yang2018.pdf

Therapeutic Apheresis and Dialysis 2019; 23(2):167–172 doi: 10.1111/1744-9987.12770 © 2018 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy Self-Care Behavior of Hemodialysis Patients With Arteriovenous Fistula in...

Therapeutic Apheresis and Dialysis 2019; 23(2):167–172 doi: 10.1111/1744-9987.12770 © 2018 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy Self-Care Behavior of Hemodialysis Patients With Arteriovenous Fistula in China: A Multicenter, Cross-Sectional Study Miao-miao Yang,1 Hui-hua Zhao,1 Xiao-qiang Ding,1 Guo-hong Zhu,1 Zhen-hua Yang,2 Lin Ding,3 Xiong-hao Yang,4 Yuan Zhao,5 Lei Chen,6 Ren-mei Yang,7 Jian Fang,8 and Clemente Neves Sousa9 1 Zhongshan Hospital Fudan University, 2Rui Jin Hospital Shanghai Jiao Tong University School of Medicine, 3 Changhai Hospital of Shanghai, 4Renji Hospital Shanghai Jiao Tong University School of Medicine, 5Xinhua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, 6Shanghai General Hospital, 7The 455th Hospital of Chinese People’s Liberation Army, 8The Sixth People’s Hospital of Shanghai, Shanghai, China and 9Nursing School of Porto, Porto, Portugal Abstract: Improving the level of arteriovenous fistula the patients’ self-care behavior about AVF. Measures (AVF) self-care behavior by people receiving hemodialy- included demographic questionnaire, and the Chinese sis is an effective way to reduce the occurrence of compli- ASBHD-AVF. The Chinese ASBHD-AVF that included cations and mortality. The aim of this study was to assess 12 items has a good internal consistency (α = 0.865) and the self-care behavior of Chinese patients undergoing content validity (CVI = 0.979). Principal component anal- hemodialysis with arteriovenous fistula. The assessment of ysis generated two factors which explained 53.525% of self-care behaviors with arteriovenous fistula in hemodial- the total variance. About 69.9% of hemodialysis patients’ ysis (ASBHD-AVF, Portuguese version) was translated AVF self-care behavior were at a low or moderate level. into Chinese using Brislin’s translation model. The con- The level of self-care behavior and knowledge need to be tent validity was evaluated by six experts. Then we improved. Nurses should give specific guidance according involved 301 hemodialysis patients with AVF to explore to the patients’ own characteristics and different influence the construct validity of the Chinese version of ASBHD- factors, in order to improve the recipients’ self-care AVF. Ultimately 216 patients from eight dialysis centers behavior. Key Words: Arteriovenous fistula, Hemodialy- of general hospitals in China were recruited to evaluate sis, Scale, Self-care. Native arteriovenous fistula (AVF), arteriovenous the life of patients. Adib-Hajbagheri et al. (5) graft and central venous catheter (CVC) are the reported that there was a significant association three main types of vascular access (1). The arterio- between patients’ self-care and the occurrence of venous fistula has become the first choice for AVF-related complications. Clinical practice guide- patients receiving hemodialysis due to the advan- lines strongly recommend that all patients should be tages of providing good blood flow for dialysis, last- taught the “basics” of how to take care of their vas- ing more durable and lower morbidity and mortality cular access (6). Therefore, in order to optimize and (2,3). According to the United States Renal Data adjust the education scheme according to the needs System (USRDS), 62.9% of prevalent dialysis of patients, nurses need to understand the patient’s patients were using an AVF by May 2016 (4). As self-care status. However, after a systematic litera- the lifeline of hemodialysis patients, AVF function ture review, it was verified that little was known on determines the dialysis adequacy and even threatens the state of AVF self-care behavior, especially in China. The scale of assessment of self-care behav- Received September 2018; revised October 2018; accepted iors with arteriovenous fistula in hemodialysis October 2018. (ASBHD-AVF) was designed and validated in Por- Address correspondence and reprint requests to Mrs Hui-hua Zhao, Deputy director of nursing department, 180 Fenglin Road, tugal to measure the self-care behavior in hemodial- Xuhui District, Shanghai 200032, China. Email: [email protected] ysis patients with arteriovenous fistula (7). Thus, the 167 168 M-m Yang et al. aim of this study was to translate the ASBHD-AVF physicians, and a teacher. A 4-point Likert point into Chinese, test the reliability and validity of the scale was used to assess the content validity Chinese ASBHD-AVF, and to assess the self-care (1 = not relevant; 2 = must be modified otherwise it behavior of Chinese patients undergoing hemodialy- is irrelevant; 3 = quite relevant but requires some sis with AVF. modification; 4 = most relevant). The content valid- ity of each item (I-CVI) and the overall scale (S- CVI) were 0.833 and 0.979. PATIENTS AND METHODS A total of three items were suggested to be modi- Study design and sample fied in order to enhance the comprehensibility. A total of 216 hemodialysis patients with AVF (i) Considering hirudoid gel with its major compo- from eight dialysis centers in China were selected nent being mucopolysaccharide polysulfate conven- by convenience sampling between November 2016 tionally used under the condition that hematoma and January 2017. The inclusion criteria for patients goes without further aggravation after 24 h of its were: age ≥ 18 years, receiving maintenance hemo- coming into being, item 4 “I will apply some oint- dialysis (MHD) for at least 3 months, undergoing ment if hematoma appears” was modified to “I will dialysis with native AVF, and ability to speak Chi- apply some ointment 24 hours later if hematoma nese. Those who could not answer the question- appears”. (ii) The experts suggested altering item naires due to cognitive deficit or had converted 12 “I allow the nurse to draw blood from the fistula from AVF to either a catheter or graft were arm” to “If the nurse draws blood from the fistula excluded. The study was approved by the Hospital arm, I will remind her