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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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The Effectiveness of a self-efficacy theory based videotape intervention designed to facilitate fluid adherence among fluid nonadherent hemodialysis patients
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Brady, Beverly A
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vi, 156 leaves : ; 29 cm.

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Kidneys ( jstor )
Magnetic storage ( jstor )
Motivation ( jstor )
Motivation research ( jstor )
Patient compliance ( jstor )
Questionnaires ( jstor )
Renal dialysis ( jstor )
Weight gain ( jstor )
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Psychology thesis, Ph. D ( lcsh )
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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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Typescript.
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Vita.
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by Beverly A. Brady.

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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




Full Text
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.


51
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



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PAGE 165

/' e}O 81,9(56,7< 2) )/25,'$


109
Table 4.5
Least Squares Mean Fluid Adherence Efficacy Expectation
Scores of the Control Group and the Intervention Group at
Baseline. Post-Intervention, and Follow-Up
Post-
Baseline
Intervention
Follow-Up
Control
38.97
35.13
30.89
Intervention
42.33
48.67
56.33
Research Hypothesis 4 stated that at post-intervention
and follow-up, patients who view the Fluid Adherence
Facilitation videotape will have significantly higher fluid
adherence outcome expectations than patients who view the
control videotape. A 2X3 repeated measures analysis of
variance (ANOVA) was performed to test this hypothesis.
The results of this ANOVA did not support Research
Hypothesis 4. No group, time, or interaction effect was
found indicating that the fluid adherence outcome
expectations of the patients in the control group and the
intervention group did not significantly differ at post
intervention or at follow-up. The results of this analysis
are summarized in Table 4.6. Although the model was not
significant, an examination of the least squares means
revealed that the fluid adherence outcome expectation scores
of patients in the intervention group did increase over
time; in contrast, the fluid adherence outcome scores of


108
intervention group did not significantly differ at post
intervention or at follow-up. The results of this analysis
are summarized in Table 4.4. Although the model was not
significant, an examination of the least squares means
revealed that the fluid adherence efficacy expectation
scores of patients in the intervention group did increase
over time; in contrast, the fluid adherence efficacy
expectation scores of patients in the control group
decreased over time. The least squares mean fluid adherence
efficacy expectation scores of the control group and the
intervention group at baseline, post-intervention, and
follow-up are summarized in Table 4.5.
Table 4.4
Group X Time Repeated Measures ANOVA of Fluid Adherence
Efficacy Expectations
Source
DF
MS
F-Value
p-level
Between
Group
1,21
3376.44
0.94
0.3432
Within
Time
2,42
49.99
0.10
0.9070
Time X Group
2,42
690.09
1.35
0.2702


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.


85
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 r201) (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 &


22
Cooing 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


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-Efficacv. 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).


76
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.


11
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


10
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.


LD
1780
1993
.£83l
UNIVERSITY OF FLORIDA


CHAPTER V
DISCUSSION
This study was conducted primarily to assess the
effectiveness of a self-efficacy theory based videotape
intervention in facilitating fluid adherence efficacy
expectations, fluid adherence outcome expectations, fluid
adherence motivation, and actual fluid adherence among fluid
nonadherent hemodialysis patients. Differences in fluid
adherent patients and fluid nonadherent patients,
demographic factors associated with fluid adherence, and the
actual positive consequences of being fluid adherent and the
actual negative consequences of being fluid nonadherent as
perceived by hemodialysis patients were also investigated.
Summary and Interpretation of the Results
The first research question investigated hemodialysis
patients' views regarding the positive consequences of being
fluid adherent and the negative consequences of being fluid
nonadherent. The twenty-four fluid adherent patients
interviewed identified 8 positive consequences of being
fluid adherent and 14 negative consequences of being fluid
nonadherent. However, there was little agreement among
patients on the positive or negative consequences as
115


114
Table 4.10
Results of Group X Time Repeated Measures ANCOVA for Fluid
Adherence
Source
DF
MS
F-Value
¡3-level
Between
Group
1, 22
0.12
0.23
0.6343
Within
Time
2,44
0.94
2.22
0.1204
Time X Group
2,44
0.09
0.22
0.8059
Time X Urine
2,44
0.08
0.20
0.8206
Time X MWT1
2,44
1.14
2.70
0.0786
Table 4.11
of the Control
Group and
the Intervention GrouD
at Baseline.
Post-Intervention, and Fo11ow-Ud
Baseline
Post-
Intervention
Follow-Up
Control
Intervention
3.53 kgs
3.53 kgs
3.27 kgs
3.25 kgs
3.69 kgs
3.45 kgs


41
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


4
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?


25
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,


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


81
Table 3.1
Patient Demographic Information
Phase I
Fluid
Adherent
(n = 24)
Phase III
Fluid
Nonadherent
(n = 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%


33
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.


15
(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


100
The patients interviewed reported that by adhering to
their fluid restrictions they avoided the following negative
consequences: (a) longer dialysis sessions (n = 2), (b)
muscle cramps during dialysis sessions (n = 6), (c) feeling
tired and sick after dialysis sessions (n =2), (d) feeling
bloated (n = 7), (e) swollen feet and legs (n = 4), (f)
feeling physically uncomfortable (n = 5) (g) feeling
sluggish (n = 1), (h) shortness of breath (n = 1), (i)
headaches (n = 1) (j) fluid build up in lungs (n = 1), (k)
heart problems (n = 2) (1) elevated lab results (n = 1),
(m) hospitalization (n = 2), and (n) death (n = 1).
Prior to performing the analyses to address the second
research question and Hypotheses 1-6, preliminary analyses
were performed to determine if patients' responses to the
Fluid Adherence Self-Efficacy Questionnaire and the Fluid
Adherence Motivation Questionnaire were influenced by the
desire to give socially acceptable responses. Pearson
Correlations were computed to determine any association
between subjects' Marlowe-Crowne Social Desirability Scale
(SDS) scores and the following dependent variables: fluid
adherence efficacy expectations (EFFICACY), fluid adherence
outcome expectations (OUTCOME), and fluid adherence
motivation (MOTIVATION). Because multiple comparisons were
conducted, the significance criteria was adjusted using the
Bonferroni procedure. The adjusted criterion was pc.Ol.
The Pearson Correlation coefficients and p-values of the


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


16
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


154
Strain, J. (1981). Impediments to psychological care of the
chronic renal patient. In N. B. Levy (Ed.),
Psvchonephroloav 1: Psychological factors in hemodialysis
and transplantation (pp. 19-34). New York: Plenum.
Strecher, V., DeVellis, B., Becker, M., Rosenstock, I.
(1986). The role of self-efficacy in achieving health
behavior change. Health Education Quarterly. 13, 73-92.
Streltzer, J. (1983). Cultural aspects of adjustment to end-
stage renal disease. In N. B. Levy (Ed.), Psvchonephroloqy
2: Psychological problems in kidney failure and their
treatment (pp. 53-69). New York: Plenum.
Streltzer, J., & Hassell, L. (1988). Noncompliant
hemodialysis patients: A biopsychosocial approach.
General Hospital Psychiatry. 10., 255-259.
Swartz, C. D. (1967). Indications for chronic hemodialysis.
In A. N. Brest & J. H. Moyer (Eds.), Renal failure: A
symposium sponsored bv Hahnemann Medical College (pp.
211-213). Philadelphia: J. B. Lippincott.
Tourkow, L. (1974). Psychic consequences of loss and
replacement of body parts. Journal of the American
Psychoanalytic Association. 22. 170-181.
Tucker, C. M. (1989). The effects of behavioral intervention
with patients, nurses, and family members on dietary
noncompliance in chronic hemodialysis patients.
Transplantation Proceedings. 21, 3985-3988.
Tucker, C. M., Chennault, S. A., Green, D. J., Ziller, R. C.,
& Finlayson, G. (1986) Assessment-based group counseling
to address concerns of chronic hemodialysis patients.
Patient Education and Counseling. 8., 51-61.
Tucker, C. M., Mulkerne, D. J., & Ziller, R. (1982) An
ecological and behavioral approach to outpatient dialysis
treatment. Journal of Chronic Diseases. 35., 21-27.
Tucker, C. M., Ziller, R., Chennault, S., Somer, E., Schwartz,
M., Swanson, L., Blake, H., & Finlayson, G. (1987).
Adjustment to hemodialysis treatment through behavioral
controls. Journal of Psychopathology and Behavioral
Assessment 9., 219-227.
Tucker, C. M., Ziller, R. C., Smith, W. R., Mars, D. R., &
Coons, M. P. (1991). Quality of life on in-center
hemodialysis versus CAPD. Peritoneal Dialysis
International. 11, 341-346.


36
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.


60
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.


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.


142
YES NO 7. If I had a way to keep track of how much liquid
I drink I would be able to drink less.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 8. If I had a way to control how much liquid I drink
I would drink less.
10%--20%--30%--40%--50%--60%--70%80%--90%--100%
YES NO 9. If I got more encouragement to drink less liquid
I would drink less.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%


APPENDIX B
INFORMED CONSENT FORM (PHASE III)
You are being invited to participate in a research
study. The purpose of this study is to investigate how to
help patients adhere to their treatment regimens. If you
agree to participate in this study, you will be asked to
participate in three separate interviews over a six-week
period. During these interviews, you will be asked
questions about your treatment plan. These interviews will
take place during your regularly scheduled dialysis sessions
and will each take approximately 30-minutes. Your responses
to these questions will be identified by a code number
rather than by your name in order to protect your
confidentiality. This information will be kept in a locked
file at the University of Florida. In addition to
participating in these interviews, you will be asked to view
a different 5-minute segment of a videotape about dialysis
patients at each of your dialysis sessions for a 3-week
period.
By signing this form, you will be giving the principal
investigator and two advanced researchers permission to
obtain information such as your age, marital status, and
length of time on dialysis from your patient file, and
information about medications, weight gain, etc., from your
medical records. This information will also be identified
135


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 reasearch. 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


27
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,


23
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


58
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.


