The Effectiveness of a self-efficacy theory based videotape intervention designed to facilitate fluid adherence among fl...

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The Effectiveness of a self-efficacy theory based videotape intervention designed to facilitate fluid adherence among fluid nonadherent hemodialysis patients
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Thesis (Ph. D.)--University of Florida, 1994.
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Includes bibliographical references (leaves 145-155).
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by Beverly A. Brady.
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Typescript.
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Vita.

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THE EFFECTIVENESS OF A SELF-EFFICACY THEORY BASED
VIDEOTAPE INTERVENTION DESIGNED TO
FACILITATE FLUID ADHERENCE
AMONG FLUID NONADHERENT HEMODIALYSIS PATIENTS















By

BEVERLY A. BRADY











A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

1994








ACKNOWLEDGEMENTS

I would like to express my appreciation to my

chairperson, Dr. Carolyn Tucker, and my committee members, Dr.

Mary Fukuyama, Dr. Mary Howard-Hamilton, Dr. Scott Miller, Dr.

Max Parker, and Dr. Bob Ziller. Special thanks are extended

to Dr. Tucker who has been a mentor, a friend, and a source of

inspiration. Her support and encouragement were instrumental

in completing this research and many other projects.

I also extend my appreciation to Dr. Paul Alfino, Dr.

Gordon Finlayson, and Dr. Darrell Tarrant for their assistance

in conducting this research. A special thank you is also due

to the many staff members and patients at the Gainesville

Kidney Center East and the Gainesville Kidney Center West who

participated in this research. I would also like to thank my

research assistants, Ms. Suzanne Apon, Ms. Jill Diesner, Ms.

Jill Ehrenreich, and Ms. Dawn Miller. Dr. John Dixon is also

gratefully acknowledged for his statistical consultation.

A very special note of acknowledgement goes to my

parents, Albert and Louise Brady, my brothers, Alonzo and

Stephen Brady, and my sister, Debbie Brady. Without their

love and support I could not have achieved my goals. To all

my friends and extended family members who have supported me

throughout my education, I extend a very warm thank you.

Finally, to Eustache Mine', who has shared the best times and

been a source of strength during the difficult times, I

express my deepest appreciation.

ii











TABLE OF CONTENTS


ACKNOWLEDGEMENTS ..................... .......... ........... ii

ABSTRACT.................................... ............ V

CHAPTERS

I INTRODUCTION................... ...................... 1

II REVIEW OF THE LITERATURE........................... 6

The Hemodialysis Treatment Regimen................... 6
Overview of Kidney Failure and Hemodialysis...... 6
Medical Complications Associated with
Hemodialysis................................... 10
Stages of Adjustment to the Hemodialysis
Regimen ........................................ 11
Psychosocial Ramifications of Chronic
Hemodialysis..................... ............. .. 12
Factors Associated with Patients' Adherence
to Treatment Regimens .......................... 29
The Problem of Fluid and Dietary Nonadherence
Among Hemodialysis Patients....................... 41
Prevalence of Nonadherence Among Hemodialysis
Patients ....................................... 41
Methods Used to Assess Adherence/Nonadherence
to the Hemodialysis Regimen..................... 44
Consequences of Nonadherence to Dietary and
Fluid Restrictions............................. 47
Strategies to Increase Patients' Adherence to
Hemodialysis Treatment Regimen.................. 50
Self-Efficacy Theory............................... 54
The Self-Efficacy Mechanism....................... 54
Self-Efficacy and Health Related Behaviors....... 62
Motivation and Self-Efficacy...................... 67
Motivation, Self-Efficacy, and Health Related
Behaviors ...................................... 68
Self-Efficacy Theory and Adherence Motivation:
Implications for Modifying Fluid Adherence..... 70
Use of Peer Teaching for Behavior Modification..... 72
Use of Videotape Interventions for Behavior
Modification................... .................. 74
Summary of the Research............................ 76









III METHODOLOGY .......................................... 78

Subjects ................................. .......... 78
Phase I Subjects ................................. 78
Phase III Subjects ............................... 79
Other Research Participants........................ 84
Research Assistants .............................. 84
Dialysis Center Staff ............................ 84
Instruments .............. ... .. ..... ............ 84
The Patient Demographic and Medical Information
Sheet .......................................... 85
The Marlowe-Crowne Social Desirability Scale
Short-Form (M-C SDS [20]) ...................... 85
The Fluid Adherence Self-Efficacy Questionnarie.. 86
The Fluid Adherence Motivation Questionnarie..... 87
The Structured Interview Questionnarie........... 88
Procedure..................... .................... 88
Training of Researchers .......................... 88
Recruitment of Phase I Subjects................... 89
Phase I Data Collection .......................... 90
Phase II Videotape Production.................... 91
Recruitment of Phase III Subjects................. 92
Phase III Data Collection ........................ 94
Research Questions and Hypotheses................... 96

IV RESULTS ................................... ......... 99

V DISCUSSION ........................................... 115

Summary and Interpretation of the Results.......... 115
Limitations of the Study and Suggestions for
Future Research.................................. 125

APPENDICES .................................. ........... 132

A INFORMED CONSENT FORM (PHASE I) .................... 132

B INFORMED CONSENT FORM (PHASE III) .................. 135

C PATIENT DEMOGRAPHIC AND MEDICAL INFORMATION SHEET.. 138

D MARLOWE-CROWNE SOCIAL DESIRABILITY SCALE (20) ...... 139

E FLUID ADHERENCE SELF-EFFICACY QUESTIONNAIRE........ 141

F FLUID ADHERENCE MOTIVATION QUESTIONNAIRE........... 143

G STRUCTURED INTERVIEW QUESTIONNAIRE.................. 144

REFERENCES .................................... .......... 145

BIOGRAPHICAL SKETCH....................................... 156








Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy


THE EFFECTIVENESS OF A SELF-EFFICACY THEORY BASED
VIDEOTAPE INTERVENTION DESIGNED TO
FACILITATE FLUID ADHERENCE
AMONG FLUID NONADHERENT HEMODIALYSIS PATIENTS

By

Beverly A. Brady

December 1994

Chairperson: Dr. Carolyn M. Tucker
Major Department: Psychology

Nonadherence to fluid restrictions continues to be one

of the most pervasive and life-threatening problems in the

treatment of hemodialysis patients. This study tested the

effectiveness of a self-efficacy theory based videotape

intervention in increasing hemodialysis patients' fluid

adherence efficacy expectations, fluid adherence outcome

expectations, fluid adherence motivation, and actual fluid

adherence [i.e., average weekend interdialysis fluid weight

gain (WG)]. Differences between fluid adherent patients (n

= 26) and fluid nonadherent patients (n = 24) and the

demographic factors associated with fluid adherence were

also examined. Four repeated measures ANOVAs and a repeated

measures ANCOVA with level of urine output and baseline WG

as covariates were applied to test the effectiveness of the

videotape intervention. Results failed to support the

hypothesized effects. However, the least square means from

the analysis indicated that among the intervention group,

but not the control group, the fluid adherence efficacy








expectations, fluid adherence outcome expectations, and

fluid adherence motivation increased at post-intervention

and at follow-up. The WG of the intervention group and the

control group decreased slightly at post-intervention, but

returned to near baseline levels at follow-up. However, at

both periods, the intervention group had lower WGs. Other

findings were as follows: (1) fluid adherent patients had

higher fluid adherence efficacy expectations and higher

fluid adherence motivation than fluid nonadherent patients;

(2) patients who were on dialysis longer and patients who

did not regularly take potentially thirst inducing

medications had higher fluid adherence efficacy

expectations; and (3) patients with diabetes had higher WGs

than nondiabetic patients. Results suggest that for

patients similar to those in this study, fluid adherence

motivation and fluid adherence efficacy expectations are

associated with actual fluid adherence. Perhaps with a

larger sample size and a more potent and long-term self-

efficacy theory based intervention, the increase in fluid

adherence efficacy expectations, fluid adherence outcome

expectations, and fluid adherence motivation observed in

this study may reach statistical significance. In addition,

actual fluid adherence behavior may follow the increase in

fluid adherence efficacy expectations, fluid adherence

outcome expectations, and fluid adherence motivation that

occurred in the present study.














CHAPTER I
INTRODUCTION



Adherence to dietary, fluid, and medication

instructions is a critically important factor in determining

the health and well-being of chronic hemodialysis patients

(Blackburn, 1977; Schmicker & Baumbach, 1990). Abuse of

dietary and fluid restrictions can result in a buildup of

toxic fluids and metabolic end products in the blood stream

which may lead to cardiovascular problems, uremic symptoms,

and even death (Cummings, Becker, Kirscht, & Levin, 1981;

Czackes & Kaplan De-Nour, 1978; Murray, 1983). The

consequences of treatment nonadherence among dialysis

patients are more immediate and potentially lethal than in

any other chronic disease syndrome (Armstrong & Woods,

1983). Despite the serious consequences to hemodialysis

patients of nonadherence to their treatment regimens,

estimates of treatment nonadherence among these patients

range from 93% (Betts & Crotty, 1988) to 15% (Yanitski,

1983) depending on the aspect of the treatment regimen

studied and the criteria used to determine adherence. This

study tested the effectiveness of a videotape intervention

in increasing hemodialysis patients' fluid adherence

efficacy expectations, fluid adherence outcome expectations,










fluid adherence motivation, and actual fluid adherence

[i.e., average weekend interdialysis fluid weight gain

(WG)].

The majority of adherence research focusing on

hemodialysis patients is theoretical (Epstein & Cluss,

1982) and the factors that influence adherence behavior

among dialysis patients are still not clearly understood.

However, it is clear that simply providing health education

to patients does not lead to the desired behavior change;

additionally, these patients need to be motivated to engage

in adherence behaviors (Blackburn, 1977; Caesar & Tucker,

1991; Schneider, Friend, Whitaker, Wadhwa, 1991), and they

must feel capable of performing adherence behaviors

(Bandura, 1977a; Evans, 1989; Strecher, DeVellis, Becker,

Rosenstock, 1986).

Given the particularly stringent restrictions of

hemodialysis treatment and the critical importance of

adherence to dietary and fluid guidelines as a part of this

treatment, two types of research seem warranted: (1)

research that examines ways of increasing a sense of

personal mastery among chronic hemodialysis patients, and

(2) research focused on developing effective techniques for

motivating chronic hemodialysis patients to adhere to

treatment restrictions.

Self-efficacy theory has been receiving increased

recognition for its ability to predict change in and










maintenance of health behaviors. Research studies in a

variety of areas including cigarette smoking (Colletti,

Supnick, & Payne, 1985; DiClemente, 1981), alcoholism

(Solomon & Annis, 1990), cystic fibrosis (Bartholomew,

Parcel, Swank, & Czyzewski, 1993), and epilepsy (Dilorio,

Faherty, & Manteuffel, 1992) have shown that patients'

perceived level of self-efficacy is related to adherence

with health behaviors.

Bandura's (1977b) self-efficacy theory states that

behavior change and maintenance are a function of both

efficacy expectations (expectations about one's ability to

execute the behavior) and outcome expectations (expectations

that engaging in the behavior will lead to a specific

outcome). In addition to strong efficacy expectations and

outcome expectations, self-efficacy theory specifies that

effective functioning requires that individuals develop the

competencies and skills needed to execute the target

behavior (Evans, 1989).

Self-beliefs of efficacy also play a central role in

the self-regulation of motivation (Bandura, 1990).

Individuals initially motivate themselves through proactive

control by setting challenging standards that create a sense

of disequilibrium. Perceived negative discrepancies between

actual performance and the pre-set standard results in

dissatisfaction which motivates the individual to make

corrective changes (Bandura, 1977b). Self-motivation is










best generated and sustained by the adoption of attainable

subgoals that lead to more challenging future goals. In

addition to increasing motivation, attainment of these

proximal goals serves as a vehicle for the further

development of self-percepts of efficacy (Bandura, 1982).

In the first phase of the study, a fluid adherence

facilitation videotape based on self-efficacy theory was

developed. The final phase of the study focused on testing

the effectiveness of this videotape in increasing

hemodialysis patients' fluid adherence efficacy

expectations, fluid adherence outcome expectations, fluid

adherence motivation, and actual adherence to fluid

restrictions.

The following questions were addressed:

(1) Do fluid adherent patients have higher fluid adherence

efficacy expectations and higher fluid adherence

outcome expectations than fluid nonadherent patients?

(2) Are fluid adherent patients more motivated to be fluid

adherent than fluid nonadherent patients?

(3) Is viewing the fluid adherence facilitation videotape

an effective strategy for increasing fluid adherence

efficacy expectations, fluid adherence outcome

expectations, fluid adherence motivation, and actual

fluid adherence?

(4) Does increasing fluid adherence efficacy expectations,

fluid adherence outcome expectations, and/or fluid

adherence motivation increase actual fluid adherence?









5

(5) What are the positive consequences of being fluid

adherent and the negative consequences of being fluid

nonadherent?














CHAPTER II
REVIEW OF THE LITERATURE



The Hemodialysis Treatment Regimen

Overview of Kidney Failure and Hemodialysis

Healthy kidneys perform six vital functions. They (1)

continuously and automatically eliminate waste materials

from the blood in the form of urine, (2) regulate the level

of fluids in the body, (3) filter the blood to maintain the

proper balance of electrolytes (i.e., sodium, phosphorous,

etc.), (4) aid in the production of red blood cells, (5)

maintain healthy bones by converting vitamin D into an

active form, and (6) maintain the correct balance of calcium

and phosphorous (Phillips, 1987).

When the kidneys are no longer functioning properly,

this condition is referred to as kidney failure or renal

failure. There are two types of renal failure, acute and

chronic (Phillips, 1987). Acute renal failure is

characterized by sudden onset with kidney functioning

deteriorating in a matter of hours or, at most, in a matter

of days. Acute renal failure can result from a number of

conditions including surgery, massive injuries, or toxic

chemicals. Usually this condition only lasts for a short

time. If the circumstances that lead to the renal failure

6










can be resolved, the kidneys usually resume functioning;

however, dialysis is often necessary in the interim. In

cases where there is significant kidney damage, the short-

term kidney malfunctioning may progress to chronic renal

failure.

