Hemodialysis Eating Education Intervention to Improve the Depression, Treatment Adherence, Cardiovascular Risks, Quality of Life, and Healthcare Utilization Among Hemodialysis Patients: A Quasi-experimental Design

The investigator have completed the surveys on dietary intake, anthropometrics, clinical assessments, body compositions, and biochemical parameters and so on in designed hospitals. Assessment of cardiovascular disease risk factors: The diagnosed values were defined by the National Kidney Foundation Kidney Disease Outcomes Quality Initiative Work Group.

Health Literacy Health literacy will be also measured by Chew's 3 brief health literacy screening questions (BHLS), each with 5 possible response options [1]: (1) "How often do participants have problems learning about participants' medical condition because of difficulty understanding written information?" (always, often, sometimes, occasionally, or never); (2) "How often do participants have someone help participants read hospital materials?" (always, often, sometimes, occasionally, or never); and (3) "How confident are participants filling out medical forms by participants self?" (extremely, quite a bit, somewhat, a little bit, or not at all). The BHLS demonstrated evidence of construct validity among hemodialysis patients [2]. To identify the level of health literacy, sum scale of 3 screening questions will be calculate and classify into 3 levels: (1) Limited health literacy (=< 6 scale); (2) Marginal health literacy (7-8 scale); (3) Adequate health literacy (>= 9 scale) on the scale of 15 scale [3].

Dietary knowledge The dietary knowledge of nurses and patients will be evaluated pre-intervention and post-intervention, using a 10-item questionnaire developed by Kim and colleague [4]. The tool is to measure knowledge on protein, potassium, phosphorus, sodium, and water. The correct answer was treated as 'correct', incorrect or 'do not know' answers were treated as 'incorrect'; the highest scale possible was 10 points.

Treatment adherence Biological markers: The bio-markers to identify the dietary adherence are serum potassium (Pre-dialytic serum potassium ≤ 5.5 mEq/L), and phosphorus (Pre-dialytic serum phosphorus ≤ 4.5 mg/dL); fluid adherence is inter-dialysis weight gain (IDWG ≤ 4% of dry weight gain); medication adherence are (phosphate binders, antihypertensive, calcium supplements, and vitamin).

Self-report: The subjective adherence will be measured using the adherence behaviors subscale of the ESRD-Adherence Questionnaire (ESRD-AQ) [6]. The four subscales will be used which ask about treatment adherence to hemodialysis treatment (item 14 "During the last month, how many dialysis treatments did participants miss completely?", 17 "During the last month, how many times have participants shortened participants' dialysis time?", and 18 "During the last month, when participants' dialysis treatment was shortened, what was the average number of minutes?"), medications (item 26 "During the past week, how often have participants missed participants' prescribed medicines?"), fluid restrictions (item 31 "During the past week, how often have participants followed the fluid restriction recommendations?"), and diet recommendations (item 46 "During the past week, how many times have participants followed the diet recommendations?"). The ESRD-AQ is designed with the 5-point Likert scale, such that higher scales indicate better adherence.