that she cannot do so”, for Ethics Committee (B2014-083). the reason that positive questions were easier to understand. (iii) Item 14 “I try not to go to places with large temperature difference” was changed to Instruments “I try to keep the fistula arm warm.” Because the Demographic questionnaire main effect of temperature on fistula was that The questionnaire designed by the first author extremely low temperature led to vasospasm, which included: patient age, gender, marital status, educa- could easily cause fistula thrombosis. tional status, income, employment, the type of pri- After that, a pretest was performed in 20 hemodi- mary cause of end-stage renal disease, timing of alysis patients so as to evaluate whether the Chinese dialysis therapy initiation, timing of AVF start to ASBHD-AVF was understandable. Results showed use, AVF reconstruction and so on. that the Chinese ASBHD-AVF was understandable without ambiguity except for the translation of “if The Chinese version of ASBHD-AVF the hand of the fistula’s side has color change.” To The Chinese version of ASBHD-AVF was trans- redress this issue, we changed the “hand” to “finger lated and adapted from the Portuguese version of skin and fingernails.” After which, a convenience Scale of Assessment of Self-Care Behaviors with sample of 301 hemodialysis patients were recruited Arteriovenous Fistula in Hemodialysis (ASBHD- to examine the internal consistency reliability and AVF) (7). The original ASBHD-AVF included construct validity. 16 items in two subscales: management of signs and The internal consistency reliability was deter- symptoms (six items), and prevention of complica- mined using Cronbach’s alpha coefficient and tions (10 items) using a 5-point Likert scale (one showed that Cronbach’s alpha had an increase after represented never, and five represented always). deleting item 2, 6, 12, 15 (Table 1). Construct valid- The total score ranged from 16 to 80, with a higher ity of the Chinese ASBHD-AVF was assessed by score indicating a higher level of self-care behavior. item analysis and exploratory factor analysis. The With the authorization from ASBHD-AVF’s item-to-total correlation give an indication of the developer, Brislin’s translation model was used to degree to which each item correlates with the total translate the original version of the ASBHD-AVF score; correlations less than 0.30 indicated that the into Chinese (8). A doctor of medicine of hemodial- item was insufficient and probably unnecessary (9). ysis and the original author compared the back- The item analysis of the Chinese ASBHD-AVF translated version with the original to achieve the showed that all of the items, except item 6, 12, goals of cultural and functional equivalence. Cross- 15 had a satisfactory item-to-total correlation. Thus, cultural adaptation (e.g. content relevance, content the Chinese ASBHD-AVF was then reduced from coherence, and clarity of the question) was evalu- 16 to 12 items, taking account of the item analysis ated by six experts including registered nurses, and the internal consistency reliability results. © 2018 International Society for Apheresis, Ther Apher Dial, Vol. 23, No. 2, 2019 Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy  Arteriovenous Fistula Self-Care Behavior 169 TABLE 1. The internal consistency reliability of Chinese 2, 6, 12, 15 may not be necessary for Chinese ASBHD-AVF (N = 301) context. Item Cronbach’s alpha if item was deleted 1 0.844 2 0.853 Data analysis 3 0.839 Continuous variables were reported as mean  4 0.840 5 0.845 standard deviation (SD) or median (interquartile 6 0.852 range) according to their distribution. While cate- 7 0.831 gorical variables were expressed as frequency, per- 8 0.830 9 0.842 centage. All data analyses were performed by SPSS 10 0.834 22.0 statistical software. 11 0.842 12 0.855 13 0.837 14 0.840 RESULTS 15 0.855 16 0.843 Demographic and clinical characteristics of the participants Of all the 224 patients, 216 patients completed the survey. Among them 63.9% were male. The Considering the unsatisfactory item analysis, mean age of patients was 55.81  13.89. Table 3 exploratory factor analysis was used to explore the presents the participants profile. The most common underlying factors. Three factors with eigenvalues type of primary cause of end-stage renal disease was greater than 1.0 (4.913, 1.510, 1.259) were generated chronic glomerulonephritis (n = 63, 29.2%), fol- by principal component analysis with varimax rota- lowed by hypertensive nephropathy (n = 51, tion, which accounted for around 64.016% of the 23.6%), diabetic nephropathy (n = 36, 16.7%), and total scale variance rather than two factors origi- other/unknown (n = 46, 21.3%). Polycystic kidney nally hypothesized. The load of each item was (n = 20) accounted for 9.3% of renal disease. greater than 0.4. Factor 3 only contains items 9 and 11, which could not demonstrate the significance of this factor. A two-factor solution which explained 53.525% of the total variance was proposed. Mean- AVF self-care behavior while item 11, “I protect the arm on the fistula’s Table 4 shows the range, median and mean score side from any bumping” was reorganized and of AVF self-care behavior and the item score of loaded onto “prevention of complications” instead subscale in hemodialysis patients. The findings sug- of “management of signs and symptoms” (Table 2). gested that, “I check daily if the finger skin and fin- In summary, the Chinese ASBHD-AVF that gernails on the fistula’s side has color changes” was included 12 items in two domains has a good inter- the worst self-care behavior. The best self-care nal consistency and content validity. With regards to behavior was found to be “I protect the arm on the construct validity, the findings suggested that items fistula’s side from any bumping.” With regard to the total score of self-care behav- ior and the subscale score not conforming to a nor- TABLE 2. Factor loading of two-factor solution mal distribution, the total score and the subscale were divided into low level, moderate level and high Factors level according to the P25 and P75. Overall Score: Item 1 2 low level (