Effect of Multidimensional Educational Interventions Among Dialysis Patients



Bryal D’souza1, *, Ravindra Prabhu2, Bhaskaran Unnikrishnan3, Rajesh Kamath1
1 PSPH, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India
2 Department of Nephrology, KMC Manipal, Manipal, Karnataka 576104, India
3 KMC, Mangalore, Manipal Academy of Higher Education, Manipal, Karnataka 575001, India


Article Metrics

CrossRef Citations:
0
Total Statistics:

Full-Text HTML Views: 246
Abstract HTML Views: 123
PDF Downloads: 77
ePub Downloads: 74
Total Views/Downloads: 520
Unique Statistics:

Full-Text HTML Views: 170
Abstract HTML Views: 83
PDF Downloads: 63
ePub Downloads: 53
Total Views/Downloads: 369



© 2018 D’souza et al.

open-access license: This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International Public License (CC-BY 4.0), a copy of which is available at: https://creativecommons.org/licenses/by/4.0/legalcode. This license permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

* Address correspondence to this author at the Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal, Karnataka 576104, India; E-mail: brayal.dsouza@manipal.edu


Abstract

Patient education is associated with better patient outcomes and supported by international guidelines and organizations like KDIGO, DOQI, CDC, DA vita that provide essential resources for patient information across the spectrum of kidney disease but a range of barriers prevent widespread implementation of comprehensive education for people with progressive kidney disease. It is not only of prime importance to have an adequate number of nephrologists only but also of equal importance to have a multidisciplinary team of renal dietician, renal nurses, social worker, clinical psychologist and pharmacist to improve patient’s knowledge about disease management and treatment options.

This review paper aims at reviewing the effects of various educational interventions among maintenance hemodialysis patients. There are substantial systematic reviews and narrative reviews on the effect of predialyis education, however evidence on the effectiveness of education intervention among end stage renal failure patients on maintenance dialysis needs compilation and extensive research of its effect on various patient outcomes. This review aims to compile evidence on effective components of dialysis education programs on patient related outcomes. PubMed Medline, Cochrane Library with the main search terms of “hemodialysis ”, “maintenance dialysis”, “multidisciplinary ”, “interdisciplinary “, “education”, “information”, and “decision” were performed.

Keywords: Multidimensional, Interventions, KDIGO, DOQI, CDC, DA.



1. INTRODUCTION

Burden of End stage renal failure is rising universally and in India is associated with premature deaths, morbidity, higher hospitalization frequency and increase in health care expenditure. These indicates itself the need for a strong quality improvement initiative and education through interdisciplinary clinics is one such solution to improvement [1]. Extensive research and improved patient outcomes on the effectiveness of predialysis education among pre ESRD patients have been explored and found to be effective however the group with end stage failure remain neglected and under researched. Patients knowledge regarding their disease management improves with increased frequency of contact with nephrologist or as a result of worsening of condition they tend to seek information [2]. This is also similarly seen among the Indian population and health care system. An informed patient and a prepared proactive team is the key towards achieving better patient outcomes and amongst the dialysis patients a multidisciplinary proactive team can play a crucial role in educating patients towards better patient outcomes. Patient provider and system factors could contribute as barriers to patient education. Poor understanding of the condition limited health literacy, readiness to learn, access to information, time constraint, communication challenge, and lack of interdisciplinary care models [3]. To improve adherence, patients must have knowledge of their disease condition through which they can have their questions, concerns and needs addressed and can also be taught on self-care management by a multidisciplinary approach. The multidisciplinary approach can be delivered through a team or a nurse in a resource constraint setting.

2. Education Interventions and Patient Outcomes

2.1. Effectiveness of Nutritional Intervention and Fluid Restriction on Patient Outcomes

Malnutrition is common among ckd patients and highly prevalent (25-50%) among dialysis patients [4-7] and is associated with morbidity and mortality [8-12].

Adequate protein and calorie, safe levels of sodium, potassium, phosphorous and fluid intake are important for the wellbeing of dialysis patients. Nutritional intervention that is tailored specifically considering barriers can result in improved albumin levels even among patients with high c reactive proteins. These barriers could be lack of knowledge, poor appetite, depression, inadequate dialysis or support to cook [13]. A nurse led intervention educating the patients on hyperphoshetemia their symptoms, use of phosphate binder with their benefits for improving health related quality of life had improved albumin and reduced hyphosphetemia [14].

