albumin, creatinine (entry), and Kt/V values and the scores of four items of the DDFQ (P > 0.05). A weak and negative relationship was found between the calcium (Ca++) level and FFN scores (P < 0.05). No statistically significant relationship was found between individuals’ Ca++ levels and FDN, DDN, and DFN scores (P > 0.05). The authors found a weak relationship between phosphorus levels and FDN, DDN, and FFN scores, and a moderate, positive, and significant
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Table 1 Distribution of diet non-adherence mean scores and medians of individuals included in the study Frequency of diet non-adherence (0–14 days) Mean ± SD
Median
Min.
Degree of diet non-adherence (0–4)
Max.
Mean ± SD
Median
Min.
Max.
Characteristics
N
Sex Female Male
46 75
6.0 ± 4.7 4.0 0.0 14.0 6.1 ± 4.3 5.0 1.0 14.0 MW-U = 1677.000, P = 0.796
1.9 ± 0.9 2.0 ± 0.8
Age, years 21–35 36–50 61–65
16 27 78
9.4 ± 5.3 12.0 1.0 6.2 ± 4.8 4.0 0.0 5.3 ± 3.8 4.0 1.0 KW = 7.532, P = 0.023
14.0 14.0 14.0
2.6 ± 1.0 3.0 1.0 2.0 ± 0.8 2.0 0.0 1.8 ± 0.8 2.0 0.0 KW = 7.800, P = 0.020
4.0 4.0 4.0
37 76
5.9 ± 4.2 5.9 ± 4.5
4.0 4.5
1.0 0.0
14.0 14.0
2.1 ± 0.8 1.9 ± 0.8
2.0 2.0
0.0 0.0
4.0 4.0
8
8.5 ± 4.9
8.5
1.0
14.0
2.2 ± 0.2
2.0
1.0
3.0
Educational level Not educated Primary school graduate High school graduate and above
KW = 2.273, P = 0.321 Marital status Married Single
2.0 0.0 2.0 1.0 t = 0.326, P = 0.745
4.0 4.0
KW = 4.202, P = 0.122
100 21
5.9 ± 4.3 4.0 0.0 14.0 6.7 ± 4.8 6.0 1.0 14.0 MW-U = 957.500, P = 0.213
1.9 ± 0.8 2.0 0.0 2.2 ± 1.0 2.0 1.0 MW-U = 881.500, P = 0.213
4.0 4.0
Someone in the family who helps with care and treatment Yes No
97 24
5.4 ± 4.0 4.0 0.0 14.0 8.8 ± 5.1 9.0 2.0 14.0 MW-U = 712.500, P = 0.003
1.9 ± 0.8 2.0 0.0 2.4 ± 0.9 2.0 1.0 MW-U = 805.500, P = 0.012
4.0 4.0
Someone who shares the problems Yes No
82 39
5.5 ± 4.1 4.0 0.0 14.0 7.2 ± 5.0 6.0 1.0 14.0 MW-U = 1316.500, P = 0.114
1.9 ± 0.8 2.2 ± 0.8
4.0 4.0
Salt consumption habit in meals Salted Normally salted Less salted Without salt
40 29 43 9
8.1 ± 4.8 8.0 2.0 5.6 ± 4.3 4.0 0.0 4.9 ± 3.6 4.0 1.0 4.0 ± 3.9 2.0 1.0 KW = 12.890, P, P = 0.005
14.0 14.0 14.0 10.0
2.2 ± 0.9 2.0 1.0 2.0 ± 0.8 2.0 0.0 1.9 ± 0.8 2.0 0.0 1.4 ± 0.7 1.0 1.0 KW = 6.922, P = 0.074
4.0 4.0 4.0 3.0
Interdialytic weight gain 0–1.4 kg 1.5–2.9 kg 3.0–4.4 kg ≥4.5 kg
16 37 50 18
4.5 ± 3.8 3.0 1.0 4.6 ± 3.6 4.0 0.0 6.4 ± 4.5 5.0 1.0 9.4 ± 4.6 10.0 3.0 KW = 16.109, P = 0.001
14.0 14.0 14.0 14.0
1.7 ± 0.5 2.0 1.0 2.0 0.0 1.8 ± 0.8 2.0 ± 0.9 2.0 1.0 2.5 ± 0.8 3.0 1.0 KW = 11.148, P = 0.011
2.0 4.0 4.0 4.0
2.0 0.0 2.0 1.0 t = 2.169, P = 0.032
KW, Kruskal–Wallis test; MW-U, Mann–Whitney U-test; SD, standard deviation; t, Student’s t-test independent groups.