Chronic renal failure is usually permanent and

irreversible. This condition develops slowly over a period

of months or years and typically is not diagnosed until it

is quite advanced. However, there are several signs of

impending kidney failure. Some of the early signs include

(1) more frequent passing of urine, (2) chronic fatigue, (3)

anemia, (4) neuropathy, and (5) edema (Phillips, 1987).

Primary kidney disease is the most frequent causes of renal

destruction, accounting for more than 90% of patients

treated by chronic hemodialysis (Jungers, Zingraff, Man, &

Drueke, 1978). However, renal failure may occur for a

number of reasons including the existence of

glomerulonephritis, hypertension, diabetes, and lupus

erythematosus (Phillips, 1987).

It is estimated that 300,000 400,000 people in the

United States suffer from some degree of chronic renal

failure (Phillips, 1987). The exact number of new cases of

end stage renal disease (ESRD) is difficult to ascertain due

to the unavailability of centrally collected data, the lack

of a uniform selection criteria, and the difficult task of

identifying untreated patients (Newberry, 1989).










Maintenance hemodialysis and kidney transplantation are the

two main methods of preventing death from uremia (abnormal

accumulation of urea in the blood) in patients with

irreversible renal failure (Wright, 1981). Chronic

hemodialysis is instituted when the patient experiences

disabling irreversible uremia despite optimal medical

management (Swartz, 1967). The aim of chronic hemodialysis

is to allow the survival of patients whose kidney

functioning has decreased to less than 5% of the normal

level (Jungers et al., 1978).

Patients entering a chronic dialysis program must make

significant changes in their life style and maintain strict

dietary and fluid restrictions (Streltzer, 1983; Swartz,

1967). Dialysis patients must restrict protein, sodium,

potassium, and fluid intake between dialysis session.

Patients who do not adhere to prescribed fluid restrictions

experience excessive weight gain, hypertension, pulmonary

edema, pericarditis (inflammation of the membrane around the

heart), and congestive heart failure. These conditions can

be quite dangerous to the patient and place excessive stress

on the patient's heart, lungs, and entire body (Henry,

1972).

Although no theoretical limit exists for the survival

of hemodialysis patients, conclusive data on the survival

rate of patients on maintenance hemodialysis is not

available. Raw data indicate that 90% of patients survive










at least one year, while 60% are still alive after five

years. Several hundred dialysis patients have survived more

than ten years (Jungers et al., 1978). Patients older than

50, those with diabetes mellitus, and those with

hypertensive or atherosclerotic cardiovascular disease tend

to do less well (Wright, 1981).

The five- and ten-year survival rates of patients in

hospital hemodialysis centers is significantly lower than

the equivalent patient survival rate for patients who

dialyze at home (Hakim & Lazarus, 1984). This difference is

probably related to the selection criteria used for

referring patients to home dialysis and hospital-center

dialysis. Presumably patients with other associated medical

conditions or who are generally unstable on hemodialysis are

referred to hospital-center dialysis; therefore the center

dialysis population undoubtedly includes the majority of

high risk patients (Wright, 1981).

An examination of demographic factors reveals that a

slight majority of facility dialysis patients are female;

however, this is counterbalanced by the greater proportion

of males who receive transplantation or home dialysis

(Newberry, 1989). Racial factors in the incidence of ESRD

are not fully understood. It appears that the incidence

rates of certain diseases resulting in renal failure are

higher among African-Americans than Caucasians. Despite

this, the majority (64%) of the ESRD population is










Caucasian. The typical age of patients with ESRD has been

more carefully analyzed. The majority of chronic dialysis

patients worldwide are 45 or older and over half are

disabled or retired (Newberry, 1989).

Medical Complications Associated with Hemodialysis

A majority of patients experience unpleasant symptoms

during dialysis sessions. Between 15 and 45% of treatments

are associated with complications such as hypotension,

dizziness, muscle cramps, pruritus (itching), nausea,

vomiting, or headaches (Hakim & Lazarus, 1984; Van Stone,

1983). These symptoms occur more frequently among new

patients beginning treatment than in long-term stabilized

patients (Newberry, 1989). The incidence and severity of

these complications can be reduced by proper management of

the dialysis prescription.

Hypotension is the most serious frequent intradialysis

complication of dialysis, occurring in approximately 30% of

dialysis sessions (Gotch & Keen, 1991). The degree of

hypotension may range from a mild, asymptomatic decrease in

blood pressure to profound shock and loss of consciousness.

Hypotension usually occurs in the latter part of dialysis,

but may occasionally occur shortly after initiation of

dialysis. Among the more serious complications associated

with dialysis treatments are infectious hepatitis, a

dangerous inflammation of the liver, and dialysis dementia,

a gradual loss of mental functioning (Phillips, 1987).

However, these complications rarely occur.










Fatigue is probably the most common complaint of

dialysis patients (Wright, 1981). Oberley & Oberley (1992)

estimate that about 90% of patients on dialysis suffer from

some degree of fatigue. The hematocrit, the percentage of

blood that is composed of red blood cells, is normally about

45%. However, for individuals on dialysis this number is

usually reduced to between 20 and 30% (Phillips, 1987). The

development of a new form of erythropoietin (a protein that

enhances the formation of red blood cells) has improved this

situation for many patients (Oberley & Oberley, 1992).

Stages of Adjustment to the Hemodialysis Regimen

Abraham (1969) describes three phases in the process of

adaptation to hemodialysis. The first phase, "the shift to

physiological equilibrium," occurs during the first three

weeks of dialysis. The beginning of this phase is

characterized by initial apathy resulting from uremia which

lessens between the first and third dialysis sessions.

Next, euphoria occurs when the patient realizes death is not

imminent. Anxiety is also present but is believed to be

transient and related to concerns about the dialysis

process. The second phase, "the convalescent phase", occurs

between the third week and third month. Conflicts of

dependency versus independence become particularly salient

at this time. The patient reaches physiological equilibrium

during this phase and is confronted with the reality of the

situation. The patient is also faced with leaving the










hospital and relinquishing the regressed and dependent

position. During the third phase, "struggle for normalcy",

patients return to daily activities and continue with the

process of adjusting to the complications of the dialysis

regimen.

Reichsman & Levy (1972) similarly have identified three

stages of adaptation to hemodialysis: the honeymoon period,

the period of disenchantment and discouragement, and the

period of long-term adaptation. During the honeymoon

period, there is marked improvement, physically and

emotionally, which lasts from six weeks to six months. As

the feelings of confidence and hope of the honeymoon period

decrease, the dialysis patient begins to experience a sense

of helplessness and sadness. The onset of this period is

usually associated with the stress involved in resuming

daily activities. This stage usually lasts from three to

twelve months. The final stage of long-term adaptation is

characterized by the patient's acceptance of her/his

physical limitations and the restrictions of the dialysis

regimen. The transition to this stage is gradual and is

marked by fluctuations in the patient's sense of emotional

and physical well being.

Psychosocial Ramifications of Chronic Hemodialysis

Despite numerous studies, no consensus about the

psychological impact of dialysis has been reached. This

lack of consensus is due to two primary reasons: the










variety of individuals' responses to dialysis and the lack

of a standard frame of reference for interpreting patients'

behavior (Wright, 1981). In addition, many of the studies

regarding the psychological problems associated with

dialysis are based on clinical observations and include only

small samples. Comparison of results, replications, and

assessment of change are therefore exceedingly difficult.

Kaplan De-Nour (1983) acknowledges that there is a dire need

for systematic, integrated, large-scale, long-term research.

In the early 1960s, the struggle for survival was the

main concern of hemodialysis patients, therefore emotional

problems tended to be suppressed. Today, psychological

problems are the major cause of disability among dialysis

patients (Fortner-Frazier, 1981). The process of adapting

to kidney disease and chronic hemodialysis is extremely

stressful for patients, family members, and medical

personnel (Czackes & Kaplan De-Nour, 1978; Fortner-Frazier,

1981).

Impact of dialysis treatment on patients

Accurately assessing the psychological reaction of

patients to long-term dialysis is difficult. The typical

patient is not motivated to seek counseling even when under

extreme stress due to the social stigma associated with

psychiatric treatment. This is particularly true for the

dialysis patient for whom preservation of self-esteem with

fellow patients is often vital. The refusal of psychiatric










aid is often viewed as a sign of strength and a way of

maintaining a mental and bodily integrity which may be

inwardly crumbling (Abram, 1974).

Understanding the emotional difficulties associated

with dialysis is important in order to assist patients in

finding better methods for handling stress. Wright, Sand,

and Livingston (1966) investigated the kinds of

psychological stress associated with dialysis and the

variety of patient reactions and adaptations to these

stresses. The 12 patients studied experienced at least some

of the following stresses associated with actual or

threatened losses: (1) loss of body parts or body function,

(2) loss of membership in groups, (3) failure of plans, (4)

changes in way of life, (5) loss of home, possessions, or

financial status, and (6) loss of job or occupation. These

stresses were closely related to patients' self-image and

required defensive reactions such as denial of the extent

and functional impact of the disease or projection of

difficulties onto other patients.

Similarly, Czackes and Kaplan De-Nour (1978) have

identified six factors that are frequent sources of stress

for dialysis patients: (1) losses, (2) restrictions, (3)

changes in body image, (4) dependency conflicts, (5)

increased aggression, and (6) the threat of death. Patients

with chronic renal failure live with the fear of death

coupled with the fear of a life that may not be acceptable










(Beard, 1969). The increased aggression seen in some

dialysis patients includes anger because of loss of physical

health (Beard, 1969), increased restrictions, and loss of

freedom (Tourkow, 1974). Although dialysis patients have

many reasons to be angry, the direct expression of this

anger is often perceived as being "dangerous" since their

lives depend on others (Czackes & Kaplan De-Nour, 1978).

The major psychiatric complications that have been

observed in dialysis patients include psychosis, anxiety,

depression, and suicide. Czackes and Kaplan De-Nour (1978)

found that non-severe psychotic symptoms frequently occur

over the course of dialysis. Of 100 patients who survived

at least six months on dialysis, 18 developed transient

psychotic symptoms relating to delusions that the medical

staff wanted to harm them. These paranoid reactions were

found to be of psychogenic rather than organic origin.

There is some disagreement about the frequency and

severity of anxiety in chronic dialysis patients.

Isiadinso, Sullivan, and Baxter (1975) reported prominent

symptoms of anxiety in all 84 patients studied. However,

Czackes and Kaplan De-Nour (1978) found that 75% of patients

did not have any symptoms of overt anxiety, 20% had moderate

anxiety, and only 7% had severe anxiety.

Depression is the most common psychiatric complication

of chronic hemodialysis (Czackes & Kaplan De-Nour, 1978;

Friedman, Goodwin, & Chaudhry, 1970b; Newberry, 1989) and










frequently becomes a way of life for many patients (Abram,

1974). In an early study, Beard (1969) found that 57% of

dialysis patients described conscious feelings of

depression. Later studies have also confirmed the

prevalence of depression among dialysis patients. Reichsman

and Levy (1972) found that all 25 of their patients were

significantly depressed, while Holcomb and MacDonald (1973)

found 43% of their patients reporting extreme depression.

At a two-year follow-up, Foster, Cohn, and McKegney (1973)

found that 47% of patients were intermittently depressed.

Although depression is clearly a common psychiatric problem

among dialysis patients, due to the small sample size of

most studies on patient depression it is difficult to

ascertain whether the differences are due to differences in

patient populations, in units, or in the psychological tests

used to measure depression (Kaplan De-Nour, 1983).

The available research indicates that suicidal thoughts

are common among dialysis patients, with self-destructive

behavior taking a variety of forms from repeated dietary

indiscretions to active suicidal attempts (Abram, 1974).

Abram, Moore, and Westervelt (1971) sampled 2,706 center

dialysis patients and 772 home dialysis patients. The

incidence of suicidal behavior was found to be 400 times the

rate of the general population (assuming ten suicides per

100,000 as the average rate). Nonadherence to the treatment

regimen (ingestion of large amounts of fluids and forbidden









17

foods) was the cause of death of 117 of the 192 patients who

exhibited suicidal behavior.

In additional studies investigating suicidal behavior

of dialysis patients, Foster, Cohn, and McKegney (1973)

reported that 43% of dialysis patients made suicidal threats

and 19% of patients attempted suicide. Similarly, Holcomb

and MacDonald (1973) found that 35% of their patients had

suicidal thoughts. Czackes and Kaplan De-Nour (1978) found

a slightly lower rate with 27 out of 100 patients having

suicidal thoughts and 2 of the 27 actually committing

suicide.

Goldstein and Reznikoff (1971) concur that the suicide

rate of long-term hemodialysis patients is alarmingly high.

However, they suggest that failure to adhere to treatment

may not always be a form of suicidal behavior. Dietary

abuse may be an attempt to adjust to the stresses associated

with the dialysis regimen. Wright (1981) also suggests that

dietary excess can be viewed as an attempt to derive

enjoyment from continued survival rather than as an act of

rebellion or a masked suicidal gesture.

The experience of survival through dialysis involves at

least a partial loss of sexual interest (Charmet, 1988).

Due to chronic anemia, intermittent uremia, and the medical

complications associated with dialysis, most patients are

unable to assume their previous level of physical or

emotional involvement with the significant others in their









18
lives (Levy, 1973). The sexual problems associated with the

hemodialysis regimen have been found to occur more often in

males than in females (Czackes & Kaplan De-Nour, 1978;

Fortner-Frazier, 1981); however, the frequency of sexual

activity of female patients has also been found to be

drastically reduced (Czackes & Kaplan De-Nour, 1978). This

deterioration of sexual functioning may be caused by organic

factors, changes in the marital relationship, psychological

complications, or glorification of the past (Czackes &

Kaplan De-Nour, 1978).

In a survey of 64 male patients conducted by Kaplan De-

Nour (1983), half of the patients reported severe sexual

problems and a quarter reported no interest, satisfaction,

or sexual functioning. In another study of sexual

functioning, Levy (1981) mailed questionnaires to 429

hemodialysis patients and concluded that male patients on

dialysis seem to have problems with impotence which exceed

that of patients with other chronic medical illnesses.

Although little objective data is available about the

social activities of chronic dialysis patients, the general

consensus is that patients' activities are limited (Czackes

& Kaplan De-Nour, 1978). The results of Friedman, Goodwin,

and Chaudhry's (1970b) research indicate that this may be

true mainly for single patients. Twelve of the 13 married

patients in their study were able to maintain or improve

friendships despite the burdens of hemodialysis; however,










the unmarried patients' social activities were severely

impaired.