14
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


29
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'


101
Marlowe-Crowne Social Desirability Scale (SDS) scores with
each of the dependent variables are summarized in Table 4.1.
No statistically significant correlations were obtained for
an alpha level of p<.01; consequently, SDS scores were not
included as covariates in the ANCOVAs performed to address
the second research question nor in any of the other
analyses involving fluid adherence efficacy expectations,
fluid adherence outcome expectations, or fluid adherence
motivation.
Table 4.1
Pearson
Correlation Coefficients
and D-values
of Marlowe-
Crowne ;
Social Desirabilitv Scale
(SDS) Scores
and EFFICACY.
OUTCOME
. and MOTIVATION
SDS EFFICACY
OUTCOME
MOTIVATION
SDS
0.14
-0.03
0.22
0.32
0.83
0.12
The second research question asked whether there were
differences in fluid adherence efficacy expectations
(EFFICACY), fluid adherence outcome expectations (OUTCOME),
fluid adherence motivation (MOTIVATION), and actual fluid
adherence (FLUID) due to (a) length of time on dialysis
(DIALYSIS), (b) number of concurrent medical conditions
(CONDITIONS), (c) presence or absence of diabetes mellitus
(DIABETES), (d) presence or absence of either Catapres,


26
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.


153
Schmicker, R., & Baumbach, A. (1990). Dietary compliance in
hemodialysis patients. In A. Albertazzi, P. Cappelli, G.
Del Rosso, B. Di Paolo, M. Evangelista, P. Palmieri (Eds.),
Nutritional and pharmacological strategies in chronic renal
failure (pp. 115-123) New York: Karger.
Schneider, M., Friend, R., Whitaker, P., & Wadhwa, N. (1991).
Fluid noncompliance and symptomatology in end-stage renal
disease: Cognitive and emotional variables. Health
Psychology. 10., 209-215.
Schnoll, S. (1981). Patient motivation. Maryland State
Medical Journal 30., 40-43.
Shapiro, D. (1983). Dimensions relevant to the health care
and therapeutic use of self-control strategies: A system
model for applied research. Perspectives in Biology and
Medicine. 26., 568-586.
Shea, E., Bogdan, D., Freeman, R., & Schreiner, G. (1965).
Hemodialysis for chronic renal failure. Annals of Internal
Medicine, 62., 558-563.
Sherwood, R. (1983). The impact of renal failure and
dialysis treatments on patients' lives and on their
compliance behavior. In N. B. Levy (Ed.), Psvchonephrologv
2: Psychological problems in kidney failure and their
treatment (pp. 53-69). New York: Plenum.
Smith, W. R. (1989). Self-efficacy and compliance among
hemodialysis patients. (Doctoral dissertation, University
of Florida, 1988). Dissertation Abstracts International.
50. 1657B.
Solomon, K., & Annis, H. (1990). Outcome and efficacy
expectancy in the prediction of post-treatment drinking
behavior. British Journal of Addiction. 85., 659-665.
Somer, E., & Tucker, C. M. (1988) Patient life engagement,
spouse marital adjustment, and dietary compliance of
hemodialysis patients. Journal of Compliance in Health
Care. 3., 57-65.
Steidl, J., Finkelstein, F., Wexler, J., Feigenbaum, H.,
Kitsen, J., Kliger, A., & Quinlan, D. (1980). Medical
condition, adherence to treatment regimens, and family
functioning. Archives of General Psychiatry. 37 1025-1027.
Strahan, R., & Gerbasi, K. C. (1972). Short, homogeneous
versions of the Marlowe-Crowne Social Desirability Scale.
Journal of Clinical Psychology. 28, 191-193.


20
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.


129
being fluid adherent, and the remaining patients could only
identify one or two positive consequences. The difficulty
these patients had identifying positive consequences
indicates that more attention needs to be given to talking
with hemodialysis patients about the positive consequences
of being fluid adherent. The need for medical personnel to
focus on increasing hemodialysis patients' awareness of the
positive benefits of adhering to their treatment regimens is
further supported by the findings of Rorer, Tucker, and
Blake (1988). According to these researchers, nurses do not
spend any more time talking with nonadherent hemodialysis
patients about their treatment (including adherence to
treatment regimens) than they do with adherent hemodialysis
patients. In addition, as nursing tenure increases, the
amount of time nurses spend talking with patients about
their hemodialysis treatment regimens decreases.
Another possible limitation of this research is that
the demographic characteristics of the population of
dialysis patients used in this study differs from the
national statistics reported for dialysis patients. The
U.S. Renal Data System (1993) reports a gender distribution
of 48% female and 52% male and an ethnic distribution of 60%
Caucasian and 35% African-American. The population of in
center dialysis patients used in this study was
overwhelmingly female (70%) and African-American (74%).
Cohen & Tucker (1994) also found that the in-clinic dialysis


28
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).


57
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


96
Prednisone was recorded on the Patient Demographic and
Medical Information Sheet. Patients' level of urine output
and the presence or absence of diabetes mellitus, cancer,
heart disease, hypertension, pulmonary disease, polycystic
kidney, and psychiatric complications was also recorded on
the Patient Demographic and Medical Information Sheet.
Knowledge of this medical data allowed analyses to determine
the need to control for possible differences in fluid
adherence associated with these medications and/or medical
conditions.
Research Questions and Hypotheses
The following two research questions were addressed:
(1) What are the positive consequences of being fluid
adherent and the negative consequences of being fluid
nonadherent?
(2) Are there differences in fluid adherence efficacy
expectations, fluid adherence outcome expectations,
fluid adherence motivation, and actual fluid adherence
due to (a) length of time on dialysis, (b) number of
concurrent medical conditions (i.e., diabetes mellitus,
cancer, heart disease, hypertension, pulmonary disease,
polycystic kidney, or psychiatric complications), (c)
presence or absence of diabetes mellitus, (d) presence
or absence of one of three possibly thirst inducing
medications Catapres, Tenex, or Wytensin, or (e)
level of urine output?


Ill 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
iv


122
groups did not differ with respect to fluid adherence
outcome expectations. This finding is also consistent with
the above cited studies which indicate that efficacy
expectations may be better predictors of behavior than
outcome expectations (Desharnais, Bouillon, & Godin, 1986;
Manning & Wright, 1983; Solomon & Annis, 1990)
Research Hypothesis 3 through Research Hypothesis 6
investigated differences at post-intervention and follow-up
in patients who viewed the Fluid Adherence Facilitation
videotape (intervention group) and patients who viewed the
control videotape (control group). Research Hypothesis 3
predicted that at post-intervention and follow-up, patients
in the intervention group would have significantly higher
fluid adherence efficacy expectations than patients in the
control group. Research Hypothesis 4 predicted that at
post-intervention and follow-up, patients in the
intervention group would have significantly higher fluid
adherence outcome expectations than patients in the control
group. Research Hypothesis 5 predicted that at post
intervention and follow-up, patients in the intervention
group would have significantly higher fluid adherence
motivation than patients in the control group.
Although the model was not significant for Research
Hypothesis 3, Research Hypothesis 4, or Research Hypothesis
5, an examination of the least squares means revealed that
the fluid adherence efficacy expectations, the fluid


110
patients in the control group remained relatively stable.
The least squares mean fluid adherence outcome expectation
scores of the control group and the intervention group at
baseline, post-intervention, and follow-up are summarized in
Table 4.7.
Table 4.6
Results of Group X Time Repeated Measures ANOVA for Fluid
Adherence Outcome Expectations
Source
DF
MS
F-Value
p-level
Between
Group
1,21
4485.83
0.95
0.3421
Within
Time
Time X Group
2,42
2,42
380.73
271.55
0.36
0.26
0.6978
0.7732
Table 4.7
Least Souares Mean
Fluid
Adherence
Outcome
ExDectation
Scores of the Control Group and the Intervention Group at
Baseline. Post-Intervention, and Follow-Up
Post-
Baseline
Intervention
Follow-Up
Control
36.67
34.36
37.18
Intervention
46.33
50.00
60.67


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21
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.


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


126
responsiveness of patterns of fluid overloading to most
psychotherapeutic interventions, the baseline, intervention,
and follow-up periods likely needed to have been longer than
3 weeks in order to modify such long standing and ingrained
habits. Another limitation of this study was the small
number of subjects in each group. In future studies, it is
recommended that a larger number of subjects be used and
that the baseline, intervention and follow-up phases be
extended.
Another possible limitation of this study was the
instrument used to assess patients' fluid adherence efficacy
expectations and fluid adherence outcome expectations. The
Fluid Adherence Self-Efficacy Questionnaire is the only
available instrument designed to assess hemodialysis
patients' efficacy expectations and outcome expectations
with regard to their fluid intake. During the course of the
study, several problems were noted with this instrument.
Several patients stated that it was more difficult for them
to monitor their intake of foods that contained fluids (i.e,
grits, rice) than it was for them to monitor their intake of
liquids. The Fluid Adherence Self-Efficacy Questionnaire
specifically asks about the amount of liquid the patient
drinks, but does not directly address the amount of fluids
contained in ingested foods.
In addition, some of the questions on the Fluid
Adherence Self-Efficacy Questionnaire were not relevant for


7
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) .


72
(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.


