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Year : 2017  |  Volume : 10  |  Issue : 5  |  Page : 1165-1168
Effect of narrative writing on quality of life in chronic renal failure patients underwent hemodialysis

1 Department of Clinical Psychology, Substance Prevention Research Center, Kermanshah University of Medical Sciences, Kermanshah, Iran
2 Department of Clinical Psychology, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 Department of Clinical Psychology, Medical School, Kermanshah University of Medical Sciences, Kermanshah, Iran
4 Department of Nursing, Nursing and Midwifery School, Golestan University of Medical Sciences, Golestan, Iran
5 Department of Biostatistic and Epidemiology, Public Health School, Kermanshah University of Medical Sciences, Kermanshah, Iran
6 Department of Nursing, Nursing and Midwifery School, Kermanshah University of Medical Sciences, Kermanshah, Iran

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Date of Web Publication6-Nov-2017


Background: Chronic renal failure is the most common chronic disease affects the physical and psychological health of suffers and their quality of life (QOL). Recently, narrative writing is considered as a new approach to improve the problems of these patients, moreover, there is a paucity of information in this regard; hence, the current study was conducted to determine the effect of narrative writing on the QOL of hemodialysis patients. Methods: In a clinical trial, 28 hemodialysis patients of Imam Reza Hospital of Kermanshah were enrolled to the study in 2015. They are divided into two groups: case and control through randomization. The information was gathered through the short form-36 QOL questionnaire before and after intervention. Data were entered into SPSS-22 and analyzed by descriptive and inferential statistics. Findings: The mean of QOL score for case and control groups was 94.92 and 97.53, respectively, before intervention, which increased to 98.85 in case group and declined in control group to 90.80. The analysis of covariance test showed a significant difference between two groups after intervention (P = 0.004). Conclusion: The results indicate narrative writing can enhance the QOL of hemodialysis patient; however, it is required to carry out more studies with higher sample size.

Keywords: Chronic renal failure, hemodialysis, narrative writing, quality of life

How to cite this article:
Ahmadzade A, Ahmadi SM, Sadeghi K, Sanagu A, Amiri SM, Moghadam AP, Abdi A. Effect of narrative writing on quality of life in chronic renal failure patients underwent hemodialysis. Ann Trop Med Public Health 2017;10:1165-8

How to cite this URL:
Ahmadzade A, Ahmadi SM, Sadeghi K, Sanagu A, Amiri SM, Moghadam AP, Abdi A. Effect of narrative writing on quality of life in chronic renal failure patients underwent hemodialysis. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Jun 6];10:1165-8. Available from:

   Introduction Top

Nowadays, health-care workers are confronting to the progressive growth of chronic diseases prevalence in the 21st century.[1] The chronic disease is a special medical condition that induces much disabilities and symptoms and demands a long-term management and planning. The management composed of preparing facilities of which the patients to be adapted to the symptoms, improving lifestyle to controlling the signs, and establishing some measures for preventing side effects and the complications.[2] Chronic renal failure (CRF) is one of the most prevalent chronic conditions with disturbing physical and psychological states of the patients.[3] This irreversible progressive disorder causes an imbalance in body fluids and electrolytes, consequently uremia and azotemia, so that the patients are compiled to underwent substantial treatments such as hemodialysis and kidney transplantation.[4],[5] The most common reasons of CRF are hypertension, diabetic nephropathy, and glomerulonephritis.[6] The number of individuals suffering from CRF was about 1.1 million people in 2009, worldwide. In Iran, in an increased state, this statistic has enhanced from 49.9 cases/million population in 2000 to 130 individuals in 2015.[7]

Although hemodialysis removes the additional body fluids and materials, prevents some side effects induced by aggregation of urea components, and reduces the mortality rate of the CRF patients,[8] it is along with many physical and psychological problems, such as anxiety, stress, cognitive difficulties, sleep disorders, depression, and body image defects,[9],[10] as a results, the quality of life (QOL) of patients would be diminished.[11] It is notable, due to reducing the activity power and needs to frequent treatments, most of the CRF patients with hemodialysis lost their jobs. Hence, all aspects of their life such as social, economic, and familial domains would be exacerbated.[12],[13],[14]

Nowadays, some approaches have been presented to enhance the QOL of hemodialysis patients, such as exercise and muscle relaxation.[15],[16] Herewith, many of the psychological treatments are more costly and time-consuming, also the patients likely do not seek such therapies, therefore, due to the high cost of CRF treatments, it is fundamental to give the short-term and affordable interventions for improving the psychological health of these patients.[17] One of the recently noted therapeutic approaches that derived from postmodern philosophy is narrative writing.[18] Narrative writing is a way that one attempts to write his/her thoughts, in some points that are hard to express.[19] Some researchers used the notion of “narrative dialog” indicating the approach to describe the writing of stressful events to rectify the people's physical and mental conditions.[20] The previous studies represented the positive effects of narrative therapy onto some physical aspects of health, such as immune system function, blood pressure, liver and respiratory system, and psychological rehabilitation of cancer patients.[20],[21] Moreover, other various investigations revealed the narrative writing would improve the psychological issues such as well-being, women's willingness to forgive, body image, depression, and post-traumatic stress disorder.[22],[23],[24],[25],[26] Regarding the adverse effects of hemodialysis on the QOL of CRF patients,[16] it is essential to establish an affordable and feasible method of behavior therapy to promote the QOL of hemodialysis patients. Thus, due to a lack of information to narrative writing, the current study was aimed to determine the effect of this approach on the QOL of hemodialysis patient in Kermanshah-Iran.