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Table 2 The distribution of fluid non-adherence mean scores and medians of individuals included in the study Frequency of fluid non-adherence (0–14 days) Characteristics
N
Sex Female Male
46 75
Age, years 21–35 36–50 61–65
16 27 78
Educational level Not educated Primary school graduate High school graduate and above
Mean ± SD
Max.
Mean ± SD
7.0 ± 5.3 6.0 0.0 14.0 6.4 ± 4.7 4.0 0.0 14.0 MW-U = 1676.000, P = 0.792
2.1 ± 1.1 2.2 ± 1.0
Median
Min.
10.6 ± 4.3 12.0 2.0 8.6 ± 5.3 10.0 0.0 5.2 ± 4.3 3.5 0.0 KW = 17.756, P = 0.0001
Median
Min.
2.0 0.0 2.0 0.0 t = 0.148, P = 0.883
Max. 4.0 4.0
14.0 14.0 14.0
2.9 ± 0.9 3.0 1.0 2.3 ± 1.0 3.0 0.0 1.9 ± 1.0 2.0 0.0 KW = 12.549, P = 0.002
4.0 4.0 4.0
37 76
6.6 ± 4.9 6.6 ± 5.0
6.0 4.0
0.0 0.0
14.0 14.0
2.2 ± 1.2 2.1 ± 1.0
3.0 2.0
0.0 0.0
4.0 4.0
8
7.5 ± 5.3
8.5
1.0
14.0
2.1 ± 0.8
2.0
1.00
3.0
KW = 0.100, P = 0.951 Marital status Married Single
Degree of fluid non-adherence (0–4)
KW = 0.860, P = 0.650
100 21
6.5 ± 4.9 4.0 0.0 14.0 7.3 ± 5.2 8.0 0.0 14.0 MW-U = 964.500, P = 0.555
2.1 ± 1.0 2.0 0.0 2.5 ± 1.1 3.0 0.0 MW-U = 836.000, P = 0.128
4.0 4.0
Someone in the family who helps with care and treatment Yes No
97 24
6.0 ± 4.7 4.0 0.0 14.0 9.4 ± 5.2 10.0 1.0 14.0 MW-U = 755.500, P = 0.007
2.02 ± 1.1 2.0 0.0 2.7 ± 0.9 3.0 1.0 MW-U = 775.000, P = 0.008
4.0 4.0
Someone who shares the problems Yes No
82 39
5.9 ± 4.9 4.0 0.0 14.0 8.1 ± 4.8 10.0 1.0 14.0 MW-U = 1190.500, P = 0.022
1.9 ± 1.1 2.6 ± 0.9
Salt consumption habit in meals Salted Normally salted Less salted Without salt
40 29 43 9
8.1 ± 5.0 8.0 1.0 6.0 ± 4.8 4.0 0.0 6.2 ± 4.9 3.0 0.0 4.5 ± 4.6 3.0 0.0 KW = 7.183, P = 0.066
14.0 14.0 14.0 14.0
2.5 ± 0.9 3.0 1.0 2.1 ± 1.0 2.0 0.0 1.9 ± 1.1 2.0 0.0 1.5 ± 1.0 1.0 0.0 KW = 10.792, P = 0.013
4.0 4.0 4.0 3.0
Interdialytic weight gain 0–1.4 kg 1.5–2.9 kg 3.0–4.4 kg ≥4.5 kg
16 37 50 18
4.5 ± 4.6 3.0 0.0 5.0 ± 4.3 3.0 0.0 6.8 ± 4.9 5.0 0.0 11.6 ± 3.0 12.0 4.0 KW = 24.817, P = 0.0001
14.0 14.0 14.0 14.0
1.6 ± 1.1 1.5 0.0 1.9 ± 1.1 2.0 0.0 2.2 ± 1.0 2.0 0.0 3.1 ± 0.7 3.0 1.0 KW = 20.597, P = 0.0001
4.0 4.0 4.0 4.0
2.0 0.0 3.0 1.0 t = 3.485, P = 0.001
4.0 4.0
KW, Kruskal–Wallis test; MW-U, Mann–Whitney U-test; SD, standarddeviation; t, Student’s t-test independent groups.