151
Lawson, V. Traylor, M., & Gram, M. (1976). An audio
tutorial aid for dietary instruction in renal dialysis.
Journal of the American Dietetic Association. 69. 390-396.
Levy, N. B. (1973). The psychology and care of the
maintenance hemodialysis patient. Heart and Lung. 2,
400-405.
Levy, N. B. (1980). The 'uncooperative' patient with ESRD,
causes and treatment. Proceedings of the European Dialysis
and Transplant Association. 17, 523-527.
Levy, N. B. (1981). Psychological reactions to machine
dependency: Hemodialysis. Psychiatric Clinics of North
America. 4, 351-363.
Maddux, J., & Stanley, M. (1986). Self-efficacy theory in
contemporary psychology: An overview. Journal of Social
and Clinical Psychology. 4., 249-255.
Manley, M., & Sweeney, J. (1986). Assessment of compliance
in hemodialysis adaptation. Journal of Psychosomatic
Research. 30. 153-161.
Manning, M., & Wright, T. (1983). Self-efficacy
expectancies, outcome expectancies, and the
persistence of pain control in childbirth. Journal of
Personality and Social Psychology. 45, 421-431.
Mass, M., & Kaplan De-Nour, A. (1975). Reactions of families
to chronic hemodialysis. Psychotherapy Psychosomatic. 26.,
20-26.
McKevitt, P., Jones, J., Lane, D., Sc Marion, R. (1990). The
elderly on dialysis: Some considerations in compliance.
American Journal of Kidney Diseases. 16, 346-350.
Murray, E. A. (1983). Dietary management. In J. C. Van
Stone (Ed.), Dialysis and the treatment of renal
insufficiency (335-356). New York: Grue & Stratton.
Newberry, M. A. (1989). Textbook of hemodialysis for patient
care personnel. Springfield: Charles C. Thomas.
Oberley, E., St Oberley, T. (1992). Understanding vour new
life with dialysis. Springfield, IL: Charles C. Thomas.
O'Brien, M. (1990). Compliance behavior and long-term
maintenance dialysis. American Journal of Kidney Diseases.
15. 209-214.


42
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
compilers and 39% were good compilers, 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


40
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


113
mean weekend interdialysis weight gain (MWT1) and level of
urine output (URINE) were entered as covariates in the
repeated measures ANCOVA used to test Hypothesis 6.
The results of this ANCOVA did not support Hypothesis
6. There was no group, time, or interaction effect
indicating that the fluid adherence of the patients in the
control group and the intervention group did not
significantly differ at post-intervention or at follow-up.
The results of this analysis are summarized in Table 4.10.
An examination of the least squares means revealed that the
mean weekend interdialysis fluid weight gains of patients in
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 patients
in the intervention group had lower mean weekend
interdialysis fluid weight gains. The least squares mean
weekend interdialysis fluid weight gains of the control
group and the intervention group at baseline, post
intervention, and follow-up are summarized in Table 4.11.


CHAPTER IX
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


64
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,


APPENDIX E
FLUID ADHERENCE SELF-EFFICACY QUESTIONNAIRE
Directions: Please listen carefully to each of the following
sentences. Respond with a "YES" if you think that the
sentence is true for you now or with a "NO" if you do not
think the sentence is true for you now. After you respond to
each question, you will be asked to indicate how sure you are
about your response. For example, if you are very sure that
you can control how much liquid you drink when you are at
home, you might respond with 80% If you are not very sure of
your answer, you might respond with 20%.
YES NO 1. I can control how much liquid I drink when I'm at
home.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 2. I can control how much liquid I drink on a day
when I'm away from home.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 3. I can control how much liquid I drink on a day
when I eat out at a restaurant.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 4. I can control how much liquid I drink on a day
when I go to a party.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 5. I can control how much liquid I drink on a day
when it is hot outside.
10%--20%--30%--40%--50%--60%--70%--80%--90%--100%
YES NO 6. I can control how much liquid I drink on a day
when I am thirsty.
10%20%--30%--40%--50%--60%--70%--80%--90%--100%
141


92
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


53
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


13
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


APPENDIX A
INFORMED CONSENT FORM (PHASE I)
You are being invited to participate in a research
study. The purpose of this study is to investigate how to
help patients adhere to their treatment regimens. If you
agree to participate in this study, you will be asked to
participate in an interview during which you will be asked
questions about your treatment plan. This interview will
take place during one of your regularly scheduled dialysis
sessions and will take approximately 30-minutes. Your
responses to these questions will be identified by a code
number rather than by your name in order to protect your
confidentiality. This information will be kept in a locked
file at the University of Florida.
After this interview, you will be asked approximately
one week later to participate in a second interview that
will take approximately 15-minutes. During this interview
you will be asked to provide some background information
about yourself and to answer several questions about your
fluid adherence treatment regimen. Your responses to these
questions will be videotaped and portions of this videotape
may be shown to other hemodialysis patients, including some
patients at your dialysis center.
By signing this form, you will be giving the principal
investigator and two advanced researchers permission to
obtain information such as your age, marital status, and
length of time on dialysis from your patient file, and
132


148
Drees, A., & Gallagher, E. (1981). Hemodialysis,
rehabilitation, and psychological support. In N. B. Levy
(Ed.), Psvchonenhroloav 1: Psychological factors in
hemodialysis and transplantation (pp. 133-146). New York:
Plenum.
Epstein, L., & Cluss, P. (1982) A behavioral medicine
perspective on adherence to long-term medical regimens.
Journal of Consulting and Clinical Psychology. 50. 950-971.
Evans, R. (1989) Albert Bandura: The man and his ideas -
A dialogue. New York: Praeger.
Fortner-Frazier, C. (1981). Social work and dialysis: The
medical and psychosocial aspects of kidney disease.
Berkeley: University of California.
Foster, F., Cohn, G., & McKegney, P. (1973).
Psychobiological factors and individual survival
on chronic renal hemodialysis A two year follow-up.
Psychosomatic Medicine. 35, 64-82.
Fraboni, M., & Cooper, D. (1989). Further validation of
three short forms of the Marlowe-Crowne Scale of Social
Desirability. Psychological Reports. 65 595-600.
Friedman, E., Goodwin, N., & Chaudhry, L. (1970a).
Psychosocial adjustment to maintenance hemodialysis: Part
I. New York State Journal of Medicine. 70., 629-637.
Friedman, E., Goodwin, H., & Chaudhry, L. (1970b).
Psychosocial adjustment of family to maintenance
hemodialysis: Part II. New York State Journal of Medicine.
70. 767-774.
Goldstein, A., & Reznikoff, M. (1971) Suicide in chronic
hemodialysis patients from an external locus of control
framework. American Journal of Psychiatry. 127. 1204-1207.
Gonsalves-Ebrahim, L., Sterin, G., Gulledge, A., Gipson, W.,
Rodgers, D. (1987). Noncompliance in younger adults on
hemodialysis. Psvchosomatics. 28. 34-41.
Gotch, F.( & Keen, M. (1991). Care of the patient on
hemodialysis. In M. Cogan & P. Schoenfeld (Eds.),
Introduction to dialysis. New York: Churchill Livingstone.
Hakim, R. M., & Lazarus J. M. (1984). Complications during
hemodialysis. In A. Nissenson, R. Fine, D. Gentile (Eds.),
Clinical dialysis. Norwalk, Connecticut: Appleton-Century-
Crofts.


48
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


BIOGRAPHICAL SKETCH
Beverly Anne Brady received her Bachelor of Science in
psychology from the University of Pennsylvania in 1984. She
then entered the M.S./Ph.D. counseling psychology program at
the University of Florida where she received her Master of
Science in 1991. Ms. Brady completed her predoctoral
internship at the Counseling Center for Human Development at
the University of South Florida. She will receive her
Doctor of Philosophy degree in December 1994.
156


52
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


155
U.S. Renal Data System. (1993). SRDS 1993 Annual Data
Report. Bethesda, MD: The National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney
Diseases.
Van Stone, J. C. (1983). Hemodialysis prescription. In
J. C. Van Stone (Ed.), Dialysis and the treatment of renal
insufficiency (119-142). New York: Grue & Stratton.
Viederman, M. (1974). Adaptive and maladaptive regression in
hemodialysis. Psychiatry. 37, 68-77.
Weinberg, R., Hughes, H., Critelli, J., England, R., &
Jackson, A. (1984). Effects of preexisting and manipulated
self-efficacy on weight loss in a self-control program.
Journal of Research in Personality. 18, 352-358.
Wilson, Muzekari, Schneps, & Wilson. (1974). Time-limited
group counseling for chronic home hemodialysis patients.
Journal of Counseling Psychology. 21, 376-379.
Winokur, M., Czackes, J., & Kaplan De-Nour, A. (1973).
Intelligence and adjustment to chronic hemodialysis.
Journal of Psychosomatic Research. 17 29-34.
Wolcott, D., Maida, C., Diamond, R., & Nissenson, A. (1986).
Treatment compliance in end-stage renal disease patients on
dialysis. American Journal of Nephrology. 6., 329-338.
Wright, L. F. (1981). Maintenance hemodialysis Boston:
G. K. Hall Medical Publishers.
Wright, R., Sand, P., & Livingston, G. (1966). Psychological
stress during hemodialysis for chronic renal failure.
Annals of Internal Medicine. 64., 611-621.
Yanitski, A. (1983). Compliance of the hemodialysis patient.
American Association of Nephrolocrv Nurses and Technicians.
10. 11-16.
Zetin, M., Plummer, R., Vaziri, N., Cramer, M. (1981). Locus
of control and adjustment to chronic hemodialysis. Clinical
Experimental Dialysis and Aphresis. 5, 319-334.


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.


