Article

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

Authors:
  • Lister Hospital, East and North Hertfordshire NHS Trust, ListerStevenage, UK
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Hemodialysis patients are at risk of serious health complications, yet treatment non-adherence remains high. Warnings about health risks associated with non-adherence may trigger defensive reactions. We studied whether an intervention based on self-affirmation theory (Steele 1988) reduced patients' resistance to health-risk information and improved adherence. One hundred twelve patients either self-affirmed or completed a matched control task before reading about the risks associated with a lack of phosphate control. Serum phosphate was collected from baseline up to 12 months. Self-affirmed patients had significantly reduced serum phosphate levels at 1 and 12 months. However, contrary to the predictions derived from self-affirmation theory, self-affirmed participants and controls did not differ in their evaluation of the health-risk information, behavioural intention or self-efficacy. A low-cost, high-reach health intervention based on self-affirmation theory was shown to reduce serum phosphate over a 12 month period. Further work is required to identify mediators of the observed effects.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Change in IDWG. Selfreported measure of fluid intake (1-5 scale), Selfefficacy 12 m / Partially positive / Benefits persisted @ 12 m Wileman V et al (2014) [49] Cluster randomized / HD (Diet + Medication) / Psychologist (selfaffirmation theory) 112 (57/55) / 60. 5 Re-affirmation act before receiving health information about phosphate control and risks at baseline and briefer reaffirm-ation act before health information at 1,3 and 6 months. The act required participants to recall past act of kindness. ...
... Psychologists were the interventionists in seven trials, while a pharmacist [43] and relaxation therapy In fifteen studies (42%), theoretical models of behaviour relevant to treatment adherence formed the basis of the trialled intervention. The health belief model [27,32,41,45] was the most commonly used, while self-efficacy theory [7,45,46], social cognitive theory [30,47], self-affirmation theory [48,49], trans-theoretical models (TTM) [35,37], self-regulation theory [34], King's theory of goal attainment [12] and the ABC (Antecedents, Behaviour, Consequences) model relevant to rational emotive therapy [33] were also invoked. Six out of seven studies, where the interventionist was a psychologist, had a theoretical behavioural underpinning. ...
... The dominant category was assigned by consensus, with guidance when necessary from the senior psychologist among the authors. Eleven studies evaluated educational or cognitive interventions, four had behavioural or counselling interventions [6,12,27,45], four had psychological or affective interventions [33,39,48,49] and fourteen studies had elements of different categories in the trialled intervention (refer to Table 1). ...
Full-text available
Article
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 1st 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.
... Specifically, the study piloted a self-affirmation theory-based intervention aimed at improving phosphate binder medication adherence in patients receiving haemodialysis. A cluster randomised controlled trial demonstrated a significant effect of self-affirmation processes on improving patients' phosphate treatment control over 12 months (Wileman et al., 2014). However, the trial also revealed some unexpected findings; self-affirmed and control patients did not significantly differ in their responses to the health-risk information or their intentions to control their phosphate. ...
... The self-affirmation intervention utilised in the current study was developed within studies assessing public health behaviour change and is relatively new in this clinical setting with just one prior study (Wileman et al., 2014). Therefore, there is limited evidence on which to estimate its potential effect, and hence a pragmatic approach was adopted to estimate the required sample size following Medical Research Council guidelines. ...
... This is just the second study to evaluate the efficacy of a behavioural intervention based on selfaffirmation theory among people with ESKD receiving haemodialysis. To our knowledge, it is one of the only two studies to assess the unique effects of self-affirmation in a clinical setting such as ESKD (Wileman et al., 2014). This study aimed to determine whether a self-affirmation theory-based intervention altered patients' perceptions of the health-risk information and subsequent behaviour indicated by an improvement in fluid control (reduction in IDWG). ...
Article
Objective: Haemodialysis patients are at risk of serious health complications; yet, treatment non-adherence remains high. Warnings about health risks associated with non-adherence may trigger defensive reactions. We studied whether an intervention based on self-affirmation theory reduced resistance to health-risk information and improved fluid treatment adherence. Design: In a cluster randomised controlled trial, 91 patients either self-affirmed or completed a matched control task before reading about the health-risks associated with inadequate fluid control. Outcome measures: Patients' perceptions of the health-risk information, intention and self-efficacy to control fluid were assessed immediately after presentation of health-risk information. Interdialytic weight gain (IDWG), excess fluid removed during haemodialysis, is a clinical measure of fluid treatment adherence. IDWG data were collected up to 12 months post-intervention. Results: Self-affirmed patients had significantly reduced IDWG levels over 12 months. However, contrary to predictions derived from self-affirmation theory, self-affirmed participants and controls did not differ in their evaluation of the health-risk information, intention to control fluid or self-efficacy. Conclusion: A low-cost, high-reach health intervention based on self-affirmation theory was shown to reduce IDWG over a 12-month period, but the mechanism by which this apparent behaviour change occurred is uncertain. Further work is still required to identify mediators of the observed effects.
... Reviews on the self-management of CKD have included only papers published between 2003 and 2013. Several randomized controlled trials (RCTs) assessing the efficacy of self-management programs for CKD have been published since then (Blakeman et al., 2014;Hare et al., 2014;He et al., 2014;Valsaraj et al., 2016;Wang, 2014;Wileman et al., 2016Wileman et al., , 2014). An updated systematic review of the effect of selfmanagement on CKD was therefore needed. ...
... Interdialytic weight (kg) gain was measured by the amount of weight gain between the end of one dialysis session and the beginning of the next session in five studies (Hare et al., 2014;Moattari et al., 2012;Sharp et al., 2005;Tsay, 2003;Wileman et al., 2016). Self-efficacy was determined using the Strategies Used by People to Promote Health in three studies and evaluation of health-risk information in one study (Lii et al., 2007;Moattari et al., 2012;Tsay and Hung, 2004;Wileman et al., 2014). Ten studies assessed HRQOL. ...