Patients' degree of rehabilitation is one of the major

criteria for successful treatment (Czackes & Kaplan De-Nour,

1978). However, comparison of rehabilitation data is

difficult due to the use of different criteria. Some

studies identify rehabilitation as full time employment;

however, this criteria fails to take into consideration

those patients who work part time. Other studies use income

level to assess the amount of work done by patients;

however, this criteria does not apply to certain groups of

patients such as students and housewives (Czackes & Kaplan

De-Nour, 1978).

Despite the lack of a standard criteria, it has been

noted that the majority of patients achieve their level of

vocational rehabilitation by the end of six months after

beginning dialysis and this level tends to remain stable

(Czackes & Kaplan De-Nour, 1978). Most dialysis patients

experience some level of decreased efficiency and

satisfaction with respect to work. Czackes and Kaplan De-

Nour (1978) have found that home dialysis patients typically

do better in terms of vocational rehabilitation (70%) than

center dialysis patients (40%). This discrepancy is

probably due to logistical as well as personality factors.

These researchers also found the pre-dialysis level of work,

satisfaction with work, level of dependency needs, and sick

role all correlated significantly with patients vocational

rehabilitation.










Many sources of stress have been identified in the

renal disease and dialysis literature, but for the most

part, researchers have only inferred that these are indeed

major sources of stress for dialysis patients. Very few

studies have actually elicited patients' views (Kaplan De-

Nour, 1983). Sherwood (1983) interviewed 55 dialysis

patients and concluded that the areas that patients

identified as being most affected by their illness and

dialysis treatment were employment activities, vacation and

leisure activities, eating habits, and sexual activity. Of

the 55 dialysis patients interviewed, 65% stated that

employment activities were either greatly or moderately

affected by being a dialysis patient. Patients with higher

educational levels reported less impact of illness on

employment activities. This latter finding is probably due

to the type of employment opportunities available to

patients with higher educational levels. Fifty-six percent

of patients reported that their eating habits were greatly

or moderately affected by their illness, and 53% of patients

said that their level of sexual activity had been greatly or

moderately affected by their kidney disease and dialysis

treatments. Forty percent of patients stated that their

ability to enjoy life had been greatly or moderately

affected by their kidney disease, and 36% of patients

reported that their self-esteem had been severely or

moderately affected by their illness.










Tucker, Mulkerne, and Ziller (1982) also sought to

accurately identify concerns of dialysis patients. These

researchers devised a Concerns Inventory consisting of a

list of concerns that nurses had observed or heard patients

mention. The responses of 25 out of the 60 patients who

agreed to anonymously complete the inventory revealed that

the most common patient concerns were needle stick anxiety,

loss of energy, sexual performance difficulties, depression,

weight, dietary restrictions, blood test results, and

insomnia.

In a later study, Tucker, Chennault, Green, Ziller, and

Finlayson (1986) developed the Dialysis Patient Concerns

Inventory (DPCI). The DPCI consists of 29 concerns of

patients reported in informal group discussions or in

individual discussions with patients at the Kidney Center.

Fifteen of the 55 chronic hemodialysis outpatients agreed to

complete the inventory. The following items were rated as

areas of 'strong concern' or 'some concern' by more than 25%

of the patients completing the DPCI: needle sticks, loss of

energy, feeling depressed, being on a special diet, results

of blood tests, not being able to sleep, transportation to

dialysis, losing too much weight, not working, physical

appearance, sexual identity, loss of mate's love, and

parenting. These researchers concluded that dialysis

patients have strong concerns about their emotional states

and relationships with others in addition to physical health

related concerns.









22

Coping mechanisms. Dialysis is one of the few forms of

treatment which places a large group of people in such a

long-term, medically dependent position. Unlike other

patients with chronic illness, dialysis patients have

relatively little respite from their illness (Levy, 1981).

How a patient responds to this stress depends upon a number

of factors, including previous coping patterns and available

support systems (Campbell, 1983; Drees & Gallagher, 1981).

A review of the literature indicates that dialysis

patients utilize the full range of psychological defense

mechanisms to defend themselves against the stresses

associated with the dialysis regimen. The primary defenses

used by dialysis patients are denial, depression,

aggression, and regression (Fortner-Frazier, 1981). These

defense mechanisms help individuals to reduce anxiety and

regain control in periods of extreme stress.

The primary defense mechanism used by dialysis patients

is denial (Abraham 1974; Fortner-Frazier, 1981). Denial is

defined as patient behavior that is contrary to consensual

expectation in the absence of psychotic thought disorder and

after explanation of medical factors (Cummings, 1970). The

use of denial has been accepted as an almost universal

defense in dialysis patients (Beard & Sampson, 1981).

Patients shift back and forth from denial to objectivity in

a rapid and continuous manner (Beard & Sampson, 1981). It

is believed that balanced shifting between these two










strategies enables the patient to effectively use both

mechanisms and facilitates adaptation to the prolonged

ordeal of life as a dialysis patient. Denial by itself

would lead patients to disastrous nonadherence and possibly

to treatment refusal. Objectivity serves the purpose of

reorienting patients to the rigors of the dialysis treatment

program. This shift fills alternately the need for reality

orientation and the need for reduction of anxiety (Beard &

Sampson, 1981).

Kaplan De-Nour, Shaltiel, and Czackes (1968) in one of

the early studies of dialysis patients observed that all

patients regardless of age, sex, education, or premorbid

personality used denial, displacement, reaction formation,

and projection to cope with the stresses of the dialysis

regimen. Although this defensive structure was adaptive in

that it allowed patients to function, the defensive

structure was brittle, making patients vulnerable to

transient breakdowns with the appearance of anxiety or

depressive reactions. These researchers hypothesized that

the main stress of chronic hemodialysis for patients is the

dependency on the dialysis machine and the staff, the

aggression resulting from this dependency, and the need to

block expression of this aggression.

Newberry (1989) also notes that most dialysis patients

employ a combination of repression and denial to cope with

their anxiety. These psychoreactive states are commonly










expressed by dietary indiscretions, large interdialytic

weight gain, failure to take medication, or failure to

appear for scheduled dialysis sessions. Although patient's

use of denial is generally not regarded as maladaptive

(Levy, 1980), excessive use of denial may lead to

difficulties such as lack of cooperation (Czackes & Kaplan

De-Nour, 1978). Abram (1974) agrees that denial is not

necessarily psycho-pathological; however, he notes that

although denial seems to be an effective defense, under

severe psychological stress, underlying anxiety or in

extreme cases, psychosis, may erupt.

Regression, the ability to follow orders and let others

"take over", is essential to patients' survival during the

acute stage of an illness and may be necessary throughout a

chronic illness such as renal disease (Strain, 1981).

Successful adaptation to the hemodialysis treatment

procedure requires patients to successfully regress to a

stage reminiscent of early infantile dependency (Viederman,

1974). Dialysis patients must be able to tolerate

regression to the point that they can literally and

figuratively place their lives in the hands of another.

However, the patient who finds these regressive pulls too

tempting remains overly dependent, while the patient who

finds these pulls too threatening may become rebellious and

even refuse treatment (Abram, 1974). Several researchers

have noted that regression is frequently observed in










dialysis patients (Abram, 1974; Czackes & Kaplan De-Nour,

1978; Fortner-Frazier, 1981; Wright, 1981). Although this

regression is not viewed as pathological per se, it becomes

problematic when the patient's desire to remain dependent

outweighs the reality of physical and mental limitations

(Strain, 1981).

This struggle of independence versus dependence is a

major psychosocial issue for dialysis patients (Fortner-

Frazier, 1981; Newberry, 1989), and a principal factor in

the failure to rehabilitate most patients successfully

(Wright, 1981). Dialysis patients are placed in a "double-

bind" situation of being dependent upon dialysis machines

and treatment staff for their lives, while simultaneously

being encouraged to function as independently as possible

(Streltzer, 1983).

It is evident that maintenance hemodialysis has major

psychosocial ramifications (Newberry, 1989) with depression,

aggression, denial, and mature acceptance appearing at

different stages of the dialysis process (Newberry, 1989).

Some patients react to the demands associated with dialysis

by expressing direct feelings of hostility and anger towards

family members and medical personnel (Newberry, 1989), while

other patients tend to withdraw (Fortner-Frazier, 1981).

Extreme mood swings are also common (Czackes & Kaplan De-

Nour, 1978), but most patients move through these emotional

episodes and regain some measure of equilibrium (Cummings,










1970). Other patients become overtly psychotic; however,

this is extremely rare and develops in fewer than 1% of

patients placed on dialysis (Wright, 1981).

The need to come to terms with the threat of death, to

accept dialysis as a method to delay that event, and the

need to comply with a restrictive medical regimen are

stressors that all hemodialysis patients experience. These

stressors are maximal at the beginning of maintenance

hemodialyses and then gradually decrease (Wright, 1981).

Although many of the stressors dialysis patients experience

are inherent in the chronic dialysis situation, other

stressors are related to the reaction of the patient's

family and the medical staff (Kaplan De-Nour, 1983).

Impact of dialysis treatment on family members

Assessment of the impact of dialysis on family dynamics

is even more difficult than assessment of the social and

vocational aspects of patient adjustment. Many variables

need to be studied simultaneously and family members tend to

be reluctant to discuss difficulties (Czackes & Kaplan De-

Nour, 1978). Although little is known about families'

reactions, available research indicates that overprotection

of patients by family members is the universal initial

reaction to dialysis. This overprotection gradually

disappears in most nondependent patients. Feelings of

aggression and hostility towards the patient are also common

reactions among spouses of chronic hemodialysis patients.










Spouses were found to use several different methods for

handling these feelings including displacement, denial, and

introjection (Czackes & Kaplan De-Nour, 1978).

Family members of dialysis patients experience a great

deal of stress associated with the pre-dialysis phase of

diminishing renal failure as well as with dialysis itself

(Drees & Gallagher, 1981). Feelings of anxiety and

depression are also frequent problems (Kaplan De-Nour,

1983). Often family members' emotions, such as anger or

depression, parallel those of the patient (Campbell, 1983;

Oberley & Oberley, 1992).

A number of possible sources of stress for spouses have

been identified including a decrease in economic and

financial status (Friedman, Goodwin, & Chaudhry, 1970b).

Relationships typically undergo changes due to the stresses

and losses (e.g., loss of financial security) associated

with dialysis, especially if the individual on dialysis held

the position of responsibility in the family (Oberley &

Oberley, 1992). When the dialysis patient was the major

wage earner, family income falls and living conditions for

the family usually deteriorate (Isiadinso, Sullivan, &

Baxter, 1975). In addition to assuming more financial

responsibility, the spouse of a dialysis patient may have to

take on the role of both parents with the children (Salmons,

1980). The spouse may inwardly resent the partner's

dependency, but be unable to voice these feelings (Salmons,











1980). Some families react by overprotecting the patient

while others may handle their aggression by displacing it

onto the medical team (Salmons, 1980). The stressfulness of

dialysis for spouses depends primarily on their previous

level of dependency needs. For the basically independent

spouse, dialysis is less stressful than for the dependent

spouse (Czackes & Kaplan De-Nour, 1978).

Contrary to the commonly held belief, the frequency of

psychopathological reactions in spouses is surprisingly

lower in spouses of home dialysis patients. One of the

considerations for home dialysis is a supportive spouse.

This selection criteria may contribute to the lower, but

still high, rate of complications in this group (Czackes &

Kaplan De-Nour, 1978).

The reaction of children of dialysis patients is not

well documented. Mass and Kaplan De-Nour (1975) interviewed

seven low income families with a spouse on dialysis. These

researchers found that all children were restricted in

bringing friends home and several children were ashamed to

tell peers about their parent's illness.

Impact of dialysis treatment on medical personnel

The patient-practitioner relationship in hemodialysis

treatment is qualitatively different from the patient-

practitioner relationship in acute-care treatment as

patients typically dialyze at the same facility for an

extended period of time (Rorer, Tucker, & Blake, 1988).










Chronic dialysis is stressful for patients, as well as the

medical staff. In many units, nurses "drop out" at a higher

than normal frequency despite the increased status and pay

associated with the position. Physicians have also been

noted to make decreased visits to dialysis units (Czackes &

Kaplan De-Nour, 1978).

The issue of patient cooperativeness, especially

adherence to the medical regimen, is one of the most common

concerns of nephrology team members (Levy, 1980). Working

with chronic patients who often do not follow medical

recommendations is stressful for physicians and nursing

staff. Levy (1981) notes that the professional staff tend

to be highly productive individuals and often project their

high expectations onto the patients. These expectations are

often based on incomplete data and are usually derived at

during the time the patient is in the "honeymoon" phase of

adaptation -- a time when limitations are minimized.

Staff's expectations are often frustrated when patients do

not achieve the desired level of adjustment (Czackes and

Kaplan De-Nour, 1978). When this occurs, denial may be used

by dialysis unit personnel to prevent discouragement and

disillusionment which can interfere with effective patient

treatment (Abram, 1974).

Factors Associated with Patients' Adherence to Treatment
Regimens

Past research has examined a variety of demographic and

psychosocial factors in an attempt to predict patients'








30

adherence with hemodialysis treatment regimens. A review of

these studies indicates that few factors can be found which

reliably predict patient compliance (Lamping & Campbell,

1990b). Although some studies have indicated that certain

demographic and psychosocial factors may be associated with

increased adherence, the majority of the research is

inconclusive.

Demographic factors in treatment adherence

Age is one of the few factors which has been fairly

consistently associated with patient adherence. Significant

differences in compliance of younger hemodialysis patients

(ages 19 to 34) versus older hemodialysis patients (ages 35

to 79) were found by Gonsalves, Sterin, Gulledge, Gipson,

and Rodgers (1987). The noncompliance rate for the younger

group was 88% while the noncompliance rate for the older

group was only 41%. Younger patients were also found to

have lower frustration tolerance and more difficulty dealing

with regimen restrictions. These researchers hypothesize

that the combination of the constellation of stresses

associated with ESRD and the stresses associated with life

transitions of young adulthood make compliance particularly

difficult for younger patients. Consistent with these

results, Czackes and Kaplan De-Nour (1978) found that

compliance with diet improves with age. Several other

researchers (Caesar & Tucker, 1991; Check, 1982; Schmicker &

Baumback, 1990) have also found older patients to be more

adherent than younger patient.