140
T F 13. At times, I have really insisted on having
things my own way. (F)
T F 14. There have been occasions when I felt like
smashing things. (F)
T F 15.1 would never think of letting someone else be
punished for my wrong-doings. (T)
T F 16. I never resent being asked to return a favor.
(T)
T F 17.1 have never been irked when people expressed
ideas very different from my own. (T)
T F 18. There have been times when I was quite jealous
of the good fortune of others. (F)
T F 19. I am sometimes irritated by people who ask
favors of me. (F)
T F 20. I have never deliberately said something that
hurt someone's feelings. (T)
Note. A score of 1 is given for responses like those in
parentheses. A score of 0 is given otherwise.


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-efficacv 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.


137
I have received a copy of this description and have been
fully informed of the above-described study and the benefits
and risks of participating in this research. I agree to
participate in this study.
Signature of Patient
Date


CHAPTER IV
RESULTS
The first research question of this study asked about
the views of hemodialysis patients regarding the positive
consequences of being fluid adherent and the negative
consequences of being fluid nonadherent. A review of the 24
Phase I fluid adherent patients' videotaped interviews
revealed that patients identified many more negative
consequences than positive consequences. Of the 24 patients
interviewed, 1 patient reported more than one positive
consequence, 10 patients reported more than one negative
consequence, 9 patients did not report any positive
consequences, 1 patient did not report any negative
consequences, and 7 patients did not report any positive or
negative consequences.
Patients identified the following as positive
consequences of being fluid adherent: (a) dialysis
treatments are shorter (n = 1), (b) there are fewer
complications during dialysis treatments (n = 1), (c) less
likely to feel sick after being dialyzed (n = 2), (d) have
more energy (n = 2), (e) feel better physically (n = 1), (f)
can rest without discomfort (n = 1), (g) avoid further
damaging your body (n = 1), and (h) increased life span (n =
2) .
99


38
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


133
information about medications, weight gain, etc., from your
medical records. This information will also be identified
by a code number rather than by your name, and will be kept
in a locked file at the University of Florida.
You will receive $5.00 at the end of the videotaped
interview for having participated in both interviews. This
monetary compensation is being provided for your time and
does not depend upon your responses.
There are no anticipated risks to you because of your
participation in this study. Information obtained during
this study may potentially help other hemodialysis patients
to adhere to their treatment regimens. Your participation
in this study is voluntary. You may withdraw your consent
and discontinue participation at any time. Whether or not
you decide to participate in this study, you will receive
the same treatment and care at the dialysis center. If you
have any questions about this study or your participation,
you may call the Principal Investigator, Ms. Beverly Brady,
at (904) 392-9436.
I have fully explained to
the nature and purpose of the above-described study and the
benefits and risks of participating in this research.
Signature of Principal Investigator/Researcher
Date


97
The following six hypotheses were tested:
(1) Fluid adherence (i.e., average weekend interdialysis
fluid weight gain) will have a significant negative
correlation with fluid adherence efficacy expectations,
fluid adherence outcome expectations, and fluid
adherence motivation. There will be a significant
positive correlation among fluid adherence efficacy
expectations, fluid adherence outcome expectations, and
fluid adherence motivation.
(2) Fluid adherent patients (Phase I patients) as compared
with fluid nonadherent patients (Phase III patients at
baseline) will have significantly higher fluid
adherence efficacy expectations, fluid adherence
outcome expectations, and fluid adherence motivation.
3) At post-intervention and follow-up, patients who view
the Fluid Adherence Facilitation videotape will have
significantly higher fluid adherence efficacy
expectations than patients who view the control
videotape.
4) At post-intervention and follow-up, patients who view
the Fluid Adherence Facilitation videotape will have
significantly higher fluid adherence outcome
expectations than patients who view the control
videotape.
At post-intervention and follow-up, patients who view
the Fluid Adherence Facilitation videotape will have
5)


117
immediate negative physical consequences and less aware of
the long term medical consequences of fluid nonadherence.
However, given that these responses were obtained from fluid
adherent patients, this group of patients may have been less
likely to experience the more severe medical consequences.
The second research question investigated differences
in fluid adherence efficacy expectations, fluid adherence
outcome expectations, fluid adherence motivation, and actual
fluid adherence due to (a) length of time on dialysis, (b)
number of concurrent medical conditions, (c) presence or
absence of diabetes, (d) presence or absence of either
Catapres, Tenex, or Wytensin, or (e) urine output. Results
indicated that patients who had been on dialysis longer and
those patients who did not regularly take Catapres, Tenex,
or Wytensin had higher fluid adherence efficacy
expectations. The first part of this finding suggests that
as patients became more familiar with the hemodialysis
treatment regimen, they gained more confidence in their
ability to control their fluid intake. However, this
increased sense of efficacy with respect to fluid adherence
may not result in decreased fluid weight gains as evidenced
by the nonsignificant finding for differences in fluid
adherence due to length of time on dialysis. Procci (1978)
similarly concluded that chronicity of dialytic treatment
showed no significant relationship to patient compliance.
In contrast, Schmicker and Baumback (1990) and Brown and


43
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 compilers (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


APPENDIX D
M-C SDS (20)
Directions: For each of the following statements, please
indicate whether you consider the statement to be True (T) or
False (F).
T F
T F
T F
T F
T F
T F
T F
T F
T F
T F
T F
T F
1. I never hesitate to go out of my way to help
someone in trouble. (T)
2. I have never intensely disliked anyone. (T)
3. I sometimes feel resentful when I don't get my
way. (F)
4. I like to gossip at times. (F)
5. There have been times when I felt like
rebelling against people in authority even
though I knew they were right. (F)
6. I can remember "playing sick" to get out of
something. (F)
7. There have been occasions when I took
advantage of someone. (F)
8. I'm always willing to admit it when I make a
mistake. (T)
9. I always try to practice what I preach. (T)
10. I sometimes try to get even, rather than
forgive and forget. (F)
11. When I don't know something I don't at all
mind admitting it. (T)
12. I am always courteous, even to people who are
disagreeable. (T)
139


95
videotape during each of the 9 dialysis sessions in the 3-
week intervention period (i.e., at each of the three routine
weekly dialysis sessions). The patients in the Control
Group similarly individually viewed a different 5-minute
segment of the control videotape at each of the 9 dialysis
sessions in the 3-week intervention period. The Director of
Nursing or a staff member appointed by the Director of
Nursing set up the equipment and inserted the correct tape
for each patient. These professionals were informed of the
nature of the study and instructed not to initiate
discussion of the content of the videotape with patients;
however, they were told to briefly respond to questions
asked by patients. A researcher verbally re-administered
the assessment battery to each of the patients at the end of
the 3-week intervention period and again at the end of the
3-week follow-up period. Each patient received $15.00 at
the completion of the third interview after signing a
receipt.
Computer printouts of each patient's weekend
interdialysis fluid weight gains were obtained for the
baseline period (3 weeks), the intervention period (3
weeks), and the follow-up period (3 weeks). Patients'
interdialysis fluid weight gain data is routinely recorded
in patients' charts at each of their three weekly dialysis
treatment sessions. Whether or not each patient regularly
took Insulin, Catapres, Tenex, Wytensin, Mellaril, or


CHAPTER III
METHODOLOGY
Subjects
Phase I 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
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
78


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,
1


146
Bandura, A., Adams, N., Hardy, A., & Howells, G. (1980).
Tests of the generality of self-efficacy theory. Cognitive
Therapy and Research. 4, 39-66.
Bandura, A., & Cervone, D. (1983) Self-evaluative and self-
efficacy mechanisms governing the motivational effects of
goal systems. Journal of Personality and Social Psychology,
45. 1017-1028.
Bartholomew, L., Parcel, G., Swank, P., & Czyzewski, D.
(1993) Measuring self-efficacy expectations for the self-
management of cystic fibrosis. Chest, 103. 1524-1530.
Beard, B. H. (1969). Fear of death and fear of life.
Archives of General Psychiatry. 21, 373-380.
Beard, H., & Sampson, T. (1981). Denial and objectivity in
hemodialysis patients. In N. B. Levy (Ed.),
Psvchonephroloov 1: Psychological factors in hemodialysis
and transplantation (pp. 169-175). New York: Plenum.
Betts, D., & Crotty, G. (1988). Response to illness and
compliance of long-term hemodialysis patients. American
Nephrology Nurses' Association. 15. 96-100.
Blackburn, S. L. (1977). Dietary compliance of chronic
hemodialysis patients. Journal of the American Dietetic
Association. 70., 31-37.
Bollin, B., Sc Hart, L. (1982). The relationship of health
belief motivations, health locus of control, and health
valuing to dietary compliance of hemodialysis patients.
American Association of Nephrology Nurses and Technicians,
9, 41-47.
Brown, J. Sc Fitzpatrick, R. (1988). Factors influencing
compliance with dietary restrictions in dialysis patients.
Journal of Psychosomatic Research. 32., 191-196.
Caesar, C., & Tucker, C. M. (1991). Predicting dietary
adherence in hemodialysis patients by examining locus of
control and self-efficacy. Contemporary Dialysis &
Nephrology. July, 19-28.
Campbell, A. (1983). Education of the renal patient:
Assistance for change. In J. C. Van Stone (Ed.), Dialysis
and the treatment of renal insufficiency (287-333) New
York: Grue Sc Stratton.
Cheek, J. (1982). Patient feelings about illness: Do they
affect compliance with the therapeutic regimen? American
Association of Nephrology Nurses and Technicians. 9, 17-20.


74
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


80
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.


