The effect of a training program on the self‐care efficacy of hemodialysis patients with mineral and bone disorders: A quasi‐experimental study

Abstract Background and Aims Patients who have chronic kidney disease (CKD) and mineral and bone disorders (MBD) often do not know much about their diseases. A training program can help them improve their quality of life. This study aimed to assess the effect of a training program on the self‐care efficacy of the hemodialysis patients with MBDs in southeastern Iran. Method We conducted a quasi‐experimental study involving 49 patients with CKD‐MBD in southeastern Iran in 2021. The patients were randomly assigned to either the control or intervention group. The intervention group received 12 self‐care training sessions delivered through WhatsApp, whereas the control group received routine information. We administered CKD‐MBD knowledge and behavior questionnaires of the intervention, and measured laboratory parameters before and 1 month after the intervention. The data were analyzed by SPSS15 with descriptive and analytical statistics. Paired t test, independent t, analysis of covariance, and Mann–Whitney U tests were using for data analysis. Results The mean knowledge scores of the control group were 4.78 ± 1.78 and 6.22 ± 2.11 before and after the intervention, respectively (p = 0.200), whereas the mean knowledge scores of the intervention group were 6.08 ± 2.24 and 22.23 ± 4.55 before and after the intervention, respectively (p = 0.001). The mean behavior scores of the control and intervention groups were 75.61 ± 7.13 and 73.85 ± 7.49 before the intervention, respectively (p = 0.070), but they received the mean scores of 78.87 ± 5.58 and 82.50 ± 5.35 after the intervention, respectively (p = 0.001). The result showed a significant increase in the mean knowledge and behavior scores after the intervention. The researchers found no significant difference in the mean scores of the laboratory parameters between them before and after the intervention (p = 0.090); therefore, the intervention could not affect the laboratory parameters. Conclusion To sum up, the study found that the training program improved the knowledge and behavior of hemodialysis patients with MBD. WhatsApp was a good and cheap way to teach them self‐care, and it helped them do it better. These results implied that this training program could help the patients have a better quality of life.


| INTRODUCTION
Chronic kidney disease (CKD) is a noncommunicable disease that continues to increase in prevalence. 1 In the United States,~37 million adults suffer from this disease. 2 Globally, CKD affects 13.4% of the population, [2][3][4][5] with the highest prevalence found in Asia, accounting for 60% of cases worldwide. Studies have shown that 5%-15% or even up to 23% of the Iranian population may be affected by this disease. 6 CKD is often accompanied by a mineral and bone disorder (MBD) referred to as CKD-MBD. This disorder can affect the bones, heart, and blood vessels of individuals with CKD, 7,8 with 33%-67% of the patients with end-stage CKD suffering from MBD; its prevalence increases as kidney damage progresses, leading to higher mortality rates. 9 CKD-MBD occurs when impaired kidney function leads to abnormal levels of calcium, phosphorous, parathyroid hormone, and Vitamin D in blood due to reduced mineral elimination. The secondary complications of renal failure include some abnormalities in bone turnover, mineralization, bone density, linear growth, and ectopic calcium in blood vessels and soft tissue. 10 The kidneys play a crucial role in regulating phosphorous homeostasis, but abnormal levels of phosphorous can result in some complications in patients with CKD such as vascular calcification, bone and mineral disease, and hyperthyroidism. 11 In addition, hyperparathyroidism secondary to chronic renal failure is a condition characterized by abnormal metabolism of calcium and phosphate and inappropriate secretion of parathyroid hormone. Abnormal mineral metabolism can lead to osteoporosis and vascular calcification, which can increase the risk of sudden cardiovascular problems and worsen the prognosis of the disease. 12 Patients with CKD experience many complications that can significantly affect their daily lives; 13 therefore, some measures are necessary to improve their quality of life, including increasing their knowledge and self-care capabilities. 14 The CKD knowledge is crucial for self-management as recent evidence has shown that patients with CKD have insufficient knowledge of their disease and its treatment, 15 so training plays a critical role in improving their knowledge. It is essential to recognize how actions can affect one's health behavior, particularly if it has turned into a habit.16 Self-care training programs improve quality of life of the patients and their families and increase their participation in self-care programs. 17 These programs help patients to improve their selfcare abilities and personal commitment to their own health, leading to greater awareness and sound decisions about therapies and life changes, which can increase their emotional and physical well-being. 18 With the advancements in technology, virtual education can now be accompanied by text, voice, pictures and films, making it more accessible to patients. Social media have proven to be useful for exchanging health materials between patients and health professionals. 19,20 Therefore, this study aimed to investigate the impact of virtual training on the self-care of CKD patients with MBDs, who were undergoing hemodialysis in southern Iran in 2021.