Reduced interdialytic weight gain, improved adherence, however no improvement of mean blood pressure was seen upon teaching patients with weekly reinforcement about diet, fluids and control of weight gain [15], Similarly a nurse working on a protocol and administering patient education on disease management showed improved hemoglobin and albumin level of patients [16]. Since renal nurses at the dialysis unit have a long term relationship with the patients educating patients through them would be an ideal reinforcement and channel of communication. However, this may become a challenge in a low resources setting like India where there is a shortage of nurses or inadequate nurse patient ratio.

Nutritional status of dialysis patients receiving nutritional educational program has shown to be as effective as oral supplementation to prevent and treat malnutrition among dialysis patients [17].

Public marketing campaign, media messages, listing of phosphorus content on food labels are opportunities in public health to improve hyperphospethemia [18].. An educational intervention is as effective as Oral supplementation to prevent malnutrition and treatment of malnutrition. Improved creatinine, protein serum values, and other biochemical parameters were the markers of effectiveness [19]. A nurse administered protocol, training received through case based training, guided reading, and theoretical input can show significant improvement in patient education [20].

Significant number of educational training on improving phosphate and calcium levels have proven to be effective [21, 23]. Reduced interdialytic weight gain, reduction in blood pressure and improvement in serum creatinine level [24]. However, a systematic review on efficacy of dietary interventions showed that nutritional therapies for controlling blood pressure are still questionable and further research is needed and the best nutritional therapy to control blood pressure needs to be researched further for evidence [25].

Creating consistent interactive communication, using talking control technique, emphasizing positive action, acknowledging typical food pattern, focusing on single goal than multiple goals can promote adherence to nutritional advice given in a nutritional program to dialysis patients [26].

2.2. Exercise Counselling and Patient Outcomes

Several studies have used aerobic exercise, resistance exercise or combination of both and yoga based exercises among dialysis patients. Amongst the studies done on dialysis patients, Afshar et al. used a combination approach of exercise (aerobic and resistance) resulting in reduction of CRP and creatinine [27]. Akiba et al (exercise training with usual care) resulted in the reduction of VO2 max (P < 0.05) and VO2AT [28]. Baria et al. (aerobic exercise at center and home) resulted in reduction of visceral fat and waist circumference constituting the abdominal distribution of fat decreased with improvement in leg lean mass [29]. Cheema et al. (resistance training) resulted in increase in muscle strength [30] Chen et al (intradialytic low- intensity strength training) improved lower body strength [31].Dong (resistance training plus nutrition) increased the weight and strength however no difference in body mass was seen [32]Yurtkuran (yoga-based exercises with usual care) resulted in improvement in pain, fatigue, strength, creatinine and cholesterol [33] as shown in Table 1. Van Vilsteren (resistance and aerobic during HD) improved muscle strength of the lower extremity and quality of life [34].

Exercise can improve many indicators of physical functioning, such as fitness, muscle mass, physical performance, and self-reported physical functioning. Fewer data are available to address cardiovascular indices. However, preliminary evidence suggests that exercise can enhance the management of hypertension, reduce inflammation, and improve endothelial function [35].