   Methods Top

This study was done as a clinical trial in 2015 and registered in Iranian Registry of Clinical Trials (IRCT) with the number of IRCT2015120925442N1. The population was all the CRF patients underwent hemodialysis in Hemodialysis Center of Imam Reza hospital affiliated to the Kermanshah University of Medical Sciences (KUMS) in Iran. The sample was 28 people who recruited as a convenience and divided into two groups: case and control, randomly.

The narrative writing was done for case group based on the guideline conducted by Akbari.[27] Hence, the participants were requested to write their experiences and feelings within 8 weeks, once a week, and during the hemodialysis sessions. The samples completed the QOL questionnaire. Short form-36 scale composed of 36 questions and eight subscale including physical function, role disruption induced by physical health, role disruption due to emotional health, energy/fatigue, excitement well-being, social function, pain, and general health. This questionnaire was developed and validated by Iranian researchers.[28] In our study, the Cronbach's alpha was calculated 0.76 for all the questionnaires and 0.65–0.85 for subscales.

Data were gathered with referring to the hemodialysis settings after taking the permission from research deputy of KUMS. With explaining the objectives of research, the participants were assured about anonymity and confidentiality of personal information, then the questionnaires were completed by them before and after narrative writing courses by both groups, after which the data were entered into SPSS-22 software (SPSS v.22.0; SPSS Inc., Chicago, IL, USA) and analyzed by descriptive and inferential statistics. For descriptive statistices, frequency, frequency percent, mean, and standard deviation (SD) were determined. The normality of quantitative variables was assessed by Kolmogorov–Smirnov test, Chi-square and exact fisher tests were made for determining the personal variablesdifference of the groups. Independent t-test and analysis of covariance (ANCOVA) were applied for comparing the quantitative variables within two groups. The significant level of the tests was 0.05.

   Findings Top

Of the 28 hemodialysis patients (15 in control and 13 in case groups), 16 (57.1%) were female and 22 (78.5%) married. The mean and SD of age were 37.11 ± 5.13 years (experimental = 35.15 ± 6.56 and control = 38.80 ± 2.7, P = 0.06). Most of them (18 people, 64.2%) were employed. The difference between two groups in term of demographic characteristics was not significant [Table 1].
Table 1: Personal characteristics of the participants

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For indicating the normality and homogeneity of the dependent variable (QOL), Kolmogorov–Smirnov and Leon test representing to be normal and equal variance distribution of the variable in pretest and posttest stages.

The mean of QOL for narrative writing (case) group was increased from 94.92 to 98.85 after intervention; however, this rate was reduced regarding the control group of the 97.53–90.80 [Table 2]. Hence, ANCOVA test revealed the two groups have a remarkable significant difference in this regard (P = 0.004) [Table 3].
Table 2: Mean and standard deviation of quality of life in experimental and control groups

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Table 3: ANCOVA test for study of difference between two group

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   Discussion Top

Chronic disease leads to a change in some aspects of life including imposing new role as a patient, loss of job/unemployment due to the disease, restriction of daily activity, and additional costs of treatments, thereupon, these induced a stressful and complicated situations, which resulted in reducing the QOL.[6] The previous research has approved the structured writing of damaging stressful experiences would improve physical and psychological states of the patients and reduces their stress.[29] Therefore, we conducted the current study to this concern, and the results reflect the narrative writing can improve the QOL of hemodialysis clients through creating the opportunity to inscribe the thoughts, feelings, and other unpleasant experiences. Consequently, we concluded the QOL of the participants was exceeded after the intervention compared to the control group, significantly. Carmack et al. remarked, the merging of writing into verbal expression is effective over the psychological disturbances caused by cancer, which resulted in betterment in psychological function and QOL.[30] Moreover, Henry et al. found that narrative writing enhances the physical and psychological health of woman with cancer.[31] Smyth also demonstrated writing the emotions could be effective onto the physical health, psychological well-being, psychological, and general functioning,[32] accordingly, the researchers believe, some of the social restraints avoid considering the chronic diseases, so that the adaptation of the patients would be affected since narrative writing assists the people to state their emotion in the form of a tale without any limitations or any negative feedback/critique, this can help physical and psychological health.[33] The results of Pennebaker and Beall study indicated the students who have spoken about their injurious feelings/senses had more healthy physical condition rather than the control group.[20] These results comply with our study; however, in some investigation, the opposite results were achieved.[33] In a review study, Merz et al. examined the effects of narrative writing onto QOL of cancer patients that the results revealing no considerable effect.[34] Other meta-analysis research by Frisina et al. (2004) representing the effect of narrative writing over nonclinical population more than patients;[35] in this regard, Faller et al. also maintained repeated and longer narrative writing is more effective than short-term sessions over two population of patients and healthy people.[36]

   Conclusion Top

We concluded the narrative writing, as an affordable measure, will improve the QOL of hemodialysis patients, therefore, for further confirmation, it is suggested that other studies would be undertaken over other clinical groups.


Since writing is not well unified into Iranian culture, hence, it could be considered as a limitation for widely fulfilling the approach, and we gave a complete education to the patients to write their experience before intervention.


The study is derived of the MSc dissertation approved by ethical committee of research center of KUMS, herewith, we appreciate the assistance of the officials of the research deputy of KUMS and the Hemodialysis Ward of Imam Reza hospital affiliated to KUMS as well as the patients who participated in the study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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Correspondence Address:
Khirollah Sadeghi
Department of Clinical Psychology, Medical School, Kermanshah University of Medical Sciences, Kermanshah
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ATMPH.ATMPH_105_17

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  [Table 1], [Table 2], [Table 3]


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