Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital Bantul Yogyakarta

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1 ISSN (Print), ISSN (Online) Jurnal Ners dan Kebidanan Indonesia Tersedia online pada: INDONESIAN JOURNAL OF NURSING AND MIDWIFERY Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital Bantul Yogyakarta Cicirosnita J. Idu 1, Winda Irwanti 2, Pratiwi 1 1 Department of Nursing, Faculty of Health Sciences, Universitas Alma Ata, Jl. Brawijaya No. 99, Tamantirto, Yogyakarta 2 Department of Nutrition, Faculty of Health Sciences, Universitas Alma Ata, Jl. Brawijaya No. 99, Tamantirto, Yogyakarta Abstract Dietary adherence on patients with chronic renal failure undergoing hemodialysis is one of the problems faced by clients and it is required intervention. The purpose of this study was to understand the effect of motivation on dietary adherence of chronic renal failure patients undergoing hemodialysis in Panembahan Senopati Hospital Bantul Yogyakarta. This experimental study used quasi-experimental methods with one group pretest posttest without control group design. Population on this study were 130 patients with chronic renal failure undergoing hemodialysis in RSUD Panembahan Senopati Bantul Yogyakarta. The Purposive sampling was a techniques used to determine researech respondents, thereby resulted 21 respondents. Motivation affected patient level of adherent on the diet in which the McNemar test showed p value of 0,004 or p 0,05, it means that H a was accepted and H 0 was rejected. Pretest undertaken before intervention showed that those who adhere to diet were 3 respondents (14,3%) and non-adhere were 18 respondents (85,7%), after intervention patient who adherence showed increase to 12 respondets (57,1%) and non-adhere were 9 respondents (42,9%). Motivation gives a significant impact on dietary adherence chronic renal failure undergoing hemodialysis in Panembahan Senopati Hospital Bantul Yogyakarta. Therefore, the necessity of motivation as nursing implications on the standard operational procedures in every nursing actions. Keywords: dietary adherence, motivation, chronic renal failure, hemodialysis INTRODUCTION Increasing number of deaths of patients with chronic renal failure, one of which is influenced by non-compliance of patients in running chronic renal failure diet. Diet is one of the most important factors in the management of CKG patients undergoing hemodialysis (1). Patients with chronic renal failure who undergo dialysis need to control their diet to be able to control the waste and fluid products that accumulate between handling or dialysis action. A good diet for dialysis patients is adequate in protein intake, caloric adequacy, low potassium, low sodium, low phosphorus and controlled fluids (2). Therefore, it is important for patients to always adhere to the diet of chronic renal failure. Compliance is the obedience of a person in carrying out the act of therapy, while noncompliance to follow and implement the recommended treatment or treatment by health professionals is a severe medical problem and is considered very important (3). Failure of patients with chronic renal failure in controlling and maintaining their diet is a matter that must be monitored continuously, because it will cause the occurrence of nutritional deficiency, fluid balance disorders and electrolytes and there will be accumulation of excess metabolism waste S Cicirosnita J. Idu, Winda Irwanti, Pratiwi, JNKI, Vol. 5, No. 3 (Suplement 2), Tahun 2017,

2 products that will accelerate the schedule of therapy has been determined and exacerbate the cost of dialysis therapy (4). Another effect of dietary disability in patients with chronic renal failure is the increasing number of deaths of patients with chronic renal failure. Chronic renal failure is one of the causes of death in Indonesia where the number of people with kidney failure continues to increase to date (5). The total mortality rate of patients with chronic renal failure who underwent hemodialysis in 2011 amounted to 2,476 people and in 2012 that amounted to people, there is an increase from 2011 to 2012 of 856 people (6.7). This expression is supported also by pravelensi non-adherence diet patients with chronic renal failure is for 2-39% and 19-57% (8). Meanwhile, the level of pravity of dietary non-compliance of hemodialysis patients was 81.4% (9). This affects the increased morbidity and mortality of hemodialysis patients. Non-compliance of patients in running a chronic renal failure diet is certainly influenced by many factors. Based on the result of research related to factors influencing non-compliance of hemodialysis patient in having diet pattern that is responder have high education, low knowledge, respondent have positive attitude, have good behavior, more than half respondent have less motivation, and respondent have good culture ). This is what triggers the need for a good intervention to improve patient compliance in running a chronic renal failure diet. One model of chronic disease treatment developed today is The Chronic Care Model (CCM), a model of