Stages of change and uid intake in dialysis patients

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1 Patient Education and Counseling 49 (2003) 5±12 Stages of change and uid intake in dialysis patients Elaine Fontenot Molaison a,*, M. Kathleen Yadrick b a School of Human Ecology, Louisiana Tech University, P.O. Box 3167 T.S., Ruston, LA 71272, USA b School of Family and Consumer Science, The University of Southern Mississippi, P.O. Box 5035, Hattiesburg, MS , USA Received 23 July 2001; received in revised form 11 December 2001; accepted 20 December 2001 Abstract Nutrition professionals constantly strive to improve adherence to dietary recommendations in hemodialysis patients. The purpose of this study was to evaluate the effects of a 12-week intervention based on stages of change to decrease uid gain in dialysis patients. Readiness to change, knowledge of appropriate weight gain, and mean weight gains were obtained from patients in ve intervention (n ˆ 216) and ve control (n ˆ 100) dialysis units. Intervention had more participants in the maintenance and precontemplation stages at the end of the intervention (P ˆ 0:001) compared to the control group. Knowledge scores signi cantly increased in the intervention group (P < 0:001) during the course of the intervention. However, uid gains did not decrease in either group. Although this intervention did not produce behavior change, the results can aid other educators in planning intervention programs for renal failure and other chronic diseases. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Stages of change; Hemodialysis; Interdialytic weight gain 1. Introduction Behavior change theories have recently been brought to the forefront of nutrition education research in an attempt to improve the nutrition education process. The use of a theoretical model can help to explain behaviors and plan interventions. Unfortunately, there still remains a gap between current nutrition education practices and the use of change theories [1]. Nutrition therapy can be an integral part of the management and treatment of renal disease, but compliance with dietary recommendations is minimal. Previous research indicates that adherence to recommendations in this patient population can be as low as 24% [2]. Behavioral change theories may provide practitioners with the tools necessary to create effective education and intervention techniques. One approach that may be appropriate for promoting change in the hemodialysis patient is the Transtheoretical Model (TTM) (stages of change). Programs based on this theory have aided in the progression of stage improved healthful behaviors; therefore, its use in the dialysis population may improve compliance with recommendations [3]. Stages of change is the core construct of a model of behavioral change called the TTM. The TTM conceives behavioral change as a process, not a dichotomous event. * Corresponding author. address: molaison@hec.latech.edu (E.F. Molaison). Rather, in changing a particular behavior, a person progresses through ve stages with the ultimate outcome being the maintenance of change. The stages of change include precontemplation, contemplation, preparation, action, and maintenance. Passage through the stages is not always linear, and relapse is common. When using this model in planning intervention studies, the primary goals are to achieve maintenance of the desirable behavior and to prevent relapse into an earlier stage [1]. Early work with stages of change was done in smoking cessation programs [4]. More recently, the theory has been used in health promotion programs to increase fruit and vegetable intake or decrease fat intake [5±9]. It has been suggested that interventions that provide information speci c to an individual's particular stage have been more bene cial in promoting behavior change [3]. In order to individualize information, interventions should be based on the three core constructs of the TTM: processes of change (those activities that an individuals uses in an attempt to progress through the ve stages of change), decisional balance (the bene ts and barriers of changing a behavior), and self-ef cacy (the con dence a person feels about performing an activity and overcoming barriers to that activity). Use of these constructs aids in improving outcomes based on this model [1,7,8,10±16]. In the renal failure patient population, there is little evidence of the effectiveness of intervention programs improving adherence to dietary recommendations. Patients who are /02/$ ± see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. PII: S (02)