Article
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.
... Self-affirmation interventions have been found to increase message acceptance and reduce message defensiveness towards a range of health threat messages in 'high-risk' individuals, for example, smoking (DiBello et al., 2015) and alcohol consumption (Klein et al., 2015) and can increase levels of physical activity and intentions to be more physically active (Cooke et al., 2014); decrease defensiveness and increase acquisition of free sunscreen samples following health threat information (Jessop et al., 2009). In addition, selfaffirmation interventions have been found effective in clinical settings (Wileman et al., 2014(Wileman et al., , 2016. ...
... Research has found self-affirmation has produced successful outcomes for several health behaviours: smoking, alcohol consumption, physical activity, use sunscreen and medication adherence (Cooke et al., 2014;DiBello et al., 2015;Jessop et al., 2009;Klein et al., 2015;Wileman et al., 2014Wileman et al., , 2016. With regard to dietary salt, we report no effect of self-affirmation implementation intentions or self-affirmation upon outcomes. ...
Full-text available
Article
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.
... The mechanisms underlying the positive effects were not clear and did not directly align with the theory guiding intervention development. (13,14) Additionally, in meta-analysis there was no association between intervention efficacy and the role or expertise of individuals delivering the interventions, the underlying theory, or the type of intervention (e.g. educational or psychological). ...
Article
Background: Patients with end-stage kidney disease treated with hemodialysis in the U.S. have persistently higher rates of nonadherence compared to patients in other developed countries. Nonadherence is associated with 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 U.S. 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. Additionally, 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 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.
... To support engagement, motivational interviewing principles will be weaved into the delivery of the programme including Elicit-Provide-Elicit Framework for offering advice/feedback as opposed to didactic delivery, and HED-Start will focus on the following key skills, shown to support emotional adjustment: goal setting and working towards attainable goals 27 46 ; cognitive reframing 47 ; acceptance, gratitude and mindfulness 48 ; personal strengths and affirmations. 49 HED-Start will comprise four sessions to be delivered every 2 weeks in groups of 5-8 participants (as per safe management procedures). Sessions, lasting 120 min each, are to be cofacilitated by two renal HCPs (ie, medical social workers) following training and an internal pilot to ensure consistency. ...
Full-text available
Article
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 .
... Consistently offering in-centre HD patients the opportunity to learn about and participate in their treatment potentially enables access to some of the health benefits that are associated with HHD as well as impacting on patient activation and health literacy while aligning with the goals of person-centred care [4,5]. Self-management programmes for in-centre hemodialysis patients have been associated with improvements in empowerment, perceived self-efficacy, medication adherence, phosphate control and interdialytic weight gain between dialysis sessions which all correlate with mortality and symptom burden [6][7][8][9][10]. ...
Full-text available
Article
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.
... 14 Self-care approaches have been successful in other chronic disease states as well as in chronic kidney disease. [15][16][17][18][19][20][21][22] One of the barriers to self-care hemodialysis both in the home and in-center settings has been the absence of technology that enables patients to easily learn and confidently manage their treatment in a time efficient manner with minimal burden on health care workers or caregivers. 15 The Tablo hemodialysis system is an all-in-one, patientcentric system designed to be easy to learn and manage with on-demand dialysate production and two-way wireless connectivity. ...
Full-text available
Article
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.
... A range of psychosocial interventions have promise in improving outcomes, personality traits, and adherence in chronic conditions, but evidence is lacking in KRT populations. Self-affirmation has been shown to improve phosphate and fluid management in adult patients on hemodialysis (27,28). A systematic review of personality traits changes through intervention found marked differences over 24 weeks in personality trait measures (29). ...
Article
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.
... 80 Similarly, self-affirmation -which involves reflection on one's personal values in order to reduce resistance to healthrisk information -has been successfully used to improve adherence. 81 These patient empowerment techniques address the most influential factors of phosphate binder adherence, including beliefs and attitudes. 10 Other potential novel approaches for patient empowerment in improving medication adherence include the use of electronic monitoring devices. ...
Full-text available
Article
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.
... All guidelines provide advice about reducing dietary intake of foodstuffs with a high phosphate content, because dietetic and other interventions designed to increase patient education and improve compliance can lead to a reduction in serum phosphate concentration, certainly in the short term (7)(8)(9). ...
Article
Hyper- and hypophosphatemia are recognized risk factors for all-cause mortality in peritoneal dialysis (PD) patients. Recent changes have now focused PD solute clearance targets on urea clearance, rather than on larger solutes, including phosphate. We therefore studied peritoneal phosphate clearance in a cohort of PD patients to determine which factors were clinically relevant.We reviewed results from 451 adult PD patients who were attending for their first assessment of peritoneal membrane function [31.2% treated by continuous ambulatory PD (CAPD); 24.2.%, by automated PD (APD); and 44.6% by APD with a daytime exchange]. Demographics, PD adequacy parameters, peritoneal phosphate clearance, and transport status were reviewed.Of the study patients, 119 (26.4%) were hyperphosphatemic, and 59 (30.1%) were hypophosphatemic; 22.2% were fast transporters. Total daily peritoneal phosphate losses were greater for the hyperphosphatemic than for the hypophosphatemic patients [15 mg/ dL (range: 10.5-18.6 mg/dL) vs. 25.7 mg/dL (range: 15.5-29.8 mg/dL), p < 0.01], although peritoneal phosphate clearance was less [2.7 mL/min/1.73 m2 (range: 1.6-4.1 mL/min/1.73 m2) vs. 4.2 mL/ min/1.73 m2 (range: 2.1-4.1 mL/min/1.73 m2), p < 0.001]. Peritoneal phosphate clearance was greater for faster compared with slower transporters [3.5 mL/ min/1.73 m2 (range: 2.5-4.5 mL/min/1.73 m2) vs. 1.6 mL/min/1.73 m2 (range: 1.1-2.2 mL/min/1.73 m2), p < 0.05] and for patients treated either with APD plus a daytime exchange or with CAPD compared with APD alone [3.44 mL/min/1.73 m2 (range: 2.3-5.0 mL/ min/1.73 m2) vs. 2.9 mL/min/1.73 m2 (range: 1.5- 4.4 mL/min/1.73 m2) vs. 1.6 mL/min/1.73 m2 (range: 1.1-2.4 mL/min/1.73 m2, p < 0.001)]. On multivariate analysis, increased peritoneal clearance was associated with faster peritoneal transport status, younger age, lower serum albumin, and lower serum phosphate.Peritoneal phosphate clearance depends not only PD modality, but also patient factors, including peritoneal transport status and variables associated with inflammation.