A survey of the compliance rates of 100 hemodialysis

patients by Schmicker and Baumback (1990) revealed that

females had a significantly higher compliance rate (43.5%)

than males (24.1%). Kirilloff (1981) similarly found that

women, more often than men, complied with their treatment

regimen.

Another variable that has been the focus of several

adherence studies is length of time on dialysis. Schmicker

and Baumback (1990) and Brown and Fitzpatrick (1988) found

that the longer a patient remains on dialysis, the less

likely the patient is to comply with treatment. Blackburn

(1977) also found that patient compliance decreased as time

on dialysis increased, despite increased understanding of

dietary restrictions.

In contrast to the above studies, several researchers

have found that demographic variables do not influence

patients' adherence rates. Brown and Fitzpatrick (1988)

investigated dietary compliance among a sample of 41

dialysis patients. The level of dietary abuse was quite

high with 58% of the group evidencing some degree of abuse

in weight gain, potassium levels, and/or urea levels.

However, gender was not found to be related to abuse scores.

In another study, Procci (1978) examined compliance rates

among a sample of 31 dialysis patients. Age, gender, race,

education, marital status, and chronicity of dialytic

treatment showed no significant relationship to patient










compliance. A comparison of patients with respect to age,

race, marital status, and educational level by Kirilloff

(1981) also revealed no significant differences in the

numbers of patients judged to be compliant versus

noncompliant.

Social factors in treatment adherence

The effect of friends and family members on patients'

adherence has been investigated by several researchers.

Beard (1969) found that patients who had the ability to

relate satisfactorily with others, had a strong relationship

with a significant person, and had the ability to draw upon

that relationship in times of stress made the best

adjustment to dialysis. The results of Cheek's (1982) study

which indicated that individuals not living with a spouse or

significant other were more likely to be noncompliant

support these results. Cheek suggests that patients living

alone may not feel responsible to another and therefore may

be less likely to adhere to treatment restrictions.

Patients living alone may also be more likely to eat away

from home where a restricted diet may not be available.

In another study investigating the relationship of

family support to adherence Christensen, Smith, Turner,

Holman, Gregory, and Rich (1992) surveyed 78 hemodialysis

patients. Patients who perceived their family as more

supportive, and characterized by greater cohesion and

expressiveness and less intrafamily conflict, exhibited










significantly more favorable adherence to fluid-intake

restrictions than did patients reporting less family

support. These researchers also suggest that family support

may facilitate the self-regulatory process necessary for

patients to comply with fluid-intake restrictions.

The results of a study by Sherwood (1993) indicated

that the greater the negative impact of the patient's

illness on family and friends, the less compliant the

patient was with respect to weight gain. Sherwood (1993)

also found that patients who identified themselves as

compliant, experienced a greater disruption in social

contacts. He hypothesized that compliant patients may avoid

social events because others may not be aware of the

patient's dietary restrictions and inadvertently influence

the patient to be noncompliant. Consistent with this

hypothesis, Kaplan De-Nour (1983) reported that dialysis

patients experience a severe drop in interest in social

activities and an even greater drop in actual participation.

Somer and Tucker (1988) investigated the hypothesis

that dietary compliance among chronic hemodialysis patients

is related to their engagement in social, vocational, and

recreational activities and to the marital adjustment of

their spouses. The patients who evidenced better dietary

compliance were the ones who engaged in recreational

activities and whose spouses reported higher levels of

marital adjustment.










Steidl, Finkelstein, Wexler, Feigenbaum, Kitsen,

Kliger, and Quinlan (1980) suggest that family assessment

can be used for early identification of patients at risk for

poor adherence to treatment regimens. In a population of 23

stable maintenance long-term dialysis patients, high

adherence ratings were found for patients whose families (1)

exhibit respectful shared adult leadership, (2) have strong

parental coalitions, (3) have the ability to take individual

responsibility, (4) demonstrate effective problem solving

skills, and (5) have an open, responsive stance to the

opinions of others.

Positive interactions with physicians and staff have

been found to increase patient compliance (Schmicker &

Baumback, 1990), while lack of agreement about expected

behavior and unrealistic expectations of medical staff have

been found to hinder patient adjustment (Kaplan De-Nour,

1981). Rorer, Tucker, and Blake (1988) studied the

interactions of 18 patients with the nursing staff at an

independent hemodialysis-treatment facility. Patients'

average between-treatment weight gain was used as the index

of patient compliance. The emotionally positive and

emotionally negative verbal responses of nurses were found

to be positively associated with patient noncompliance.

These results suggest that nurses may be unintentionally

reinforcing patient noncompliance. The authors concluded

that there is a need for nurses to focus attention on










increasing patient compliance by initiating treatment-

related questions and providing additional information about

the treatment regimen, especially among treatment

nonadherent patients.

Psychological factors in treatment nonadherence

Despite the many years of research, we still lack

sufficient knowledge about the psychological factors

associated with dialysis (Kaplan De-Nour, 1983). Several

psychological variables have been investigated as predictors

of patient adherence including frustration tolerance, locus

of control, health beliefs, sick role behavior, acceptance

of disability, depression, self-control, and denial.

However, due to the limited number of studies and lack of

consistent findings, it is difficult to draw any definite

conclusions about the predictive value of these variables

(Lamping & Campbell, 1990b).

Schlebusch and Levin (1982) tested 25 adult long-term

hemodialysis patients and found that the compliers were more

conscientious, persevering, conservative, and self-

disciplined, while the noncompliers were more venturesome,

more inclined to experiment, and had less effectively

developed internal controls. Compliant patients have also

been found to be more motivated (Murray, 1983) and more

involved in their treatment (Tucker, Ziller, Chennault,

Somer, Schwartz, Swanson, Blake, & Finlayson, 1987).










In a study of 24 dialysis patients (Kaplan De-Nour &

Czackes, 1972), low frustration tolerance and primary and

secondary gains from the sick role were identified as the

most frequent causes of non-compliance. Dansak (1972) also

found that for some hemodialysis patients, being sick

resulted in the gratification of previously unsatisfied

needs or desires. These secondary gains interfered with

patients' successful adaptation. Depression has also been

found to lower compliance rates of dialysis patients (Kaplan

De-Nour & Czackes, 1976).

Betts and Crotty (1988) and Cheek (1982) examined

patients' responses to illness and level of compliance.

Cheek (1982) administered the Response to Illness

Questionnaire to 27 of the 42 patients in a chronic

hemodialysis unit. Responses of patients in the compliant

group, as measured by weight gain, reflected acceptance of

illness, no blame to others, acceptance of responsibility

for care, and ability to control anxiety concerning their

illness. Patients in the noncompliant group looked on their

illness as an enemy or burden which rendered them

defenseless and powerless. These patients were preoccupied

with their illness but resisted becoming involved in their

care. Betts and Crotty (1988) also used the Response to

Illness Questionnaire in their study of 46 dialysis patients

but found no significant relationship between patients'

scores on this instrument and patients' between-dialyses

weight gain or serum potassium and phosphorous levels.









37
Patients' locus of control and health beliefs have been

the focus of a significant number of research studies.

Goldstein and Rezinkoff (1971) found that patients on

chronic hemodialysis evidence a significantly greater degree

of external locus of control than do patients with minor

medical problems. This shift to an external orientation

occurs as dialysis patients fail to experience a return to

health in an attempt to cope with the continuous anxiety and

responsibility of keeping themselves alive by complying with

a rigid treatment regimen. Goldstein and Reznikoff (1971),

note that this external locus of control can produce

disastrous consequences for dialysis patients, since the

patient's cooperation is essential for treatment. Wilson,

Muzekari, Schneps, and Wilson (1974) tested 18 dialysis

patients and also found that these patients had higher

external locus of control scores after an average of 15

months on dialysis. A year later these scores were even

higher.

Bollin, and Hart (1982) studied 30 patients who had

been dialyzed for at least 10 months to determine the

relationship between dietary adherence and patients' locus

of control and health beliefs. The overall compliance rate

for these subjects was 50%. All but one of the subjects

placed a high value on health, however health beliefs were

not related to compliance levels. Patients who were

internally controlled were significantly more compliant than











those who were not, but over two-thirds of the sample was

externally controlled. Zetin, Plummer, Vaziri, and Cramer

(1981) also found that patients with higher external locus

of control had poorer overall compliance and higher

interdialytic weight gain. Similarly, Wenerowicz, Riskind,

and Jenkins (1978) administered the Rotter Internal-External

Locus of Control Scale to 19 chronic hemodialysis patients

and found that dialysis patients with an internal locus of

control had a higher rate of compliance to medication and

dietary restrictions.

Caesar and Tucker (1991) examined the role of health

locus of control and fluid intake self-efficacy in the fluid

intake adherence of 23 home hemodialysis patients and 24 in-

center hemodialysis patients. Both groups of patients had

average daily fluid weight gains in the nonadherent range

(average daily fluid weight gain over 2.0 lbs). Internal

health locus of control and fluid intake self-efficacy were

not predictive of fluid intake adherence, and neither

internal health locus of control nor fluid intake self-

efficacy increased as fluid intake adherence increased.

Caesar and Tucker (1991) state that simply believing that

fluid intake adherence is under one's control, is one's

responsibility, and is beneficial to one's health, may not

be sufficient reasons for patients to restrict fluid intake;

motivation may also be necessary. Motivation to control

fluid intake may be lacking or may be minimized since the








39

negative consequences of fluid overload are often denied or

delayed (Caesar & Tucker, 1991). Streltzer and Hassell

(1988) also point out that dialysis patients may be

experiencing positive reinforcement for excessive fluid

intake, particularly when fluid is consumed to combat the

"washed out" feeling often present after dialysis sessions.

Poll and Kaplan De-Nour (1980) sought to gain a more

complete understanding of the relationship of locus of

control to patient adjustment by investigating several

aspects of adjustment of a comparatively large group of

dialysis patients. Forty adult patients from four dialysis

centers were interviewed to determine compliance with fluid

and dietary restriction, vocational rehabilitation,

acceptance of disease, and locus of control. Patients with

an internal locus of control were found to have better

compliance with diet, better vocational rehabilitation, and

greater acceptance of their disease.

In a recent study, Schneider, Friend, Whitaker, and

Wadhwa (1991) examined the cognitive and emotional factors

underlying fluid compliance of 50 dialysis patients.

Although the subjects in this study demonstrated a wide

range of anxiety, depression, and anger, negative emotions

were not found to predict fluid compliance. The results did

demonstrate that cognitive variables (perceived success of

past adherence, attributing success to effort, motivation to

adhere, and efficacy expectations) predicted interdialytic











weight gain both in the present and at 4-month follow-up.

However, patients' locus of control was not found to be

related to fluid compliance.

Rosenbaum and Ben-Ari Smira (1986) studied 53 dialysis

patients and found that most patients reported that they

were highly motivated to comply with fluid restrictions,

were convinced of the importance of adhering to these

restrictions, and believed that success was solely dependent

on their actions. A majority of these patients also

reported having extreme difficulty adhering to fluid

restrictions. Neither subjects' health beliefs, nor

motivation to comply, nor perceived difficulties in

complying with fluid restrictions had any relation to either

their actual compliance or their self-reported

resourcefulness. However, subjects perceptions of their

past success with fluid compliance, their attribution of

success to their own efforts, and their self-efficacy

expectations significantly correlated with actual past

adherence and with adherence at 3-month and 1-year follow-

up.

Although some factors have been shown to be associated

with adherence, the results are inconsistent. In most

studies, adherence behavior is generally assumed to be a

stable and relatively enduring characteristic of the

individual or situation. The measures used to predict

adherence are typically based on dispositional models of










behavior. However, adherence may be highly situation-

specific, and determined to a large extent by environmental

contingencies that vary over time and across situations

(Lamping & Campbell, 1990b).

Despite the prevalence of nonadherence among a majority

of dialysis patients, there is a substantial proportion of

patients who do well on dialysis. It is important for

practical, as well as theoretical reasons, to determine why

some patients adjust well to dialysis while others do not.

The ability to identify and predict which patients will be

noncompliant with treatment regimens is the first step in

developing and implementing compliance-improving

interventions (Lamping & Campbell, 1990b).

The Problem of Fluid and Dietary Nonadherence Among
Hemodialysis Patients

Prevalence of Nonadherence Among Hemodialysis Patients

A review of the studies of dialysis patients reveals

that complying with dietary and fluid restrictions is a

major problem for a significant number of patients.

Estimates of nonadherence range from a high of 93% (Betts &

Crotty, 1988) to a low of 15% (Yanitski, 1983). Patients

may be nonadherent to their treatment regimen some, but not

all, of the time or they may comply with some aspects of

their regimen, but not others.

Dietary nonadherence has been documented as early as

1965. Shea, Bogdan, Freeman, and Schreiner (1965) found

that in six of eight patients there was a considerable










amount of dietary indiscretion even though patients

understood the diet and expressed a desire to adhere to

restrictions. In a study of 20 hospital center dialysis

patients, Friedman, Goodwin, and Chaudhry (1970a) reported

that patient compliance with the dietary component of the

therapeutic regimen was disappointing. Despite coercion,

cajoling, and scolding, 15 of the 20 patients rarely or

never followed their physician's advice regarding diet.

Procci (1978) assessed dietary compliance rates of

thirty-one maintenance hemodialysis patients by measuring

potassium elevation and weight gain between dialysis

sessions. Compliance was rated as good (mean weight gain

between dialysis sessions of two pounds or less; mean

predialysis serum potassium of 5.5 mEq/liter or less) or

poor (mean weight gain between dialysis sessions greater

than two pounds; mean predialysis serum potassium of greater

than 5.5 mEq/liter). Of the 31 patients, 61% were poor

compliers and 39% were good compliers, with excessive weight

gain being more common than potassium elevation. Streltzer

and Hassell (1988) also assessed compliance on the basis of

inter-dialysis weight gain and reported that approximately

one-third of their patients were chronic noncompliers with

regard to fluid intake, gaining an average of well over 2 kg

between dialysis sessions.

Blackburn (1977) studied 53 patients representing a

broad range of psychosocial characteristics and found that










79% of the population were potassium compliant, 62% were

phosphorous compliant, and 49% were weight compliant.

