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Saudi J Kidney Dis Transpl 2016;27(2):250-255

© 2016 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Influence of Nutritional Education on Hemodialysis Patients’

Knowledge and Quality of Life
Hossein Ebrahimi1, Mahdi Sadeghi2, Farzaneh Amanpour3, Ali Dadgari2
1
Center for Health-Related Social and Behavioral Sciences Research, 2Department of Nursing,
School of Nursing and Midwifery, 3Department of Epidemiology and Biostatistics, School of
Public Health, Shahroud University of Medical Sciences, Shahroud, Iran

ABSTRACT. To determine the effects of educational instructions on hemodialysis patients’

knowledge and quality of life (QOL), we studied 99 patients randomly assigned to control and
experimental groups after participation in a pretest exam. The two groups were not significantly
different in terms of demographic composition. The instrument used in this study was a
questionnaire regarding patients’ knowledge and the standard questionnaire to assess QOL for
end-stage renal disease (ESRD) patients. Then, intervention (nutritional education) was conducted
in the experimental group lasting for 12 weeks. After 16 weeks, a post test regarding subjects’
knowledge on dietary instructions and their QOL were as conducted. There was no significant
difference in QOL score and knowledge score before and after intervention in the control group,
but there was a significant difference in the experimental group. In addition, after the
intervention, the difference in knowledge and QOL score persisted between the two groups. The
results of this study supported the positive effects of educational program on patients’ knowledge
and QOL among ESRD patients. It is recommended that dietary instruction be included in all
educational programs to improve ESRD patients’ QOL.

Introduction Hemodialysis (HD) in an effective modality of

End-stage renal disease (ESRD) is a world-
wide health issue.1 According to Iranian
Nephrology Association, more than 16,600
patients with ESRD are under dialysis treat-
ment in 355 units in scattered areas in Iran.2
Correspondence to:
Dr. Mahdi Sadeghi,
Department of Nursing, School of Nursing
and Midwifery, Shahroud University of
Medical Sciences, Shahroud, Iran.
E-mail: mahdisadeghi@shmu.ac.ir
treatment; however, management of patients
maintained on dialysis is very difficult.3
Moreover, quality of life (QOL) among
patients under treatment of HD is low, which
affect their life style.4-6
In recent years, there has been growing
interest in patients’ QOL through conducting
different educational programs.7-9 HD patients
express high levels of stress and encounter a
variety of physical, psychological, and social
problems.10,11 Health professional, especially
nurses, can play a key role in the evaluation of
QOL in HD patients.12
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Nutritional education in hemodialysis patients
One of the most important aspects of nursing
career is educating HD patients, and this can
reflect positively on their QOL.13-16 Improve-
ment of the nutritional status of HD patients is
an essential component of nursing intervention
to reduce the complications of the disease.17,18
Nurses have close contact with their patients
and can instruct them to follow a healthy
diet.19
Previous studies in our country revealed con-
troversial results regarding association of diet
control and QOL among HD patients. In one
study, the investigators found that dietary
interventions did not influence QOL;20 however,
a more recent study showed that nutritional
intervention could significantly improve the
QOL of HD patients.21 The aim of this study was
to determine the effects of educational instruc-
tions on HD patients’ knowledge and QOL.
Methods
We studied 99 patients undergoing HD treat-
ment at the Imam Hossein Hospital in
Shahroud, Semnan Province, IR, Iran. We in-
cluded patients older than 18 years, maintained
on HD treatment during the last 12 months, do
not have evident psychoemotional problems
and do not receive any psychotropic medi-
cations. All the patients and/or their family
members were able to read and write or com-
municate orally and use written instructions.
All the patients were compliant to HD treat-
ment at the same hospital and had reliable
access to telephone contact at home.
All the patients in the study were informed
about the purpose of the study and signed the
informed consent form. This study was con-
ducted on approval and close monitoring of
university ethics committee in Shahroud Uni-
versity of Medical Sciences.
The instrument used in this study was a
questionnaire consisted of 15 demographic
questions, a questionnaire regarding subjects’
dietary status consisted of 14 questions, and
the standard questionnaire to assess QOL for
ESRD patients.22
Faculty members, experts in dialysis treatment,
251
assessed and confirmed the content and face
validity of the dietary questionnaire. To eva-
luate the reliability of the questionnaire, test-
retest method was applied with r = 0.86 bet-
ween two assessments. Previous investigators
had previously assessed and approved the
reliability and validity of QOL questionnaire.22
The questionnaire had a high internal consis-
tency23 and provided wide and deep interpre-
tation of variables in relations with QOL HD
patients.24 Complementary data were collected
from the medical records of the patients.
The investigators considered the possibility
of contamination of data between the patients
in the control and the experimental groups.
Therefore, the patients on HD on even days
(Saturday, Monday and Wednesday) were
assigned to the experimental group and the
patients on HD on odd days (Sunday, Thurs-
day, and Thursday) were assigned to the con-
trol group.
The intervention in the experimental group
consisted of face-to-face educational sessions
lasting 30–40 min followed by 10–15 min time
to answer the questions. The face-to-face
method is a common educational strategy in
clinical settings, since it provides better possi-
bility to evaluate the behavioral changes.25,26
Moreover, all family members of the patients
were asked to support them using the ma-
terials. The educational material was a pam-
phlet including information regarding the
importance of adherence to a healthy diet,
avoiding harmful consequences of poison
accumulation in blood and tissues, and a list of
food restriction and limitations in fluid intake.
The educational instructions were delivered
twice a week lasting for 12 weeks and each
session lasted 40–60 min. Four weeks after
complementing the program, a post test eva-
luation regarding patients’ knowledge on die-
tary instructions and their QOL was done in
both the control and the experimental groups.
Statistical Analysis
Analysis was done using the SPSS software,
version 19.0 (IBM Corp., Armonk, NY) One-
way ANOVA, Student’s t-test and paired t-test
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252 Ebrahimi H, Sadeghi M, Amanpour F, et al