... Applications of self-affirmation have varied widely over the past few decades, ranging from reducing the negative impacts of stress toward academic performance (e.g., Cohen, Garcia, Apfel, & Master, 2006;Creswell et al., 2005) to improving adherence to potentially life-saving health interventions (e.g., Wileman et al., 2014). However, most notable for this study is the influence that self-affirmation has on how people respond to persuasive messages, especially in the health-risk context. ...
Article
Research suggests a limited influence for corrective information in promoting more accurate beliefs, a phenomenon attributed to directional-motivated reasoning. We consider whether an act of self-affirmation—providing people with an alternative source of self-worth—reduces directional-motivated reasoning, thereby improving the effectiveness of corrective information. Across two experiments, self-affirmation was found to mitigate the influence of prior attitudes in how people responded to corrective information, resulting in greater belief accuracy. This effect was especially notable among those for whom the correction ran counter to existing attitudes. These findings contribute to our understanding of when corrections are likely to be effective and suggest practical approaches that might be implemented to improve the success of corrective information.
... 1. there would be significant differences between adolescents and young adults in relation to psychosocial correlates of adherence[13] 2. greater pain (and impact of this pain) would be associated with better adherence[6, 14] 3. illness perceptions, in particular higher perceptions of chronicity, consequences and treatment control, would be predictive of higher adherence [9, 15] 4. beliefs about medicines, in particular perception of greater necessity of prophylactic treatment , would be predictive of better adherence [9,[16][17][18][19]. 5. patients with greater negative mood would have lower adherence scores[20][21][22]. ...
Full-text available
Article
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.
... For HD patients, interventions based on education have been shown to improve knowledge but not adherence (Wells, 2011). In this patient group, there are few interventions based on psychological theories related to behavior change, and so far mixed results that fail to support the efficacy of the theory-driven approaches chosen (Molaison and Yadrick, 2003;Wileman et al., 2014). Interventions may need to be tailored for particular patients; moreover, it is clear from our results that the different members of the renal multidisciplinary team all need to play important roles as the locus of control data point to differential impact on adherence among patients. ...
Full-text available
Article
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.
... Field studies among individuals with chronic diseases find that self-affirmation can increase health and well-being. Hemodialysis patients, a group wherein treatment nonadherence is common, self-affirmed or completed a control activity before reading health-related information emphasizing treatment adherence (Wileman et al., 2014). Affirmed patients were more likely to adhere to their treatment regimen , showing healthier blood tests up to 12 months after the self-affirmation intervention. ...
Full-text available
Article
Public policies designed to improve health and well-being are challenged by people’s resistance. A social psychological perspective reveals how health policies can pose a psychological threat to individuals and result in resistance to following health recommendations. Self-affirmation, a brief psychological intervention that has individuals focus on important personal values, can help reduce resistance to behavior change and help promote health and well-being in four health-policy domains: graphic cigarette warning labels designed to get people to quit smoking, community health programs targeted at high-risk populations, alcohol intervention and prevention programs targeted at problem drinkers, and adherence to medical recommendations and treatment regimens among people coping with disease. Using self-affirmation has important strengths and limitations as a tool to help policymakers and practitioners encourage better health choices.
Article
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.
Article
Nonadherence to therapy (dietary/fluid restrictions, medications, and dialysis treatment), is common in patients with end-stage kidney disease (ESKD) undergoing dialysis. It is associated with a higher risk of mortality and adverse outcomes. Clinical trials evaluating adherence improvement interventions have largely addressed patient-related factors by employing educational/cognitive, counselling/behavioral, psychological strategies, or combinations thereof. A major barrier to progress in addressing ESKD-related adherence is the difficulty in comparing these trials due to the highly diverse nature of interventions and adherence outcomes. Surrogate outcomes like changes in inter-dialysis weight gain or phosphate levels are frequently used without adjusting for confounders, with the potential for biased efficacy estimates. A majority of trials reported improvement in some adherence measures, but some of the same studies showed no improvement in other adherence markers, questioning the validity of outcome measurement. Among the interventions, cognitive/behavioral strategies, combination strategies, and individually delivered interventions may have some advantages. Relapse of nonadherence, which is common on follow-up, should be managed to sustain long-term adherence. Technology-based interventions hold great future potential for addressing ESKD nonadherence. Streamlining intervention strategies and standardizing outcome measures in future clinical trials will provide reliable guidance to manage nonadherence effectively, which may improve clinical outcomes in dialysis patients.