Table 1. Exercise counselling and patient outcomes.
STUDY N
(SAMPLE SIZE)
EDUCATION MODULE THEME RCT /OBSERVATIONAL STUDY DURATION SETTING OUTCOME MEASURES AND RESULT
Effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis.
Afshar et al. (2010)
21 males
maintenance HD > 3 months; age > 20 years
Aerobic and resistance training RCT 8 weeks HD unit in Tehran Blood lipids and inflammation status
Blood chemistry (urea, creatinine, lipids, CRP), Kt/V and anthropometric measure in HD
Result: CRP and creatinine reduction in aerobic exercise (P = 0.005) and resistance (P = 0.036), no effect on weight, urea, lipids or Kt/V
Effects of Recombinant Human Erythropoietin and Exercise Training on Exercise Capacity in Hemodialysis Patients(akiba et al 1995) 12
HD patients with low physical function and activity levels
Exercise training & usual care RCT 12weeks Tokyo, HDU Aerobic capacity
Result
VO2 max (P < 0.05) and VO2AT (P < 0.05) were decreased among controls and unchanged among intervention grou
Effects of intradialytic cycling compared with pedometer on physical function in chronic outpatient hemodialysis: A prospective randomized trial(Clara Bohm et al 2014) 60 Patients
Ergometer group cycled for 24 weeks. Pedometer participants followed a home-based walking program for 24 weeks
intradialytic low-intensity, strength training & stretching RCT 24 weeks HDU and home setting Primary outcome: aerobic capacity [VO2peak and 6-minute walk (6MW)
Secondary outcome: Secondary outcomes included lower extremity strength, flexibility, physical activity (accelerometer) and health-related quality of life.
Result: SS testing in the ergometer group improved from 10.2 (SD 3.4) to 11.4 (SD 2.5) cycles from baseline to 24 weeks (P < 0.005). Similarly, in the pedometer group, SS cycles improved from 10.1 (SD 3.3) to 12.2 (SD 3.5) (P < 0.005) No significant changes in secondary outcome
The effect of resistance exercise to augment long-term benefits of intradialytic oral nutritional supplementation in chronic hemodialysis patients.
Dong J et al 2011
32 patients on HD Resistance training plus nutrition and only nutrition in the control group Interventional study 6 months HDU Body composition, muscle strength,
Biochemical parameters, recall dietary
Result: No difference in lean body mass. Weight and strength increased in intervention group
A modified yoga-based exercise program in hemodialysis patients: A randomized controlled study
(Yurtkuran M 2007)
37 Patients on HD yoga-based exercises versus usual care RCT 12 weeks HDU Pain, fatigue, sleep, grip strength, biochemical variables
Result: Improvement in pain −37%, fatigue −55%, sleep disturbance −25%, strength +15%, Ht +13%, creatinine −14%, cholesterol −15%

2.3. Medication Counselling and Patient Outcomes

Pharmacist-provided counseling have significantly improved the knowledge attitude and practice among patients [36]similarly satvik et al., showed improved knowledge assessment scores at the end of a 8 week trained pharmacist patient training program [37] forgetfulness, lack of knowledge, inconvenience and scheduling problems are the main reasons for non-adherence therefore counselling aiming at educating patients must incorporate ways to remind to take their medications and helping patients with lower education levels to understand the importance of medication compliance and strategies to be complian [38].Active participation of pharmacists in the management of anemia in hemodialysis patients has therapeutic and pharmacoeconomic impact [39].

Face to face training and pamphlet training are equally effective in improving knowledge and adherence to treatment including pharmaceutical regimen, however, face to face training were more effective over latter [40] hypertensive patients need patient education for better retention of knowledge and improving their adherence, this can be similarly attributed to all patients for improved adherence and retention of knowledge [41]. Pharmaceutical Services Division, Ministry of Health Malaysia has developed the Renal Medication Therapy Adherence Clinic (MTAC) which was managed by pharmacists as one of the strategies in optimizing patients’ knowledge by assessing potential barriers to medication knowledge and implementing comprehensive strategies to increase adherence [42].

3. Quality of Life and Self-Care Management

Self-care management includes diet care, vascular access and ability to perform activities of daily living among dialysis patients. It is a complicated characteristic of individuals that enables them to perform some actions for identified and specific needs [43]. Inability to perform activities of daily living may be contributed to weakness, fatigue or depression among dialysis patients. Sathvik et al saw that the quality of life of hemodialysis patients was significantly impaired in comparison to healthy individuals of the general population and renal transplant patients particularly with respect to the physical, psychological, and social relationship domains [44]. Research on nutrition interventions and exercise have been effective in improving muscle mass, and strength. Self-care management program implementation and education focusing on disease knowledge, storage and adherence of medication, diet instructions, exercise modalities, emotion sharing and discussion of problem during and after dialysis was found to be effective to improve quality of life among dialysis patients [45].Priscila Silveira Duarte approach using cognitive behavior therapy showed to be effective in the treatment of depression and increase in quality of life score in patients undergoing hemodialysis [46].

4. RESULTS

Empowerment, self-care self-efficacy and depression levels improved among patients receiving empowerment program using by identifying problem areas and exploring emotions associated with self-care management developing goals and strategies to overcome and implementation of behavioral change plans. Face to face self-care education training had better influence on quality of life among dialysis patients.

CONCLUSION

Individual discipline has proven educational interventions to be effective among dialysis patients to improve quality of life, self-care management, knowledge, biochemical parameters and therapeutic adherence. There for a multidisciplinary approach covering dietary, nursing, primary physician, physical therapist and counsellor using coordinated strategies than working in silos in educating dialysis patients can aim and prove to improve the patient’s outcomes to larger extents. The best proven practices and principles can be incorporated in the module and delivered to patient. It is of foremost importance to use coordinated strategies in educating patients in improving patient outcomes among dialysis patients.

