Evidence That Self-Affirmation Improves Phosphate Control in Hemodialysis Patients: A Pilot Cluster Randomized Controlled Trial

Context Matters: A Qualitative Synthesis of Adherence Literature for People on Hemodialysis

BACKGROUND

Patients with ESKD treated with hemodialysis in the United States have persistently higher rates of nonadherence compared with patients in other developed countries. Nonadherence is associated with an increased risk of death and higher medical expenditure. There is an urgent need to address it with feasible, effective interventions as the prevalence of patients on hemodialysis in the United States continues to grow. However, published adherence interventions demonstrate limited long-term efficacy.

METHODS

We conducted a synthesis of qualitative studies on adherence to hemodialysis treatment, medications, and fluid and dietary restrictions to identify gaps in published adherence interventions, searching PubMed, CINAHL, PsychInfo, Embase, and Web of Science databases. We analyzed qualitative data with a priori codes derived from the World Health Organization's adherence framework and subsequent codes from thematic analysis.

RESULTS

We screened 1775 articles and extracted qualitative data from 12. The qualitative data revealed 20 factors unique to hemodialysis across the World Health Organization's five dimensions of adherence. In addition, two overarching themes emerged from the data: (1) adherence in the context of patients' whole lives and (2) dialysis treatment as a double-edged sword. Patient-level factors reflected in the qualitative data extended beyond knowledge about hemodialysis treatment or motivation to adhere to treatment. Patients described a profound grieving process over the loss of their "old self" that impacted adherence. They also navigated complex challenges that could be exacerbated by social determinants of health as they balanced treatment, life tasks, and social roles.

CONCLUSIONS

This review adds to the growing evidence that one-size-fits-all approaches to improving adherence among patients on hemodialysis are inadequate. Adherence may improve when routine care incorporates patient context and provides ongoing support to patients and families as they navigate the logistical, physical, and psychological hardships of living with dialysis. New research is urgently needed to guide a change in course.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

Effectiveness of a brief positive skills intervention to improve psychological adjustment in patients with end-stage kidney disease newly initiated on haemodialysis: protocol for a randomised controlled trial (HED-Start)

INTRODUCTION

Initiation onto haemodialysis is a critical transition that entails multiple psychosocial and behavioural demands that can compound mental health burden. Interventions guided by self-management and cognitive-behavioural therapy to improve distress have been variably effective yet are resource-intensive or delivered reactively. Interventions with a focus on positive affect for patients with end-stage kidney disease are lacking. This study will seek (1) to develop a positive life skills intervention (HED-Start) combining evidence and stakeholder/user involvement and (2) evaluate the effectiveness of HED-Start to facilitate positive life skills acquisition and improve symptoms of distress and adjustment in incident haemodialysis patients.

METHODS AND ANALYSIS

This is a single/assessor-blinded randomised controlled trial (RCT) to compare HED-Start to usual care. In designing HED-Start, semistructured interviews, a codesign workshop and an internal pilot will be undertaken, followed by a two-arm parallel RCT to evaluate the effectiveness of HED-Start. A total of 148 incident HD patients will be randomised using a 1:2 ratio into usual care versus HED-Start to be delivered in groups by trained facilitators between January 2021 and September 2022. Anxiety and depression will be the primary outcomes; secondary outcomes will be positive and negative affect, quality of life, illness perceptions, self-efficacy, self-management skills, benefit finding and resilience. Assessments will be taken at 2 weeks prerandomisation (baseline) and 3 months postrandomisation (2 weeks post-HED-Start completion). Primary analyses will use an intention-to-treat approach and compare changes in outcomes from baseline to follow-up relative to the control group using mixed-effect models.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Nanyang Technological University Institutional Review Board (IRB-2019-01-010). Written informed consent will be obtained before any research activities. Trial results will be disseminated via publications in peer-reviewed journals and conference presentations and will inform revision(s) in renal health services to support the transition of new patients to haemodialysis.

TRIAL REGISTRATION NUMBER

NCT04774770.

A breakthrough series collaborative to increase patient participation with hemodialysis tasks: A stepped wedge cluster randomised controlled trial

BACKGROUND

Compared to in-centre, home hemodialysis is associated with superior outcomes. The impact on patient experience and clinical outcomes of consistently providing the choice and training to undertake hemodialysis-related treatment tasks in the in-centre setting is unknown.