Again, compliance with fluid restrictions was the most

difficult problem for patients. Yanitski (1983) also found

fluid adherence to be the most difficult problem for

dialysis patients. His study of 29 patients revealed that

only 30% of the subjects adhered to fluid restrictions;

however, compliance to potassium restrictions was

significantly higher with 85% of the subjects being

adherent. In a similar pattern, of the 46 dialysis patients

examined by Betts and Crotty (1988), only 6.5% stayed within

acceptable limits for weight gain (0-4 lbs) between dialysis

sessions), 23.9% stayed within acceptable limits for

phosphorous levels (3.5-5.0 mg/100 ml range) and 71.7%

stayed within acceptable limits for potassium (3.5-5.5

mEq/L).

Kaplan De-Nour and Czackes (1972) examined 43 dialysis

patients and found that 24 were major "abusers of diet" as

evaluated by pre-dialysis blood pressure, serum potassium,

and weight changes between dialysis sessions. Another study

of 83 patients revealed that compliance with diet was poor

in 40% of the patients, and only 25% of patients were rated

as good compliers (Kaplan De-Nour & Czackes, 1974). Czackes

and Kaplan De-Nour (1978) later studied 100 patients. Only

23% were found to comply well with the diet, 38% complied

fairly well, and 39% abused the diet. The basic pattern of









44

compliance of this group of dialysis patients was determined

in the early stages of dialysis. The compliance rate of 65%

among these patients was the same at 6, 12, and 24 month

follow-ups (Czackes & Kaplan De-Nour, 1978).

Plummer and Zetin (1981) interviewed 15 of 25 patients

undergoing regular dialysis treatment regarding their

adherence with prescribed medications. In response to

direct questioning, 53% of patients admitted non-compliance

with taking prescribed medications despite the emphasis

staff members placed on medication compliance.

Given the high rate of nonadherence found in the

majority of studies, Betts and Crotty (1988) and Manley and

Sweeney (1986) suggest that researchers need to determine if

the standards currently used are overly restrictive or

unrealistic for ESRD patients. Betts and Crotty (1988) also

stress the importance of examining intervening variables

such as motivation, available resources, and background

factors that may impede or facilitate adherence to

therapeutic regimens. If the process by which individuals

become adherent is understood, this knowledge would allow

staff members to intervene more effectively.

Methods Used to Assess Adherence to Hemodialysis Treatment
Regimens

The major difficulty in assessing adherence among

hemodialysis patients is the lack of a standardized

definition and measurement. Some researchers assess

adherence using a global index based on adherence to several









45
components of the treatment regimen, while other researchers

use separate measures to assess adherence to specific

aspects of the treatment regimen. When using a global

index, researchers often have difficulty classifying

patients since adherence levels to different aspects of the

treatment regimen may vary. The use of a global index also

obscures potentially important individual differences.

Wolcott, Maida, Diamond, and Nissenson (1986) have

proposed a multidimensional categorization of noncompliance

behavior in ESRD patients which includes the following

parameters: (1) duration, (2) specific regimen behaviors,

(3) primary versus secondary, (4) endogenous versus

reactive, and (5) continuous, mixed, or episodic.

Noncompliant behavior lasting less than 3-months is

considered short-term with noncompliance of longer duration

categorized as long-term. Noncompliance beginning at the

onset of treatment is considered primary, while secondary

noncompliance is behavior which begins after a compliant

interval of at least 6-weeks. Endogenous noncompliance is

not associated with any known factors such as underlying

psychiatric syndrome or health beliefs, while reactive

noncompliance is associated with one of these factors.

Both subjective and objective measures have been used

to assess the adherence of hemodialysis patients.

Subjective measures include patient self-report and ratings

by staff members, both of which are susceptible to response









46
biases. The traditional objective measures of adherence are

serum potassium (K), phosphate (P), blood urea nitrogen

(BUN), and interdialytic weight gain (IWG). However, each

of these parameters may be influenced by factors unrelated

to adherence with prescribed medical and dietary regimens.

Serum K and P may be affected by the adequacy of the

dialysis prescription. Drugs such as beta-blockers and

nonsteroidal anti-inflammatory agents may increase serum K,

and the use of calcitrol may increase serum P.

Interdialytic weight gain may be influenced by seasonal

variation, activity level, and perspiration (Desmond &

Tucker, 1993; Kobrin, Kimmel, Simmens, & Reiss, 1991;

Lamping & Campbell, 1990a; Manley & Sweeney, 1986). In the

majority of studies, adherence is assessed using objective

measures. Subjective measures, such as patient self-report,

are rarely used as the sole measure of adherence.

There is a great deal of inconsistency across studies

in the measures that are used to assess adherence. The most

commonly used measures are interdialytic weight gain and

potassium. Of the studies reviewed by Lamping and Campbell

(1990a), interdialytic weight gain is reported in 80% and

potassium is reported in 65%. There is also considerable

variation across studies in the criteria used to define

adherence (Lamping & Campbell, 1990a). Currently, there is

no single best way to operationally define adherence.

Without a standard method of defining and measuring











adherence, it is difficult to interpret results or make

accurate comparisons among studies.

Consequences of Nonadherence to Dietary and Fluid
Restrictions

Adherence to the dietary and fluid requirements of

dialysis is often the deciding factor between relatively

good health and death (Oberley & Oberley, 1992; Winokur,

Czackes, & Kaplan De-Nour, 1973). Failure to adhere to

treatment requirements can result in severe consequences

necessitating emergency medical treatment or

hospitalization, and may even be fatal (Lamping & Campbell,

1990a).

For most patients, the fluid restriction is the most

difficult part of the dialysis regimen (Czackes & Kaplan De-

Nour, 1978; Streltzer & Hassell, 1988). Exaggerated fluid

intake necessitates increased ultrafiltration during

dialysis sessions. Patients who are fluid overloaded prior

to beginning dialysis are more likely to experience

complications such as cramping and hypotension (Czackes &

Kaplan De-Nour, 1978; Newberry, 1989). Gross abuse of fluid

intake also results in the deterioration of the patient's

cardiovascular system, particularly among older patients.

Overdrinking causes excessive strain on the myocard and can

lead to congestive heart failure (Czackes & Kaplan De-Nour,

1978). Hemodialysis patients who do not comply with

dietary, fluid, and medication regimens, may also experience

hyperkalemia (a greater than normal concentration of










potassium) and/or hyperphosphatemia (an abnormally high

concentration of phosphates) which can result in increased

morbidity and premature death (Blackburn, 1977; Procci,

1981).

Many of the complications associated with chronic renal

failure can be prevented or reduced in frequency and

severity by careful dietary management (Newberry, 1989).

Past research has indicated how critically important it is

for patients to understand the dialysis process, dietary

restrictions, prescribed medications, and the factors

associated with possible complications. Newberry (1989)

stresses that this educational process should be continuous

rather than limited to the orientation period, which may be

the worst time for patients to acquire new information due

to the fear and confusion associated with the initiation of

dialysis.

All of the nonadherence-in-hemodialysis literature is

based upon the presumption that nonadherence decreases

patients' chances of medical survivorship (Armstrong & Wood,

1983). Despite the generally agreed upon premise that

adherence with hemodialysis and dietary regimens is

associated with favorable long-term outcome, few studies

have clearly demonstrated this association (Korbin, Kimmel,

Simmens, & Reiss, 1991). The studies that have examined

this association elicited results ranging from a strong

correlation between noncompliance and poor outcome (Czackes











& Kaplan De-Nour, 1978) to noncompliant patients having a

better outcome than complaint patients (O'Brien, 1990)

Based on the results of a 5-year study, Czackes and

Kaplan De-Nour (1978) concluded that compliance with diet

and fluid restrictions positively influences patients'

survival. At the end of the study, these researchers found

that 28% of patients who were still alive complied well with

the diet, 51% complied fairly well, and only 21% abused the

diet. Of the patients who died on dialysis, only 18%

complied well with the diet, 24% complied fairly well, and

58% abused the diet.

O'Brien's (1990) 9-year longitudinal study of ESRD

patients treated with maintenance hemodialysis revealed

surprising results. It was found that patients who died the

earliest demonstrated the highest compliance and surviving

patients reported the lowest compliance. It is suggested

that these findings may be explained by the concepts of

"ritual" versus "reasoned" compliance. Some surviving

patients reported strict adherence to the prescribed regimen

while others reported that although they did not strictly

adhere to fluid and dietary restrictions, they had learned

their own limits and were careful not to endanger their

lives. These patients also placed importance on factors

such as attending treatment sessions and taking prescribed

medications.











Strategies to Increase Patients' Adherence to Hemodialysis
Treatment Regimens

While the problem of adherence to treatment regimens is

widely acknowledged, relatively little is known about the

effectiveness of various interventions aimed at modifying

adherence behavior (Cummings, Becker, Kirscht, & Levin,

1981). Both pharmacologic and psychological interventions

have been used to improve compliance. However, the only

interventions that have been systematically investigated are

those psychological interventions based on behavioral

approaches. Results of these studies indicate that

behavioral interventions are effective in increasing

compliance, but follow-up data indicates that these effects

may be short-lived (Lamping & Campbell, 1990b).

Hart (1979) established a token economy program to

promote dietary compliance of dialysis patients. Subjects

received tokens for reporting to sessions within 5% of their

dry weight. Tokens could be exchanged for shorter sessions,

hot meals, or canteen booklets. The 10 male patients who

volunteered to participate in this study showed a decrease

in intersession weight gain; however, no follow-up data are

reported so the long-term effectiveness of this intervention

is unknown. Kean, Prue, and Collins (1981) examined the

long-term effects of a behavioral contracting procedure with

two patients with extensive histories of fluid over-loading.

Each patient received individualized contingencies over a

40-week period in order to improve the degree of compliance.










Behavioral contracting effectively reduced intersession

weight gain for both patients; however, the researchers were

unable to determine if the social reinforcers (praise and

conversations) or the tangible reinforcers (access to early

sessions and preferred meals) were responsible for the

observed changes. The results of this research indicate

that patients for whom the potential for future illness and

complications is too far removed to exert control over their

daily routine will respond to more immediate consequences.

The relative efficacies of three intervention

strategies designed to increase hemodialysis patients'

compliance with regard to following dietary restrictions and

limiting fluid intake were examined by Cummings, Becker,

Kirscht, and Levin (1981) using a sample of 116 hemodialysis

patients. All three interventions (behavioral contracting,

behavioral contracting with a family member or friend, and

weekly telephone contacts by clinic nurses) resulted in

substantial reductions in patients' serum potassium levels

and in weight gains between dialysis sessions. However, the

effects of these 6-week interventions tapered off to

preintervention levels once the interventions were

discontinued suggesting the need for long-term intervention

programs.

Tucker (1989) also conducted a research study to test

the effectiveness of three multimodal behavioral

interventions on fluid intake noncompliance of 103 chronic











hemodialysis patients. The interventions involved a

combination of self-monitoring, nurse praise, monetary

reward, self-reinforcement, behavioral control, and family

support. Although the interventions were not implemented

consistently by the patients, nurses, and family members,

the findings suggest that showing noncompliant hemodialysis

patients that they have behavioral control over their fluid

weight gain facilitates fluid intake compliance. No

significant differences were found in patients'

noncompliance due to demographic variables. The long-term

effects of teaching patients behavioral control of their

fluid adherence were not assessed.

Hegel, Ayllon, Thiel, and Oulton (1992) administered a

cognitive intervention and/or a behavioral intervention to a

sample of eight male hemodialysis patients in order to

determine the relative effectiveness of these interventions

in reducing interdialytic weight gain. The behavioral model

included behavioral contracting, positive reinforcement,

shaping, and self-monitoring. The cognitive model consisted

of a counseling intervention designed to modify patients'

health beliefs through information giving and the

development of problem solving skills. Both interventions

produced immediate reductions in interdialytic weight gain,

however the behavioral intervention was superior to the

cognitive intervention in maintaining fluid adherence.

Combining the behavioral and cognitive interventions did not











result in an improvement over the behavioral intervention.

Due to the small number of subjects used in this study,

generalization of these results is limited.

Lawson, Traylor, and Gram (1976) designed a study to

test the effectiveness of a videotape program for improving

patients' motivation to adhere to dietary prescriptions.

The content of the videotape encompassed both the rationale

for and the means of restricting protein, sodium, fluid, and

potassium. Videotape cassettes, 10 minutes in length, were

chosen as the medium for the program due to their

versatility and the low educational level of many of the

subjects. Sixteen of the 30 patients were randomly selected

to participate in the study. Post-test data was collected

one month after the administration of the videotape program.

The videotapes stimulated a positive response resulting in

subjects asking many more questions about their dietary

prescriptions and evidencing significantly greater knowledge

on oral information post-tests, regardless of degree of

literacy. Positive behavioral changes in dietary adherence

were also noted with the less educated subjects evidencing a

slight improvement in mean protein scores and significant

decreases in sodium scores and mean intake of water. No

long-term follow-up data was collected.

The success of psychological interventions with

patients already on dialysis is limited. Individual

supportive psychotherapy, psychoanalytic oriented











psychotherapy, group psychotherapy, and hypnosis were all

unsuccessful in decreasing dietary abuse among dialysis

patients (Czackes & Kaplan De-Nour, 1978; Kaplan De-Nour &

Czackes, 1972). Recognizing that various psychological

methods have failed to improve compliance, Kaplan De-Nour

and Czackes (1980) tested the effectiveness of a saliva-

substitute solution in reducing thirst in seven fluid

noncompliant hemodialysis patients. Patients were

instructed to use the solution two to four times daily.

Weight gains of over 1 kg were found in only 34 of 72

dialyses (47%) as compared with 114 out of 142 dialyses

(80%) at baseline. Although a significant decrease in fluid

noncompliance was noted among the patients who used the

solution regularly, some patients refused to use the

solution and others did not always use it regularly.

Self-Efficacy Theory

The Self-Efficacy Mechanism

Of all the mechanisms of personal agency, none is more

central or pervasive than individuals' beliefs about their

capability to exercise control over their behavior (Bandura,

1991). An individual's level of perceived self-efficacy

influences the choices that are made, the level of effort

that is mobilized, the level of persistence in the face of

difficulties, and the amount of stress experienced when

coping with taxing demands (Bandura, 1991).