| Sample and setting
The present quasi-experimental study was done in hemodialysis wards of Valiasr and Shariati hospitals in Fasa, Fars Province, Iran, in 2021; these two hospitals have 18 active beds and 106 patients undergoing hemodialysis for 8 or 12 h per week.
The inclusion criteria were the patients aged 18-67 years, who had been undergoing hemodialysis for at least 3 months and received hemodialysis 2 or 3 times per week. They had disrupted levels of calcium, phosphorous, or parathyroid hormone according to the physician's opinion, could read and write in the Persian language, had auditory and verbal abilities to answer questions, and could use smartphones and other virtual media. The exclusion criteria were patients with any psychiatric disorders or other diseases such as primary hyperparathyroidism, hypoparathyroidism, hyperthyroidism, bone and mineral disorder, who could not complete more than 10% of the questionnaire.
A total of 106 patients were screened for the study, 66 of whom met the inclusion criteria, but 56 patients were willing to participate in the study. The patients were selected using the census sampling method and the consort flow diagram was attached ( Figure 1). The patients were randomly assigned to either the intervention or control group by a nurse who was not aware of the patients and groups. One participant in the intervention group was excluded due to a malfunctioning smartphone and two participants in the control group were excluded, because they received kidney transplantation. In addition, one person in the intervention group and two in the control group passed away, whereas one person in the control group migrated, resulting in their exclusion from the study. Finally, 26 patients in the control group and 23 patients in the intervention group participated in the study.
The researcher observed that patients with CKD-MBD had difficulty in concentrating and understanding the training provided by the personnel during and after hemodialysis. As these patients underwent hemodialysis three or four times a week, they could not assign extra time to participate in face-to-face training, so this training was conducted separately from the routine training during dialysis.

| Intervention
The ward nurse provided routine information to the control group, whereas the intervention group received training on WhatsApp.
In the first session, the researcher explained the study goals,

| Measures
The data collection tools included a demographic and CKD-MBD-KB questionnaire, and a checklist of laboratory parameters.
The demographic questionnaire included gender, marital status, age, position, education level, the duration of kidney disease, the duration of hemodialysis treatment, medications, and other diseases such as high blood pressure or diabetes.
We used CKD-MBD-KB questionnaire introduced by Shi et al. 21 and consisted of three parts. The first part contained 23 items assessing disease-related knowledge, diet-related knowledge, and medicine-related knowledge. Each item had two scores, with wrong and right answers receiving 0 and 2 scores, respectively. The total score of this part ranged from 0 to 46.
The second part consisted of 24 items assessing compliance and attitude, rated on a Likert scale ranging from one (never) to five (always). The total score of this part ranged from 0 to 120. The last section had three open-ended questions to clarify the reasons for patients' poor medication adherence, their points of view on the most qualified instructors for treatment, and the main factors for patient training.
Therefore, the CKD-MBD-KB questionnaire included 50 items with a single total score (166 points), with the higher scores representing patients' higher knowledge, compliance, and attitude towards their disease. 21 As the questionnaire had not been translated into Persian before this study, the research team measured the validity and reliability of In addition to the questionnaire, laboratory parameters were used to measure self-efficacy.
The laboratory testing center used in this study was one of the well-equipped centers in Fasa. A sample of tests was checked in this center and in another center, and the results were found to be the same. The person in charge of the hemodialysis department interpreted the tests. The laboratory parameters were measured for both groups using the same machine and method before and after the intervention. These parameters included the levels of calcium, phosphorous, parathyroid hormone, alkaline phosphatase, and 25hydroxyvitamin D. The study patients' laboratory parameters received a score of 1 or 0, depending on whether they were normal or abnormal. If the result of the test was normal, a score of 1 was given, and if it was not normal, a score of 0 was given. Moreover, if all test results were either normal or abnormal, they received a score of 5 or 0, respectively. The total score was between 0 and 5, with a higher score indicating that most of the tests were normal.

| Statistical analysis
The data were analyzed by SPSS15 as well as descriptive and analytical statistics (frequency, mean, and SD). The significance level was considered 0.05. According to the Kolmogorov-Smirnov test, the distributions of the data was normal, so independent t test was used. The within-group comparison was done using the paired t test, whereas the between-group comparison was done by independent t test.