METHODS

A stepped-wedge cluster randomised trial in 12 UK renal centres recruited prevalent in-centre hemodialysis patients with sites randomised into early and late participation in a 12-month breakthrough series collaborative that included data collection, learning events, Plan-Study-Do-Act cycles, and teleconferences repeated every 6 weeks, underpinned by a faculty, co-production, materials and a nursing course. The primary outcome was the proportion of patients undertaking five or more hemodialysis-related tasks or home hemodialysis. Secondary outcomes included independent hemodialysis, quality of life, symptoms, patient activation and hospitalisation. ISRCTN Registration Number 93999549.

RESULTS

586 hemodialysis patients were recruited. The proportion performing 5 or more tasks or home hemodialysis increased from 45.6% to 52.3% (205 to 244/449, difference 6.2%, 95% CI 1.4 to 11%), however after analysis by step the adjusted odds ratio for the intervention was 1.63 (95% CI 0.94 to 2.81, P = 0.08). 28.3% of patients doing less than 5 tasks at baseline performed 5 or more at the end of the study (69/244, 95% CI 22.2-34.3%, adjusted odds ratio 3.71, 95% CI 1.66-8.31). Independent or home hemodialysis increased from 7.5% to 11.6% (32 to 49/423, difference 4.0%, 95% CI 1.0-7.0), but the remaining secondary endpoints were unaffected.

CONCLUSIONS

Our intervention did not increase dialysis related tasks being performed by a prevalent population of centre based patients, but there was an increase in home hemodialysis as well as an increase in tasks among patients who were doing fewer than 5 at baseline. Further studies are required that examine interventions to engage people who dialyse at centres in their own care.

Self-care training using the Tablo hemodialysis system

INTRODUCTION

Recently published results of the investigational device exemption (IDE) trial using the Tablo hemodialysis system confirmed its safety and efficacy for home dialysis. This manuscript reports additional data from the Tablo IDE study on the training time required to be competent in self-care, the degree of dependence on health care workers and caregivers after training was complete, and participants' assessment of the ease-of-use of Tablo.

METHODS

We collected data on the time required to set up concentrates and the Tablo cartridge prior to treatment initiation. We asked participants to rate system setup, treatment, and takedown on a Likert scale from 1 (very difficult) to 5 (very simple) and if they had required any assistance with any aspect of treatment over the prior 7 days. In a subgroup of 15 participants, we recorded the number of training sessions required to be deemed competent to do self-care dialysis.

FINDINGS

Eighteen men and 10 women with a mean age of 52.6 years completed the study. Thirteen had previous self-care experience using a different dialysis system. Mean set up times for the concentrates and cartridge were 1.1 and 10.0 minutes, respectively. Participants with or without previous self-care experience had similar set-up times. The mean ease-of-use score was 4.5 or higher on a scale from 1 to 5 during the in-home phase. Sixty-five percent required no assistance at home and on average required fewer than four training sessions to be competent in managing their treatments. Results were similar for participants with or without previous self-care experience.

CONCLUSIONS

Participants in the Tablo IDE trial were able to quickly learn and manage hemodialysis treatments in the home, found Tablo easy to use, and were generally independent in performing hemodialysis.

Reporting of key methodological and ethical aspects of cluster trials in hemodialysis require improvement: a systematic review

Background

The hemodialysis setting is suitable for trials that use cluster randomization, where intact groups of individuals are randomized. However, cluster randomized trials (CRTs) are complicated in their design, analysis, and reporting and can pose ethical challenges. We reviewed CRTs in the hemodialysis setting with respect to reporting of key methodological and ethical issues.

Methods

We conducted a systematic review of CRTs in the hemodialysis setting, published in English, between 2000 and 2019, and indexed in MEDLINE or Embase. Two reviewers extracted data, and study results were summarized using descriptive statistics.

