الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
CKD is a progressive reduction in renal function over a period of months or years with glomerular filtration rate less than 60 mL/min/1.73 m2 for 3 months or more. The key risk factors are the increasing age of the population, diabetes mellitus, hypertension and medications, as the long use of analgesics. Kidney disease is associated with a massive economic load. The high burden of ESRD and associated costs, related adverse outcomes, and decreased productivity are even worse in most developing countries, as renal replacement therapy is often unavailable or out of reach. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was expected to double by 2030. HD therapy requires complete coordination between the health care team which includes nephrologists, nutritionists, nurses, technicians and social workers. However, non-adherence is common in HD patients. Studies suggesting interventions to improve adherence in dialysis patients have mainly focused on four domains of therapy; namely, adherence to dietary recommendations, fluid control, dialysis sessions and medications. Social cognition models such as the Health Belief Model (HBM) have protruded to assist in an increased and systematic understanding of factors which influence adherence.
This study was conducted on a sample of HD patients in Alexandria.
A predesigned structured interview questionnaire was developed by the researcher to collect the following data:
1) Personal sociodemographic data
2) HD patients’ disease related data and medical records.
3) Knowledge about renal dietary regimen and fluid restrictions.
5) Self-reported Dietary adherence.
6) HBM constructs:
Perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy and cues to action. These constructs were assessed using scales developed by the researcher based on a literature review and expert opinions from the Renal Adherence Attitudes Questionnaire (RAAQ) and the Renal Adherence Behavior Questionnaire (RABQ)
Results:
The results of the present study can be summarized as follows:
• Only 15.00% of the studied HD patients had satisfactory level of knowledge, while more than one third (36.00%) of them had poor level of knowledge.
• Concerning adherence, only 4.50% of the studied HD patients had good level of self-reported adherence, while the majority (83.00%) had fair level and 12.50% had poor level regarding dietary and fluid adherence.
• The majority (94.50%) of the studied HD patients had high perceived susceptibility to complications of non-adherence to the required dietary and fluid regimen, while (5.50%) had moderate level, and no one had low perceived susceptibility.
• The majority (94.0%) of the studied HD patients had high perceived severity of complications of non-adherence to the required dietary and fluid regimen, while (6.0%) had moderate perceived severity, and no one had low perceived severity.
• The majority (95.5%) of the studied HD patients had high perceived benefits of adherence to the required dietary and fluid regimen, while (4.5%) had moderate perceived benefits, and no one had low perceived benefits.
• More than half (51.50%) of the HD patients had low perceived barriers to adhere to the required dietary and fluid regimen, while more than two fifths (44.00%) had moderate perceived barriers and 4.5% had high perceived barriers.
• More than half (53.50%) of the HD patients had high perceived self-efficacy to adhere to the required dietary and fluid regimen, while two fifths (40.50%) had moderate perceived self-efficacy and 6.00% had low perceived self-efficacy.
• Nearly one fifth (18.5%) of the HD patients had high level of perceived cues to adhere to the required dietary and fluid regimen, while more than two thirds (67.5%) had moderate level, and 14.0% had low level of perceived cues to action.
• Patients’ self-reported adherence had moderate positive correlation with perceived self-efficacy, perceived barriers and total HBM (r= 0.65, r= 0.55 and r= 0.56), respectively and weak positive correlation with perceived cues to action (r= 0.35).
• A very weak positive correlation was found between self-reported adherence with knowledge and perceived susceptibility (r =0.18, r =0.16), respectively. On the other hand, there was negative very weak correlation between self-reported adherence and IWG (r = -0.22).
• When applying stepwise multiple regression analysis, it was found that two variables: self-efficacy and cues to action, contributed to explain significantly 44.0% of the variation of self-reported adherence total score and two variables proved to significantly predict (IWG) total score: self-efficacy and perceived severity, as both variables explained 14.70% of the variation of the IWG score.
The results of this study revealed that a certain degree of non-adherence with diet and fluid restrictions is evident in the ESRD population.
Based on the findings, many recommendations are suggested and summarized as follows:
• Future studies are needed to help clarifying what other factors influence dietary and fluid adherence, and thus health outcomes, in patients on HD.
• More strategies to improve adherence should be directed towards changing HD patients’ beliefs regarding the dietary and fluid regimen.
• Organization of educational programs which address health care providers to their crucial role in hemodialysis patients’ care.