Chapter
The management of end-stage renal disease (ESRD) is complex and necessitates significant self-management behaviors, including treatment adherence, which are often stressful and challenging for patients. Estimates of adherence to the various aspects of ESRD management vary as a product of the behavior under investigation (such as taking medicines, dietary restrictions, or dialysis attendance) and the heterogeneity of assessment methods employed. Despite this, nonadherence is a common problem that is associated with adverse clinical outcomes. Patient-, disease-, and treatment-related factors are all associated with nonadherence in ESRD patients. Psychosocial factors including mood, self-efficacy, social support, illness, and treatment perceptions have all been shown to be particularly important predictors of adherence and may be amenable to intervention. There is emerging evidence showing the benefits of psychosocial interventions for supporting adherence. Identifying ESRD patients who show problematic adherence and establishing the most effective interventions designed to better support adherence require further research informed by theory. Ultimately, understanding how to best implement evidence-based interventions to support adherence as part of routine ESRD care is critical if we are to improve patient and clinical outcomes.
Full-text available
Article
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.
Article
Introduction: Traditionally hemodialysis (HD) treatments are undertaken by dialysis staff. Self-care has been reported to improve psychological well-being and treatment compliance for patients with chronic diseases. We evaluated our shared-care HD program to determine whether shared-care benefits patients. Methods: We reviewed the electronic health care and HD sessional records and psychological distress thermometer (DT) scores of patients in our HD centers. HD shared care was classified as grade 0-none, grade 1 patients weighing themselves and measuring blood pressure (BP), grade 2 performs HD, and grade 3 additionally troubleshoots problems. Findings: We reviewed 675 HD patients; mean age 64.1 ± 16.3 years, 62.3% male, 45.9% diabetic, Stoke-Davies co-morbidity grade 1 (1-1), frailty score 4 (3-5), DT 3 (0-5). 60.3% performed no shared care, 19% grade 1, 14.8% grade 2, and 6% grade 3. Patients performing more shared care were younger, less frail, less co-morbid, and physically stronger. We then propensity matched 113 patients with grade ≥ 2 shared care for age and frailty with 113 no shared-care patients. Fewer shared-care patients were prescribed antihypertensives (50.7 vs. 70.7%, P < 0.01), and had lower serum N terminal probrain natriuretic peptide 3033 (1083-8502) vs. 4814(1514-135821) pg/mL), phosphate (1.62 ± 0.49 vs. 1.78 ± 0.62 mmol/L), and higher albumin (40.7 ± 4.3 vs. 38.0 ± 4.3 g/L), all P < 0.05 but no differences in psychological DT scores. Discussion: Although there was no significant benefit in psychological well-being, as measured by the self-reported DT, patients performing more shared care demonstrated other benefits in terms of blood pressure and volume control.
Article
Objective: Hyperphosphatemia is a common complication in patients with end-stage renal disease on hemodialysis. The mainstay of phosphate management involves a low-phosphate diet and use of phosphate binders, yet these are often insufficient. This study was the first to use behavioral change techniques to encourage the use of phosphate binders and dietary modifications through a series of Phosphate Education and Planning (PEP) talks. Design and methods: A total of 46 hemodialysis patients with hyperphosphatemia were enrolled. All patients were eligible to receive a series of 4 talks, each with defined goals of the long-term management of serum phosphate levels. Qualitative data from the talks were gathered during each intervention, whereas serum phosphate was selected as an outcome measure. Results: There was a modest improvement (-0.31 mg/dL) in the serum phosphate levels of the patients who received the entire PEP talk series. Furthermore, the most common self-identified barriers for patients were phosphate binder prescriptions not tailored to their eating routines and lack of resources for suitable dietary changes. Conclusions: The PEP talk series model is appropriate to manage persistent hyperphosphatemia despite usual management in outpatient dialysis unit by identifying patient-specific barriers and providing resources that can mitigate them. The strength of this model lies in using a multifaceted approach by applying both pharmacotherapy and dietary changes, along with behavioral change, to achieve lasting improvements in serum phosphate levels in hemodialysis patients with persistently elevated serum phosphate levels.
Full-text available
Article
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. Statement of contribution What is already known on this subject? Hearing impairment is more disabling than diabetes, yet hearing aid use is suboptimal. Anxieties about ageing may undermine hearing aid use. What does this study add? The study tests a brief theory-based psychological intervention to reduce anxiety about ageing and promote hearing aid use. Results show that the brief psychological intervention reduced anxiety and marginally increased objective hearing aid use. Further work is required to identify other situations in which anxieties about ageing undermine behaviour change efforts. The very brief, flexible nature of the intervention means it could be adapted and deployed in numerous other health care settings.
Full-text available
Article
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.
Article
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.
Article
We test the effect of self-affirmation on behavioral intentions and delay discounting. • Number of health risks was included as a moderator. • Self-affirmation increased general intentions among people with more health risks. • However, self-affirmation did not impact specific consumption intentions. • Self-affirmation did not impact preferences for immediate vs. delayed rewards. a b s t r a c t Numerous studies indicate that focusing on one's important values or attributes, a process known as self-affirmation, facilitates forming intentions to change one's behaviors in self-threatening domains. However, little is known about the mechanisms that underlie these effects. The present study tested the pre-registered hypothesis that self-affirmation increases intentions to change health-relevant behaviors among participants with relatively high health risks as a result of broadening their temporal perspectives. Among participants with relatively high health risks, self-affirmation indeed led to greater general intentions to increase consumption of fruits and vegetables, but not specific consumption intentions. Furthermore, there was no significant effect of the self-affirmation manipulation on temporal perspective, as assessed by a monetary delay discounting task. These findings confirm the beneficial effects of self-affirmation on general intentions to change health-relevant behaviors among those with a relatively high health risk, while drawing further attention to the need to elucidate the underlying psychological mechanisms of self-affirmation.