patient care focusing on the interaction of an informed and active patient with a proactive and ready-to-serve health team (11). Currently there is a need for interaction between health workers and patients in creating a positive reciprocal relationship to the knowledge and beliefs of patients motivated in making decisions about their health (12). Through an active health promotion strategy, each individual is given the motivation to perform a specific health program (3). Motivation is part of the personality defined as the factors that exist in the human being that actively manages and directs the behavior towards the purpose of one's life (13). Motivation has been shown to influence a person's behavior, where a motivation refers to the forces that determine the direction and intensity of one's business behavior changes (14,15). Based on the results of the study, there was a correlation between education, knowledge and motivation with dietary adherence in patients with chronic renal failure, with value (p = 0.000) (16). Other results also showed that motivation by using interview technique has an effect on patient compliance improvement through hemodialysis both in terms of treatment and patient's diet (17). So it can be concluded that the motivation is very important in supporting the adherence of diet patients with chronic renal failure who undergo hemodialysis. The results of preliminary study conducted by researchers in the Hemodialysis Room of Panembahan Senopati Bantul General Hospital showed that the number of chronic renal failure patients who undergo routine hemodialysis reached 130 people. The average number of chronic renal failure patients underwent hemodialysis per day was approximately 44 people, with hemodialysis frequency of 2 times a week, and duration of therapy. Based on interviews of 10 patients, 2 people said "the patient obeyed the diet recommended by the nurse", while 8 people said " sometimes still often consume foods that are banned by nurses ". In addition, of the 10 patients 7 people said "rarely get motivation to obey diet from nurses" and 3 people said "get motivation from nurse when patient finishes hemodialysis". Based on the above background description, the researcher Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital... S - 103

3 is interested to conduct research on the effect of giving motivation to diet compliance of chronic renal failure patients undergoing hemodialysis at RSUD Panembahan Senopati Bantul Yogyakarta. Based on the background of GGK disease in relation to dietary and motivational adherence, then the research problem formula is whether there is influence of motivation on diet compliance of patients with chronic renal failure who underwent hemodialysis at RSUD Panembahan Senopati Bantul Yogyakarta?. The purpose of this study was to determine the characteristics of respondents, the level of patient compliance before given motivation and after given the motivation and the level of significance of the effect of motivation on adherence to chronic renal failure diet who underwent hemodialysis in Panembahan Senopati Hospital Bantul Yogyakarta. MATERIALS AND METHODS The type of this research is quantitative analytical research using quasi experiment method. The design used in this research is the design of one group pretest posttest approach, without control group design. The population in the study were all patients with chronic renal failure who underwent hemodialysis at Panembahan Senopati Hospital Bantul Yogyakarta. Sampling technique using non probability sampling with purposive sampling technique. The results of a large calculation of research samples got 21 respondents research. Data analysis using univariate and bivariate analysis with McNemar test. In addition, independent variables of this study is the provision of motivation, while the dependent variable was dietary compliance of patients with chronic renal failure who underwent hemodialysis. RESULTS AND DISCUSSION Characteristics of Respondents The characteristics of respondents in Hemodialysis Unit of Panembahan Senopati Bantul General Hospital are presented in Table 1. Table 1. Characteristics of Respondents at Hemodialysis Unit of Panembahan Senopati Bantul Hospital 2015 Age (years old) Sex Male Female Character N Percentage (%) Duration of Hemodialysis (year) Education Not graduated from elementary school Elementary school Junior high school Senior high school College Occupation Farmer/Breeders /Fisher Labor Civil servant/police Housewive/not work Source: Primary Data Characteristics of respondents based on age. Table 1 shows that respondents in the Hemodialisa Unit of Panembahan Senopati Bantul General Hospital are mostly over the age of 40 years, amounting to 17 respondents (81.0%). The result of distribution of age frequency of GGK patients in this study was based on total respondents of 21 respondents indicated that respondents aged years were 4 respondents (19.0%) and respondents aged 40 years were 17 respondents (81.0%). This means that respondents who undergo hemodialysis most aged 40 years. These results are consistent with the data that the pravelability of chronic renal failure in Indonesia shows an increase with age. Patients with chronic renal failure increased sharply in the year age group (0.3%), followed by age years (0.4%), and age years (0.5%) (18). According to one theory, patients with chronic renal failure are more commonly found in S Cicirosnita J. Idu, Winda Irwanti, Pratiwi, JNKI, Vol. 5, No. 3 (Suplement 2), Tahun 2017,