Table 1. Sociodemographic and clinical data of the patients undergoing hemodialysis.

Control Intervention
Variable P-value
mean ± SD mean ± SD
Age (year) 50.3 ± 10.1 51.6 ± 11.9 *0.54
No. (%) No. (%)
Sex
Male 30 (58.8%) 31 (64.6%) **0.56
Female 21 (41.2%) 17 (35.4%)
Educational status
Primary 23 (45.1%) 19 (39.6%) **0.76
Middle school 10 (19.6%) 12 (25%)
Diploma and higher 18 (35.3%) 17 (35.4%)
Occupational status
Unemployed/retired 13 (25.4%) 9 (18.7%) **0.33
Employed 19 (37.3%) 26 (45.2%)
Housewife 19 (37.3%) 13 (27.1%)
Dialysis duration (year)
<2 year 8 (15.7%) 6 (12.5%) **0.75
2–4 year 24 (47.1%) 16 (34.3%)
4 years and higher 19 (37.2%) 26 (53.2%)
Frequency of dialysis (per week)
Twice per week 16 (31.4%) 13 (27.1%) **0.62
3 times/week 33 (64.7%) 31 (64.6%)
4 times/week 2 (3.9%) 4 (8.3%)
*One-way ANOVA, **Chi-square test.

were applied to compare the means, and Chi-
square test was used for comparison of pro-
portions in both groups.
Results
The mean age of the patients was 50.92 ±
10.98 years. Of all patients of the study 38
(38.4%) were females and 61 (61.6%) were
males. Baseline demographic data are pre-
sented in Table 1. The patients of the study
showed no significant difference in variables
such as age, sex, educational level, employment
status, history of dialysis treatment (years),
and adequacy of dialysis treatment (per-week)
between the experimental and the control
groups.
The comparison of the results pertaining to
Table 2. Comparisons of mean knowledge score in hemodialysis patients in the experimental and the
control groups.
Knowledge score (mean ± SD) Before intervention
Control 7.27 ± 1.22
Experiment 7.23 ± 1.38
Independent sample t-test t = 0.17, P = 0.86
patients’ knowledge indicated that there were
no significant differences between pre- and
post-results in the control group (P = 0.22);
however, in the experimental group, the com-
parison showed a significant difference bet-
ween the pre- and post-results (P = 0.00).
Furthermore, the comparison of patients’ know-
ledge between the two groups after the inter-
vention, indicated a significant difference bet-
ween the experimental and control groups (P =
0.00) (Table 2).
The comparison of the mean QOL score in
the two groups before the intervention showed
no significant difference (P = 0.24) whereas
after the intervention, the mean QOL score
significantly increased in the experiment group
compared with the control group (P = 0.00)
(Table 3). In addition, the QOL score showed
After intervention Paired sample t-test
7.47 ± 1.50 t = −1.26, P = 0.22
10.4 ± 2.11 t = −12.98, P <0.001
t = −8.09, P < 0.001
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Nutritional education in hemodialysis patients
Table 3. Comparisons of mean QOL score in hemodialysis patients in the experimental and the control
groups.
QOL score (mean ± SD) Before intervention
Control 59.0 ± 5.89
Experiment 60.0 ± 5.33
Independent sample t-test P = 0.24, t = −1.18 P <0.001, t = −8.09
no significant difference before and after the
intervention in the control group (P = 0.43).
However, a significant difference was observed
in the experimental group before and after the
intervention (P = 0.00).
Discussion
Inappropriate diet was associated with low
QOL and increased complications among
chronic HD patients.24 In addition, these pa-
tients, having specific dietary needs and
treated with a variety of medications, require
constant education to cope with the ever-
changing needs both in physical and emotional
aspects.27
In our study, the patients’ mean score of