Article
How can progress in research on health behavior change be accelerated? Experimental medicine (EM) offers an approach that can help investigators specify the research questions that need to be addressed and the evidence needed to test those questions. Whereas current research draws predominantly on multiple overlapping theories resting largely on correlational evidence, the EM approach emphasizes experimental tests of targets or mechanisms of change and programmatic research on which targets change health behaviors and which techniques change those targets. There is evidence that engaging particular targets promotes behavior change; however, systematic studies are needed to identify and validate targets and to discover when and how targets are best engaged. The EM approach promises progress in answering the key question that will enable the science of health behavior change to improve public health: What strategies are effective in promoting behavior change, for whom, and under what circumstances? Expected final online publication date for the Annual Review of Psychology Volume 68 is January 03, 2017. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Article
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.
Chapter
Many messages that aim at changing people’s health behaviors highlight the negative consequences of continuing to engage in current behaviors (insufficient physical activity and smoking). However, such messages are often less effective than desired because people respond defensively to threatening communication by ignoring or derogating it. In this chapter, we discuss how self-affirmation theory can assist both in understanding individual defensive responses and in improving the effectiveness of health messages. Self-affirmation theory proposes that messages that highlight negative consequences of current behavior provoke defensive responses because they threaten a person’s view of themselves as being good and adequate. However, the theory also poses that if people affirm an unrelated domain of their self-system, defensive responses decrease and more adaptive behavior ensues. In this chapter, we provide an updated review of the evidence for self-affirmation effects on health behavior change, discuss circumstances under which self-affirmation might work better or worse, outline the psychological processes mediating self-affirmation effects and present some recommendations for the use of self-affirmation in interventions to change health behaviors.
Article
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.
Article
The research partnership between the British Kidney Patient Association and British Renal Society has just become stronger. Over the next year, the number of research-funded grant rounds will increase to two per year, doubling the amount of available research funding to support renal research. Paula Ormandy and Paddy Tabor discuss how this work is improving care and service delivery.
Article
Non-adherence to medication is a significant problem in the UK and can be owing to poor understanding of conditions, lack of social support and complex regimens. Although improving adherence can be challenging for health professionals, there are some useful approaches to try. Rebecca Walker shares her thoughts on improving adherence to phosphate binders.
Article
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. DesignCross-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 >1.6mmol/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. ResultsBeliefs 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 (=-.22, p=.01) and self-reported adherence (=.30, p.01). Both BMQconcerns 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.
Full-text available
Article
An experiment tested whether a positive experience (the endorsement and recall of one's past acts of kindness) would reduce biased processing of self-relevant health-risk information. Women college students (N = 66) who reported high or low levels of daily caffeine use were exposed to both risk-confirming and risk-disconfirming information about the link between caffeine consumption and fibrocystic breast disease (FBD). Participants were randomly assigned to complete an affirmation of their kindness via questionnaire or to a no-affirmation condition. Results indicated that the affirmation manipulation made frequent caffeine drinkers more open, less biased processors of risk-related information. Relative to frequent caffeine drinkers who did not affirm their kindness, frequent caffeine drinkers in the affirmation condition oriented more quickly to the risk-confirming information, rated the risk-confirming information as more convincing than the risk-disconfirming information, and recalled less risk-disconfirming information at a 1-week follow-up. They also reported greater perceived personal control over reducing their level of caffeine consumption. Although frequent caffeine drinkers in the affirmation condition initially reported lower intentions to reduce their caffeine consumption, there was no evidence that they were less likely to decrease their caffeine consumption at the follow-up. The possibility that positive beliefs and experiences function as self-regulatory resources among people confronting threats to health and well-being is discussed.
Full-text available
Article
Some propose using phosphate binders in the CKD population given the association between higher levels of phosphorus and mortality, but their safety and efficacy in this population are not well understood. Here, we aimed to determine the effects of phosphate binders on parameters of mineral metabolism and vascular calcification among patients with moderate to advanced CKD. We randomly assigned 148 patients with estimated GFR=20-45 ml/min per 1.73 m(2) to calcium acetate, lanthanum carbonate, sevelamer carbonate, or placebo. The primary endpoint was change in mean serum phosphorus from baseline to the average of months 3, 6, and 9. Serum phosphorus decreased from a baseline mean of 4.2 mg/dl in both active and placebo arms to 3.9 mg/dl with active therapy and 4.1 mg/dl with placebo (P=0.03). Phosphate binders, but not placebo, decreased mean 24-hour urine phosphorus by 22%. Median serum intact parathyroid hormone remained stable with active therapy and increased with placebo (P=0.002). Active therapy did not significantly affect plasma C-terminal fibroblast growth factor 23 levels. Active therapy did, however, significantly increase calcification of the coronary arteries and abdominal aorta (coronary: median increases of 18.1% versus 0.6%, P=0.05; abdominal aorta: median increases of 15.4% versus 3.4%, P=0.03). In conclusion, phosphate binders significantly lower serum and urinary phosphorus and attenuate progression of secondary hyperparathyroidism among patients with CKD who have normal or near-normal levels of serum phosphorus; however, they also promote the progression of vascular calcification. The safety and efficacy of phosphate binders in CKD remain uncertain.
Full-text available
Article
The aim of the present study was to examine whether self-affirmation promotes acceptance of threatening type 2 diabetes information and risk-testing behaviour. In an experimental study (N = 84), we manipulated self-affirmation by allowing participants to affirm a value that was either personally important or unimportant to them, and measured participants' risk level prior to reading threatening type 2 diabetes information. As dependent variables, we measured message derogation, intentions to do an online type 2 diabetes risk test and online risk-testing behaviour. Findings showed that self-affirmation decreased message derogation, increased intentions to do an online risk test and promoted online risk test taking among at-risk participants. Among participants not at-risk, self-affirmation decreased intentions and online risk test taking. Therefore, it is concluded, that for an at-risk population self-affirmation can decrease defensive responses to threatening health information and promote (online) risk test taking for diseases.