Results

We identified 26 completed CRTs and five study protocols of CRTs. These studies randomized hemodialysis centers (n = 17, 55%), hemodialysis shifts (n = 12, 39%), healthcare providers (n = 1, 3%), and nephrology units (n = 1, 3%). Trials included a median of 28 clusters with a median cluster size of 20 patients. Justification for using a clustered design was provided by 15 trials (48%). Methods that accounted for clustering were used during sample size calculation in 14 (45%), during analyses in 22 (71%), and during both sample size calculation and analyses in 13 trials (42%). Among all CRTs, 26 (84%) reported receiving research ethics committee approval; patient consent was reported in 22 trials: 10 (32%) reported the method of consent for trial participation and 12 (39%) reported no details about how consent was obtained or its purpose. Four trials (13%) reported receiving waivers of consent, and the remaining 5 (16%) provided no or unclear information about the consent process.

Conclusion

There is an opportunity to improve the conduct and reporting of essential methodological and ethical issues in future CRTs in hemodialysis.

Review Registration

We conducted this systematic review using a pre-specified protocol that was not registered.

Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: A systematic review and meta-analysis of randomized intervention trials

Background

In patients with end stage kidney disease (ESKD) on dialysis, treatment non-adherence is common and results in poor health outcomes. However, the clinical benefits of interventions to improve adherence in dialysis patients are difficult to evaluate since trialled interventions and reported outcomes are highly diverse/ heterogeneous. This review summarizes existing literature on randomized controlled trials (RCTs) evaluating adherence interventions in ESKD patients focusing on the intervention category, outcome efficacy and persistence of benefit beyond the intervention.

Methods

We performed electronic database searches in Medline, Embase & Cochrane CENTRAL upto 1^st July 2018 for RCTs evaluating interventions to improve diet, fluid, medication or dialysis adherence in ESKD patients. Study characteristics including category of interventions, outcomes, efficacy and follow-up were assessed. Meta-analysis was used to compute pooled estimates of the effects on the commonest reported outcome measures.

Results

From 1311 citations, we included 36 RCTs (13 cluster-randomized trials), recruiting a total of 3510 dialysis patients (mean age 55.1 ± 5.8 years, males 58.1%). Overall risk of bias was ‘high’ for 24 and of ‘some concern’ for 12 studies. Most interventions (33 trials, 92%) addressed patient related factors, and included educational/cognitive (N = 11), behavioural / counselling (N = 4), psychological/affective (N = 4) interventions or a combination (N = 14) of the above. A majority of (28/36) RCTs showed improvement in some reported outcomes. Surrogate measures like changes in phosphate (N = 19) and inter-dialytic weight gain (N = 15) were the most common reported outcomes and both showed significant improvement in the meta-analysis. Sixteen trials reported follow-up (1–12 months) beyond intervention and the benefits waned or were absent in nine trials within 12 months post-intervention.

Conclusions

Interventions to improve treatment adherence result in modest short-term benefits in surrogate outcome measures in dialysis patients, but significant improvements in trial design and outcome reporting are warranted to identify strategies that would achieve meaningful and sustainable clinical benefits.

Limitations

Poor methodological quality of trials. Frequent use of surrogate outcomes measures. Low certainly of evidence.

Associations with Wellbeing and Medication Adherence in Young Adults Receiving Kidney Replacement Therapy

BACKGROUND AND OBJECTIVES

Young adults receiving kidney replacement therapy (KRT) have impaired quality of life and may exhibit low medication adherence. We tested the hypothesis that wellbeing and medication adherence are associated with psychosocial factors.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a cross-sectional online survey for young adults on KRT. Additional clinical information was obtained from the UK Renal Registry. We compared outcomes by treatment modality using age- and sex-adjusted regression models, having applied survey weights to account for response bias by sex, ethnicity, and socioeconomic status. We used multivariable linear regression to examine psychosocial associations with scores on the Warwick-Edinburgh Mental Wellbeing Scale and the eight-item Morisky Medication Adherence Scale.

RESULTS

We recruited 976 young adults and 64% responded to the survey; 417 (71%) with transplants and 173 (29%) on dialysis. Wellbeing was positively associated with extraversion, openness, independence, and social support, and negatively associated with neuroticism, negative body image, stigma, psychologic morbidity, and dialysis. Higher medication adherence was associated with living with parents, conscientiousness, physician access satisfaction, patient activation, age, and male sex, and lower adherence was associated with comorbidity, dialysis, education, ethnicity, and psychologic morbidity.

