| Abstract|| |
Introduction: After transplantation, patients require lifelong follow-up care. The present research was conducted to explore effects of the self-management program on the quality of life among renal-transplant patients in Hazrat Abolfazl Health and Medical Charity in Isfahan in 2015. Materials and Methods: This randomized controlled clinical trial had 2 groups involving 3 stages, namely, before, right after, and 3 months after the intervention. It was conducted on 72 kidney-transplant patients. The participants having inclusion criteria were selected using the simple sampling method and were randomly placed in the experimental and control groups. Each group included 36 participants. The chronic disease self-management program (CDSMP) workshop was presented for the experimental group in a 2½-h session held once a week for 6 months. The control group attended a training session on diet. To collect data, the standard Kidney Transplant Questionnaire was used. Data analysis was performed using SPSS. Results: After the intervention, the means of the quality of life among the patients in the experimental group were 3.82 ± 1.03, 4.49 ± 0.81, and 5.12 ± 0.62 before, right after, and 3 months after the intervention, respectively (P < 0.05). However, the means of the quality of life in the control group at the 3 time points were not significantly different (P > 0.05). Conclusion: Due to the positive effect of the CDSMP on the quality of life among the kidney-transplant patients, it is recommended that authorities accept the self-management program much more.
Keywords: Chronic disease, quality of life, renal transplantation, self-management program
|How to cite this article:|
Kuwaiti S, Ghadami A, Yousefi H. Effects of the self-management program on the quality of life among kidney-transplant patients in Isfahan's Hazrat Abolfazl Health and Medical Charity in 2015. Ann Trop Med Public Health 2017;10:1607-12
|How to cite this URL:|
Kuwaiti S, Ghadami A, Yousefi H. Effects of the self-management program on the quality of life among kidney-transplant patients in Isfahan's Hazrat Abolfazl Health and Medical Charity in 2015. Ann Trop Med Public Health [serial online] 2017 [cited 2018 Aug 16];10:1607-12. Available from: http://www.atmph.org/text.asp?2017/10/6/1607/222681
| Introduction|| |
Progressive and irreversible impairment in the end-stage renal disease (ESRD) is regarded as one of the main health problems worldwide. In this condition, the body's ability to sustain metabolism and maintain the balance between fluids and electrolytes fails. The prevalence of chronic renal failure is 242 cases per million people worldwide and approximately 8% is added to this rate yearly. The population suffering from the chronic ESRD is annually increasing by 6%. Despite considerable effort put into preventing this trend, the number of these patients is also increasing in Iran. These patients are not able to survive without renal replacement therapy. Among conventional methods for renal replacement therapy are hemodialysis, peritoneal dialysis, and kidney transplantation. In Iran, 48% of patients are on hemodialysis, 3% undergo peritoneal dialysis, and 49% receive kidney transplantation. Kidney transplantation is considered to be the greatest advance in modern medicine and the best method for replacement therapy among patients with the ESRD. With more than 20,000 kidney transplants yearly, Iran is ranked first. Approximately 250 kidney transplants are performed in the province of Isfahan annually. Despite so many benefits of kidney transplantation patients encounter a host of physical, mental, and social problems after transplantation due to complications of immunosuppressants., Complications arising from medications affect various aspects of the quality of kidney-transplant patients' life and reduces the quality of their life., The quality of life is regarded as a crucial predictive factor for death among patients with the ESRD and is the most significant indicator for explaining health outcomes. In terms of diagnosis, prediction, and assessment; evaluating the quality of life can contribute to the provision of care and implementation of effective treatment methods for helping patients with chronic diseases. One of the programs which enhance patients' quality of life is the self-management program, which is one of rehabilitation methods. It emphasizes treatment and care activities with the aim of achieving maximum independence, self-determination, and the improvement of personal health on the basis of capabilities, personal lifestyle, and the enhancement of the quality of life. The patient has a central role in it. Moreover, it increases the patient's self-efficacy. One of these programs is the chronic disease self-management program (CDSMP) which was used for the first time at Stanford University in 1998. This is the most acceptable self-management program in the world. It has the potential to improve the overall health of patients with chronic diseases and prevent the further loss of function. In addition, patients who have undergone