knowledge of the dietary needs significantly
increased after condensed dietary instructions.
This finding is in accordance with previous
studies which supported the positive effects of
dietary education on patients’ knowledge
regarding their daily diet.19,21,26,28 Ford et al
found that properly instructed patients showed
significant improvement in their knowledge on
food and diet.29 Hasanzadeh et al showed a
positive and significant improvement of die-
tary education on HD patients’ knowledge in
Iranian HD population.26
According to previous studies, limited health
literacy is associated with poor QOL. Impro-
ving health literacy is a major step to improve
the health outcomes of HD patients.14,30
Moshtagh et al. found that dietary educational
intervention for HD patients improved their
health status including mental health. More-
over, in accordance with the findings of present
study, the subjects of the study demonstrated
significant improvement in their physical and
social performance, reduction of anxiety and
depression after participate in program.21
Thomas et al found that patient’s counseling
253
After intervention Paired sample t-test
58.8 ± 6.21 P = 0.43, t = −0.79
67.4 ± 5.99 P <0.001, t = −16.42
could postpone their needs to HD and increase
their QOL. They also concluded that dietary
instructions should be included as an impor-
tant component of any educational interven-
tion.31 Rahimi et al found that the continued care
model could improve many dimensions of QOL
(general and specific) among HD patients.32
In contrast to our findings, Aghakhani et al
found that dietary instruction program could
be effective only in the physical health dimen-
sion of QOL.20 This diversity of results may be
due to the confounding variables such as older
age and lower level of education among sub-
jects of those studies.
Since our results support the positive effects
of educational intervention on patients’ know-
ledge, QOL, and the different dimensions of
health, it can be concluded that education as a
whole and dietary educational intervention as
a specific approach can facilitate patients’
health status, reduce the consequence of di-
sease, and improve patients’ QOL.
However, there are some limitations for this
study, such as some confounding variables
including subjects’ personal emotional charac-
teristics, cultural, and social background, inter-
personal relationships, economic diversities,
and different level of driving and deterrent
forces among subjects of the study, which
could affect their learning. Moreover, there
was a possibility of data contamination by
transferring information between groups by
dialysis ward personnel and patients. To mini-
mize this, they were informed to avoid conta-
mination of the data.
We conclude that our study findings suggest
that educational intervention on diet for chro-
nic HD patients improved both knowledge and
QOL. Nurses are in proper position to faci-
litate patients’ leaning in order to promote
health and QOL.
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254
Acknowledgments
It is a pleasure to acknowledge all nursing
staff of HD ward in Imam Hossein Hospital in
Shahroud, Semnan Province. This study would
not be able to achieve its goals without the
patients who actively participated in it. This
study was sponsored by the Vice Chancellor
for research at Shahroud University of Medical
Sciences (research grant no. 9116).
Conflict of Interest
Authors declare that they have no conflict of
interest.
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