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Adherence to diet and fluid restriction
Table 3 Relationship between laboratory results of individuals included in the study and Dialysis Diet and Fluid Non-adherence Questionnaire Frequency of diet non-adherence Laboratory findings Hemoglobin, g/dL Hematocrit, % K+, mmol/L (input) Na+, mmol/L Ca++, mg/dL Phosphorus, mg/dL Albumin, g/dL BUN, mg/dL (input) Creatinine, mg/dL (input) Kt/v
Degree of diet non-adherence
Frequency of fluid non-adherence
Degree of fluid non-adherence
rs
P
rs
P
rs
P
rs
P
−0.06 −0.12 −0.09 0.07 0.01 0.23 0.12 0.12 0.16 −0.02
0.538 0.211 0.343 0.431 0.952 0.013 0.203 0.193 0.090 0.871
−0.08 −0.10 −0.17 0.10 0.05 0.18 0.05 0.14 0.11 −0.02
0.414 0.298 0.067 0.259 0.600 0.044 0.624 0.120 0.253 0.833
−0.08 −0.12 −0.14 0.01 −0.22 0.24 0.06 0.12 −0.0.01 −0.01
0.395 0.195 0.130 0.934 0.017 0.007 0.534 0.203 0.949 0.898
−0.12 −0.15 −0.11 0.05 −0.12 0.28 0.12 0.20 0.03 0.07
0.184 0.113 0.253 0.624 0.177 0.002 0.175 0.031 0.763 0.478
Bold text indicates statistical significance. BUN, blood urea nitrogen; rs, Spearman’s rank correlation coefficient.
relationship between phosphorus levels and DFN scores (P < 0.05). A weakly positive significant relationship was found between pre-dialysis blood urea nitrogen (BUN) levels and DFN (P < 0.05). No statistically significant relationship was found between BUN levels and FDN, DDN, and FFN scores (P > 0.05) (Table 3). Frequency of diet non-adherence and DFN score medians of those who consumed salted food were higher than those who did not (P < 0.05) but with no statistically significant difference between DDN and FFN score medians (P > 0.05). FDN, DDN, FFN, and DFN score medians of those who had 4.5 kg or more interdialytic weight gain were higher than those who gained less weight (P < 0.05) (Tables 1,2).
Factors affecting non-adherence Frequency of diet non-adherence, DDN, FFN, and DFN score medians in HD-treated individuals in the 21–35 year age group were found to be higher than in the other age groups (P < 0.05). No statistically significant difference was found between the sex of the HD-treated individuals and the FDN and FFN score medians and DDN and DFN score means (P > 0.05). No statistically significant difference was found between marital status and education level and the FDN, DDN, FFN, and DFN score medians (P > 0.05) (Tables 1,2).