2 6 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 placed on hemodialysis face a multitude of dietary changes to compensate for the loss of kidney functioning. Nutrients such as potassium, sodium, phosphorus, and uid are limited due to the kidneys' inability to excrete wastes. Even with all of these restrictions, the patients often cite the uid restriction as one of the most dif cult recommendations [17]. As renal disease progresses, the patient that is placed on hemodialysis ultimately loses the ability to produce and excrete urine. Therefore, the amount of uid consumed must be regulated. To maintain uid balance and replace insensible water losses in the oliguric patient, recommended intake is 1000 ml per day [18]. Fluid intake is monitored using interdialytic weight gain (IDWG), weight gain occurring as a result of uid retention (or accumulation) between dialysis treatments. A patient with excessive IDWG is more likely to experience hypertension, dizziness, shortness of breath, and severe muscle cramping [19,20]. With a dialysis schedule of every other day, recommended IDWG is 2.5 kg [21]. The dif culty in maintaining appropriate weight gains between treatments and a history of poor adherence to dietary recommendations are cause for the dietitian to explore the use of a behavioral theory to aid in promoting adherence. Effectiveness of nutrition education programs with renal patients is increasing, but remains limited and results are not consistent [22,23]. The stages of change theory may be a means for the nutrition educator to increase adherence to dietary recommendations. Therefore, the purpose of this study was to design and evaluate a 12-week nutrition education intervention program based on stages of change to improve adherence with uid restriction recommendations in hemodialysis patients. 2. Subjects The design of the study was experimental, using 10 dialysis units in southeast Louisiana in the main study. A corporation manages all the units, and a similar protocol for patient care is followed in each of the facilities. Five dietitians staff the 10 units with an approximate ratio of one registered dietitian per 200 patients. Five of the units were randomly selected as intervention units, while the remaining ve units were used as a control. Patients who did not have the mental capacity to answer the questions were excluded from the study. Since, between treatment weight gain was used as an outcome measure of uid intake and collection and estimation of residual urine production is dif cult to control, those patients who continued to produce urine were also excluded. 3. Methods A 12-week intervention program was developed using the principles of stages of change to improve uid intake patterns of the patients. Data were collected prior to the intervention (baseline), at mid-point (6 weeks), and after the intervention (12weeks). Effectiveness of the intervention was assessed using progression in stage, adherence to uid gain recommendations, and increased knowledge of appropriate interdialytic weight gain as criteria of success Data collection Participants' stage of readiness to change was assessed using a staging algorithm, modi ed from previous stages of change research [24]. This instrument consisted of six questions that required yes/no answers. Based on the responses of the subjects, they were placed in one of the ve stages of readiness to change. The staging algorithm, originally developed to measure stage associated with fat intake, was modi ed based on recommendations of dietitians in a separate group of dialysis units which served a similar patient population, to re ect uid intake patterns and commonly used language of the patients. Prior to initiation of the main study, the modi ed staging algorithm and knowledge questionnaire were pre-tested on patients in another dialysis unit to establish face validity. The dietitian in a pilot dialysis unit evaluated wording of the instrument and understanding of the questions by the subjects. Minor changes were made to the algorithm, and the tool that was produced served to gauge the participants' readiness to change uid intake habits (Table 1). Knowledge was assessed at baseline, 6 and 12weeks with a questionnaire adapted from an instrument developed by Tanner [22]. The knowledge questionnaire consisted of two multiple-choice questions and one listing question to assess participants' knowledge of appropriate uid intake, appropriate interdialytic uid gain, and complications associated with uid overload. Participants were given two points for each correct answer on the 11 possible responses, with a maximum of 22 points. The questionnaire was evaluated for face validity by a panel of experts in renal nutrition prior to the intervention. After obtaining informed consent from the patient, a computerized charting system was used to gather patient demographic information including gender, race, age, length of time on dialysis, and total years of education. Data on interdialytic weight gain also were collected using this charting system. To calculate average interdialytic weight gain during the study, uid gain information was gathered three times a week for 3 weeks prior to baseline and 3 weeks prior to the 6- and 12-week follow-up periods. Permission to conduct the study was obtained from the Human Subjects Protection Review Committee at the University of Southern Mississippi and from the medical corporation that manages the dialysis units Intervention The intervention units were exposed to the nutrition education intervention aimed at increasing adherence to