Full-text available
Article
The fear appeal literature is examined in a comprehensive synthesis using meta-analytical techniques. The meta-analysis suggests that strong fear appeals produce high levels of perceived severity and susceptibility, and are more persuasive than low or weak fear appeals. The results also indicate that fear appeals motivate adaptive danger control actions such as message acceptance and maladaptive fear control actions such as defensive avoidance or reactance. It appears that strong fear appeals and high-efficacy messages produce the greatest behavior change, whereas strong fear appeals with low-efficacy messages produce the greatest levels of defensive responses. Future directions and practical implications are provided.
Full-text available
Article
Cardiovascular events are the leading cause of death in end stage renal disease (ESRD). Adherence to phosphate binding medication plays a vital role in reducing serum phosphorus and associated cardiovascular risk. This poses a challenge for patients as the regimen is often complex and there may be no noticeable impact of adherence on symptoms. There is a need to establish the level of nonadherence to phosphate binding medication in renal dialysis patients and identify the factors associated with it. The online databases PsycINFO, Medline, Embase and CINAHL were searched for quantitative studies exploring predictors of nonadherence to phosphate binding medication in ESRD. Rates and predictors of nonadherence were extracted from the papers. Thirty four studies met the inclusion criteria. There was wide variation in reported rates of non-adherence (22-74% patients nonadherent, mean 51%). This can be partially attributed to differences in the way adherence has been defined and measured. Demographic and clinical predictors of nonadherence were most frequently assessed but only younger age was consistently associated with nonadherence. In contrast psychosocial variables (e.g. patients' beliefs about medication, social support, personality characteristics) were less frequently assessed but were more likely to be associated with nonadherence. Nonadherence to phosphate binding medication appears to be prevalent in ESRD. Several potentially modifiable psychosocial factors were identified as predictors of nonadherence. There is a need for further, high-quality research to explore these factors in more detail, with the aim of informing the design of an intervention to facilitate adherence.
Article
Self-affirmation processes are being activated by information that threatens the perceived adequacy or integrity of the self and as running their course until this perception is restored through explanation, rationalization, and/or action. The purpose of these constant explanations (and rationalizations) is to maintain a phenomenal experience of the self-self-conceptions and images as adaptively and morally adequate—that is, as competent, good, coherent, unitary, stable, capable of free choice, capable of controlling important outcomes, and so on. The research reported in this chapter focuses on the way people cope with the implications of threat to their self-regard rather than on the way they cope with the threat itself. This chapter analyzes the way coping processes restore self-regard rather than the way they address the provoking threat itself.
Article
Introduction: This chapter describes the characteristics of adult patients on renal replacement therapy (RRT) in the UK in 2011. The prevalence rates per million population (pmp) were calculated for Primary Care Trusts in England, Health and Social Care areas in Northern Ireland, Local Health Boards in Wales and Health Boards (HB) in Scotland (PCT/HB areas). Methods: Data were electronically collected from all 71 renal centres within the UK. A series of cross-sectional and longitudinal analyses were performed to describe the demographics of prevalent RRT patients in 2011 at centre and national level. Age and gender standardised ratios for prevalence rates in PCT/ HBs were calculated. Results: There were 53,207 adult patients receiving RRT in the UK on 31st December 2011. The UK adult prevalence of RRT was 842 pmp. This represented an annual increase in prevalent numbers of approximately 4%, although there was variation between centres and PCT/HB areas. The growth rate from 2010 to 2011 for prevalent patients by treatment modality in the UK was an increase of 1.7% for haemodialysis (HD), a fall of 2.2% for peritoneal dialysis (PD) and an increase of 4.7% with a functioning transplant. There has been a slow but steady decline in the proportion of dialysis patients receiving PD since 2000. In contrast, the number of patients receiving home HD has increased 16% since 2010. Median RRT vintage for patients on HD was 3.3 years, PD 1.8 years and for those patients with a transplant, 10.3 years. The median age of prevalent patients was 58.2 years (HD 66.5 years, PD 62.7 years, transplant 51.7 years) compared to 55 years in 2000. For all ages the prevalence rate in men exceeded that in women, peaking in age group 75-79 years at 2,918 pmp in males. For females the peak was in age group 65-69 years at 1,460 pmp. The most common recorded renal diagnosis was glomerulonephritis (biopsy proven/not biopsy proven) (19%), followed by uncertain (18%). Transplantation was the most common treatment modality (48.6%), HD in 43.9% and PD 7.6%. However, HD was increasingly common with increasing age and transplantation less common. Conclusions: The HD and transplant population continued to expand whilst the PD population contracted. There were national, regional and dialysis centre level variations in prevalence rates. Prevalent patients were on average three years older than 10 years ago. This has implications for service planning and ensuring equity of care for RRT patients.
Article
General practice p 676The British pioneer clinical epidemiologist Archie Cochrane defined three concepts related to testing healthcare interventions.1 Efficacy is the extent to which an intervention does more good than harm under ideal circumstances (“Can it work?”). Effectiveness assesses whether an intervention does more good than harm when provided under usual circumstances of healthcare practice (“Does it work in practice?”). Efficiency measures the effect of an intervention in relation to the resources it consumes (“Is it worth it?”). Trials of efficacy and effectiveness have also been described as explanatory and management trials, respectively,2 and efficiency trials are more often called cost effectiveness or cost benefit studies.Almost all clinical trials assess efficacy. Such trials typically select patients who are carefully diagnosed; are at highest risk of adverse outcomes from the disease in question; lack other serious illnesses; and are most likely to follow and respond to the treatment of interest. This treatment will be prescribed by doctors who are most likely to …
Article
In a recent paper (Harris & Epton, Social and Personality Psychology Compass, 2009; 3, 962–978), we reviewed the evidence showing that self-affirming – the act of reflecting upon cherished values or attributes – can reduce resistance to health-risk information. In this companion paper, we extend the discussion of issues arising from that review and describe key questions for future research. Overall, we regard the picture emerging from this nascent literature as encouraging. Nevertheless, more needs to be discovered about how self-affirming achieves its effects and their limits. Despite lowering an important barrier to health behaviour change by reducing message resistance, there is currently only limited evidence that self-affirming changes subsequent health behaviour. We consider why. We also discuss issues to address in interventions involving self-affirmation and examine evidence that self-affirming alters relationships between variables. There is also scope for extending the range of samples, health information and health behaviours examined and for assessing more spontaneous self-affirmation.