I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Carolyn MiI TucXer, Chair
Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Clinical Professor
f Counselor Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Assistant Professor of Counselor Education
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of Philosophy.
Scott A. Miller
Professor of Psychology
I certify that I have read this study and that in my
opinion it conforms to acceptable standards of scholarly
presentations and is fully adequate, in scope and quality,
as a dissertation for the degree of Doctor of~'Phiilrosophy.
fCobert^Cl Zlller
Profe(ssor of Psychology


94
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


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


TABLE OF CONTENTS
page
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


147
Christensen, A., Smith, T., Turner, C., Holman, J., Gregory,
M., & Rich, M. (1992). Family support, physical
impairment, and adherence in hemodialysis: An investigation
of main and buffering effects. Journal of Behavioral
Medicine. 15. 313-325.
Cohen, J., & Tucker, C.M. (1994). Denial and depression as
quality of life factors in hemodialysis patients.
Contemporary Dialysis and Nephrology, May, 22-26.
Colletti, G., Supnick, J., & Payne, T. (1985). The smoking
self-efficacy questionnaire (SSEQ): Preliminary scale
development and validation. Behavioral Assessment. 7,
249-260.
Crowne, D. P., & Marlowe, D. (1960). A new scale of social
desirability independent of psychopathology. Journal of
Consulting Psychology. 24. 349-354.
Cummings, J. W. (1970). Hemodialysis: Feelings, facts,
fantasies: The pressures and how patients respond.
American Journal of Nursing. 70., 70-76.
Cummings, K., Becker, M., Kirscht, J., & Levin, N. (1981).
Intervention strategies to improve compliance with medical
regimens by ambulatory hemodialysis patients. Journal of
Behavioral Medicine. 4, 111-127.
Czackes, J., & Kaplan De-Nour, A. (1978). Chronic
hemodialysis as a wav of life. New York: Brunner/Mazel.
Dansak, D. A. (1972). Secondary gains in long-term
hemodialysis patients. American Journal of Psychiatry. 129,
128-131.
Desharnais, R., Bouillon, J., & Godin, G. (1986). Self-
efficacy and outcome expectancies as determinants of
exercise adherence. Psychological Reports. 59, 1155-1159.
Desmond, F., & Tucker, C. M. (1993). Seasonal variation of
fluid intake adherence in hemodialysis patients.
Contemporary Dialysis and Nephrology. March, 15-16.
Diclemente, C. (1981). Self-efficacy and smoking cessation
maintenance: A preliminary report. Cognitive Therapy and
Research. 5, 175-187.
Dilorio, C., Faherty, B., Manteuffel, B. (1992). The
development and testing of an instrument to measure self-
efficacy in individuals with epilepsy. Journal of the
American Association of Neuroscience Nurses. 24., 9-13.


32
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
noneompliant.
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


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


107
expectations (F (1, 48) = 9.61, p < .0032) and the model for
fluid adherence motivation (F (1,48) = 8.54, p < .0053) were
significant. As predicted, fluid adherent patients had a
significantly higher mean fluid adherence efficacy
expectation (M =73.05, S.D. = 29.02), than that of the fluid
nonadherent patients (M = 43.20, S.D. = 38.05), and fluid
adherent patients had a significantly higher mean fluid
adherence motivation (8.87, S.D. = 2.05) than that of the
fluid nonadherent patients (7.00, S.D. = 2.45).
Research Hypothesis 3 through Research Hypothesis 6
investigated differences in the dependent variables
(EFFICACY, OUTCOME, MOTIVATION, and FLUID) at post
intervention and follow-up in patients who viewed the Fluid
Adherence Facilitation videotape (the intervention group)
versus patients who viewed the control videotape (the
control group). Research Hypothesis 3 stated that at post
intervention and follow-up, patients who view the Fluid
Adherence Facilitation videotape will have significantly
higher fluid adherence efficacy expectations than patients
who view the control videotape. A 2X3 repeated measures
analysis of variance (ANOVA) was performed to test this
hypothesis.
The results of this ANOVA did not support Research
Hypothesis 3. No group, time, or interaction effect was
found indicating that the fluid adherence efficacy
expectations of the patients in the control group and the


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


149
Hart, R. (1979) Utilization of token economy within a
chronic dialysis unit. Journal of Consulting and Clinical
Psychology. 47. 646-648.
Hegel, M., Ayllon, T., Thiel, G., Sc Oulton, B. (1992).
Improving adherence to fluid restrictions in male
hemodialysis patients: A comparison of cognitive and
behavioral approaches. Health Psychology. 11, 324-330.
Henry, R. (1972). Diet therapy for hemodialysis patients.
In G. Bailey (Ed.), Hemodialysis: Principles and practice.
New York: Academic Press.
Hofstetter, C., Sallis, J., & Hovell, M. (1990). Some health
dimensions of self-efficacy: Analysis of theoretical
specificity. Social Science Medicine. 9, 1051-1056.
Holcomb & MacDonald (1973). Social functioning of artificial
kidney patients. Social Science and Medicine. 7, 109-119.
Ifuda, O., Dulin, A., Sc Friedman, E. (1994). Interdialytic
weight gain correlates with glycosylated hemoglobin in
diabetic hemodialysis patients. American Journal of
Kidney Diseases. 23., 686-691.
Isiadinso, O., Sullivan, J., & Baxter, J. (1975) .
Psychological adaptation to long-term hemodialysis: A study
of 84 patients. Bulletin of the New York Academy of
Medicine 51. 797-804.
Iwasiw, C., Sc Goldenberg, D. (1993). Peer teaching among
nursing students in the clinical area: Effects on student
learning. Journal of Advanced Nursing. 18., 659-668.
Jordheim, A. (1976). A comparison study of peer teaching and
traditional instruction in venereal disease education.
Journal of American College Health Association. 24., 286-289.
Jungers, P., Zingraff, J. Man, N., Sc Drueke, T. (1978) The
essentials in hemodialysis. London: Hague.
Kanfer, F. H. (1980). Self-management methods. In F. H.
Kanfer Sc A. P. Goldstein (Eds.), Helping people change: A
textbook of methods (pp. 334-389). New York: Pergamon.
Kanfer, H., Sc Grimm, L. G. (1977). Behavioral analysis.
Behavior Modification. 1, 7-28.
Kaplan De-Nour, A. (1981). Prediction of adjustment to
chronic hemodialysis. In N. B. Levy (Ed.), Psvchonephrology
1: Psychological factors in hemodialysis and
transplantation (pp. 117-132). New York: Plenum.


103
No significant results were found for the ANCOVA with
fluid adherence outcome expectations as the dependent
variable or for the ANCOVA with fluid adherence motivation
as the dependent variable. However, the ANCOVA with actual
fluid adherence as the dependent variable was significant (F
(5,44) = 3.01, p < .02). Patients with diabetes mellitus
had higher average weekend interdialysis weight gains (M =
2.89 kg, S.D. = 1.23) than patients without diabetes
mellitus (M = 2.16, S.D. = 1.25). The results of the
ANCOVAs are summarized in Table 4.2.
Table 4.2
Analyses of Covariance to Assess Differences in Efficacy
Expectations. Outcome Expectations. Motivation, and Fluid
Adherence as a Function of Time on Dialysis. Number of
Medical Conditions. Presence or Absence of Diabetes.
Medications. and Urine Output
Dependent Variable
Efficacy Expectations
Source
DF
MS
F-value
p-value
Omnibus
5,44
3405.06
3.02
0.02*
Dialysis
1,44
5734.04
5.08
0.03*
Conditions
1,44
2.19
0.00
0.96
Diabetes
1,44
3428.74
3.04
0.09
Medications
1,44
6537.03
5.79
0.02*
Urine
1,57
350.43
0.31
0.58


82
Table 3.2
Patient Medical Characteristics
Phase I
Fluid
Adherent
(n = 24)
Phase III
Fluid
Nonadherent
(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%


66
Self-efficacv 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-efficacv 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


124
expectations, fluid adherence outcome expectations, and
fluid adherence motivation that occurred in the present
study.
The decrease in the mean weekend interdialysis fluid
weight gains and the increase in fluid adherence motivation
scores observed among the control patients at the post
intervention period suggest that the control videotape may
have inadvertently influenced patients' fluid adherence
motivation and actual fluid adherence behavior. Informal
discussions with patients after the follow-up period
revealed that although the control videotape was designed to
be neutral in effect, some patients in the control group
experienced positive effects after watching the control
videotape. The control videotape consisted of Phase I fluid
adherent patients discussing general background information
about themselves that was not related to their dialysis
treatment (i.e., types of work experiences, hobbies, future
plans). Some of the patients in the control group stated
that after watching the videotapes of hemodialysis patients
discussing various activities and hobbies, they were
motivated to follow their doctor's advice. It appears that
the control videotape may indeed have inadvertently served
as an intervention to increase patients' motivation to be
fluid adherent and patients' actual fluid adherence
behavior.


49
Sc 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.


50
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.


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


significantly higher fluid adherence motivation than
patients who view the control videotape.
At post-intervention and follow-up, controlling for
urine output and baseline fluid adherence levels,
patients who view the Fluid Adherence Facilitation
videotape will have significantly higher levels of
fluid adherence than patients who view the control
videotape.