3 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 7 Table 1 Questions used to assess stage of change and evaluation of stage of change Question Possible response 1. Have you ever decreased the amount of fluid you drink? Yes/no (skip to #2) 1A. If yes, are you limiting the amount of fluid you Yes/no (skip to #2) are going to drink today? 1B. If yes, how long have you been limiting the amount Less than 30 days, since the spring (<6 months), since last of fluid you drink? fall (>6 months), over a year (stop here if patient answers #1B) 2. In the past month, have you thought about changes you Yes (skip to 2A)/no (stop here) could make to decrease the amount of fluid you drink? 2A. Do you think you will make some changes to the Yes, definitely; probably; maybe; no, definitely amount of fluid you drink in the next month? Evaluation of stage Stage Question Answer Precontemplation 1 No 2No Contemplation 1 No 2Yes 2A or 1 Maybe/no or yes 1A No 2Yes 2A Maybe/no Preparation 1 No 2Yes 2A or 1 Yes/probably or yes 1A No 2Yes 2A Yes/probably Action 1 Yes 1A Yes 1B <30 days/since spring Maintenance 1 Yes 1A Yes 1B Since fall/ >1 year uid restrictions during the 12-week study period. Due to the recommendation that education should be based on the core constructs of the theory and the speci c needs of each stage, the intervention was designed around building awareness, providing skills training, and instructing on how to maintain change [8]. Because of the close proximity of the patients to each other, it would have been dif cult to disseminate stagespeci c education material to an individual patient without other subjects being exposed to information not appropriate for their stage. Therefore, the intervention was developed around two stages: preaction (precontemplation and contemplation) and action (preparation, action, and maintenance), and delivered in the same sequence to all patients receiving the intervention during the same time intervals. While piloting the algorithm in a separate dialysis unit, the dietitian reported that more than half of the patients were in preaction stages. Therefore, the decision was made to present the preaction material related to adherence to uid restrictions during the rst 6-week phase of the intervention, and the action material during the second 6 weeks. The education material was provided in such a manner that all patients in the intervention units would be exposed to the intervention material. The intervention used three methods to communicate stage-speci c information to patients during each of the two intervention phases. These included bulletin board displays, patient education handouts, and patient feedback. Four separate bulletin board displays were developed, two for each intervention phase, and each was hung in the waiting room of the dialysis center for 3 weeks. The dietitians in the intervention units met with the patients in the waiting room and conducted group education sessions (lasting approximately 20 min) to assure that all patients in the intervention groups were exposed to the material. Patients also received three handouts during the intervention, each of which was reviewed with individual patients by the dietitian as a part of their monthly lab report and nutrition education. In addition to this, the dietitian gave speci c feedback to each of the patients who exceeded the average 2.5 kg weight gain limit for each month. The education material planned for the rst 6 weeks was developed based on the recommendations of other

4 8 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 Table 2 Educational strategies based on the core constructs Time frame Learning objective Educational strategy Components of constructs used Weeks 1±6 To understand the effects of fluid overload Bulletin board Consciousness raising, contingency management, self-reevaluation, social reevaluation, decisional balance To identify sources of fluid in the diet Bulletin board Consciousness raising, self-reevaluation To describe interdialytic weight gain Handout Consciousness raising To distinguish between a pound and a kilogram Handout Consciousness raising Weeks 7±12To comprehend the amount of Bulletin board Consciousness raising; self-reevaluation, social-reevaluation fluid allowed daily To demonstrate avoiding excess fluid intake Bulletin board Consciousness raising, self-reevaluation, social-reevaluation, self-liberation, counter conditioning, stimulus control, self-efficacy Throughout intervention To demonstrate estimating appropriate fluid intake To demonstrate the ability to maintain appropriate interdialytic weight gain Handout Dietitian feedback Consciousness raising, self-reevaluation, social reevaluation, self-liberation, counter conditioning, self-efficacy Consciousness raising, self-reevaluation, social-reevaluation, self-liberation, counter conditioning, contingency management, decisional balance, self-efficacy researchers, with the intervention focusing on consciousness raising [7,10,12]. Educational objectives during this time included increasing knowledge of the sources of uid in the diet and understanding the meaning of interdialytic weight gain. It is suggested that when the pros outweigh the cons, those in the lower stages will progress to higher stages [16]. Therefore, increased awareness of personal susceptibility to adverse effects of excessive interdialytic weight gain also was used as an educational strategy during this time period. The bene ts of changing uid intake habits and the importance of minimizing weight gain were emphasized. During the second 6 weeks, education efforts