CONCLUSIONS

Wellbeing and medication adherence were both associated with psychologic morbidity in young adults. Dialysis treatment is associated with poorer wellbeing and medication adherence.

Phosphate-control adherence in hemodialysis patients: current perspectives

OBJECTIVES

This review summarizes factors relevant for adherence to phosphate-control strategies in dialysis patients, and discusses interventions to overcome related challenges.

METHODS

A literature search including the terms "phosphorus", "phosphorus control", "hemo-dialysis", "phosphate binder medications", "phosphorus diet", "adherence", and "nonadherence" was undertaken using PubMed, PsycInfo, CINAHL, and Embase.

RESULTS

Hyperphosphatemia is associated with cardiovascular and all-cause mortality in dialysis patients. Management of hyperphosphatemia depends on phosphate binder medication therapy, a low-phosphorus diet, and dialysis. Phosphate binder therapy is associated with a survival benefit. Dietary restriction is complex because of the need to maintain adequate protein intake and, alone, is insufficient for phosphorus control. Similarly, conventional hemodialysis alone is insufficient for phosphorus control due to the kinetics of dialytic phosphorus removal. Thus, all three treatment approaches are important contributors, with dietary restriction and dialysis as adjuncts to the requisite phosphate binder therapy. Phosphate-control adherence rates are suboptimal and are influenced directly by patient, provider, and phosphorus-control strategy-related factors. Psychosocial factors have been implicated as influential "drivers" of adherence behaviors in dialysis patients, and factors based on self-motivation associate directly with adherence behavior. Higher-risk subgroups of nonadherent patients include younger dialysis patients and non-whites. Provider attitudes may be important - yet unaddressed - determinants of adherence behaviors of dialysis patients.

CONCLUSION

Adherence to phosphate binders, low-phosphorus diet, and dialysis prescription is suboptimal. Multicomponent strategies that concurrently address therapy-related factors such as side effects, patient factors targeting self-motivation, and provider factors to improve attitudes and delivery of culturally sensitive care show the most promise for long-term control of phosphorus levels. Moreover, it will be important to identify patients at highest risk for lack of control, and for programs to be ready to deliver flexible person-centered strategies through training and dedicated resources to align with the needs of all patients.

Involved, United, and Efficacious: Could Self-Affirmation Be the Solution to California's Drought?

Self-affirmation theory posits that thoughts and actions that affirm an important aspect of the self-concept can make people more susceptible to change by casting their self in a positive light. Whereas much of the current literature has been restricted to individual-level concerns, the current study provides longitudinal evidence for behavioral outcomes in the context of the California drought, advancing our theoretical knowledge regarding the underlying processes that lead self-affirmed individuals to address societal risks and collective concerns. The results of a three-wave experimental study (N = 91) indicated that relative to nonaffirmed counterparts, self-affirmed participants reported on higher levels of support for water conservation policies, as well as on reduction of water use that endured for 30 days following the self-affirming manipulation. In both cases, the effects were mediated by collective-efficacy but not by self-efficacy. Relevant explanations are considered and practical and theoretical implications are discussed.

Effects of self-management on chronic kidney disease: A meta-analysis

BACKGROUND

Self-management programs may facilitate the improvement of outcomes in medical, role, and emotional management and health-related quality of life in patients with chronic kidney disease. Studies on the effect of three self-management tasks have reported conflicting findings. In addition, systematic reviews are unavailable.

OBJECTIVE

This study evaluated the effects of self-management programs on medical, role, and emotional management and health-related quality of life in chronic kidney disease.

DESIGN

Meta-analysis of randomized controlled studies.

DATA SOURCES

The meta-analysis involved an online search of the English literature from PubMed, Cochrane, Web of Science, and CINAHL and the Chinese literature from the Airiti Library that were published from the inception of the websites until January 1, 2017.