63
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-efficacv 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


119
stimulated increased fluid ingestion which resulted in
increased interdialytic weight gain. The significant
finding in this study of differences in fluid adherence due
to the presence or absence of diabetes provides further
empirical evidence of the need to control for diabetes in
future studies.
Research Hypothesis 1 proposed that fluid adherence
(i.e., average weekend interdialysis fluid weight gain)
would have a significant negative correlation with fluid
adherence efficacy expectations, fluid adherence outcome
expectations, and fluid adherence motivation. It was also
proposed that there would be a significant positive
correlation among fluid adherence efficacy expectations,
fluid adherence outcome expectations, and fluid adherence
motivation.
As predicted, there was a significant negative
correlation between fluid adherence and fluid adherence
efficacy expectations. However, fluid adherence outcome
expectations and fluid adherence motivation were not found
to be negatively correlated with fluid adherence. Fluid
adherence efficacy expectations, fluid adherence outcome
expectations, and fluid adherence motivation were also not
found to be significantly correlated.
The finding that fluid adherence efficacy expectations,
but not fluid adherence outcome expectations, were
associated with fluid adherence is consistent with the


127
several patients, therefore these patients had difficulty-
responding to these questions. For example, a significant
proportion of patients had difficulty responding to Item #3
(I can control how much liquid I drink on a day when I eat
out at a restaurant) and Item #4 (I can control how much
liquid I drink on a day when I go to a party). Several
patients stated that they rarely eat out at restaurants and
several responded that they did not go to parties. The
standard alternative item used by all researchers for Item
#4 was "I can control how much liquid I drink on a day when
I go to a family or a church gathering".
The difficulty several patients had responding to items
on the Fluid Adherence Self-Efficacy Questionnaire and the
Fluid Adherence Motivation Questionnaire supports the need
for culturally sensitive research. It is recommended that
the Fluid Adherence Self-Efficacy Questionnaire and the
Fluid Adherence Motivation Questionnaire be revised prior to
being used in future studies investigating the fluid
adherence efficacy expectations, the fluid adherence outcome
expectations, and the fluid adherence motivation of
hemodialysis patients. Specifically it is recommended that
the Fluid Adherence Motivation Questionnaire, and Item #3
and Item #4 of the Fluid Adherence Self-Efficacy
Questionnaire, be revised to be applicable to a wider
variety of hemodialysis patients. It is also recommended
that the revised Fluid Adherence Self-Efficacy Questionnaire


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
v


75
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


84
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.


102
Tenex, or Wytensin (MEDICATIONS), or (e) urine output
(URINE). Because some of the independent variables were
continuous and some were categorical, analyses of covariance
(ANCOVAs) were applied to answer this research question.
The independent variables entered in all four ANCOVAs were
(a) length of time on dialysis, (b) number of concurrent
medical conditions, (c) presence or absence of diabetes
mellitus, (d) presence or absence of either Catapres, Tenex,
or Wytensin (all possibly thirst inducing medications), and
(e) urine output.
The dependent variable in the first ANCOVA was fluid
adherence efficacy expectations. Results indicated
significant differences in fluid adherence efficacy
expectations (F (5,44) = 3.02, p < .02) due to length of
time on dialysis and presence or absence of Catapres, Tenex,
or Wytensin. An examination of patients' mean fluid
adherence efficacy expectation scores revealed that patients
who regularly took either Catapres, Tenex, or Wytensin had
lower fluid adherence efficacy expectations (M = 40.60, S.D.
= 37.50) than patients who did not take these medications (M
= 62.31, S.D. = 35.76). Follow-up data plots were examined
to determine the direction of the relationship between fluid
adherence efficacy expectations and length of time on
dialysis. These plots indicated that there was a positive
relationship between these two variables. Patients who had
been on dialysis longer tended to have higher fluid
adherence efficacy expectations.


116
indicated by the fact that for the majority of reported
consequences only one or two patients gave each response.
Only two of the interviewed patients identified an increased
life span as being a positive consequence of adhering to
fluid restrictions and only one patient identified death as
a possible negative consequence of being fluid nonadherent.
The lack of a strong perceived association between fluid
adherence and medical survivorship among these hemodialysis
patients is in contrast to the presumption in most of the
nonadherence-in-hemodialysis literature that nonadherence
decreases patients' chances of medical survivorship
(Armstrong & Wood, 1983) However, Korbin, Kimmel, Simmens,
and Reiss (1991) concluded that despite this generally
agreed upon premise, few studies have clearly demonstrated
an association between compliance and a favorable long-term
outcome.
The remaining 7 positive consequences (e.g., shorter
treatments, fewer complications during treatments, feel
better physically) and the remaining 13 negative
consequences (e.g., increased ultrafiltration during
dialysis sessions, muscle cramps during dialysis sessions,
deterioration of the cardiovascular system) identified by
the patients in this study are similar to those consequences
commonly reported in the literature (Czackes & Kaplan De-
Nour, 1978; Lamping & Campbell, 1990a; Newberry, 1989). The
patients in this study appeared to be more cognizant of the


24
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


130
patients in their study were predominantly African-American
(71%) Similarly, Caesar and Tucker (1991) found that
African-Americans comprised 66% of the in-center dialysis
population. The preponderance of African-Americans and
female patients in the current research suggests that the
findings in this study may only be applicable to a subset of
dialysis patients. Caution should be used when generalizing
these results to dialysis populations that significantly
differ from the population used in this research.
Given the preponderance of African-American and female
patients in this study and the limited educational
background of the majority of patients in this study, it is
recommended that a similar self-efficacy theory based
videotape intervention be tested with other populations of
hemodialysis patients. It is also recommended that the
intervention be administered prior to the initiation of
dialysis and that the baseline, intervention, and follow-up
periods be extended. Support for a preventive approach is
provided by Streltzer and Hassell (1988) and Czackes and
Kaplan De-Nour (1978). Streltzer and Hassell (1988)
concluded that the greatest potential to minimize fluid
overloading may be a preventive approach since patterns of
overloading are established at the beginning of dialysis and
typically persist despite admonitions and symptomatic
evidence of the consequences. Czackes and Kaplan De-Nour
(1978) also concluded that the success of psychological
interventions with patients already on dialysis is limited.


APPENDIX F
FLUID ADHERENCE MOTIVATION QUESTIONNAIRE
Please respond to the following questions using the 10-point
scale below each question.
1. How important is it to you to reduce your fluid intake?
1 2 3 4 5 6 7 8 9 10
(Not Very Important) (Very Important)
2. How much effort do you put into following your fluid
restrictions?
1 2 3 4 5 6 7 8 9 10
(Not Very Much) (Very Much)
3. How determined are you to reduce your fluid intake?
1 2 3 4 5 6 7 8 9 10
(Not Very Determined) (Very Determined)
4. How satisfied are you with your current level of fluid
intake?
1 2 3 4 5 G 7 8 9 10
(Not Very Satisfied) (Very Satisfied)
143


89
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.


REFERENCES
Abram, H. S. (1969). The psychiatrist, the treatment of
chronic renal failure, and the prolongation of life. Part
II. American Journal of Psychiatry. 126. 43-53.
Abram, H. S. (1974) Psychiatry reflections on adaptation to
repetitive dialysis. Kidney International. 6., 67-72.
Abram, H., Moore, G., & Westervelt, F. (1971). Suicidal
behavior in chronic dialysis patients. American Journal of
Psychiatry. 127. 1199-1204.
Anderson, L., DeVellis, B., & DeVellis, R. (1987). Effects
of modeling on patient communication, satisfaction, and
knowledge. Medical Care. 25, 1044-1056.
Armstrong, S., & Woods, A. (1983). Patient self-reported
adjustment and health beliefs in compliant versus
noncompliant hemodialysis patients. In N. B. Levy (Ed.),
Psvchonephrology 2: Psychological problems in kidney
failure and their treatment (pp. 79-92). New York: Plenum.
Bandura, A. (1977a). Social learning theory. Englewood
Cliffs, NJ: Prentice-Hall.
Bandura, A. (1977b). Self-efficacy: Toward a unifying
theory of behavioral change. Psychological Review. 84.,
191-215.
Bandura, A. (1982). Self-efficacy mechanism in human agency.
American Psychologist. 37, 122-147.
Bandura, A. (1984). Recycling misconceptions of perceived
self-efficacy. Cognitive Therapy and Research. 8, 231-255.
Bandura, A. (1986). Social foundations of thought and
action. Englewood Cliffs, NJ: Prentice-Hall.
Bandura, A. (1990). Perceived self-efficacy in the exercise
of personal agency. Applied Sport Psychology. 2, 128-163.
Bandura, A. (1991). Social cognitive theory of self
regulation. Organizational Behavior and Human Decision
Processes. 50., 248-287.
Bandura, A. (1992). A social cognitive approach to the
exercise of control over AIDS infection. In R. J.
DiClemente (Ed.), Adolescents and AIDS: A generation in
ieopardv (pp. 89-116. Newbury Park, CA: Sage.
145


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,


73
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.


35
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) .


152
Pauker, S. (1986). A new use for videotape in liaison
psychiatry: A case from the burn unit. General Hospital
Psychiatry. 8., 11-17.
Phillips, R. H. (1987). Coping with kidney failure. New
York: Avery.
Plummer, M., & Zetin, M. (1981). Hemodialysis patients'
views of their treatment. Clinical Experimental Dialysis
and Apheresis. 5., 381-389.
Poll, I., & Kaplan De-Nour, A. (1980). Locus of control and
adjustment to chronic hemodialysis. Psychological Medicine,
10, 153-157.
Procci, W. R. (1978). Dietary abuse in maintenance
hemodialysis patients. Psvchosomatics. 19, 16-24.
Reichsman, F., & Levy, N. (1972) Problems in adaptation to
maintenance hemodialysis: A four-year study of 25 patients.
Archives of Internal Medicine. 130. 859-865.
Rickert, V., Jay, M., & Gottlieb, A. (1991). Effects of a
peer-counseled AIDS education program on knowledge,
attitudes, and satisfaction of adolescents. Journal of
Adolescent Health. 12, 38-43.
Rorer, B., Tucker, C. M., & Blake, H. (1988). Long-term
nurse-patient interactions: Factors in patient compliance
or noncompliance to the dietary regimen. Health Psychology.
7, 35-46.
Rosenbaum, M., & Ben-Ari Smira, K. (1986). Cognitive and
personality factors in the delay of gratification of
hemodialysis patients. Journal of Personality and Social
Psychology. 51. 357-364.
Sackett, D., & Snow, J. (1979). The magnitude of compliance
and noncompliance. In R. Haynes, D. Taylor, & D. Sackett
(Eds.), Compliance in health care (pp. 11-22). Baltimore:
Johns Hopkins University Press.
Salmons, P. (1980). Psychosocial aspects of chronic renal
failure. British Journal of Hospital Medicine. 23 617-622.
Sarason, I., Sarason, B., Pierce, G., Sayers, M., &
Rosenkranz, S. (1992). Promotion of high school blood
donations: Testing the efficacy of a videotaped
intervention. Transfusion. 32., 818-823.
Schlebusch, L. & Levin, A. (1982) Psychotherapeutic
management of good and poor compliance in patients on
hemodialysis. SA Medical Journal 16., 92-94.