focused on the principles related to the action stages. Information was concentrated on the skills needed to implement and maintain appropriate interdialytic uid gain. Participants were taught the appropriate method for measuring and consuming 1000 ml of uid per day. The intervention also was geared towards counterconditioning and stimulus control in an attempt to help participants progress to the maintenance stage and prevent relapse to an earlier stage [12]. The patients were given strategies to avoid excessive uid intake and ways to substitute other items for liquid. Motivational messages and skills building also were used [7,10,16]. Table 2 summarizes the educational objectives and core competencies used during the intervention. Prior to implementing the intervention, seven renal dietitians reviewed the education material to assure that all information was accurate and appropriate for the dialysis population. The dietitian and the patients in the pilot intervention unit gave feedback regarding the clarity of the information. The education material was modi ed in accordance with all recommendations. In the control units, dietitians, nurses, and technicians were instructed to follow usual protocol during the 12-week study period, but not to distribute any handouts or develop bulletin boards on uid control. In a case where the patient's health was in danger due to excessive uid overload, the dietitians in the control units were instructed to educate the patient as necessary. 4. Data analysis To examine differences in demographic variables between intervention and control groups, w 2 analysis was used for gender and race comparisons, while independent t-tests were used to compare average age, years on dialysis, and years of education. Friedman's test for ranking variables was used to assess movement through the stages of readiness to change uid intake habits. The w 2 analysis was used to compare groups' stage of change at baseline, 6, and 12weeks. Differences in knowledge and interdialytic weight gain were evaluated using a mixed design ANOVA. The within subjects factor was time (baseline, 6, and 12weeks) and the between subjects factor was groups (intervention, control), with dialysis unit ( ve intervention, ve control) nested in group. A regression model was used to evaluate demographic characteristics as predictors of mean IDWG at 12 weeks. Regression analysis was also used to determine if demographic characteristics were signi cant predictors of stage of change at 12weeks. 5. Results The ve intervention dialysis units contributed 216 subjects to the study, while the control units contributed 100 subjects. The groups did not differ signi cantly based on demographic data. The intervention group was 49.5% male and 80.1% African American, compared to 54% male and 84% African American for the control group. The average age of patients was 54.8 with a standard deviation

5 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 9 of 15.0 years for the intervention group and 52:8 14:5 (S.D.) years for the control group. Intervention participants had been on dialysis for 3:7 3:7 (S.D.) years, compared to 4:4 3:6 (S.D.) years for those in the control group. Average number of years of education was just under 12for both groups. Progression in stage was used as one of the criteria of intervention success. Individuals in the intervention group had a positive, signi cant progression in stage (P < 0:001), whereas no progression in stage occurred in the control group. At baseline, there was no signi cant difference between the intervention and control groups in the proportion of participants in each of the ve stages. At 6 weeks, the control group had a smaller percentage of participants in the preparation and action stages than the intervention group and a larger percentage of control group participants in precontemplation (P ˆ 0:04). At 12weeks, the intervention group had a smaller proportion of subjects in precontemplation than the control group (P ˆ 0:001). Percentages of participants in each stage are summarized in Table 3. Knowledge scores are reported in Table 4. There was a signi cant effect of time on knowledge (F 2; 304 ˆ7:74, Table 3 Participants' stage of change before, during, and after the intervention Stage of readiness to change Percentage of participants Baseline 6 Weeks 12Weeks Precontemplation Intervention a Control b Contemplation Intervention Control Preparation Intervention Control Action Intervention Control Maintenance Intervention Control a n ˆ 216. b n ˆ 100. Table 4 Knowledge scores at baseline, 6, and 12weeks Knowledge scores a Intervention (n ˆ 216) Mean (S.D.) Control (n ˆ 99) Mean (S.D.) Baseline 6.7 (3.8) a 5.7 (2.9) a 6 Weeks 7.6 (3.4) b 5.9 (2.7) a 12Weeks 8.7 (3.3) c 5.8 (2.7) a Means within columns with different letters (a, b, c) are significantly different at the P < 0:05 level. a Range of possible knowledge scores ˆ Table 5 Interdialytic weight gains at baseline, 6, and 12weeks Interdialytic weight gain (kg) P ˆ 0:001), a signi cant group effect (F 1; 305 ˆ 31:40, P < 0:001) and a signi cant time group interaction (F 2; 304 ˆ9:33,P < 0:001). Knowledge scores increased by 30% in the intervention group and did not change in the control group. There was no effect on