a kidney transplant experience a chronic disease  and current health-care systems use an acute care model which gives a priority to the treatment of acute and immediate symptoms. Moreover, this model is not effective in dealing with chronic diseases. Thus, it is necessary to have a self-management program to improve care for these patients. Self-management consists of 3 sections. The management of a medical diet has 2 sections. The first section includes the following: (1) infection control (hygiene measures; monitoring of infection symptoms by the patient); (2) monitoring of vital signs (weight; blood pressure); (3) medications (consumption of immunosuppressants and their side effects); and (4) symptom management (monitoring of signs and symptoms; use of appropriate interventions to relieve symptoms). The second section consists of the following: (1) no misuse of substances such as alcohol; (2) attendance at medical appointments; (3) no tobacco consumption or its cessation; (4) healthy nutrition; (5) exercise for weight management and protection against cardiovascular diseases; and (6) effective protection against the sunlight to avoid skin cancer. The third section comprises the following: (1) management of life roles (i.e. how the patient should be socially active and learn communication skills); (2) management of emotions (i.e. how the patient should manage emotional complications, such as anxiety, depression, fear, and stress, resulting from a disease). To carry out these duties, the following 6 skills are taught to the patient: problem-solving, decision-making, benefiting from resources, encouraging some collaborative networking between patients and health-care providers, designing and implementing a short-term action plan, and coordinating the program with individual characteristics., The studies performed on patients' experiences of kidney transplantation show that there are no sufficient aftercare instructions., Furthermore, according to researchers' experiences, the transplant in the majority of patients who have received a transplant is rejected due to their negligence in following treatment recommendations; and therefore, they return to the circle of dialysis patients or suffer from problems such as infection, cardiovascular diseases, and skin problems emerging from the long-term use of immunosuppressants. Regarding diagnosis, prediction, and assessment, the evaluation of the quality of life could help provide care and employ effective treatment methods for giving help to patients with chronic diseases.
Since few studies have been conducted on the effect of the self-management program on the quality of life among kidney-transplant patients and since current health-care programs are based on an acute care model, this research was aimed at investigating the effect of the self-management program on the quality of life among kidney-transplant patients who were referred to Hazrat Abolfazl Health and Medical Charity in Isfahan.
| Materials and Methods|| |
This research is a randomized controlled clinical trial with 2 groups and 3 stages. Its medical code of ethics is 394732. It was performed on 72 kidney-transplant patients who had referred to Isfahan's Hazrat Abolfazl Health and Medical Charity in 2015. The data about this study have been registered with the Iranian Registry of Clinical Trials under code number IRCT2016062828457N4. The study population was 72 persons using the equation n= (z1 + z2)2 (2s 2)/d 2 and having 10% sample attrition. After giving informed written consent, they were randomly assigned to 2 groups, namely, intervention (36 persons) and control (36 persons). In fact, first a list of persons having the inclusion criteria was provided and each was assigned a number. Next, using the random number table, they were divided into the two groups. In the experimental group, excluded were one person for being hospitalized and two persons for being absent from training classes for more than one session. In the control group, two persons were excluded from the study due to unwillingness and low morale as well as failure to complete the questionnaire. In the end, this study was conducted on 67 patients (intervention group with 33 persons and control group with 34 persons). The inclusion criteria were as follows: patients should be 18 years of age minimum; 3 months at least should pass from the kidney transplant; they should be literate; they should not simultaneously participate in another study; they should consent to take part in the study; and they should not be mentally retarded, blind, or deaf. The exclusion criteria included a patient's unwillingness to continue to participate in the program, hospitalization or death during the study, and absence from training sessions for more than one session. The intervention group received the chronic disease self-management training program. This was a 15-h comprehensive program which was presented in 2½-h sessions during 6 weeks. One expert (who according to the content of discussions could be a nurse, psychologist, or nutritionist) and one kidney-transplant