DISCUSSION Non-adherence to diet and fluid restriction Chronic renal failure (CRF) is a disease that affects eating and drinking habits and preferences and causes
many metabolic, physiological, and psychological changes in individuals (Ovayolu et al., 2007). Patients have difficulties complying with CRF treatment due to the changes they experience (Kara, 2007). Material and spiritual losses, becoming dependent on someone else, treatment side-effects, changes in the lifestyle of an individual and their family, and diet and fluid restriction are among these changes that make adherence difficult (Kara, 2007; Ovayolu et al., 2007; Ustun & Karadeniz, 2006). When adherence to diet and fluid restriction is ensured, the side-effects of the treatment decrease, the caregiver’s burden decreases, the quality of life of the patient increases, psychosocial health problems decrease, and expected life duration increases. Adherence to diet and fluid restriction is therefore important (Kara, 2007; Kutner, 2001). According to Hansen (2001), each individual experiences the problem of non-adherence to treatment to a certain degree. The authors found that 98.3% of their HD-treated individuals to experience nonadherence to diet and 95.0% to fluid restriction. Kugler et al. (2005) reported that 81.4% of HDtreated individuals experienced non-adherence to diet and 74.6% to fluid restriction. Kara et al. (2007) reported 58.1% of HD-treated individuals to be noncompliant with their diet and 68.1% with fluid restriction. The present authors found higher rates of nonadherence to diet and fluid restriction compared to other studies (Kara et al., 2007; Kugler et al., 2005). This difference may stem from the characteristics of the place the study was carried out and the individuals in the sample.
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Perceived family support The presence of someone in the family helping with the care and treatment and sharing the problems or the presence of social support are factors that facilitate adherence to HD treatment (Kara et al., 2007). The absence of social support causes stress, anxiety, and psychological changes. Such changes affect the immune system, potentially leading to other problems and death (Thong, Kaptein, Krediet, Boeschoten, & Dekker, 2007). Studies (Kugler et al., 2005; Kara et al., 2007) emphasize the importance of social and family support in adherence to diet and fluid restriction. The authors found that FDN, DDN, FFN, and DFN score medians were higher in patients with no one in the family to help with care and treatment (P < 0.05) (Tables 1,2). In addition, DDN and DFN score means and the FFN score median of those with no one to share problems with were also higher than in those who had someone (P < 0.05) (Tables 1,2). Ozturk et al. (2009) reported that CRF patients who had always been supported by their family and relatives received significantly less psychiatric support and found it easier to accept the disease. Thong et al. (2007) found HD-treated individuals who struggled with uncertainties in treatment and diet regime to accept the changes in lifestyle more easily when they had the support of friends and family. The results of these studies (Kara et al., 2007; Kugler et al., 2005; Ozturk et al., 2009; Thong et al., 2007) are similar to the present authors’ research findings in showing that having family and social support increases adherence to treatment.
Non-adherence and biochemical and biological values Increased phosphorus levels decrease the Ca++ level and a relationship has been found between these low levels and non-adherence to diet and fluid restriction (Altiparmak, 2009; Baysal et al., 2002). The authors found a weak and negative relationship between the Ca++ level and FFN scores (P < 0.05) (Table 3). There was a weak relationship between phosphorus levels and FDN, DDN, and FFN scores, and a moderate, positive and significant relation between phosphorus levels and DFN scores (P < 0.05) (Table 3). Kara et al. (2007) found a significant relationship between phosphorus level and adherence to diet and fluid restriction in HD-treated patients. These results support the present authors’ study findings. Informing subjects that increased consumption of foods containing phosphorus will decrease Ca++ levels
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and cause health problems and informing them regarding solutions will be beneficial in maintaining the balance of these ions. Restriction of salt from the diet and restriction of fluid intake are important in the prevention of cardiovascular diseases in HD-treated individuals (Baysal et al., 2002; Welch, Bennett, Delp, & Agarwal, 2006). When individuals do not restrict salt in their diet, they become thirsty and this leads to drinking more water (Welch et al., 2006). Only 5.0% of the individuals treated with HD in the present study complied with the fluid restriction. A study from the present authors’ country has reported that all family members consume tea, most commonly black tea, in all seasons, with a monthly tea consumption per family of 2.33 kg (Sayili & Gozener, 2013). The authors found that such tea-drinking habits leads to difficulty with fluid restrictions in HD-treated subjects. In addition, the present study found that the FDN, DDN, FFN, and DFN score medians of those with an interdialytic weight gain of 4.5 kg or more to be significantly higher than who gained less weight (P < 0.05) (Tables 1,2). Increased