| RESULTS
We divided 49 patients into the control and intervention groups. The mean ages of the participants in the control and intervention groups were 54.00 ± 9.52 and 52.54 ± 12.73, respectively. Most of the participants in the two groups were married. Table 1 showed no significant difference in demographic data between the two groups, so they were homogeneous in demographic data ( Table 1).
The mean knowledge scores of the control group were 4.78 ± 1.78 and 6.22 ± 2.11 before and after the intervention, respectively (p = 0.200), whereas the mean knowledge scores of the intervention group were 6.08 ± 2.24 and 22.23 ± 4.55 before and after intervention, respectively (p = 0.001). The mean difference score of knowledge in the intervention group was 16.15. The results indicated that the training program improved the main knowledge scores in the intervention group (Table 2).
Our results indicated that the mean behavior scores of the control and intervention groups were 75.61 ± 7.13 and 73.85 ± 7.49 before the intervention, respectively (p = 0.070), but the mean behavior scores of the intervention group were 73.85 ± 7.49 and 82.50 ± 5.35 before and after the intervention, respectively (p = 0.001). The results indicated that the training program improved the main behavior scores in the intervention group ( Table 3).
The mean total scores of the knowledge and behavior in the control group were 80.39 ± 8.91 and 85.09 ± 7.69 before and after the intervention, respectively, whereas the mean total scores in the intervention group were 79.93 ± 9.73 and 104.73 ± 11.09 before and after intervention, respectively (p = 0.001).
The results indicated that the mean scores of laboratory parameters in the control and intervention groups were 2.26 ± 0.81 and 2.23 ± 0.71 before the intervention, respectively; we found no significant difference in the mean scores of the laboratory parameters between them before and after the intervention (p = 0.090) ( Table 4).
The results of the study indicated no significant change in the laboratory parameters between the two groups before and after the intervention. As the p-value was found to be 0.090, it indicates that the observed difference may have arisen by chance. Therefore, we cannot conclude that the intervention had a significant impact on the laboratory parameters.

| DISCUSSION
The study aimed to assess the effect of a training program on the self-care efficacy of hemodialysis patients with MBDs in southeastern Iran. The present study indicated the positive impact of training through social media on the knowledge and behavior of the patients undergoing hemodialysis. Hosseini et al. 22 showed that nursing consultation through social media improved the self-efficacy and weight control of patients undergoing hemodialysis. Their study highlights the importance of self-efficacy in reducing complications, hospital stay, and treatment costs associated with hemodialysis. 22 Evidence suggests that education can empower patients by improving their knowledge and skills, leading to better disease management and improved health outcomes in chronic diseases. 17,18 Alanzi et al. 23 found that WhatsApp was effective in improving the self-efficacy and knowledge of patients with diabetes, whereas Ahmed et al. 24 reported that a structured training program improved the knowledge and self-management behaviors of hemodialysis patients.
The study results showed no significant difference in the mean behavior scores between the two groups before the intervention but indicated a significant difference between them after intervention, supporting the impact of virtual training on the behavior in hemodialysis patients with CKD-MBD.
Ramazani et al. 25 indicated that a self-efficacy theory-based training program improved self-care behaviors in hemodialysis patients and Lee et al. 26 concluded that a self-management training program could improve self-care behaviors related to quality of life in patients with CKD.
Choi et al. 27 studied the effect of a face-to face self-management program on the knowledge, self-care behaviors, and kidney function of patients with CKD before renal replacement therapy.
The study results found that the mean scores of laboratory parameters in the control and intervention groups were not significantly different before and after the intervention.
Sandlin et al. 28  What is already known about the topic?
• Most hemodialysis patients with mineral and bone disorders had low self-efficacy.
T A B L E 4 Comparison of laboratory parameters in the study groups before and 1 month after the intervention. • Patients could improve their self-efficacy through education.
• Face-to-face education was unavailable because of the lack of staff and busy nurses, so other educational methods could be more effective.
What this study adds?
• Use of self-care education through social media is an effective method for improving the level of knowledge and behavior of the hemodialysis patients with mineral and bone disorders, and it is more effective than the traditional method.
• As most patients have smartphones, nurses can train their patients through mobile phones.

ACKNOWLEDGMENTS
The researchers would like to thank the patients who participated in present study. In addition, they would like to appreciate the nurses and head nurses working in hemodialysis wards of Valieasr and Shariati hospitals, as well as faculty members in Razi School of Nursing, who contributed to the current study.