4 an elderly person, this is because after a person aged around 30 years, the GFR value tends to decrease at a rate of about 1 ml / min / year. At the time of the aging process occurs physiological changes of the body one of which the number of renal nephrons deficiency and reduced kemampunnya in mengfiltrasi product remnants cell metabolism, resulting in homeostatic impact. Increasing the age of a person up to 60 years, then the physiological changes of the kidney decreased by 50% (19). The above statement is relevant to the research which states that most patients with CKG in the age group 40 years is 32 respondents (78.0%) (20). In addition, the number of GGK respondents undergoing Hemodialisa mostly aged years is 20 people (48.8%) and age years ie 11 people or 26.8% (21). Some of the results of existing research are in line with the results of research conducted at Public Sector Hospitals in The Western Cape, ie most of the respondents aged 60 years or 96.7% (22). The conclusion is that patients with GGK is more prevalent in patients aged 40 years because at that age physiologically changes in the patient's body and decreased function especially in kidney organs. Characteristics of respondents based on sex. In Hemodialysis Unit of Panembahan Senopati Bantul General Hospital, female was more dominant (11.5%), while the number of male is 10 respondents or (47.6%). Gender is a form of one's self identity that is described with the nature and characteristics that exist in a person. The result of the research shows that most of the patients with chronic renal failure who undergo hemodialysis therapy in Panembahan Senopati Bantul General Hospital are female respondent (52.4%), while 10 respondents or 47.6%. The results of this study in accordance with the results of research in Public Sector Hospitals in The Western Cape, found that of 62 research samples, 36 of them are women or equal to 58.1%, while men are 26 respondents (41.9%) (22).. Some of the studies that have been disclosed are not in line with some data that chronic kidney failure is generally higher in males, ie 0.3% than women at 0.2% (18).. The results showed that the number of patients were mostly male, 27 respondents (65.9%), while women were 14 respondents (34.1%) (21). Similarly, the results of the research in RS PKU Muhammadiya Yogyakarta, the highest number of respondents were 30 male respondents (62.5%) and 18 female respondents (37.5%) (23). In addition, the results of research conducted in Nephrology and Dialysis Unit ASL 8 Cagliari Italy showed that most male respondents are 44 people and women are 24 people (24). Basically every disease can attack human beings both men and women, but there are some diseases there are differences in frequency between men and women. There is no literature that suggests that sex is a benchmark for causing a person to experience chronic renal failure. This is due to dietary factors and lifestyle of male respondents who like to smoke and drink coffee (25). Characteristics of respondents based on the duration of hemodialysis. The most respondents in Hemodialysis Unit of Panembahan Senopati Bantul General Hospital had undergone hemodialysis for 1 to 3 years, amounting to 11 respondents (52.4%), while the least respondent hemodialysis less than 1 year that amounted to 2 respondents (9.5%). The results of the frequency of respondents undergoing hemodialysis therapy in Panembahan Senopati Hospital Bantul that most have undergone hemodialysis therapy for 1-3 years, amounted to 11 respondents (52.4%) and a small part of the other 2 respondents (9.5%) underwent hemodialysis therapy 1 year. The results of this study are similar to one Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital... S - 105

5 of the results of research that explains that the highest number of respondents who undergo hemodialysis therapy 3 years, amounted to 44 respondents (73.3%) and respondents who undergo hemodialysis therapy in the period 3 years are classified as 16 respondents (26, 7%) (26). The results of the two previous studies are inversely proportional to the results of the study indicating that most respondents underwent hemodialysis 6 years of 24 respondents (68.6%) and the lowest of 11 respondents (31.4%) underwent hemodialysis 6 years (27). In addition, the results of research conducted at Kidney Centers in Mecca City in Saudi Arabia show that most of the study respondents of 50.3% had undergone hemodialysis for 6 years (28). As in a theory reveals that the longer the patient undergoes hemodialysis, the patient will be more obedient to the advice of health workers, vice versa if someone has not been long undergoing hemodialisa