CONSENT FOR PUBLICATION

Not applicable.

CONFLICT OF INTEREST

The authors declare no conflict of interest, financial or otherwise.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

[1] Johns TS, Yee J, Smith-Jules T, Campbell RC, Bauer C. Interdisciplinary care clinics in chronic kidney disease. BMC Nephrol 2015; 16(1): 161.
[2] Finkelstein FO, Story K, Firanek C, et al. Perceived knowledge among patients cared for by nephrologists about chronic kidney disease and end-stage renal disease therapies. Kidney Int 2008; 74(9): 1178-84.
[3] Narva AS, Norton JM, Boulware LE. Educating patients about ckd: The path to self-management and patient-centered care. Clin J Am Soc Nephrol 2016; 11(4): 694-703.
[4] Churchill DN. Implications of the Canada-USA (CANUSA) study of the adequacy of dialysis on peritoneal dialysis schedule. Nephrol Dial Transplant 1998; 13(90006)(Suppl. 6): 158-63.
[5] Kopple JD, Greene T, Chumlea WC, Hollinger D, Maroni BJ, Merrill D, et al. Relationship between nutritional status and the glomerular filtration rate: results from the MDRD study. [Internet]. Kidney international. U.S. National Library of Medicine 2000. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/10760105
[6] Qureshi AR, Alvestrand A, Danielsson A, Divino-Filho JC, Gutierrez A, Lindholm B, et al. Factors predicting malnutrition in hemodialysis patients: a cross-sectional study. [Internet]. Kidney international. U.S. National Library of Medicine 1998 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/9507226
[7] American journal of kidney disease [Internet]. KDOQI guidelines. National Kidney Foundation [cited 2018Feb24]. Available from: https:// www.kidney.org/ sites/ default/ files/ docs/ kdoqi2000nutritiongl.pdf
[8] Clinical practice guidelines/DOQI . National Kidney Foundation [cited 2018Feb24]. Available from: https:// www.kidney.org/ sites/ default/ files/docs/ ckd_evaluation_classification_stratification.pdf
[9] Pifer TB, McCullough KP, Port FK, et al. Mortality risk in hemodialysis patients and changes in nutritional indicators: DOPPS. [Internet]. Kidney international. U.S. National Library of Medicine 2002 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/ 12427151
[10] Adequacy of dialysis and nutrition in continuous peritoneal dialysis: Association with clinical outcomes. Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol : JASN. U.S. National Library of Medicine 1996 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/ 8785388
[11] Renal Function and Nutritional Status at the Start of Chronic Dialysis Treatment [Internet]. American society of nephrology [cited 2018Feb24]. Available from: https:// pdfs.semanticscholar.org/ ef8a/ 0cb445b1472892bf74f8f8e5a48ec4659bee.pdf
[12] Avram MM, Fein PA, Bonomini L, Mittman N, Loutoby R, Avram DK, et al. Predictors of survival in continuous ambulatory peritoneal dialysis patients: A five-year prospective study. [Internet]. Perit Dial Int . U.S. National Library of Medicine [cited 2018Feb24].Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/8728191
[13] Ekramzadeh M, Mazloom Z, Jafari P, Ayatollahi M, Sagheb MM. Major barriers responsible for malnutrition in hemodialysis patients: challenges to optimal nutrition. Nephrourol Mon 2014 ; 6(6): e23158. [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pmc/ articles/ PMC4330668/
[14] Stumm EMF, Kirchner RM, Guido Lde A, Benetti ERR, Belasco AGS, Sesso Rde CC, et al. Educational nursing intervention to reduce the hyperphosphatemia in patients on hemodialysis [Internet]. Revista Brasileira de Enfermagem. Associação Brasileira de Enfermagem [cited 2018Feb24]. Available from: http:// www.scielo.br/ scielo.php? script=sci_arttext&pid=S0034 - 71672017000100031
[15] Lee W, Campoy S, Smits G, Tran ZV, Chonchol M. Effectiveness of a chronic kidney disease clinic in achieving K/DOQI guideline targets at initiation of dialysis-a single-centre experience | Nephrology Dialysis Transplantation | Oxford Academic [Internet]. OUP Academic. Oxford University Press 2006 ; (): -. [cited 2018Feb24]. Available from: https:// academic.oup.com/ ndt/ article/ 22/3/833/ 1900350/ Effectiveness- of -a-chronic - kidney-disease-clinic