patient (who had been introduced by the charity and had been included in the program after the patient's file was studied and certified by a medical specialist at the Charity) ran the program. The content of the program included the following: (1) techniques for addressing problems such as frustration, fatigue, and isolation; (2) good exercise for maintaining and boosting strength; (3) the efficient use of medications; (4) an effective relationship with the family, friends, and health-care specialists; (5) nutrition; and (6) how to evaluate new treatments. It emphasized the skills of operational planning, problem-solving, and decision-making. The control group attended just one training session on diet. The questionnaire was completed by a questioner before, right after, and 3 months after the study for the two groups. The data collection instruments were a two-part questionnaire including demographic data (age, gender, marital status, occupation, and education) and disease-related data (the length of time after transplantation and the kidney-donor type) and the Kidney Disease Quality of Life Questionnaire, which consisted of 25 questions and 5 domains including physical symptoms (6 questions), appearance (4 questions), fear/uncertainty (4 questions), emotional aspect (6 questions), and fatigue (5 questions), and evaluated the kidney-transplant patients' quality of life. To score the instruments, each option was scored, using a range of 1–7, where 7 stood for the best score and 1 for the worst possible condition. The reliability and validity of the Kidney Disease Quality of Life Questionnaire had been confirmed abroad by Pus in 1999. It had been validated by Tayebi et al. in 2011. The reliability of the instruments was measured using Cronbach's alpha (α=0.93). The collected data were analyzed using descriptive and inferential statistical tests (mean and standard deviation, Mann–Whitney test, Chi-square test, independent t-test, paired t-test, repeated measures ANOVA, and post hoc test, LSD) with the IBM SPSS Statistics 19 software (SPSS Inc. - Wikipedia (https://en.m.wikipedia.org/wiki/SPSS_Inc.)). The P value was < 0.05.
| Results|| |
In the present study, 67 kidney-transplant patients (33 in the intervention group and 34 in the control group) were examined. The results showed that the mean age of the participants in the experimental group was 46.3 ± 14.05 and in the control group was 43.2 ± 14.1, which statistically showed no significant difference (P > 0.05). Furthermore, a high percentage of the participants were married (72.7% in the experimental group and 76.5% in the control group). The education level of the participants (42.5% in the experimental group) and (35.3% in the control group) was a high-school diploma. Most of the participants were homemakers (36.4% in the experimental group and 38.2% in the control group). A large percentage of kidney donors were nonrelatives (72.8% in the experimental group and 67.6% in the control group). Regarding the time span between the transplant and the study, ranging from 1 to 5 years, the highest percentage in the experimental group was 51.5% and in the control group 32.4%. In terms of the demographic and disease-related data, there was no significant statistical difference between the two groups and they were the same (P > 0.05) [Table 1].
|Table 1: Demographic data and information on the disease in the experimental and control groups|
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The means of the total score, as well as scores of the quality of life aspects, exhibited no significant statistical difference between the two groups before the intervention; however, right after and 3 months after the intervention, the mean in the experimental group was significantly more than that in the control group. Concerning the increase in the mean, it could be said that the program had led to an improvement in self-management in the intervention group (P < 0.05). The results of the variance analysis with repeated observations demonstrated that the means of the total score of the quality of life as well as scores of physical symptoms, appearance, fear/uncertainty, emotional aspect, and fatigue, in the control group were not significantly different at the 3 time points (P > 0.05) [Table 2].
|Table 2: The average score of the quality of life and its aspects in the control group at the different time points|
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Nevertheless, the means in the experimental group were significantly different at the 3 time points (P < 0.05) [Table 3].
|Table 3: The average score of the quality of life and its aspects in the experimental group at the different time points|
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In addition, the post hoc test (LSD) showed that the mean of the total score of the quality of life and scores of all aspects in the experimental group right after the study was significantly more than that before the study; and moreover, 3 months after the study, it was significantly more than the mean right after the study (P < 0.05).