hence the patient tends to disobey the advice given by health personnel. This is because patients who have long undergone hemodialysis has reached the stage of acceptable with the health education obtained earlier (29). Characteristics of respondents based on education level. The result of research data analysis showed that respondents in Hemodialysis Unit of Panembahan Senopati Hospital Bantul have the highest education level of elementary school that is 10 respondents (47.6%) and the lowest do not have education level (not finished primary) that is amount of 1 respondent (4.8%). The results of this study are similar to the International Comparison Study where the highest respondents have elementary education of 55.5% and the lowest educated junior high school 7.0% (30).. This data is not linear with the results of research in Dr. Wahidin Sudirohusodo Makassar that 11 respondents have high school education level (37.9%) while the lowest one respondent has elementary education level (16).. Similarly, research results conducted at Kidney Centers in Mecca City in Saudi Arabia showed that 44% of the study respondents had secondary school education and 24.7% of respondents had primary school education (28). The result of the research is supported by the theory that education level is one of the elements that is often seen related to morbidity and mortality rate, because it can affect various aspects of life in it in health maintenance (31). The higher the educational level of a person is expected exposure to the disease also decreased, one of them on disease variables about the severity of the disease and the loss of symptoms due to factors of adherence to therapy (32). Characteristics of respondents based on occupation. In Hemodiialysis Unit of Panembahan Senopati Hospital Bantul explained that most respondents did not work or as housewives that is 10 respondents (47.6%), whereas few respondents whose job as farmer is amount of 1 respondent (4.8%). The result of data frequency analysis showed that the number of respondents in Unit Hemodialisa RSUD Panembahan Senopati Bantul more than most respondents ie 10 respondents (47.6%) do not have job or just as housewife and lowest that is 1 responden (4.8%) work as a farmer. This research is different from the result of research that from 29 respondents 11 of them have job as civil servant (37.9%) and 7 respondent have job as farmer (24.1%) (16). This is similar to the results of research conducted at Dr. Wahidin Sudirohusodo Makassar is more respondents who work as civil servants that amounted to 22 respondents (53.7%), while the self-employed amounted to 19 respondents or amounted to (46.3%) (21). S Cicirosnita J. Idu, Winda Irwanti, Pratiwi, JNKI, Vol. 5, No. 3 (Suplement 2), Tahun 2017,

6 Table 2. Pre-test and Post-test Copliance of Respondent Diet in Hemodialysis Unit of Panembahan Senopati General Hospital of Bantul Analysis Pre-test Post-test n (%) n (%) Compliance of Diet Comply Not Comply % 85.7% % 42.9% Total % % Source: Primary Data 2015 Table 3. Influence of Giving Motivation to Respondent Diet Compliance in Hemodialysis Unit of Panembahan Senopati General Hospital of Bantul Pre-test Post-test Analysis n % n % Diet Compliance Comply Not Comply Total p a Source: Primary Data 2015 Respondent Diet Compliance Before and After Giving Motivation Dietary compliance of respondents in Hemodialysis Unit of Panembahan Senopati Bantul General Hospital before intervention and intervention of motivation is presented in Table 2. Based on the analysis in Table 2 explained that from 21 respondents who have measured the level of adherence of pretest diet in Hemodialysis Unit of Panembahan Senopati Bantul General Hospital showed that the majority of respondents were in non-obedient category, which were 18 respondents (85.7%) and 3 respondents 14,3%) were in obedient category to diet recommended by health worker, while posttest result shows that from 21 respondents who have measured level of dietary compliance in Hemodialysis Unit Panembahan Senopati Bantul General Hospital showed that most of respondents are in obedient category which is 12 people respondents (57.1%) and 9 respondents (42.9%) were in the nonadherence category to the diet recommended by health personnel. Based on one of the results showed that 21 respondents (72.4%) were in the diet adherence category and 8 respondents (27.6%) were classified as non-adherent to chronic renal failure diet (16).. The successful implementation of dietary adherence of chronic renal failure patients can be influenced by several factors one of which is the motivation and confidence of the patient associated with the patient's desire to recover from his illness. The above phrase is reinforced by the theory related to satisfaction factor (satisfaction) or known as motivational factor that concerns one's psychological needs include a series of conditions derived from the individual's own self (intrinsic condition). Factors of satisfaction (motivational) includes achievement, recognition, responsibility, posibility of growth, and work that can encourage a person's behavior to be better (31). Influence of Giving Motivation to Respondent Diet Compliance Bivariate analysis one of them using McNemar test. This test aims to determine and analyze the influence between independent variables to the dependent variable in two groups of research samples of the categorical variable paired scale. The results of the analysis are presented in Table 3. Based on bivariate analysis using McNemar test, the result of p value as significance level Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital... S - 107