[16] Victoria Alikari, Vasiliki Matziou. The effect of nursing counseling on improving knowledge, adherence to treatment and quality of life of patients undergoing hemodialysis. Int J Caring Sci 2015; 8(2): 514. [cited 2018Feb24]. Available from: https:// pdfs.semanticscholar.org/ a34d/ 2315956ebfe14b9143275148444c67cbf394.pdf
[17] Sehgal AR, Sullivan C, Leon JB, Bialostosky K. [Internet]. Journal of renal nutrition : The official journal of the Council on Renal Nutrition of the National Kidney Foundation. U.S. National Library of Medicine 2008 ; (): -. [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pmc/ articles/ PMC2391002/
[18] Hernández JJ, Sánchez-Villazala A, Cutillas RC, Fuentes MC. Effectiveness of a nutrition education program for the prevention and treatment of malnutrition in end-stage renal disease. [Internet]. Journal of renal nutrition : The official journal of the Council on Renal Nutrition of the National Kidney Foundation. U.S. National Library of Medicine 2014 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/ 24216257
[19] Evaluation of a nurse-led disease management programme for chronic kidney disease: A randomized controlled trial [Internet]. International Journal of Nursing Studies. Pergamon 2009 . [cited 2018Feb24]. Available from: https:// www.sciencedirect.com/ science/ article/ pii/S002074890900234X
[20] Ford JC, Pope JF, Hunt AE, Gerald B. The effect of diet education on the laboratory values and knowledge of hemodialysis patients with hyperphosphatemia. [Internet]. Journal of renal nutrition : The official journal of the Council on Renal Nutrition of the National Kidney Foundation. U.S. National Library of Medicine 2004 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/ 14740329
[21] A randomized controlled trial of an educational intervention to improve phosphate levels in hemodialysis patients [Internet]. Journal of Renal Nutrition WB Saunders 2003 . [cited 2018Feb24]. Available from: https:// www.sciencedirect.com/ science /article/ pii/ S105122760300116X?via%3Dihub
[22] Cupisti A, D’Alessandro C, Baldi R, Barsotti G. Dietary habits and counseling focused on phosphate intake in hemodialysis patients with hyperphosphatemia. [Internet]. Journal of renal nutrition : The official journal of the Council on Renal Nutrition of the National Kidney Foundation. U.S. National Library of Medicine 2004 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pubmed/ 15483782
[23] Jafari F, Mobasheri M, Mirzaeian R. [Internet]. Materia Socio-Medica. AVICENA, doo, Sarajevo 2014 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pmc/ articles/ PMC4214804/
[24] Efficacy of dietary interventions in end-stage renal disease patients; A systematic review [Internet]. Journal of Nehropharmacology [cited 2018Feb24]. Available from: http:// www.jnephropharmacology.com/ PDF/ NPJ-5-28.pdf
[25] Beto JA, Schury KA, Bansal VK. Strategies to promote adherence to nutritional advice in patients with | IJNRD [Internet]. International Journal of Nephrology and Renovascular Disease. Dove Press 2016 . [cited 2018Feb24]. Available from: https:// www.dovepress.com/ strategies- to -promote- adherence- to -nutritional-advice -in- patients -with -peer-reviewed -article-IJNRD
[26] Afshar R, Shegarfy L, Shavandi N, Sanavi S. Effects of aerobic exercise and resistance training on lipid profiles and inflammation status in patients on maintenance hemodialysis. Indian J Nephrol 2010; 20(4): 185-9.
[27] Akiba T, Matsui N, Shinohara S, Fujiwara H, Nomura T, Marumo F. Effects of recombinant human erythropoietin and exercise training on exercise capacity in hemodialysis patients. Artif Organs 1995; 19(12): 1262-8.
[28] Baria F, Kamimura MA, Aoike DT, et al. Randomized controlled trial to evaluate the impact of aerobic exercise on visceral fat in overweight chronic kidney disease patients. Nephrol Dial Transplant 2014; 29(4): 857-64.
[29] Cheema B, Abas H, Smith B, et al. Progressive exercise for anabolism in kidney disease (PEAK): A randomized, controlled trial of resistance training during hemodialysis. J Am Soc Nephrol 2007; 18(5): 1594-601.