55

It is widely acknowledged that individuals often do not

behave optimally even though they are fully aware of what

should be done (Bandura, 1982). Self-efficacy theory, with

its focus on the mediating influence of self-referent

thought, provides an avenue for explaining this discrepancy

between knowledge and behavior. Self-efficacy theory posits

that behavioral and psychological change occurs through the

alteration of an individual's sense of personal mastery

(Maddux & Stanley, 1986). Individuals process, weigh, and

integrate diverse sources of information about their

ability, and regulate their behavior and expenditure of

effort accordingly (Bandura, 1977b). Self-efficacy theory

further specifies that in addition to strong efficacy

expectations, effective functioning requires that

individuals develop the competencies and skills needed to

execute the target behavior (Evans, 1989).

In addition to efficacy expectations, Bandura (1977a;

1977b) discusses the importance of outcome expectations.

Efficacy expectation is the individual's conviction that

she/he can successfully execute the behavior required to

produce the outcome. Outcome expectancy is the individual's

estimate that a given behavior will lead to a specific

outcome. This distinction between efficacy expectations and

outcome expectations is necessary because an individual may

believe that a particular course of action will produce the

desired outcome, but question her/his ability to perform










these actions. Although both efficacy expectations and

outcome expectations are important, given the appropriate

skills and adequate motivation, it is the individual's

efficacy expectations which play a major role in determining

the choice of activities, the amount of effort that will be

expended, and the length of time the effort will be

sustained when dealing with stressful situations (Bandura,

1977b).

Self-efficacy theory places great emphasis on the

importance of how individuals judge their capabilities and

how, through their self-percepts of efficacy, these

judgements affect their motivation and behavior (Bandura,

1982). Bandura (1977a) stresses that it is an individual's

level of perceived, rather than actual, self-efficacy that

determines how difficult situations will be handled.

Therefore an important distinction is made between

information contained in environmental events and

information processed and transformed by the individual

(Bandura, 1977b).

The impact of information on efficacy expectations

depends on the manner in which the individual processes the

information. An individual's sense of self-efficacy is

lowered when, due to faulty appraisal, achievements are

credited to external factors rather than to personal

capabilities. Successes that are perceived as resulting

from skill rather than luck or external factors are more











likely to enhance self-efficacy. Even under conditions of

perceived self-determination, the impact of performance

attainments on self-efficacy will depend on whether the

individual's accomplishments are ascribed mainly to effort

or to ability. Success with minimal effort reinforces a

strong sense of self-efficacy, while success achieved

through high expenditure of effort connotates a lesser

ability and is likely to have a weaker effect on perceived

self-efficacy. Cognitive appraisals of the difficulty of

the task also affect the impact of performance

accomplishments. Succeeding at easy tasks does not

significantly alter self-efficacy, whereas mastery of

challenging tasks provides salient evidence of enhanced

competence.

Judgements of personal efficacy shape developmental

trajectories by influencing the selection of activities and

situations (Bandura, 1990). Individuals tend to avoid

activities that they believe exceed their capabilities, but

undertake those they judge themselves capable of managing.

Perceived self-efficacy also plays a role in determining

whether cognitive processes will be self-aiding or self-

hindering. Individuals with a high sense of self-efficacy

tend to devote their attention and cognitive resources to

mastering the task at hand, whereas individuals who are

plagued with self-doubt tend to focus on failure scenarios

(Evans, 1989). Expectations of personal efficacy are based










on four major sources of information: performance

accomplishments, vicarious experiences, verbal persuasion,

and physiological states (Bandura, 1977b). Performance

accomplishments provide the most dependable source of

efficacy expectations. Individuals lower their efficacy

expectations when they experience repeated failures, while

repeated success experiences raise mastery expectations.

Once positive performance expectations are established, the

negative effect of occasional failures is reduced and

occasional failures that are later overcome may even

strengthen efficacy expectations.

Efficacy expectations are also influenced by vicarious

experiences. Seeing similar others perform threatening

activities without adverse consequences can create

expectations in observers that they too possess the

capabilities necessary to master comparable activities.

However, vicarious experience is a less dependable source of

information than the direct evidence of personal

accomplishments. A number of variables such as similarity

of model and observer, the witnessing of behavior with clear

beneficial consequences, and diversified modeling in which

the observed activities are repeatedly shown to be safe by a

variety of models, positively affect mastery expectations

(Maddux & Stanley, 1986).

Because of its ease and ready availability, verbal

persuasion is widely used to influence human behavior.











Through verbal suggestion, individuals are led to believe

that they can cope successfully with situations that have

been overwhelming in the past. However efficacy

expectations induced in this manner are likely to be weak

and short-lived due to the lack of an authentic experiential

base. The impact of verbal persuasion varies substantially

depending on the perceived credibility, trustworthiness, and

expertise of the persuader.

Individuals also rely on information from their

physiological state when judging their capabilities. High

arousal in threatening and stressful situations usually

debilitates performance; therefore, individuals are more

inclined to expect success when they are not tense and

fearful.

Clearly, when forming efficacy judgements, individuals

incorporate several different configurations of efficacy-

relevant information and have to weigh and integrate

information from these diverse sources. Although it is

believed that efficacy judgements are governed by some

common judgmental processes, there has been little research

on how individuals process multidimensional efficacy

information (Bandura, 1986).

Self-efficacy expectations vary along three major

dimensions: generality, strength, and magnitude.

Generality refers to the extent to which a success or

failure experience extends to other similar behaviors and










contexts. Some experiences create circumscribed mastery

expectations while others instill a more generalized sense

of efficacy that extends beyond the specific situation.

Strength refers to the resoluteness of an individual's

conviction that she/he can successfully perform the

behavior. Weak efficacy expectations are easily

extinguished by disconfirming experiences. Magnitude of

self-efficacy refers to the number of behavioral steps the

individual feels capable of performing successfully. An

individual's efficacy expectations may be limited to simpler

tasks or may include even the most difficult behaviors.

(Bandura, 1977a; Bandura, 1977b; Maddux & Stanley, 1986).

Since self-efficacy is a situational and behavior

specific construct, the theory is based on a microanalysis

of perceived coping capabilities rather than on global

personality traits (Bandura, 1977b). To test the origins

and functions of perceived self-efficacy, Bandura, Adams,

Hardy, and Howells (1980) employed a microanalytic

methodology which allowed for a detailed assessment of the

level, strength, and generality of perceived self-efficacy.

Adults with a severe snake phobia received treatments

designed to create differential levels of efficacy

expectations, after which the degree of congruence between

self-percepts of efficacy and behavior at the level of

individual tasks was analyzed.











Subjects received either participant modeling (direct

mastery experiences), modeling alone (vicarious

experiences), or no treatment. Prior to treatment,

following treatment, and after post-test, subjects were

presented with graduated self-efficacy scales representing

tasks of increasing difficulty and asked to indicate which

tasks they felt capable of doing and the strength of their

perceived efficacy for those items they judged they could

do. The level of self-efficacy was determined by the number

of performance tasks subjects indicated that they expected

to perform. Strength of self-efficacy was computed by

summing the magnitude scores across tasks and dividing the

sum by the total number of performance tasks. To judge

generality of self-efficacy, subjects rated the level and

strength of their perceived efficacy in coping with an

unfamiliar snake as well as with a snake similar to the one

used in treatment.

As expected, experiences based on performance

accomplishments produced higher, more generalized, and

stronger efficacy expectations than did vicarious

experiences. Although the enactive and vicarious treatments

differed in their power to enhance self-efficacy, the

efficacy expectations were equally predictive of subsequent

performance irrespective of how these expectations were

instated. For all subjects, the stronger the efficacy

expectations, the higher was the likelihood that a particular

task would be successfully completed.











In another study examining self-efficacy beliefs,

Hofstetter, Sallis, and Hovell (1990) interviewed 525 adults

regarding their ability to perform actions and the perceived

consequences of their actions regarding nutrition, medical

care, exercise, and politics. The results of this study

clearly indicated that self-efficacy ratings are highly

domain-specific and that ratings of outcome efficacy were

distinct from ratings of self-efficacy. Outcome efficacy

was correlated with self-efficacy in every domain, however

the correlations between self-efficacy items within domains

were always higher.

Self-Efficacy and Health Related Behaviors

The concept of self-efficacy has been receiving

increasing recognition as a predictor of change and

maintenance of health behaviors. Perceived self-efficacy

aids in the adoption and maintenance of health-promoting

behaviors as well as in the control of risky health habits

(Evans, 1989). Individuals with a low sense of efficacy do

not typically try to adopt healthy practices and if they do

try, they quickly abandon their efforts if success is not

immediately achieved. Even individuals who believe their

habits may be harmful to their health achieve only limited

success in curtailing these behaviors unless they judge

themselves as having some efficacy to resist the cues that

instigate the behavior.










A number of studies have indicated that self-efficacy

can be enhanced by experimental manipulations and that this

enhancement is related to subsequent changes in health

behaviors (Strecher, DeVellis, Becker, & Rosenstock, 1986;

Weinberg, Hughes, Critelli, England, & Jackson, 1984).

Based on their review of studies of the self-efficacy

concept as it relates to cigarette smoking, childbirth pain,

weight control, alcohol abuse, and exercise behavior,

Strecher et al. (1986) and Evans (1989) conclude that

perceived self-efficacy appears to be a consistent predictor

of short-term and long-term success with regard to the

adoption and maintenance of health-promoting behaviors.

Self-efficacy and cigarette smoking

Colletti, Supnick, and Payne (1985) developed an

internally consistent and reliable measure of smoking self-

efficacy. Using this instrument, a significant correlation

was found between subjects' smoking self-efficacy scores and

self-reported smoking rates at 3-month (r = -.39) and 6-

month (r = -.34) follow-ups with subjects who had higher

self-efficacy scores having lower smoking rates.

In another study supporting the usefulness of the

construct of self-efficacy for investigating the maintenance

of smoking cessation, DiClemente (1981) concluded that

efficacy expectations appeared to be highly related to the

ability to maintain smoking cessation. Differences in

reported efficacy expectations measured during the initial











stages of abstinence were related to the maintenance of

abstinence 5 months after cessation with maintainers having

significantly higher self-efficacy scores than recidivists.

Self-efficacy and alcoholism

Solomon and Annis (1990) explored the relationship of

efficacy expectations and outcome expectations in a

population of alcoholic clients. Results indicated that

outcome expectancies did not predict alcohol consumption at

follow-up. However, efficacy expectations assessed at

intake were strongly associated with the level of alcohol

consumption on drinking occasions at follow-up. Among

subjects who were drinking at follow-up, those with lower

efficacy expectation scores at intake were drinking more

heavily. These findings are consistent with Bandura's self-

efficacy theory which proposes that outcome expectancies may

not add significantly to the prediction of behavior.

Self-efficacy and exercise adherence

Desharnais, Bouillon, and Godin (1986) examined the

respective contribution of both efficacy expectations and

outcome expectations. Expectation of self-efficacy was

found to be a more central determinant of adherence than

outcome expectancy. However, both variables were

significant mediators of individuals' adherence to the

exercise program. These results are consistent with

previous findings which indicated that performance deficit

is foreseeable when perceived self-efficacy is low (Bandura,









65

1982). Additional support is provided for the importance of

perceived self-efficacy in predicting behavior.

Self-efficacy and weight loss

In a study designed to investigate the effects of self-

efficacy on weight loss, subjects high and low in pre-

existing self-efficacy were randomly assigned to high or low

manipulated self-efficacy groups (Weinberg, Hughes,

Critelli, England, & Jackson, 1984). Self-efficacy was

manipulated by having subjects attribute successful task

performance to a previously unrecognized capacity for self-

control. Subjects with high pre-existing self-efficacy and

those subjects in the high manipulated self-efficacy

condition lost more weight. These results indicating that

levels of self-efficacy were predictive of actual weight

loss in a sample of obese subjects provide additional

support for Bandura's theory of self-efficacy.

Self-efficacy and childbirth

Manning and Wright (1983) examined the relative roles

of self-efficacy expectancies and outcome expectancies as

predictors of pain control during labor. Self-efficacy

expectancies and outcome expectancies were highly

correlated, however efficacy judgements were better

predictors of persistence in pain control. The Marlowe-

Crowne Social Desirability Scale was administered to

subjects to control for a possible response bias. Level of

social desirability was not related to self-efficacy

expectancy or to outcome expectancy.










Self-efficacy and cystic fibrosis

Bartholomew, Parcel, Swank, and Czyzewski (1993)

developed an instrument to measure self-efficacy

expectations for the self-management of cystic fibrosis.

Self-management is defined as the behaviors that patients

and family members perform to lessen the impact of a chronic

illness and includes complex cognitive-behavioral skills of

self-monitoring, decision-making, and communicating about

symptoms and treatment regimens. Self-efficacy expectation

is particularly important in the self-management of chronic

disease because patients and their families must learn and

perform complex self-care skills over long periods.

Bartholomew et al. (1993) found that both caretaker and

adolescent measures of self-efficacy predicted self-reports

of self-management behaviors, with subjects with lower

levels of self-efficacy engaging in lower levels of self-

management.

Self-efficacy and epilepsy

The diagnosis of epilepsy forces individuals to make

significant lifestyle changes to reduce the chance and

frequency of seizures. Dilorio, Faherty, and Manteuffel

(1992) identified the three dimensions of self-efficacy

related to self-management of epilepsy and developed a 25

item instrument based on Bandura's conceptualization of

self-efficacy. The instrument was found to have a high

degree of internal consistency and to display relative









67
stability over a 4 week period. As predicted, patients with

higher levels of self-efficacy were found to have higher

levels of self-management. Dilorio et al. (1992) discuss

the potential uses of this instrument including the

assessment of patients' level of confidence in their ability

to manage epilepsy in order to provide a foundation for

meaningful interventions.

Motivation and Self-Efficacy

An individual's level of perceived self-efficacy plays a

central role in the self-regulation of motivation. Bandura

(1990) states that individuals initially motivate themselves

through proactive control by setting challenging standards

that create a sense of disequilibrium. Perceived negative

discrepancies between actual performance and the preset

standard results in dissatisfaction which motivates the

individual to make corrective changes (Bandura, 1977b). Self-

efficacy judgements determine how much effort will be expended

and how long an individual will persist in the face of

obstacles. When beset with difficulties, individuals who have

serious self-doubt about their capabilities give up, whereas

those who have a strong sense of self-efficacy exert greater

effort to master challenges and have a greater opportunity to

engage in corrective experiences that will reinforce their

sense of efficacy. (Bandura, 1982).