knowledge of unit nested in group. Using an interdialytic weight gain of <2.5 kg as the criterion for uid compliance, only 24.6% of the total number of patients in the intervention and control groups was considered to be compliant at the beginning of the study. This percentage decreased to 19.9 at 12weeks. There was a signi cant effect of time on IDWG (F 2; 303 ˆ3:49, P ˆ 0:032), but no signi cant group effect or time group interaction. Interdialytic weight gain increased from baseline to 12weeks in the intervention group, but did not change in the control group. There was no effect on IDWG of unit nested in group (Table 5). When the variables age, gender, years on dialysis, years of education, and race were entered into a regression model, the model signi cantly predicted IDWG in the intervention group (F 5; 207 ˆ14:69, P < 0:001, R 2 ˆ 0:262), but not in the control group. Signi cant predictors were age (b ˆ 0:261, P < 0:001) and gender (b ˆ 0:381, P < 0:001). As age increased, IDWG decreased, and females were more likely, than males to have lower IDWG. The model regressing demographics on stage of change was signi cant for the control group (F 5; 94 ˆ2:564, P ˆ 0:032, R 2 ˆ 0:120), but not the intervention group. In this model, years on dialysis was the only signi cant predictor (P ˆ 0:012, b ˆ 0:248). As the number of years on dialysis increased, the participants were less likely to be ready for change. 6. Discussion Intervention (n ˆ 215) mean (S.D.) Control (n ˆ 99) mean (S.D.) Baseline 3.24 (1.19) a 3.44 (1.27) a 6 Weeks 3.36 (1.12) ab 3.58 (1.22) a 12Weeks 3.41 (1.14) b 3.57 (1.21) a Means in columns with different letters (a, b) are significantly different at the P < 0:05 level. Due to reported low levels of dietary compliance in hemodialysis patients, dietitians must nd ways to increase adherence. The use of a behavioral theory, such as stages of change, may aid in developing a more appropriate educational venue, but it does not assure positive outcomes [22]. Based on the results of the staging algorithm, the intervention group showed a progression in stage compared to the control group. The increased number of participants in the preparation, action, and maintenance stages at the two follow-up points may be attributed to the educational

6 10 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 strategies used in the intervention. Although stages research is based on the premise that progression occurs in 6 month intervals, the 3 month time frame of the intervention may have captured movement through the stages in those individuals who had been in a particular stage for an extended period of time prior to the intervention and were ready to progress. The high percentage of intervention and control participants in the maintenance stage is not uncommon for individuals suffering from chronic disease. The individual with a chronic disease is more likely to have received other nutrition education prior to the initiation of a new intervention compared to the typical healthy individual, and may perceive he or she is ready to make dietary changes, although clinical measures may indicate non-compliance. Other studies involving stages of change found that individuals with chronic conditions were more likely to be in the action and maintenance stages than in the precontemplation and contemplation stages [25±27]. In order for an individual to adopt a lifestyle change, he or she must have enough knowledge to understand the necessity and mechanisms of change [10]. The stages of change construct is based on the premise that education can promote an individual's progression through stages. The results of this study indicated the intervention was effective in signi cantly increasing knowledge of appropriate uid gains in the experimental group. Other intervention studies have shown a positive relationship between knowledge and stage [5,25,28]. Patient's gender was found to be a signi cant predictor of IDWG, the intervention group. Females have been found to be more compliant with dietary recommendations and have lower average weight gains between dialysis treatments than males [2,29±31]. Age was a signi cant predictor of IDWG in the intervention group with older patients gaining less uid than younger patients. This relationship is also supported by other studies evaluating compliance in hemodialysis patients [29,32±34]. Length of time on dialysis was a signi cant predictor of stage in the control group. Participants on dialysis for a shorter period of time were less likely to be ready to make changes in uid intake habits. Therefore, it may be necessary to incorporate behavior change theory at the initiation of dialysis to help motivate those new to dialysis to make necessary dietary changes. Several explanations may be given for the increase in knowledge and stage without an increase in adherence to IDWG recommendations. Meichenbaum and Turk note that evidence for a relationship between increased knowledge and compliance with treatment regimens is limited [35]. Other studies involving interventions aimed at decreasing uid gains in dialysis patients also found no relationship between knowledge and weight gain compliance [22,29]. The subjects suffer from chronic disease; therefore, they have been