| Discussion|| |
This study was aimed at exploring effects of the self-management program on the quality of life among kidney-transplant patients who had referred to Isfahan's Hazrat Abolfazl Health and Medical Charity. The results revealed that the implementation of the program had a significant difference in the patients' quality of life right after and 3 months after the intervention and the score of the quality of life in the experimental group compared with that of the control group had increased. Moreover, the post hoc test (LSD) showed that the mean of the total score of the quality of life and scores of all aspects in the experimental group right after the study was significantly more than that before the study and it was significantly more 3 months after the study than right after the study (P < 0.05). Constant with the present research is the study by Andrew Turner et al. who evaluated a self-management program for 486 patients with one of the 4 inclusion criteria, namely, depression, diabetes, musculoskeletal pain, and chronic obstructive pulmonary disease (COPD). The results showed that there were significant improvements in the patients' health-related quality of life, health status, anxiety, depression, and self-management skills, together with patient activation, 6 months after the self-management intervention. Kim and Youn studied the effectiveness of the CDSMP among the Korean elderly and assessed their health literacy, self-efficacy, physical activity, physical health, and mental health. The results revealed that the levels of self-efficacy and physical activity among the elderly in the CDSMP-intervention group were more than those in the control group after 6 weeks. Yu et al. carried out a study on effects of self-management education on the COPD patients' quality of life. The results revealed significant statistical differences in the quality of life between the intervention and control groups in the 3rd and 6th months (P < 0.05). Kafami et al. evaluated the effect of the self-management program on multiple sclerosis (MS) patients' health status in 2012. In this quasi-experimental study, the sample consisted of 82 MS clients who had referred to the MS Society of Tehran during 2008–2009 and was selected using convenience sampling. The data analysis before the intervention showed that there was no significant difference between the means of the health subscales in the experimental and control groups. However, after the intervention and 2 months later (except for the social function and pain), there was a significant difference in the health subscales between the two groups (P < 0.05). At 3 times of measurement, a significant difference was observed between the means of the health subscales in the 2 groups (P < 0.05). Baljani et al. studied the impact of self-management interventions on medication adherence and lifestyle among cardiovascular patients in Urmia in 2012. This quasi-experimental research included 86 cardiovascular patients, who were selected through convenience sampling in the two stages of before and 6 months after the intervention and were placed in the experimental and control groups. The experimental group received the self-management interventions related to a healthy lifestyle and adherence to a long-term medication regimen, but the control group received routine interventions. The independent t-test indicated that, after the intervention, a significant difference existed in the mean scores of adherence to a medication regimen (P < 0.01) and selection of a low-fat diet in the control and experimental groups (P < 0.05). Quite contrary to the current research, in a study investigating the effect of CDSMPs on the management of type-2 diabetes in primary care, Forjuoh et al. demonstrated that no significant difference was observed in the health-related quality of life, pain, and fatigue between the two groups. Perhaps, the difference between the result of this study and the other studies is due to cultural, social, and environmental differences among people. Exploring the impact of the CDSMP on self-efficacy among patients having undergone coronary artery bypass grafting surgery in 2014, Naderipour et al. reported that the CDSMP had no significant influence on the participants' self-efficacy. The reason for the difference between this study and the present research probably pertains to the cultural and social difference between the samples, duration and type of the follow-up, and education delivered.
| Conclusion|| |
According to the results in this research, the CDSMP considerably enhanced the quality of life among the patients with a renal transplant. Patient education and its promotion through repetition, monitoring, and management by nurses could be an important factor in making behavioral changes and improving these patients' quality of life. Hence, it is recommended that authorities pay more attention to the self-management program.
This paper was the result of the research project approved by the Vice Chancellor for Research and Technology at Isfahan University of Medical Sciences. The authors hereby would like to thank the Vice Chancellor for Research as well as the Chancellor and Vice Chancellor for Research in the Faculty of Nursing and Midwifery at Isfahan University of Medical Sciences for their collaboration. The patients who participated in the present research also receive the authors' sincere thanks. Finally, the authors wish to extend their thanks to the head, nursing management, and personnel of Hazrat Abolfazl Health and Medical Charity.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Assistant Professor, PhD in Nursing, Ulcer Repair Research Center, School of Nursing and Midwifery, Isfahan University of Medical Sciences, Isfahan
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]