REVIEW METHODS

The meta-analysis was conducted to evaluate the effects of self-management on chronic kidney disease outcomes. Electronic databases were searched by using keywords: chronic kidney disease, end-stage renal disease, renal failure, dialysis, self-management, self-efficacy, empowerment, cognitive behavioral, and educational. The methodological quality of randomized controlled trials was assessed using the Cochrane Handbook. Data were analyzed using Comprehensive Meta-Analysis software 2.0.

RESULTS

Eighteen randomized controlled trials met our inclusion criteria. The results revealed that the self-management program significantly enhanced the effects of self-management on outcomes of medical, role, and emotional management and health-related quality of life in patients with chronic kidney disease. The following Hedges' g (effect size) values were obtained: (1) interdialytic weight gain, -0.36 (95% confidence interval, -0.60 to -0.12, p<0.01); (2) self-efficacy, 0.57 (95% confidence interval, 0.18-0.96, p<0.01); (3) anxiety, -0.95 (95% confidence interval, -1.65 to -0.25, p=0.01); (4) depression, -0.63 (95% confidence interval, -0.85 to -0.41, p<0.01) (5) health-related quality of life for the mental component of the SF-36, 0.71 (95% confidence interval, 0.45-0.97, p<0.01); (6) the physical component of the SF-36, 0.61 (95% confidence interval, 0.35-0.86, p<0.01); and (7) the Kidney Disease Quality of Life, 0.41 (95% confidence interval, 0.17-0.65, p<0.01).

DISCUSSION

This study revealed a small effect of self-management on interdialytic weight gain; medium effects on self-efficacy, depression, and health-related quality of life; and a large effect on anxiety. However, high-quality randomized controlled trial designs are required to confirm these results, although the existing evidence can guide clinical practitioners and health policy makers.

Preliminary support for a brief psychological intervention to improve first-time hearing aid use among adults

Objectives

Suboptimal hearing aid use extorts significant social, health, and economic costs. The aims of this study were to (1) test the novel hypothesis that the threat associated with being diagnosed with hearing loss could be ameliorated with a self‐affirmation manipulation and (2) gauge the feasibility of deploying the manipulation in routine clinical practice.

Design

Parallel groups randomized controlled trial with 10‐week follow‐up.

Method

Fifty people, newly prescribed with a hearing aid, completed either a questionnaire that included a brief self‐affirming exercise or an identical questionnaire with no self‐affirming exercise. The main outcome measure was derived from data logging automatically stored by the hearing aid. Perceived threat (‘anxiety about ageing’), behavioural intention, and self‐efficacy were measured as potential mediators.

Results

Objectively measured hours of daily hearing aid use were marginally higher in the intervention group compared with the control group (between‐group difference = 1.94 hr, 95%CI = −1.24, 5.12, d = 0.43). At follow‐up, participants in the intervention group were significantly less anxious about ageing and more accepting of older people than were participants in the control group (between‐group difference = 0.75, 95%CI = 0.26, 1.22, d = 0.87). There was no statistically significant effect of the intervention on behavioural intention or self‐efficacy.

Conclusions

Although not statistically significant, the magnitude of the effect of the intervention on hearing aid use (d = 0.43) suggests that it would be worthwhile working towards a fully powered randomized controlled trial. The ability to reduce anxieties about ageing with this brief intervention could have far‐reaching benefits for multiple patient and general population groups.

Adherence to Prophylaxis in Adolescents and Young Adults with Severe Haemophilia: A Quantitative Study with Patients

INTRODUCTION

haemophilia is an inherited bleeding disorder caused by a deficiency in one of the blood coagulation factors. For people affected by severe haemophilia, the deficiency can cause spontaneous internal bleeding. Most young people with severe haemophilia in the UK follow a preventative treatment regimen (prophylaxis) consisting of several intravenous injections of factor concentrate each week. There is good evidence that prophylaxis reduces bleeds whilst also improving quality of life. However, levels of adherence among young people with haemophilia reported in the existing literature vary widely and are predominately based on estimations made by healthcare professionals and parents. Additionally, drivers of (non)adherence among young people specifically have not been evidenced.

AIM

to assess self-reported adherence among young people with haemophilia, provide evidence of psychosocial predictors of adherence, and to establish the associations between non-adherence and number of bleeds and hospital visits.