9
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


APPENDIX C
PATIENT DEMOGRAPHIC AND MEDICAL INFORMATION SHEET
(1)
(2)
(3)
(4)
5)
(6)
(7)
(8)
(9)
Gender:
Female Male
Ethnicity:
African-American Caucasian
Hispanic Other
Marital Status:
Single Married Divorced
Widowed
Age :
Number of Years of Education:
Date of First Chronic Dialysis:
Urine Output (cc per 24 hours):
Other Medical Conditions: (Check all that apply)
Diabetes Mellitus Cancer
Heart Disease Hypertension
Pulmonary Disease Polycystic Kidney
Psychiatric Complications
Medications Regularly Taken: (Check all that apply)
Insulin Catapres Tenex
Wytensin Mellaril Prednisone _
138


121
Questionnaire was constructed for use in this study. Due to
the number of variables being investigated, the small sample
size, and the limited years of formal education of the
majority of patients in this sample, 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 item was chosen because it was the most behaviorally
oriented question and it was the only question all patients
seemed to clearly understand. Patients' responses to the
other items on the Fluid Adherence Motivation Questionnaire
indicated that they did not clearly understand the
questions. For example, several patients stated that they
did not know how to respond to Item #1 (How important is it
to you to reduce your fluid intake?), Item #3 (How
determined are you to reduce your fluid intake), or Item #4
(How satisfied are you with your current level of fluid
intake?), and several patients were not sure of the meaning
of the word "determined."
Research Hypothesis 2 examined differences between
fluid adherent patients and fluid nonadherent patients. It
was predicted that fluid adherent patients would have
significantly higher fluid adherence efficacy expectations,
higher fluid adherence outcome expectations, and higher
fluid adherence motivation. As predicted, fluid adherent
patients had higher fluid adherence efficacy expectations
and higher fluid adherence motivation. However, the two


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


128
include items to assess patients' fluid adherence efficacy-
expectations and fluid adherence outcome expectations with
respect to the amount of fluids contained in ingested foods.
These revised instruments should be pilot tested with
hemodialysis patients of varying educational levels and
ethnic backgrounds.
The preponderance of negative consequences of being
fluid nonadherent identified by the Phase I patients in the
Fluid Adherence Facilitation videotape may have also been a
limitation of this study. Although the patients in the
Fluid Adherence Facilitation videotape were asked to discuss
the positive consequences of being fluid adherent, these
patients were still more likely to discuss the negative
consequences of being fluid nonadherent. The Fluid
Adherence Facilitation Videotape may have been more
effective in increasing patients fluid adherence efficacy
expectations, fluid adherence outcome expectations, fluid
adherence motivation, and actual fluid adherence if the
patients in the videotape had focused more on the positive
consequences of being fluid adherent rather than on the
negative consequences of being fluid nonadherent. Past
research has illustrated that fear tactics are not effective
in motivating patients to modify their behavior (Evans,
1989).
Nine of the twenty-four Phase I fluid adherent patients
(38%) were unable to identify any positive consequences of


2
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 atheoretical (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


61
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 liklihood that a particular
task would be successfully completed.


The finding that the Fluid Adherence Facilitation
videotape did not result in the predicted significant
decrease in interdialysis fluid weight gains for patients in
the intervention group, despite patients' verbal statements
that the videotape contained several helpful strategies for
controlling fluid intake, provides further support for the
intractability of patterns of fluid nonadherence among
hemodialysis patients. Fluid nonadherence typically begins
early in the course of dialysis treatment and remains
remarkably stable over time (Czackes & Kaplan De-Nour, 1978;
Streltzer & Hassell, 1988). Streltzer and Hassell (1988)
found that 25% 50% of patients continue to be fluid
nonadherent even though they know that they will suffer
negative physical consequences as a result of fluid
overloading. Chronic fluid overloading has been found to be
exceptionally resistant to psychotherapeutic interventions
(Czackes & Kaplan De-Nour, 1978; Streltzer & Hassell, 1988).
The few reports of successful psychotherapeutic
interventions produce short-term maintenance effects or have
short follow-up periods. In addition, the majority of these
successful cases occur with acute rather than chronic
noncompliance.
Limitations of the Study and Suggestions for Future Research
One of the major limitations of this study was the lack
of an extended baseline, intervention, and follow-up period.
Given the chronicity of fluid nonadherence and the lack of


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123
adherence outcome expectations, and the fluid adherence
motivation of the patients in the intervention group did
increase over time; in contrast, the fluid adherence
efficacy expectations, the fluid adherence outcome
expectations, and the fluid adherence motivation of the
patients in the control group either decreased or remained
relatively stable.
Research Hypothesis 6 predicted that at post
intervention and follow-up, patients in the intervention
group would have significantly higher levels of actual fluid
adherence than patients in the control group. Although this
hypothesis was not supported, an examination of the least
squares means indicated that the mean weekend interdialysis
fluid weight gains of patients in the intervention group and
patients in the control group decreased slightly at post
intervention, but returned to near baseline levels at
follow-up. However, at both periods, the patients in the
intervention group had lower mean weekend interdialysis
fluid weight gains.
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


118
Fitzpatrick (1988) both found that the longer a patient
remains on dialysis, the less likely the patient is to
comply with treatment.
The finding that patients who regularly took Catapres,
Tenex, or Wytensin had more difficulty controlling their
fluid intake provides support for the observation that these
medications may cause increased thirst in some patients.1
This finding also suggests the importance of controlling for
the use of these medications in studies of fluid adherence
of hemodialysis patients. A review of the nonadherence-in
hemodialysis literature revealed that this variable is
typically not included in published studies.
The analyses applied to investigate Research Question 2
also revealed that patients with diabetes had a higher mean
weekend interdialysis fluid weight gain than patients who
did not have diabetes. This finding is consistent with that
of Ifudu, Dulin, and Friedman (1994). These researchers
studied a group of 33 diabetic patients undergoing
maintenance hemodialysis and a randomly selected group of 25
nondiabetic hemodialysis patients. The patients with
diabetes were found to have a 30% greater interdialytic
weight gain. It was concluded that hyperglycemia-induced
thirst, or possibly elevated aldosterone or uremia,
1 Information regarding the association of these
medications with fluid adherence was obtained through
consultation with Drs. Paul Alfino, Gordon Finlayson, and
Robert Tarrannt of the Gainesville Kidney Center.


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


5
(5) What are the positive consequences of being fluid
adherent and the negative consequences of being fluid
nonadherent?


134
I have received a copy of this description and have been
fully informed of the above-described study and the benefits
and risks of participating in this research. I agree to
participate in this study.
Signature of Patient
Date


150
Kaplan De-Nour, A. (1983). An overview of psychological
problems in hemodialysis patients. In N. B. Levy (Ed.),
Psvchonephroloav 2: Psychological problems in kidney
failure and their treatment (pp. 3-14) New York: Plenum.
Kaplan De-Nour, A., & Czackes, J. W. (1972). Personality
factors in chronic hemodialysis patients causing
noncompliance with medical regimen. Psychosomatic Medicine,
34, 333-344.
Kaplan De-Nour, A., & Czackes, J. W. (1974). Adjustment to
chronic hemodialysis. Israel Journal of Medical Sciences,
10, 498-503.
Kaplan De-Nour, A., & Czackes, J. W. (1976). The influence
of patient's personality on adjustment to chronic dialysis.
Journal of Nervous and Mental Disorders. 162 323-333.
Kaplan De-Nour, A., & Czackes, J. (1980). A saliva
substitute as a tool in decreasing overdrinking in dialysis
patients. Israel Journal of Medical Science. 16., 43-44.
Kaplan De-Nour, A., Shaltiel, J., & Czackes, J. (1968).
Emotional reactions of patients on chronic hemodialysis.
Psychosomatic Medicine. 30 521-533.
Keane, T., Prue, D., & Collins, F. (1981). Behavioral
contracting to improve dietary compliance in chronic renal
dialysis patients. Journal of Behavior Therapy and
Experimental Psychology. 12 63-67.
Kirilloff, L. (1981). Factors influencing the compliance of
hemodialysis patients with their therapeutic regimen.
American Association of Nephrology Nurses and Technicians.
8, 15-20.
Korbin, S., Kimmel, P., Simmens, J., & Reiss, D. (1991).
Behavioral and biochemical indices of compliance in
hemodialysis patients. American Society for Artificial
Internal Organs Transactions. 37, M378-M380.
Lamping, D., & Campbell, K. (1990a). Hemodialysis
compliance: Assessment, prediction, and intervention:
Part I. Seminars in Dialysis. 3, 52-56.
Lamping, D., & Campbell, K. (1990b). Hemodialysis
compliance: Assessment, prediction, and intervention:
Part II. Seminars in Dialysis. 3., 105-111.
Lawrance, L., & McLeroy, K. (1986). Self-efficacy and health
education. Journal of School Health. 56, 317-321.