After attaining the set standard, individuals with a high

level of self-efficacy generally set an even higher standard








68

for themselves. This adoption of a higher standard further

challenges the individual and creates new motivating

discrepancies which initiates a new cycle of self-motivation.

Self-motivation is best generated and sustained by the

adoption of attainable subgoals that lead to more challenging

future goals. Attainment of these proximal goals also serves

as a vehicle for the further development of self-percepts of

efficacy (Bandura, 1982).

In a study of the self-evaluative and self-efficacy

mechanisms governing the motivational effects of goal systems,

Bandura and Cervone (1983) concluded that neither goals alone,

nor feedback alone, effected changes in motivational level.

However when both factors were present, the evaluative and

efficacy influences predicted the magnitude of motivation

enhancement. Subjects with higher self-dissatisfaction with

their performance and strong perceived self-efficacy for goal

attainment exhibited greater intensification of effort.

Motivation, Self-Efficacy, and Health Related Behaviors

The individual's level of motivation plays a crucial role

in determining if detrimental health habits will be altered

(Bandura, 1992). Verbal persuasion and information giving are

not sufficient strategies for ensuring patient adherence to

lengthy and difficult treatment regimens. Patients must also

be motivated to follow medical advice. However, motivating

patients to follow medical advice is one of the most

frustrating problems for health care providers (Schnoll,

1981).









69
Medical personnel often try to motivate patients to

change their behaviors by arousing fear about the disease;

however, findings indicate that fear arousal has little effect

(Evans, 1989). Rather perceived efficacy of ability to

maintain preventive behaviors has been found to be predictive

of whether an individual will adopt health promoting habits.

Therefore, health messages should place greater emphasis on

conveying the belief that individuals have the capability to

exercise control over their habits rather than trying to scare

patients into emitting desirable health behaviors (Evans,

1989). It is also important to provide the patient with

realistic expectations about the disease and to work with the

patient to set attainable short-term goals which will provide

the patient with positive reinforcement and facilitate

continued progress toward long-term health goals (Schnoll,

1981).

The problem of noncompliance and low motivation is

extremely prevalent in patients suffering from chronic

illnesses. Motivating the individual to make the necessary

behavior change is particularly difficult when behavior

changes have to be maintained over long periods of time or

when the individual derives some benefit from the problem

behavior. Often times the positive consequences of the

problem behavior (e.g., thirst reduction) are immediate while

the negative consequences are uncertain and distant making

behavior change even more difficult. This problem is









70
particularly prevalent in the health care field since patients

frequently engage in behaviors that are controlled by

immediate pay-off but have long term negative consequences

(Kanfer & Grimm, 1977).

Self-Efficacy Theory and Adherence Motivation: Implications
for Modifying Fluid Adherence

The research on self-efficacy and health related

behaviors has demonstrated that patients' efficacy

expectations can be enhanced by experimental manipulations

and that this enhancement results in the adoption and

maintenance of health behaviors. Similarly the research on

motivation and health related behaviors has indicated the

importance of patient motivation in facilitating adherence

to treatment regimens. Two recent studies discuss the

importance of motivation, in conjunction with self-efficacy

beliefs, in improving hemodialysis patients' adherence to

fluid restrictions.

Schneider, Friend, Whitaker, and Wadhwa (1991)

investigated the role of cognitive and emotional variables

in fluid noncompliance among 50 hemodialysis patients.

Results of their study indicated that cognitive variables,

rather than emotional variables, influence fluid compliance.

These researchers suggest that interventions aimed at

improving compliance should focus on increasing patients'

motivation and attributions of success for past performance.

Caesar and Tucker (1991) studied 23 home hemodialysis

patients and 24 in-center hemodialysis patients to determine











if perceived control over health and perceived control over

fluid intake predict fluid adherence. Based on the results

of this research which indicated that neither internal

health locus of control nor fluid intake self-efficacy is

sufficient to facilitate fluid adherence among dialysis

patients, Caesar and Tucker (1991) suggest that motivation

may be the missing factor needed to change patients fluid

intake behavior.

The problem of low motivation and the prevalence of

nonadherence to treatment regimens among dialysis patients

has been well documented. Blackburn (1977) notes that even

when dialysis patients understand treatment restrictions and

are aware of the consequences of nonadherence, they often

are nonadherent. Given the complications associated with

nonadherence to the dietary and fluid guidelines of the

hemodialysis treatment regimen, and given the high degree of

fluid nonadherence among hemodialysis patients, support is

provided for the development of strategies to decrease the

prevalence of fluid nonadherence among this population.

Together, the self-efficacy and health related

behaviors literature and the motivation and health related

behaviors literature suggest that interventions aimed at

improving hemodialysis patients' adherence to fluid

restrictions must (1) promote the belief among patients that

they can control their fluid intake, (2) provide patients

with the skills necessary to control their fluid intake, and










(3) increase patients' motivation to be fluid adherent.

Consistent with this viewpoint, Shapiro (1983) notes that

patients' level of motivation, belief in the efficacy of a

particular strategy, and belief in their ability to execute

the strategy all influence treatment outcome.

Use of Peer Teaching for Behavior Modification

Peer teaching is frequently described as students

teaching students; however, the concept of peer teaching

encompasses individuals other than traditional students. In

a broader sense, peer teaching can be viewed as one equal

teaching another (Iwasiw & Goldenberg, 1993). The

effectiveness of peer teaching has already been documented

in a variety of health areas.

Jordheim (1976) compared the effectiveness of peer

teaching and traditional instruction in venereal disease

education among 100 community college students. A standard

curriculum designed by the investigator was used by both

peer teachers and traditional health education instructors.

The students who were taught by the peer teachers scored

substantially higher on the Venereal Disease Knowledge

Inventory and the Attitude toward Venereal Disease Test than

the students who received the traditional instruction. Peer

teaching was shown to be more effective than traditional

education for changing students attitudes and increasing

knowledge about venereal disease.










In a study of the effectiveness of peer teaching on

nursing students' clinical performance, Iwasiw and

Goldenberg (1993) found that the students in the

experimental group (those students who received peer

supervision after initial instruction by the teacher) had

significantly higher scores on the cognitive test and the

psychomotor tests than the students who were taught by the

teachers alone. Students in the experimental group felt

that peer teaching was equal to or better than instructor

teaching. Those students who served as peer teachers

benefitted by having additional exposure to the material.

Iwasiw and Goldenberg (1993) suggest that implementing peer

teaching as an interactive strategy where each student

assumes the roles of both peer supervisor and supervisee may

maximize learning.

Rickert, Jay, and Gottlieb (1991) compared a peer-led

versus an adult-led AIDS education program in the knowledge,

attitudes, and satisfaction of adolescents with the

education sessions. Subjects in both groups received the

same educational information and the same videotape

presentation. However, in one group the adult counselors

responded to participants' questions while in the other

group the peer counselors responded to participants'

questions. Although both the adult and peer counselors were

equally effective in promoting knowledge acquisition and

appropriate attitude change, more questions were asked of

the peer counselors.










The above referenced studies indicate that peer

teaching is an effective method of conveying information.

Peer teaching also has the benefit of requiring considerably

less staff time which allows staff members to make optimal

use of their expertise. In addition, peer teaching provides

individuals who serve as "teachers" the opportunity for new

growth experiences.

Use of Videotape Interventions for Behavior Modification

Videotape interventions have several pragmatic

advantages over face-to-face didactic interventions

(Anderson, DeVellis, DeVellis, 1987). Videotape

interventions allow for self-administered treatments to

individuals or groups and therefore require less personnel

time and cost than face-to-face didactic methods. The major

cost of a videotape procedure is the initial development;

however once produced, it can be disseminated with a minimum

expenditure of expense and professional time. Videotapes

also allow for the convenient exchange of information among

similar medical care facilities without requiring extensive

training or the introduction of additional personnel.

In a study contrasting the effectiveness of an 11-

minute videotape with the well-thought-out and rehearsed

customary presentation, the videotape was demonstrated to be

more effective in increasing the rate of donation in high

school blood drives (Sarason, Sarason, Peirce, Sayers,

Rosenkranz, 1992). The authors of this study also point out










that the videotape presentation was easily portable,

inexpensive, and did not require extensive staff training

for effective utilization. The videotape was also reported

to be effective in keeping the attention of the students

throughout the presentation, even in schools where they had

previously found this to be a problem.

Pauker (1986) researched the psychological effects of a

videotape intervention to increase the awareness and coping

skills of medical personnel. The videotape was found to be

more effective than other routine psychiatric techniques.

The results of this project indicate the unique benefits of

this medium. Videotape interventions overcome viewer

resistance by more vigorously engaging the viewer and

lowering individual and group resistances to acknowledging

and discussing reactions to psychosocial stressors. It was

found that even individuals who are reluctant to discuss

their feelings with a psychiatrist or in a group of peers

will usually attend a videotape playback to see colleagues

discuss their experiences.

Pauker (1986) suggests that this lowered resistance is

due to the association of the videotape with other audio-

visual media techniques such as television or film. In the

mildly regressed state created by the relaxed atmosphere of

viewing the videotape, individuals feel safe and are "open"

to previously screened-out-material. Videotape

interventions also stimulate "affective" responding which










increases responsivity to the psychosocial content of the

tape. This format facilitates individual's ability to

"relate" to the information on the tape and identify similar

concerns and feelings in themselves. Viewers are better

able to "hear" what peers are saying than they would be in a

face-to-face group. The videotape intervention was also

found to be more effective in helping individuals to "see"

themselves and in encouraging more adaptive defenses.

Summary of the Research

The present study used a videotape intervention to

increase patients' motivation to adhere to their fluid

restrictions, as well as their efficacy expectations and

outcome expectations with respect to their fluid intake.

The videotape is composed of a variety of fluid adherent

patients discussing factors that motivate them to be fluid

adherent, the positive consequences they experience when

they adhere to prescribed fluid restrictions, and how they

have been able to control their fluid intake.

The Fluid Adherence Self-Efficacy Questionnaire was

used to assess changes in patients' efficacy expectations

and outcome expectations. Changes in patients' level of

motivation were measured using the Fluid Adherence

Motivation Questionnaire. Adherence to prescribed fluid

restrictions was assessed by measuring patients' average

weekend interdialysis weight gain.








77

Mean interdialysis weight gain has been shown to be an

effective indicator of patients' adherence to fluid

restrictions. Manley and Sweeney (1986) investigated three

measures of weight gain: mean interdialysis weight gain, the

ratio of absolute weight gain to the patient's dry weight

and the standard deviation of each patient from her/his own

mean weight over the duration of a 12 month study. The

latter two measures were investigated since a large weight

gain in a heavy patient may be less significant than the

same gain in a very small patient, and to determine if a

steady moderate weight gain between dialysis sessions

indicates better compliance than a weight gain that on the

average is moderate but fluctuates greatly from week to

week. It was concluded that the ratio of absolute weight

gain to the patient's dry weight and the standard deviation

of each patient from her/his own mean weight did not afford

any particular advantage over the use of the more

conventional absolute mean of the interdialysis weight gain

as a valid approximation of adherence.














CHAPTER III
METHODOLOGY



Subiects

Phase I Subiects

All patients at the Gainesville Kidney Center East (N =

70) and the Gainesville Kidney Center West (N = 87) who met

the following criteria were invited to participate in Phase

I of the study:

1. The patient has undergone hemodialysis regularly

for at least three months prior to the beginning

of Phase I of the study.

2. The patient has an average weekend fluid weight

gain (total kilograms for 3 days) 2.5 kilograms

for the three months prior to the beginning of

Phase I of the study.

3. The patient gives the researchers permission to

obtain demographic and medical information from

her/his records.

Eleven (11) of the patients at the Gainesville Kidney

Center East (16%) and fifteen (15) of the patients at the

Gainesville Kidney Center West (17%) met the criteria for

participating in Phase I of the study. Twenty-four (24) of

these 26 fluid adherent hemodialysis patients agreed to

participate in Phase I of the study. Nine (9) of these








79

twenty-four patients were from the Gainesville Kidney Center

East (38%) and fifteen (15) were from the Gainesville Kidney

Center West (62%).

Phase III Subjects

All patients at the Gainesville Kidney Center East (N =

70) and the Gainesville Kidney Center West (N = 87) who met

the following criteria were invited to participate in Phase

III of the study:

1. The patient has undergone hemodialysis regularly

for at least three months prior to the beginning

of Phase III of the study.

2. The patient has an average weekend fluid weight

gain (total kilograms for 3 days) > 2.5 kilograms

for the three months prior to the beginning of

Phase III of the study.

3. The patient gives the researchers permission to

obtain demographic and medical information from

her/his records.

Twenty-two (22) of the patients at the Gainesville

Kidney Center East (31%) and eighteen (18) of the patients

at the Gainesville Kidney Center West (21%) met the criteria

for participating in Phase III of the study. Twenty-six

(26) of these 40 fluid nonadherent patients agreed to

participate in Phase III of the study. Fourteen (14) of

these patients were from the Gainesville Kidney Center East

(54%) and twelve (12) of these patients were from the










Gainesville Kidney Center West (46%). The twenty-six (26)

fluid nonadherent patients who agreed to participate in

Phase III of the study were assigned to either the

Intervention Group or the Control Group using a stratified

sampling procedure to ensure that the groups would be

relatively balanced with respect to gender, ethnicity,

marital status, age, educational level, and length of time

on dialysis.

Three of the twenty-six patients who participated in

Phase III of the study were unable to complete the study due

to medical reasons. All three patients were from the

Gainesville Kidney Center West. One of these patients was

in the Control Group and the remaining two patients were in

the Treatment Group.

The demographic information and medical characteristics

of the 24 Phase I fluid adherent patients and the 26 Phase

III fluid nonadherent patients who participated in this

study are summarized in Table 3.1 and Table 3.2

respectively.