METHODS

91 participants were recruited during outpatient appointments in 13 haemophilia centres across England and Wales, and invited to complete a questionnaire assessing self-reported adherence (VERITAS-Pro), Haemophilia-related pain and impact of pain, Illness Perceptions, Beliefs about Medications, Self-efficacy, Outcome expectations, Positive and Negative Affect, and Social support. Number of hospital visits and bleeds during the previous six months were collected from medical files.

RESULTS

Of 78 participants with complete data, just 18% had scores indicating non-adherence. Psychosocial predictors differed between intentional (skipping) and un-intentional (forgetting) non-adherence. Overall, however, better adherence was reported where participants perceived the need for prophylaxis was greater than their concern over taking it as well as having a positive expectancy of its effectiveness, good social support and a stronger emotional reaction to having haemophilia.

CONCLUSION

The findings indicate that adherence is generally good, and that assessing illness and treatment beliefs, social support and outcome expectations may play a valuable role in identifying which individuals are at risk of non-adherence. Interventions aimed at improving adherence should particularly consider improving social support, reducing patients' concerns about prophylaxis, increasing their belief in the necessity of prophylaxis, and increasing positive outcome expectations.

Differences in Knowledge, Stress, Sensation Seeking, and Locus of Control Linked to Dietary Adherence in Hemodialysis Patients

Patients with chronic kidney disease (CKD) often require regular hemodialysis (HD) to prolong life. However, between HD sessions, patients have to restrict their diets carefully to avoid excess accumulation of potassium, phosphate, sodium, and fluid, which their diseased kidneys can no longer regulate. Failure to adhere to their renal dietary regimes can be fatal; nevertheless, non-adherence is common, and yet little is known about the psychological variables that might predict this dietary behavior. Thus, this study aimed to assess whether dietary adherence might be affected by a variety of psychological factors including stress, personality, and health locus of control, as well as dietary knowledge, in chronic HD patients. Fifty-one patients (30 men; age range 25-85) who had undergone HD for at least 3 months and had been asked to restrict at least one of potassium, phosphate or fluid, were recruited from a hospital renal unit. Measures of adherence to each of potassium, phosphate, and fluid were derived from standard criteria for these physiological indices in renal patients. Knowledge of food/drink sources of these dietary factors, and their medical implications in relation to HD and CKD were assessed by a bespoke questionnaire. Psychological factors including stress, personality and health locus of control beliefs were measured by standardized questionnaires. Having to restrict a particular nutrient was associated with better knowledge of both food sources and medical complications for that nutrient; however, greater dietary knowledge was not linked to adherence, and knowledge of medical complications tended to be associated with poorer adherence to potassium and phosphate levels. Adherence to these two nutrient requirements was also associated with lower reported stress in the past week. Adherence was associated with differences in locus of control: these differences varied across indices although there was a tendency to believe in external loci. For potassium, phosphate, and fluid restriction, adherers were less likely to be sensation seekers but did not differ from non-adherers on impulsivity, anxiety sensitivity, or hopelessness. In conclusion, the links between dietary adherence and stress, locus of control and personality suggests that screening for such psychological factors may assist in managing adherence in HD patients.

You Should Know Better: Can Self-Affirmation Facilitate Information-Seeking Behavior and Interpersonal Discussion?

This study explores whether self-affirmation has the capacity not merely to reduce the perceived threat associated with health-related information but also to facilitate interpersonal discussion and affect health information-seeking behavior. The context for the study is the ongoing California drought, which serves as suitable context to examine the intersection of self-affirmation and information-seeking behavior because it involves a threatening message (the destructive consequences of the drought) and highlights discrepancies between actual (water waste) and prosocial (water conservation) behavior. Results of a month-long longitudinal panel study demonstrate significant effects of self-affirmation on interpersonal discussion, information seeking, knowledge, and water-conserving behavior across time. Implications for theorizing longer term effects of self-affirmation and practical implications for promoting behavioral change through the enhancement of knowledge and self-esteem are considered.

How Effective are Behavior Change Interventions Based on the Theory of Planned Behavior?