Article
There is growing evidence that self-affirmation – the process of reflecting upon cherished values or attributes – may have implications for health. Postulated effects range from reducing the defensive resistance to unwelcome health-risk information to ameliorating the physiological response to stress. In this, the first detailed review of the literature on self-affirmation and health, we summarise what is known. Self-affirming can increase acceptance of unwelcome health-risk information, especially among those at greatest risk. Self-affirmed participants typically also report more intention to change behaviour postmessage. There is evidence that certain effects of self-affirming may endure. Self-affirmation has also been shown to have beneficial effects on the response to stress. There is, however, currently only limited evidence of actual health-behaviour change following self-affirmation. We discuss reasons for this and consider key research questions for the next phase of research.
Article
To test the ability of a new, brief means of affirming the self (the "self-affirming implementation intention") to decrease alcohol consumption against a standard means of self-affirmation (the self-affirming "kindness" questionnaire) and an active control condition; to test whether self-affirmation effects can be sustained beyond the experimental session; and to examine potential moderators of the effects. Two hundred seventy-eight participants were randomly allocated to one of three conditions: control questionnaire, self-affirming questionnaire, and self-affirming implementation intention. All participants were exposed to a threatening health message, designed to inform them about the health risks associated with consuming alcohol. The main outcome measure was subsequent alcohol intake. There were significant public health gains and statistically significant decreases (>1 unit/day) in alcohol consumption in the two experimental conditions but not in the control condition. At the end of the study, participants in the control condition were consuming 2.31 units of alcohol per day; people in the self-affirming questionnaire condition were consuming 1.52 units of alcohol per day; and people in the self-affirming implementation intention condition were consuming 1.53 units of alcohol per day. There were no significant differences between the self-affirming questionnaire and self-affirming implementation intention, and adherence did not moderate the effects. Self-affirmation also improved message processing, increased perceived threat, and led to lower message derogation. The findings support the efficacy of a new, brief self-affirmation manipulation to enhance the effectiveness of health risk information over time. Further research is needed to identify mediators of the effects of self-affirmation on health behavior change.
Article
Health-risk communications frequently target self-efficacy in order to encourage adaptive responses. Research has also indicated that self-affirmation may be a useful supplementary or alternative intervention technique. This study compared the effects of self-efficacy, self-affirmation and a combination of these techniques for two risk messages. Young British females (N=677) read about ultraviolet light and skin cancer or skin ageing ('photoageing') and were randomly assigned to a single intervention (self-affirmation/self-efficacy), the combined intervention or no intervention. The efficacy intervention led to greater message acceptance and perceived risk in both the cancer and photoageing conditions, while the only main effect of self-affirmation was on acceptance of the photoageing message. However, self-affirmation moderated the effect of efficacy information. For photoageing messages, efficacy information was associated with greater message acceptance only amongst self-affirmed participants, but the opposite occurred for skin cancer messages. Although these findings should be interpreted cautiously, they imply that health promoters should select efficacy information if only one intervention is used but that self-affirmation can influence responsiveness to efficacy interventions for particular messages.
Article
Phosphate binders include calcium acetate or carbonate, sevelamer hydrochloride or carbonate, magnesium and lanthanum carbonate, and aluminum carbonate or hydroxide. Their relative phosphate-binding capacity has been assessed in human, in vivo studies that have measured phosphate recovery from stool and/or changes in urinary phosphate excretion or that have compared pairs of different binders where dose of binder in each group was titrated to a target level of serum phosphate. The relative phosphate-binding coefficient (RPBC) based on weight of each binder can be estimated relative to calcium carbonate, the latter being set to 1.0. A systematic review of these studies gave the following estimated RPBC: for elemental lanthanum, 2.0, for sevelamer hydrochloride or carbonate 0.75, for calcium acetate 1.0, for anhydrous magnesium carbonate 1.7, and for "heavy" or hydrated, magnesium carbonate 1.3. Estimated RPBC for aluminum-containing binders were 1.5 for aluminum hydroxide and 1.9 for aluminum carbonate. The phosphate-binding equivalent dose was then defined as the dose of each binder in g × its RPBC, which would be the binding ability of an equivalent weight of calcium carbonate. The phosphate-binding equivalent dose may be useful in comparing changes in phosphate binder prescription over time when multiple binders are being prescribed, when estimating an initial binder prescription, and also in phosphate kinetic modeling.
Article
The reported study compared the efficacy of three self-affirmation manipulations in reducing defensive processing and instigating behaviour change in response to personally relevant information about the health risks of sunbathing. White female sunbathers (N = 162) were recruited on a beach in the south of England. Participants were randomly allocated to a 'values affirmation' condition, a 'kindness affirmation' condition, a 'positive traits affirmation' condition, or a no affirmation 'control' condition. In the 'positive traits affirmation' condition the self-affirmation task was incorporated into a leaflet presenting the health risk information. Findings supported the hypothesis that participants in the three self-affirmation conditions would engage in less-defensive processing of the health-risk information than those in the 'control' condition. For the behavioural measure, however, only those participants in the 'positive traits affirmation' condition were more likely to request a free sample of sunscreen than those in the control condition. The implications of these findings for self-affirmation theory and the development of effective health promotion campaigns are discussed.