7 0,05 with error rate α = 5%. The value of p value analysis of this research is or p value of α then Ha accepted and H0 rejected, so it means that there is a significant effect on dietary compliance of patients with chronic renal failure who underwent hemodialysis at RSUD Panembahan Senopati Bantul Yogyakarta. Motivation is a driving force of a person in behaving, both internal and external drives so that someone willing and able to achieve its goals. Based on the results of research data analysis using McNemar test shows the value of p value of or p value value α = 0.05, so Ha accepted and H0 rejected. There is a significant effect of motivation on dietary compliance of chronic renal failure patients undergoing hemodialysis at RSUD Panembahan Senopati Bantul Yogyakarta. The results of this study are also supported by the Model-Confidence-Health Theory that states the relationship between a person's beliefs with the behavior he or she is displaying (3). This theory model is structured to explain the reasons that a person attempts a health action which furthermore is used to predict adherence to therapy. Motivation appears to play a role in applying a model of health belief, in which motivation becomes a sign of one's actions. So motivation is one of the important points in a person's behavior change and then how one uses motivation as an internal and external stimulus that will change one's adherence to the diet that is run. Based on the results of the study, that motivation has a significant relationship to diet compliance rate of patients with chronic renal failure. Similarly, the results showed that there was a relationship between motivation and dietary adherence (16). The results of both studies are not much different from the results of research conducted at the Clinic of Hemodialysis Center on the United States, that the provision of motivation by using interview techniques shows the effect on improving adherence of patients undergoing hemodialysis both in terms of treatment and patient diet (17). Based on several studies and theories related to dietary compliance of patients with chronic renal failure, the researchers assume that dietary adherence to patients with chronic renal failure is one indicator that should always be improved and noticed by clients and health workers. One way health workers, especially nurses to improve diet compliance patients with chronic renal failure who undergo hemodialysis is by giving motivation or encouragement to the patient. Motivation is regarded as a condition that moves one's behavior towards a better one, so as to create a good quality of life as well. Based on motivation improvement model that is about human relation model that to improve one's healthy behavior motivation can be done by giving suggestion that every person is important and useful for people around it even more for society (31).. CONCLUSION Most of the respondents were aged 40 years, 17 respondents (81.0%), female were 11 respondents (52.4%), duration of hemodialysis 1-3 years, 11 respondents (52.4%), educated elementary school is as many as 10 respondents (47.6%), most respondents who do not work / housewife that is 10 respondents (47.6%). The result of pretest before given the motivation showed that respondents were obedient to chronic renal failure diet that is as many as 3 respondents (14.3%) and not obedient that is as many as 18 respondents (85.7%), posttest result after given motivation showed respondent obedient to diet failed chronic kidney that amounted to 12 respondents (57.1%) and disobedient amounted to 9 respondents (42.9%). There is a significant influence related to the provision of motivation to diet adherence of patients with chronic renal failure who underwent hemodialysis at RSUD Panembahan Senopati Bantul Yogyakarta with p value 0,004 value a (0.05). S Cicirosnita J. Idu, Winda Irwanti, Pratiwi, JNKI, Vol. 5, No. 3 (Suplement 2), Tahun 2017,

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10 Dr. H. Abdul Moeloek Bandar Lampung. asuhangagalginjalkronik. Diakses tanggal 24 Desember Kugler, C., Maeding, I., & Russel, C.L Non-adherence in Patients on Chronic Hemodialysis: an International Comparison Study. JNEPHROL 2011; 24(03): Diakses 15 November Notoatmodjo Pendidikan dan Perilaku Kesehatan. Jakarta: Rineka Cipta. 32. Smeltzer, S.C. & Bare, B.G Buku Ajar Keperawatan Medikal Bedah: Brunner & Suddarth s. EGC. Jakarta: Buku Kedokteran. Motivation Effect on Dietary Adherence of Chronic Renal Failure Patients Undergoing Hemodialysis in Panembahan Senopati Hospital... S - 111