87
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


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


31
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


59
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


APPENDIX G
STRUCTURED INTERVIEW QUESTIONNAIRE
1. How do you spend your free time (i.e., hobbies,
interests)?
2. What types of work experiences have you had (i.e.,
j obs,volunteer experiences)?
3. What are your plans for the future (i.e., travel, family
plans)?
4. What positive benefits do you experience when you adhere
to your prescribed fluid restrictions?
5. What do you do to control your fluid intake?
6. How do you resist drinking too much fluid when you are
really thirsty?
7. What motivates you to adhere to your prescribed fluid
restrictions?
8. What would you recommend to a patient who is having
difficulty restricting his/her fluid intake?
9. How do your religious or spiritual beliefs affect your
motivation and ability to adhere to your prescribed fluid
restrictions?
144


8
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


56
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


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.
vi


54
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-Efficacv Theory
The Self-Efficacv 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).


88
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


47
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


136
by a code number rather than by your name, and will be kept
in a locked file at the University of Florida.
You will receive $15.00 for participating in this
study. This $15.00 will be given to you at the end of the
third interview and will be contingent upon viewing the
videotapes and participating in all three interviews. This
monetary compensation is being provided for your time and
does not depend upon your responses.
There are no anticipated risks to you because of your
participation in this study. Information obtained during
this study may potentially help other hemodialysis patients
to adhere to their treatment regimens. Your participation
in this study is voluntary. You may withdraw your consent
and discontinue participation at any time. Whether or not
you decide to participate in this study, you will receive
the same treatment and care at the dialysis center. If you
have any questions about this study or your participation,
you may call the Principal Investigator, Ms. Beverly Brady,
at (904) 392-9436.
I have fully explained to
the nature and purpose of the above-described study and the
benefits and risks of participating in this research.
Signature of Principal Investigator/Researcher
Date


This dissertation was submitted to the Graduate Faculty
of the Department of Psychology in the College of Liberal
Arts and Sciences and to the Graduate School and was
accepted as partial fulfillment of the requirement for the
degree of Doctor of Philosophy.
December 1994
Dean, Graduate School


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


131
It is further recommended that this preventive self-
efficacy theory based videotape intervention be conducted in
the framework of a biopsychosocial approach as proposed by
Streltzer and Hassell (1988). The inability of the Fluid
Adherence Facilitation videotape to significantly increase
the fluid adherence efficacy expectations, the fluid
adherence outcome expectations, the fluid adherence
motivation, or the actual fluid adherence of the patients in
the intervention group, and the results of Research Question
#2 which suggest that thirst is a factor in fluid
nonadherence, provide support for the development of a
biopsychosocial approach to the treatment of fluid
nonadherence. This approach takes into account biological
factors, as well as psychosocial variables, that may
influence fluid adherence behavior. Psychological
interventions, particularly those interventions administered
after patterns of fluid nonadherence are established, have
typically not been effective in modifying fluid adherence
behavior. The addition of intervention components that
involve thirst management and social reinforcement may also
be needed.


Ill
Research Hypothesis 5 stated that at post-intervention
and follow-up, patients who view the Fluid Adherence
Facilitation videotape will have significantly higher fluid
adherence motivation than patients who view the control
videotape. A 2X3 repeated measures analysis of variance
(ANOVA) was performed to test this hypothesis.
The results of this ANOVA did not support Research
Hypothesis 5. No group, time, or interaction effect was
found indicating that the fluid adherence motivation of the
patients in the control group and the intervention group did
not significantly differ at post-intervention or at follow
up. The results of this analysis are summarized in Table
4.8. Although the model was not significant, an examination
of the least squares means revealed that the fluid adherence
motivation scores of patients in the intervention group did
increase over time; in contrast, the fluid adherence
motivation scores of patients in the control group increased
slightly and then decreased to their baseline level. The
least squares mean fluid adherence motivation scores of the
control group and the intervention group at baseline, post
intervention, and follow-up are summarized in Table 4.9.


106
Table 4.3
Pearson Correlation Coefficients of Fluid Adherence.
trncacy
nxDeccations, uutc
EFFICACY
OUTCOME
MOTIVATION
FLUID
-0.4416
0.0857
-0.2247
0.0013*
0.5541
0.1167
EFFICACY
-
-0.1998
0.1641
0.0255
0.0743
OUTCOME
-
-
-0.0276
0.8489
Note. denotes e < .01.
Research Hypothesis 2 stated that fluid adherent
patients (Phase I patients) as compared with fluid
nonadherent patients (Phase III patients at baseline) will
have significantly higher fluid adherence efficacy
expectations, higher fluid adherence outcome expectations,
and higher fluid adherence motivation. To test this
hypothesis, a MANOVA with Phase as the independent variable
and fluid adherence efficacy expectations, fluid adherence
outcome expectations, and fluid adherence motivation as the
dependent variables was conducted. The results of the
MANOVA indicated that Research Hypothesis 2 was partially
supported. The Wilks' Lambda statistic for the hypothesis
of no overall Phase effect was significant, F (3, 46) =
5.25, e < .0034. An examination of the univariate models
revealed that both the model for fluid adherence efficacy


3
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


62
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-Efficacv 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.


12
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


71
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


93
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.


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


112
Table 4.8
Results of Group X Time Repeated Measures ANOVA for Fluid
Adherence Motivation
Source
DF MS F-Value p-level
Between
Group 1,21
Within
Time 2,42
Time X Group 2,42
15.51
4.62
3.75
2.07
1.68
1.36
0.1646
0.1991
0.2672
Table 4.9
Least Sauares
Mean Fluid Adherence Motivation Scores of the
Control GrouD
and the Intervention Grouo at Baseline. Post-
Intervention.
and Follow-
Post-
Baseline
Intervention
Follow-Up
Control
7.85
8.08
7.85
Intervention
6.00
'.30
7.60
Research Hypothesis 6 stated that at post-intervention
and follow-up, patients who view the Fluid Adherence
Facilitation videotape will have significantly higher levels
of fluid adherence (i.e., lower mean weekend interdialysis
fluid weight gains) than patients who view the control
videotape. A 2X3 repeated measures analysis of covariance
(ANCOVA) was performed to test this hypothesis. Baseline


34
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


105
Research Hypothesis 1 stated that fluid adherence
(i.e., average weekend interdialysis fluid weight gain) will
have a significant negative correlation with fluid adherence
efficacy expectations, fluid adherence outcome expectations,
and fluid adherence motivation, while fluid adherence
efficacy expectations, fluid adherence outcome expectations,
and fluid adherence motivation will be positively
correlated. Pearson Correlations coefficients were computed
to test this hypothesis. Due to the number of comparisons,
the significance criteria was again adjusted using the
Bonferroni procedure. The adjusted significance criterion
was p<.01.
Results of the Pearson Correlation coefficients
provided partial support for Research Hypothesis 1. As
predicted, at an alpha level of p < .01, a significant
negative correlation was found between fluid adherence
(i.e., average weekend interdialysis fluid weight gain) and
fluid adherence efficacy expectations (r = -0.4416, p <
.0013). Patients with higher fluid adherence efficacy
expectations had significantly lower weekend interdialysis
fluid weight gains. However, fluid adherence outcome
expectations and fluid adherence motivation were not
significantly associated with fluid adherence. Fluid
adherence efficacy expectations, fluid adherence outcome
expectations, and fluid adherence motivation were also not
found to be significantly correlated. Pearson Correlation
coefficients of these variables are summarized in Table 4.3.


104
Table 4.2--continued
Dependent Variable
Outcome Expectations
Source
DF MS F-value
g-value
Omnibus
5,44
3964.47
0.90
0.49
Dialysis
1,44
9706.64
2.21
0.14
Conditions
1,44
5702.80
1.30
0.26
Diabetes
1,44
1144.61
0.26
0.61
Medications
1,44
1893.83
0.43
0.51
Urine
1,44
8400.65
1.92
0.17
Source
Motivation
DF
MS
F-value
E-value
Omnibus
5,44
5.30
0.88
0.50
Dialysis
1,44
15.56
2.59
0.11
Conditions
1,44
5.67
0.94
0.34
Diabetes
1,44
2.00
0.33
0.57
Medications
1,44
0.07
0.01
0.92
Urine
1,44
10.43
1.74
0.19
Fluid
Adherence
Source
DF
MS
F-value
E-value
Omnibus
5,44
4.08
3.01
0.02*
Dialysis
1,44
0.57
0.42
0.52
Conditions
1,44
2.48
1.83
0.18
Diabetes
1,44
6.61
4.88
0.03*
Medications
1,44
4.71
3.47
0.07
Urine
1,44
4.44
3.27
0.08
Note. denotes e < -05.


120
literature comparing efficacy expectations and outcome
expectations. Bandura (1977b) states that although both
efficacy expectations and outcome expectations are
important, 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.
Several studies of self-efficacy and health related
behaviors also support the premise that efficacy
expectations are more salient than outcome expectations.
Solomon and Annis (1990) found that efficacy expectations
assessed at intake were strongly associated with the level
of alcohol consumption at follow-up. However, outcome
expectancies did not predict alcohol consumption at follow
up. Similarly, Desharnais, Bouillon, and Godin (1986) found
expectation of self-efficacy to be a more central
determinant of adherence to exercise than outcome
expectancy. Efficacy expectations were also found to be
better predictors of persistence in pain control than
outcome expectancies (Manning & Wright, 1983) .
The lack of the predicted correlation between fluid
adherence and motivation may have been due to the measure
used to assess patients' motivation to be fluid adherent. A
review of the literature did not reveal an instrument
designed to assess patients' motivation to adhere to
treatment plans. Therefore, the Fluid Adherence Motivation


86
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


19
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.