educated on uid recommendations since the onset of their conditions. The patients may know of the recommendations, and may believe they are following uid guidelines, when they are actually not adhering to uid intake criteria. Dialysis patients who are considered uid non-compliant report that getting thirsty and measuring the amount of uid that is allowed daily are the most dif cult aspects of the renal diet [17,29]. Based on the results of this study, it appears that the dialysis patients have the knowledge and desire to control their uid intake but nd it dif cult to comply with the uid recommendations. Although it was anticipated that IDWG would decrease as knowledge and stage of change increased, participants in the intervention group exhibited a 5% increase in interdialytic weight gain at 12weeks compared to baseline. While statistically signi cant at the P < 0:05 level, this difference in IDWG was not clinically signi cant. The increase may have been due to the patients' inaccurate perception of intake associated with a change in season that occurred over the course of the study. The intervention began during August and concluded in December. While collecting data at the mid-point of the intervention, many of the subjects reported informally that they were not focusing on uid intake because of the cooler outdoor temperatures. The criterion of 2.5 kg IDWG for compliance in this study was set based on the general recommendation for uid intake of 1000 ml for patients without any urine production, which would cause a 2.5 kg weight gain between treatments [18]. This criterion has been used in other studies to measure compliance with uid intake [2,19,34]. There are several possible explanations for patients in the intervention group exhibiting a progression in stage without an accompanying decrease in IDWG. In self-assessment surveys, such as with use of a staging algorithm, subjects are asked to rely on their memory to produce answers. The ability of the individual to set criteria and measure past actions against the criteria given in the algorithm may have been limited in some patients with a lower cognitive ability. Although responses given may not have been completely representative of actions, data on self-assessment show that respondents attempt to give the answer most representative of their actions [36]. Inaccurate perceptions of behavior on the part of the participants in this study may have led to inaccurate categorization in the action and maintenance stages. Kristal et al. [37] suggest that in the context of dietary change, the stages of change construct is more a measure of what people think about their diets and their interest in change, rather than a measure of actual dietary behavior. Exposure to the intervention and/or being asked about uid gain every 6 weeks may have increased awareness of uid gains, increasing the likelihood the participant would answer more positively about intentions to change. Alternatively, the patient may have reported to the interviewer or dietitian that he or she followed uid recommendations to please or look good to the health care professional, or to avoid an unpleasant response from the professional. The progression in stage of readiness to change in the intervention group without a decrease in IDWG raises questions regarding the algorithm used to assess stage of

7 E.F. Molaison, M.K. Yadrick / Patient Education and Counseling 49 (2003) 5±12 11 change. Although the algorithm was pilot tested in a separate dialysis unit, it was not validated against an objective measure of uid intake. Use of a more speci c behavior de nition in the algorithm asking if the patient's uid intake was equivalent to four cups per day, may have resulted in more accurate staging. Another limitation of the study was the dietitians' staf ng within the intervention and control units. Three of the ve dietitians involved in the study were responsible for both intervention and control units. Without realizing it, the dietitians may have biased some of the results in either the intervention or control units. To help minimize the possibility of contamination, the dietitians who had both types of dialysis units were given strict instructions on avoiding education on uid gains and discussing any intervention-related information with subjects in the control units. In previous research, the use of computer-tailored stage information enabled study participants not only to progress in stage, but also to decrease fat intake signi cantly [3]. Use of individualized, rather than group, stage-speci c education material might be more likely to produce actual behavior change, in addition to progression in stage in a dialysis patient population. 7. Practice implications Renal dietitians in hemodialysis units can use this information to plan and implement other interventions for other dietary restrictions such as phosphorus and potassium. Based on the results of this intervention, it is possible to identify the areas that were less effective in producing change in patients. More positive outcomes may be produced using an algorithm with a detailed description of the behavior being measured to increases the predictability of intake by stage. 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