interdialytic weight gain causes problems such as shortness of breath, muscle cramps, anxiety, pulmonary edema, and hypertension in individuals (Denhaerynck et al., 2007). The recommended interdialytic weight gain for HD-treated individuals is 2.5 kg (Molaison & Yadrick, 2003). Kara et al. (2007) and Kugler et al. (2005) found HD-treated patients with high interdialytic weight gain to experience more non-adherence to diet and fluid restriction, similar to the present study. These results indicate that teaching alternative methods to decrease thirst, such as putting an ice cube into the mouth, could be effective in decreasing non-adherence of individuals to fluid restriction. Hypertension and left ventricular hypertrophy may develop when subjects are non-compliant to diet salt and fluid restriction (Welch et al., 2006). The SALTURK study from Turkey has reported a daily individual salt consumption of 18.01 g (Erdem et al., 2010). The present authors found that 33.1% of the individuals on HD treatment consumed their food with salt. FDN and DFN score medians were found to be higher in those who consumed their meals with salt than those who did not in the present study (P < 0.05) (Tables 1,2). Providing information on how high salt consumption may affect the health and checking salt consumption habits when patients come for their HD session are considered to be effective in promoting adherence to diet and fluid restriction.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Factors affecting non-adherence Adherence of HD-treated individuals to diet and fluid restriction is affected by many factors such as sex, age, sociocultural characteristics, health status, knowledge of existing disease, and familial and environmental conditions (Kammerer et al., 2007; Kara, 2007; WHO, 2003). One of the factors that affects adherence to HD treatment is age (Kammerer et al., 2007). In the present study, FDN and DDN median scores of HD-treated individuals in the of 21–35 year age group was higher than in the other age groups, and the FFN and DFN score medians of the 51–65-year age group was significantly lower than the 36–50 year age group (P < 0.05) (Tables 1,2). Leggat et al. (1998) found HD-treated individuals in the 20–39-year age group to experience more non-adherence to treatment than the 40–59-year age group. Young people are reported to experience intense feelings of being independent and therefore not wanting to accept being dependent on the HD machine and diet and fluid restrictions (Kara et al., 2007Kutner, 2001). Non-adherence to treatment is therefore more common in younger patients (Kara, 2007; Kugler et al., 2005). The results the authors obtained in the present study are similar to those found in the Leggat et al. study (1998) and other articles (Kara, 2007; Kugler et al., 2005). Based on these results, performing studies investigating adherence to diet and fluid restriction in young people and using nursing interventions and providing training according to the results obtained should be effective in increasing adherence.
CONCLUSION In conclusion, the authors found high levels of nonadherence to diet and fluid restriction in the subjects of the present study. The authors also found the Cronbach alpha value for the scale used to determine nonadherence to diet and fluid restriction to indicate a moderately reliable tool. Nurses need to be more aware that the adherence of HD patients to diet and fluid restriction is influenced by many factors such as age, family support, nutritional status before the disorder, and cultural habits. The adherence can change over time and it is therefore necessary to collect data related to the adherence of patients on HD to diet and fluid restrictions at regular intervals, and nursing interventions related to the factors influencing adherence should be planned and used. The authors recommend developing new scales with high validity
Adherence to diet and fluid restriction
and reliability to evaluate the non-adherence of patients to fluid restriction and conducting new studies on the subject.
Study limitations Some data in the study were obtained through the verbal statements of the subjects included in the sample. The reliability of the results therefore depend on the responses of these individuals. Another limitation was that the subjects were included according to meeting the inclusion criteria and only if they were residents of the province the study was conducted in. It is therefore possible to generalize the authors’ results only to individuals receiving HD treatment in that province.
ACKNOWLEDGMENT The authors are grateful to all the participants in the study.
CONFLICT OF INTEREST The authors declare no conflicts of interest with respect to the authorship and/or publication of this article.
FUNDING This research was not supported by any institution.
AUTHOR CONTRIBUTION D. E. performed the statistical analyses and drafted the manuscript, was involved in the study design, made contributions to the manuscript and the data for the analyses available, prepared the data for the analyses, read and approved the final manuscript, and was responsible for critical revisions for important intellectual content. S. K. drafted the manuscript, was involved in the study design, made contributions to the manuscript, prepared the data for the analyses, read and approved the final manuscript, and was responsible for important intellectual content.
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