[30] Bohm C, Stewart K, Onyskie-Marcus J, Esliger D, Kriellaars D, Rigatto C. Effects of intradialytic cycling compared with pedometry on physical function in chronic outpatient hemodialysis: A prospective randomized trial. Nephrol Dial Transplant 2014; 29(10): 1947-55.
[31] Dong J, Sundell MB, Pupim LB, Wu P, Shintani A, Ikizler TA. The effect of resistance exercise to augment long-term benefits of intradialytic oral nutritional supplementation in chronic hemodialysis patients. J Ren Nutr 2011; 21(2): 149-59.
[32] Yurtkuran M, Alp A, Yurtkuran M, Dilek K. A modified yoga-based exercise program in hemodialysis patients: A randomized controlled study. Complement Ther Med 2007; 15(3): 164-71.
[33] van Vilsteren MC, de Greef MH, Huisman RM. The effects of a low-to-moderate intensity pre-conditioning exercise programme linked with exercise counselling for sedentary haemodialysis patients in The Netherlands: results of a randomized clinical trial. Nephrol Dial Transplant 2005; 20(1): 141-6.
[34] Johansen KL. Exercise in the end-stage renal disease population. J American Society Nephrol 2007; 18(6): 1845-54. [cited 2018Feb24]. Available from: http:// jasn.asnjournals.org/ content/18/ 6/1845.full
[35] Ghimirey A, Sapkota B, Shrestha S, Basnet N, Shankar PR, Sapkota S. Evaluation of pharmacist counseling in improving knowledge, attitude, and practice in chronic kidney disease patients. SAGE Open Med 2013; 1: 2050312113516111.
[36] Parthasarathi G, Sathvik B, Mangasuli S, Narahari M, Gurudev K. Medication knowledge of hemodialysis patients and influence of clinical pharmacist provided education on their knowledge. Indian J Pharm Sci 2007; 69(2): 232.
[37] Bland RJ, Cottrell RR, Guyler LR. Medication Compliance of Hemodialysis Patients and Factors Contributing to Non‐Compliance [Internet]. Dialysis & Transplantation. Wiley Subscription Services, Inc, A Wiley Company 2008 . [cited 2018Feb24]. Available from: http:// onlinelibrary.wiley.com/ doi/10.1002/ dat.20207/pdf
[38] Ghimirey A, Sapkota B, Shrestha S, Basnet N, Shankar PR, Sapkota S. [Internet]. SAGE Open Medicine. SAGE Publications 2013 . [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pmc/articles/ PMC4687783/
[39] Parvan K, Hasankhani H, Seyyedrasooli A, Riahi SM, Ghorbani M. The effect of two educational methods on knowledge and adherence to treatment in hemodialysis patients: Clinical trial. J Caring Sci 2015 ; 4(1): 83-93. [cited 2018Feb24]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363655/
[40] Singh N, Kumar A, Aggarwal N, Jha L, Gandhi P. PS 17-75 Impact of education on medication knowledge and adherence behavior in hypertensive end stage renal disease patients on maintenance hemodialysis. J Hypertens 2016; 34: e495.
[41] Pharmaceutical Services Division, Ministry of Health, Malaysia. Renal Pharmacy Service Guideline 2011. [Last accessed on 2015 Dec 18]. Available from: http:/ /www.pharmacy.gov.my/ v2/sites /default/ files/document-upload/ renal-guideline.pdf
[42] Muz G, Eglence R. The evaluation of self care ability and self efficacy of patients receiving hemodialysis. Balıkesır Health Sci J 2013; 2(1): 15-21.
[43] Sathvik BS, Parthasarathi G, Narahari MG, Gurudev KC. An assessment of the quality of life in hemodialysis patients using the WHOQOL-BREF questionnaire. Indian J Nephrol 2008 ; 18(4): 141-9. [cited 2018Feb24]. Available from: https:// www.ncbi.nlm.nih.gov/ pmc/articles/ PMC2813538/
[44] Duarte PS, Miyazaki MC, Blay SL, Sesso R. Cognitive-behavioral group therapy is an effective treatment for major depression in hemodialysis patients. Kidney Int 2009; 76(4): 414-21.
[45] Tsay SL, Hung LO. Empowerment of patients with end-stage renal disease: A randomized controlled trial. Int J Nurs Stud 2004; 41(1): 59-65.
[46] Ghadam MS, Poorgholami F, Badiyepeymaie Jahromi Z, Parandavar N, Kalani N, Rahmanian E. Effect of self-care education by face-to-face method on the quality of life in hemodialysis patients (relying on ferrans and powers questionnaire). Glob J Health Sci 2015; 8(6): 121-7.