Article
Nonadherence among hemodialysis patients compromises dialysis delivery, which could influence patient morbidity and mortality. The Dialysis Outcomes and Practice Patterns Study (DOPPS) provides a unique opportunity to review this problem and its determinants on a global level. Nonadherence was studied using data from the DOPPS, an international, observational, prospective hemodialysis study. Patients were considered nonadherent if they skipped one or more sessions per month, shortened one or more sessions by more than 10 minutes per month, had a serum potassium level openface>6.0 mEq/L, a serum phosphate level openface>7.5 mg/dL (>2.4 mmol/L), or interdialytic weight gain (IDWG)>5.7% of body weight. Predictors of nonadherence were identified using logistic regression. Survival analysis used the Cox proportional hazards model adjusting for case-mix. Skipping treatment was associated with increased mortality [relative risk (RR) = 1.30, P = 0.01], as were excessive IDWG (RR = 1.12, P = 0.047) and high phosphate levels (RR = 1.17, P = 0.001). Skipping also was associated with increased hospitalization (RR = 1.13, P = 0.04), as were high phosphate levels (RR = 1.07, P = 0.05). Larger facility size (per 10 patients) was associated with higher odds ratios (OR) of skipping (OR = 1.03, P = 0.06), shortening (OR = 1.03, P = 0.05), and IDWG (OR = 1.02, P = 0.07). An increased percentage of highly trained staff hours was associated with lower OR of skipping (OR = 0.84 per 10%, P = 0.02); presence of a dietitian was associated with lower OR of excessive IDWG (OR = 0.75, P = 0.08). Nonadherence was associated with increased mortality risk (skipping treatment, excessive IDWG, and high phosphate) and with hospitalization risk (skipping, high phosphate). Certain patient/facility characteristics also were associated with nonadherence.
Article
This paper is a report of a study to examine the effectiveness of a patient education programme on fluid compliance as assessed by interdialytic weight gain, mean predialysis blood pressure and rate of fluid adherence. Patients with end stage renal disease who receive haemodialysis are often non-compliant with their treatment regime, especially adherence to fluid restrictions. An exploratory study was conducted in 2004-05 using a quasi-experimental, single group design to examine the effectiveness of patient education on fluid compliance in a dialysis centre located in a major teaching hospital in Kuala Lumpur, Malaysia. Twenty-six patients with an interdialytic weight gain of greater than 2.5 kg were identified as non-compliant and recruited to the study. The intervention was carried out over a 2-month period and included teaching and weekly reinforcement about diet, fluids and control of weight gain. Patients' mean interdialytic weight gain decreased following the educational intervention from 2.64 kg to 2.21 kg (P < 0.05) and adherence to fluid restrictions increased from 47% to 71% following the intervention. Predialysis mean blood pressure did not improve following the intervention, although the maximum recording for predialysis systolic pressure dropped from 220 mmHg to 161 mmHg. Whilst no statistically significant associations were detected between interdialytic weight gain and age, educational level, marital status or employment status, women demonstrated a greater decrease in mean interdialytic weight gain than men. Nephrology nurses often have long-term relationships with their patients and are ideally placed to provide ongoing education and encouragement, especially for those experiencing difficulties in adhering to fluid and dietary restrictions.
Article
This study reports an experiment designed to test whether self-affirmation can overcome defensive processing of risk information in a sample of UK adult smokers with low socioeconomic status. Participants (N = 57) were randomized to either a self-affirmation or control condition before reading a government-sponsored antismoking leaflet and completing measures of message acceptance, intention, and self-efficacy. Participants' subsequent behavior (taking leaflets) was recorded surreptitiously. Results showed that the manipulation significantly increased message acceptance, intention and behavior, and that the effects of the manipulation on behavior were mediated through message acceptance and intention. The practical and theoretical implications of the findings are discussed in relation to the possible use of self-affirmation manipulations to enhance the effectiveness of smoking cessation interventions.
Article
There is increasing evidence that educational interventions aimed at empowering patients are successful in chronic disease management. Our aim was to conduct a systematic review of the effectiveness of such educational interventions in people with kidney disease. SYSTEMATIC REVIEW: A comprehensive search strategy was applied by using major electronic databases from 1980 to March 2007. Researchers independently reviewed titles and abstracts and extracted data from identified studies. Patients in any of the following stages of chronic kidney disease: early, predialysis, and dialysis. Kidney transplant recipients were excluded because this group has additional educational needs that are beyond the scope of this review. Randomized controlled trials. Structured educational interventions (involving informational and psychological components) with usual care. Clinical, behavioral, psychological, and knowledge outcomes were considered. 22 studies were identified involving a wide range of multicomponent interventions with variable aims and outcomes depending on the area of kidney disease care. 18 studies provided significant results for at least 1 of the outcomes. The majority of studies aimed to improve diet and/or fluid concordance in dialysis patients and involved short- and medium-term follow-up. A single major long-term study was a 20-year follow-up of a predialysis educational intervention that showed increased survival rates. No study was found that addressed chronic kidney disease at an earlier stage. Meta-analysis was not possible because of study heterogeneity. Multicomponent structured educational interventions were effective in predialysis and dialysis care, but the quality of many studies was suboptimal. Effective frameworks to develop, implement, and evaluate educational interventions are required, especially those that target patients with early stages of chronic kidney disease. This could lead to possible prevention or delay in progression of kidney disease.
A systematic review of chronic disease management. Sydney: The University of New South Wales. Australian Primary Health Care Research Institute
  • Harris N M Zwar
Zwar N, Harris M, Griffiths R, et al. A systematic review of chronic disease management. Sydney: The University of New South Wales. Australian Primary Health Care Research Institute; 2006.