Table 3.1

Patient Demographic Information



Phase I Phase III
Fluid Fluid
Adherent Nonadherent
(n = 24) (p = 26)



Mean Age 65 58

Mean Months on Dialysis 45 64

Mean Years of Education 11 10

Gender

Female 75% 65%

Male 25% 35%

Ethnicity

African-American 75% 73%

Caucasian 25% 27%

Marital Status

Single 29% 19%

Married 25% 39%

Divorced 13% 19%

Widowed 33% 23%










Table 3.2

Patient Medical Characteristics



Phase I Phase III
Fluid Fluid
Adherent Nonadherent
(A = 24) (n = 26)



Mean Fluid Weight Gain 1.42 kg 3.53 kg

Mean Urine Output 353.96 cc 291.54 cc

Medical Conditions

Diabetes Mellitus 33% 65%

Cancer 0% 11%

Heart Disease 33% 27%

Hypertension 88% 92%

Pulmonary Disease 13% 4%

Polycystic Kidney 8% 4%

Psychiatric Complications 0% 4%

Medications

Insulin 13% 35%

Catapres 0% 19%

Tenex 13% 11%

Wytensin 0% 0%

Mellaril 4% 0%

Prednisone 0% 0%








83

The demographic characteristics of the patients at the

Gainesville Kidney Center East and the patients at the

Gainesville Kidney Center West were similar. At the

Gainesville Kidney Center East (n =23), 65% of the patients

were female and 35% were male. Similarly, at the

Gainesville Kidney Center West (n = 27), 74% of the patients

were female while only 26% were male. The ethnic

distribution at the East Unit was 70% African-American and

30% Caucasian. At the West Unit, the ethnic distribution

was 78% African-American and 22% Caucasian.

The patients at the Gainesville Kidney Center East

ranged in age from 28 to 84 with a mean age of 58, while the

patients at the Gainesville Kidney Center West ranged in age

from 40 to 75 with a mean age of 64. The number of years of

formal education ranged from 2 years to 14 years for the

patients at the Gainesville Kidney Center East with a mean

of 10 years. For the patients at the Gainesville Kidney

Center West, the mean years of education was also 10, with a

minimum of 6 years and a maximum of 16 years. The length of

time on dialysis ranged from 8 months to 15 years for the

patients at the East Unit with a mean time of 5 years. For

the patients at the West Unit, the length of time on

dialysis ranged from 11 months to 12 years with a mean time

of 4 years.










Other Research Participants

Research Assistants

Four advanced undergraduate researchers participated in

Phase I and Phase III of this study. These researchers were

all Caucasian females.

Dialysis Center Staff

The Director of Nursing at the Gainesville Kidney

Center East and the Director of Nursing at the Gainesville

Kidney Center West participated in Phase I and Phase III of

this study. In addition, each Director of Nursing appointed

two staff members to assist with conducting the study. Each

of these staff members had worked at the Center for at least

one year and were familiar with the patients. Both of the

Directors of Nursing were Caucasian females. Three of the

four appointed staff members were Caucasian females, and one

was a Caucasian male.

Instruments

The following assessment instruments were used in Phase

I and Phase III of this research: (1) The Patient

Demographic and Medical Information Sheet; (2) The Marlowe-

Crowne Social Desirability Scale, Short-Form; (3) The Fluid

Adherence Self-Efficacy Questionnaire; and (4) The Fluid

Adherence Motivation Questionnaire. Additionally, The

Structured Interview Questionnaire was administered in Phase

I.










The Patient Demographic and Medical Information Sheet

(Appendix C). This sheet was used to collect the following

data from the patient's records: gender, ethnicity, marital

status, age, educational level, length of time on dialysis,

level of urine output (cc per 24 hours), other medical

conditions (i.e., diabetes mellitus, cancer, heart disease,

hypertension, pulmonary disease, polycystic kidney,

psychiatric complications), and thirst inducing medications

regularly taken (i.e., Insulin, Catapres, Tenex, Wytensin,

Mellaril, Prednisone).

The Marlowe-Crowne Social Desirability Scale. Short-

Form (M-C SDS [201) (Appendix D). This is a 20-item scale

(Strahan & Gerbasi, 1972) based on the original 33-item

instrument (Crowne & Marlowe, 1960), which was used to

assess the patient's need to obtain social approval by

responding in a culturally appropriate manner. The scale

consists of behaviors which are culturally sanctioned but

are of improbable occurrence. The Kuder-Richardson formula

20 (K-R 20) reliability coefficients for the 20-item

instrument (.78 for university males; .83 for university

females) are similar to the K-R 20 reliability coefficients

for the original 33-item inventory (.83 for university

males; .87 for university females). Pearson product-moment

correlations between the 20-item scale and the 33-item

instrument were as high as .98, indicating adequate

construct validity for the shorter version (Fraboni &










Cooper, 1989; Strahan & Gerbasi, 1972). In the present

study, patient responses on the M-C (20) indicated whether

patients' responses to the Fluid Adherence Self-Efficacy

Questionnaire and the Fluid Adherence Motivation

Questionnaire were likely to be valid.

The Fluid Adherence Self-Efficacy Questionnaire

(Appendix E). This questionnaire was used to assess

hemodialysis patients' self-efficacy with respect to their

adherence to fluid restrictions (Smith, 1988/1989). Items 1

through 6 (Efficacy Expectations Subscale) assess patients'

belief that they can control their fluid intake in a number

of potentially difficult situations. Items 7 through 9

(Outcome Expectations Subscale) assess patients' belief that

specific strategies can potentially be effective in

assisting them to control their fluid intake. The magnitude

of efficacy and outcome expectations are indicated by the

number of items which patients indicate they can currently

perform. To assess the strength of efficacy and outcome

expectations, patients' are asked to rate their level of

confidence in their response for each item using a rating

scale ranging from 10% confidence to 100% confidence in

increments of 10.

For each item in the Fluid Adherence Self-Efficacy

Measure, patients' are asked to respond with a "yes" if they

think the statement is true or with a "no" if they think the

statement is false. In addition, for each item patients are










asked to indicate how sure they are about their response on

a scale from 10% to 100%. The confidence ratings of those

items to which patients respond with a "yes" are scored as a

positive number, whereas the confidence rating of those

items to which patients respond with a "no" are scored as a

negative number. Efficacy Expectation Subscale scores are

obtained by averaging patients' confidence ratings for Items

1 6. Outcome Expectation Subscale scores are obtained by

averaging patients' confidence ratings for Items 7 9.

Smith (1988/1989) reported that the Pearson product-

moment correlation coefficients for patients' magnitude of

self-efficacy estimates over one-week and one-month

intervals ranged from a low of r = .42 to a high of r = .83

indicating adequate test-retest reliability. Similarly, the

Pearson product-moment correlation coefficients for

patients' confidence of self-efficacy estimates ranged from

a low of r = .40 to a high of r = .86. Non-compliant

patients' (patients with an average daily fluid weight gain

greater than two pounds) estimates of magnitude and

confidence of their self-efficacy were found to be more

reliable than those of compliant patients.

The Fluid Adherence Motivation Questionnaire (Appendix

F). This questionnaire was developed by the researcher and

was used to assess patients' level of motivation to be fluid

adherent. The questionnaire consists of 4 Likert scale

items. Only Item #2 (How much effort do you put into










following your fluid restrictions?) was used as the measure

of motivation to be fluid adherent. This question was

chosen because it was the only question that all patients

seemed to clearly understand. Patients were asked to

indicate their response to this item using a 10-point Likert

scale ranging from 1 (Not Very Much) to 10 (Very Much).

The Structured Interview Questionnaire (Appendix G).

This questionnaire was developed by the researcher and was

used to obtain biographical information and to assess

patients' views regarding the following: (1) the positive

benefits of being fluid adherent, (2) how they have been

able to control their fluid intake, and (3) the factors that

motivate them to be fluid adherent. The questionnaire

consists of 9 open-ended questions.

Procedure

Training of Researchers

Four advanced undergraduate researchers were trained by

the principal investigator to administer the questionnaires.

This training focused on developing effective interviewing

skills and increasing sensitivity when working with older

and culturally diverse chronically ill patients. The

training occurred in three two-hour sessions and consisted

of roleplays and verbal administration of a Training

Knowlege Questionnaire to assure that standard

administration methods were used by all researchers. After

completing the training sessions each researcher observed










the principal investigator administer the questionnaires.

Each researcher was also observed by the principal

investigator and given feedback when first administering the

questionnaires in order to assure proficiency.

Recruitment of Phase I Subjects

A researcher, the Director of Nursing, or a staff

member appointed by the Director of Nursing at each dialysis

center invited all patients who met the Phase I selection

criteria to participate in Phase I of the study. The

Informed Consent Form (Appendix A) was read to each patient

to ensure that all patients received the same information.

Patients were informed that participating in Phase I of the

study would involve the following: (1) signing an Informed

Consent Form (Appendix A) giving researchers at the

University of Florida access to information in their patient

file such as age, length of time on dialysis, etc., and

information about their medical condition such as prescribed

medications and their fluid weight gain, (2) participating

in a 30-minute interview during which they would be asked to

respond to questions about their treatment plan (Appendices

D F), and (3) participating in a second 15-minute

interview about their fluid adherence which would be

videotaped (Appendix G). In addition, patients were

informed that portions of the videotaped interview may be

shown to other hemodialysis patients, including some

patients at their dialysis center.








90

Patients were informed that all information, except the

videotaped interview, would be identified by code numbers

rather than their names in order to protect their

confidentiality and would be kept in a locked file at the

University of Florida. Patients were told that if they

participated in the study, they would receive a monetary

compensation of $5.00 for having participated in both the

30-minute interview and the 15-minute interview, which would

occur approximately one week apart. Patients were also

informed that the monetary compensation was being provided

for their time and did not depend on their responses.

Phase I Data Collection

Each of the twenty-six (26) fluid adherent hemodialysis

patients who agreed to participate in Phase I of the study

participated in the 30-minute interview and the 15-minute

interview during regularly scheduled dialysis sessions.

Before each interview, it was stressed to patients that the

money that they would receive for participating in the

interviews was for their time and was not contingent upon

their responses. During the first interview (i.e., the 30-

minute interview), a researcher verbally administered the

assessment battery to each patient. The battery consisted

of the Marlowe-Crowne Social Desirability Scale (20), the

Fluid Adherence Self-Efficacy Questionnaire, and the Fluid

Adherence Motivation Questionnaire. In order to preserve

patient confidentiality, code numbers rather than names were

placed on the questionnaires in the assessment battery.








91

Approximately one week later, each patient took part in

a second interview (i.e., the 15-minute interview) during

which she/he was asked to respond to the nine questions on

the Structured Interview Questionnaire. All of the second

interviews were conducted by the principal investigator.

Each patient was reminded that their responses to the

Structured Interview Questionnaire were being videotaped and

that portions of the videotape may be shown to other

dialysis patients. After completing the second interview,

each patient received $5.00 after signing a receipt.

Phase II Videotape Production

During Phase II of the study, the videotaped structured

interview segments obtained in Phase I were edited to

produce a 45-minute Fluid Adherence Facilitation videotape

and a 45-minute control videotape. Four of the Phase I

fluid adherent patients appear in both the Fluid Adherence

Facilitaion videotape and the control videotape. The

content of the Fluid Adherence Facilitation videotape was

selected to emphasize the key aspects of self-efficacy

theory. This videotape is composed of nine 5-minute

segments. Each segment consists of a Phase I fluid adherent

patient responding to one or more of the following questions

from the Structured Interview Questionnaire: (1) What

positive benefits do you experience when you adhere to your

prescribed fluid restrictions?; (2) What do you do to

control your fluid intake?; (3) What motivates you to adhere










to your prescribed fluid restrictions?; and (4) What would

you recommend to a patient who is having difficulty

restricting her/his fluid intake? The patients featured in

the videotape are representative of the patient population

at the two dialysis centers used in this study. The Fluid

Adherence Facilitation videotape was used during Phase III

of the study as an intervention to increase fluid adherence

efficacy expectations, fluid adherence outcome expectations,

fluid adherence motivation, and actual fluid adherence (i.e.

average weekend interdialysis fluid weight gain).

The control videotape is also composed of nine 5-minute

segments. Each segment consists of a Phase I fluid adherent

patient responding to one or more of the following questions

from the Structured Interview Questionnaire: (1) How do you

spend your free time?; (2) What types of work experiences

have you had?; and (3) What are your plans for the future?

The patients featured in the videotape are also

representative of the patient population at the two dialysis

centers used in this study.

Recruitment of Phase III Subjects

A researcher or the Director of Nursing at each

dialysis center invited all patients who met the Phase III

selection criteria to participate in Phase III of the study.

The Informed Consent Form (Appendix B) was read to each

patient to ensure that all patients received the same

information. Patients were informed that participating in










Phase III of the study would involve the following: (1)

signing an Informed Consent Form (Appendix B) giving

researchers at the University of Florida access to

information in their patient file such as age, length of

time on dialysis, etc., and information about their medical

condition such as prescribed medications and their fluid

weight gain, (2) participating in a 30-minute interview

during which they would be asked to respond to questions

about their treatment plan (Appendices D F) on three

separate occasions over a six-week period, and (3) viewing

one 5-minute segment of videotape about dialysis patients

during each dialysis session for a 3-week period.

Patients were informed that all information would be

identified by code numbers rather than their names in order

to protect their confidentiality and would be kept in a

locked file at the University of Florida. Patients were

told that if they participated in the study, they would

receive a monetary compensation of $15.00, and that this

$15.00 would be paid at the conclusion of the last interview

and would be contingent upon having viewed the videotapes

and having participated in all three interviews. Patients

were also informed that the monetary compensation was being

provided for their time and did not depend on their

responses.










Phase III Data Collection

The twenty-four (24) fluid nonadherent hemodialysis

patients who agreed to participate in Phase III of the study

were assigned to either the Intervention Group or the

Control Group using a stratified sampling procedure to

ensure that each group would have a fairly equal

distribution with respect to age, gender, race, marital

status, educational level, and length of time on dialysis.

Each of the twenty-four (24) fluid nonadherent hemodialysis

patients participated in the three 30-minute interviews and

viewed the nine videotape segments during regularly

scheduled dialysis sessions. Before each interview, it was

stressed to patients that the money that they would receive

for participating in the interview was for their time and

was not contingent upon their responses.

During each of the interview sessions, a researcher

verbally administered the 30-minute assessment battery to

each patient. The battery consisted of the Marlowe-Crowne

Social Desirability Scale (20), the Fluid Adherence Self-

Efficacy Questionnaire, and the Fluid Adherence Motivation

Questionnaire. In order to preserve patient

confidentiality, code numbers rather than names were placed

on the questionnaires in the assessment battery.

After completing the first interview, the patients in

the Intervention Group individually viewed a different 5-

minute segment of the 45-minute Fluid Adherence Facilitation




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