Abstract. The theory of planned behavior (TPB) is a prominent framework for predicting and explaining behavior in a variety of domains. The theory is also increasingly being used as a framework for conducting behavior change interventions. In this meta-analysis, we identified 82 papers reporting results of 123 interventions in a variety of disciplines. Our analysis confirmed the effectiveness of TPB-based interventions, with a mean effect size of .50 for changes in behavior and effect sizes ranging from .14 to .68 for changes in antecedent variables (behavioral, normative, and control beliefs, attitude, subjective norm, perceived behavioral control, and intention). Further analyses revealed that the interventions’ effectiveness varied for the diverse behavior change methods. In addition, interventions conducted in public and with groups were more successful than interventions in private locations or focusing on individuals. Finally, we identified gender and education as well as behavioral domain as moderators of the interventions’ effectiveness.

A pilot randomised test of a self-affirmation implementation intention intervention to reduce dietary salt intake

Self-affirmation may reduce defensive processing towards health messages. We tested the effects of a self-affirmation implementation intentional intervention with regard to salt risk message acceptance, estimates of daily-recommended intake and self-reported intake. Participants ( n = 65) who consumed over 6 g/day of salt were randomised into three conditions: self-affirmation, self-affirming implementation intention and control. Participants attended the laboratory and completed a 2-week follow-up. There was no effect of the condition on message acceptance, salt estimation and 2-week salt intake. Across conditions, 2-week salt intake was reduced. We found no evidence for either intervention with regard to salt risk message acceptance and behaviour change.

Online Self-Affirmation Increases Fruit and Vegetable Consumption in Groups at High Risk of Low Intake

BACKGROUND

This study tested the efficacy of self-affirmation in promoting fruit and vegetable consumption in a sample of participants comprising two groups at high risk of low consumption: young adults and mothers of school-aged children with low social economic status (SES).

METHODS

Baseline fruit and vegetable consumption was recorded for 85 participants (n = 26 mothers with low SES). Following randomisation to condition (Self-Affirmed or Non-Affirmed), participants viewed targeted, online, health recommendations about fruit and vegetable consumption. Fruit and vegetable intake was reported online every day for the following seven days.

RESULTS

Self-affirmed participants reported consuming significantly more portions of fruit and vegetables (SA M = 3.96, NA M = 2.81). Analyses of simple slopes indicated that the effect was greatest amongst lowest baseline consumers.

CONCLUSIONS

The findings demonstrate the efficacy of self-affirmation in increasing fruit and vegetable consumption in individuals who are at risk of having a low intake and whose consumption put them at the greatest risk of negative health outcomes. Application of these findings could help to reduce health care costs, through the use of cost-effective online interventions and reductions in treatment costs. Further research is needed to capitalise on the increased tailoring that online intervention allows in order to optimise the effects of self-affirmation.

Medication beliefs are associated with phosphate binder non-adherence in hyperphosphatemic haemodialysis patients

OBJECTIVES

Patients with end-stage kidney disease receiving haemodialysis (HD) are at risk of cardiovascular disease and bone disorders related to high levels of serum phosphate. We studied the association between medication beliefs and depressive symptoms, with non-adherence to phosphate binding medication in a group of HD patients at risk of complications due to hyperphosphatemia.

DESIGN

Cross-sectional design.

METHODS

Baseline data from 112 patients participating in a randomized controlled trial, evaluating an adherence intervention, are presented. All patients had serum phosphate levels >1.6 mmol/l at baseline. Adherence was measured by (1) serum phosphate and (2) Medication Adherence Report Scales (MARS). Beliefs about Medicines (BMQ) and depressive symptoms (PHQ-9) were also evaluated.

RESULTS

Beliefs about Medicines Questionnaire necessity, but not concerns, beliefs were found to correlate with serum phosphate (r = -.23, p < .05) and self-reported adherence (r = .35, p < .01). In regression models, controlling for demographic, clinical and psychological variables, necessity beliefs explained the variance of serum phosphate (β = -.22, p = .01) and self-reported adherence (β = .30, p ≤ .01). Both BMQ concerns and depressive symptoms were not related to non-adherence.

CONCLUSION

Patients' beliefs about the necessity of their prescribed phosphate binding medications explain variation in non-adherence levels, measured both subjective and objectively. Dialysis patient's medication beliefs are potentially modifiable targets for future interventions.