• When formulating dietary and fluid intake guidelines, healthcare professionals should take cultural beliefs and practices into consideration allowing a certain extent of flexibility that may facilitate integration of the guidelines into daily living.
• Early psychosocial interventions and continuous support are important in maintaining patients’ morale for coping with the never-ending treatment.
Conclusion
Based on the results of the present study the following could be concluded:
1. Nearly half of the studied HD patients had fair level of knowledge about the dietary and fluid restrictions.
2. The majority of HD patients had high levels of perceived susceptibility to complications of non-adherence to dietary and fluid recommendations. They also had high levels of perceived severity and perceived benefits.
3. Half of the cases achieved low levels of perceived barriers with high level of self-efficacy.
4. More than half of the patients achieved moderate level of cues to action.
5. Most of the studied HD patients achieved high level of total Health Belief Model.
6. Most of the studied patients had fair level of total self-reported adherence to dietary and fluid regimen.
7. The most important motivation for adhering to dietary regimen is ”family support”.
8. The most important predictors of self-reported adherence were self-efficacy and cues to action, as they contributed to explain significantly 44.0% of the variation of self-reported adherence total score.
9. The most important predictors of IWG were self-efficacy and perceived severity, as both variables explained 14.70% of the variation of the IWG score.
Recommendations
Based on the findings of the present study, the following recommendations are proposed:
A. Recommendation for Policy makers (Ministry of Health, Medical Syndicate):
Chronic Kidney Disease management education program for hospitals and family health units. Our results lend support for the development of innovative education approaches for people with CKD, including self-management support, shared decision making, use of digital media, and engaging families and communities.
*Program purposes
• To increase patients’ knowledge and awareness about types of food recommended and others to be avoided in their healthy regimen, in addition to the necessity of fluid limitations.
• To increase the knowledge of the patients and the health care team about the sources of different food elements to be restricted.
• To learn the required procedures and lifestyle changes to prevent complications, and reduce cardiovascular-related outcomes of ESRD.
• To adapt the patient to his new life style and his new condition related to his dialysis treatment.
• To reinforce the patient’s ability to adhere to the required recommendations for successful dialysis sessions (executing lifestyle changes, following proper diets, or how to overcome thirst) to coincide with medical or health advice.
• To raise the awareness of the patient and his relatives about the consequences of dietary and fluid non-adherence.
• To strengthen an effective communication of the patient with the health care team for better comprehension and cooperation between them.
*Program Setting
Family health centers and outpatient clinics in General and University Hospitals providing education in group settings.
*Program Team
Health care professionals, including nephrologists, nurses, nutritionists and health educators who have the knowledge and the skills to present information on the disease specific topics and can accurately respond to the different probable related questions.
B. Recommendations for health care providers:
• Availability of health education specialists and suitable places for education and patient counseling.
• Medical Archival Retrieval System (MARS) should be secured to store patient related data and reports for health care providers on laboratory results, visits, medications, comorbid conditions and medical procedures for better help and advice of the HD patients.
• Collaborative teamwork and mutual trust between different members of health care providers should be enhanced and coordinated.
• Continuous patient education on adequate dietary habits with family involvement, identification of at-risk patients for noncompliance and assisting patients to identify and manage difficulties with life-style changes related to HD are important elements in promoting compliance.
• More patients education by healthcare provider through the mean of group lectures, video or audio to view or listen while on dialysis.
• Implementation of behavioral interventions in order to decrease HD patients’ distress over diet and improve adherence and the control of clinical parameter that implicate on their quality of life.
• Regular training of health professionals and information regarding diet and fluid restriction must be provided to individuals with one family member to help with their care, those who consumed salted food, or had high interdialytic weight gain.
C. Recommendations for the community:
- Community involvement with the private sector and charity organizations for provision of Hemodialysis centers offering affordable services for HD patients and nutritional counseling programs.
- Mass media, social network technology and community workers have a role in providing information and improving patients’ awareness about ESRD and consequences of dietary and fluid non-adherence.
D. Recommendations for further research:
- Field research should be done to set evidence based national and local guidelines and protocols providing standards for Dietary and Fluid adherence among HD patients.
- Further exploration and assessment of other factors that impair or improve HD patients’ adherence to dietary and fluid as well as medical recommendations for better intervention methods and strategies.
- Consultation of the dietitian to plan renal diet and answer questions, using patient language, explain food frequency consumption, proper planning according to patient socioeconomic status should be designed.