Hrev_master Healthcare in Low-resource Settings 2025; volume 13(s1):13122 Enhancing adherence to diet therapy and fluid restrictions in hemodialysis patients: a study using the information-motivation- behavioral skills model Zulhikmah S. Hi Arsan,1 Elly Lilianty Sjattar,2 Rosyidah Arafat2 1Student of Postgraduate Nursing Program, Faculty of Nursing, Hasanuddin University, Makassar; 2Department of Medical and Surgical Nursing, Faculty of Nursing, Hasanuddin University, Makassar, Indonesia Abstract A common issue faced by many patients undergoing the Hemodialysis (HD) is non-compliance with diet therapy and fluid intake limitation. To address this issue, the educational model aims to change the required behavior of patients. The Information Motivation Behavior Skill (IMB) model is a behavioral interven- tion designed to promote behavior change in various situations. This study sought to assess how well the IMB educational model supports adherence to diet therapy and fluid restrictions in patients receiving HD. This study was carried out in the HD departments. It was a quasi-experimental study featuring a pretest and posttest design with a control group involving 80 patients. The participants were split into an intervention group that received education based on the Information Motivation Behavior Skill model (n=40) and a control group that received standard hospital education according to standard operating procedures (n=40). After eight dialysis ses- sions over a period not exceeding four weeks, participants were evaluated for adherence to diet therapy and fluid restrictions. Significant change in diet therapy and fluid restriction in the inter- vention group with the P-value of 0.001. In the control group, there is a significant change in diet therapy and fluid restriction with P-values of 0.005 and 0.002. There are no significant differ- ences between the intervention and control groups in the pre-test for diet therapy and fluid restriction, with P-values of 0.221 and 0.146. However, in the post-test, there are significant differences between the intervention and control groups, with a P-value of 0.001. The Information Motivation Behavior Skill model of edu- cation shows great promise in promoting adherence to diet therapy and fluid restrictions. Introduction Hemodialysis (HD) is the most frequently used therapy for patients post-transplant, regardless of incidence or prevalence. HD is the most prevalent type of kidney replacement therapy world- wide, comprising about 69% of all kidney replacement treatments and 89% of all dialysis procedure.1 A 2018 cross-sectional survey of clinicians, policymakers, and patient representatives from 182 countries found that the median use of HD per country was 298.4 per million population (pmp). However, the rates varied dramati- cally, with a more than 7,000-fold difference between countries. For example, the Democratic Republic of Congo had a rate of 0.3 pmp, while Japan had a rate of 2,148 pmp, reflecting disparities in HD availability and access.2 In Indonesia, HD is similarly widespread. In 2017, 77,892 patients were receiving HD, and 30,843 new patients started treatment that year.3 In Central Sulawesi, the proportion of residents aged 15 years and older undergoing HD was 7.34%.4 Patients undergoing HD must adhere to diet therapy and fluid restrictions, which reflects their willingness to follow the pre- scribed dietary guidelines.5 Many patients with HD have a history of nonadherence to these guidelines.6 This non-compliance can lead to excessive accumulation of fluid in the body, which can potentially result in complications.7 The mortality rate is high if complications occur in patients treated at home.8 To overcome this Correspondence: Elly Lilianty Sjattar, Department of Medical and Surgical Nursing, Faculty of Nursing, Hasanuddin University, Jl. Perintis Kemerdekaan KM. 10, Tamalanrea, Makassar, Indonesia, 90245 Tel.: +62.812.422.6796 E-mail: ellylilianty@unhas.ac.id Key word: behavioral, diet, fluid, hemodialysis, information, motivation. Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: the Ethics Committee of the Faculty of Public Health, Hasanuddin University Makassar approved this study (No. 514/UN4.14.1/TP.01.02/2023). The study is conformed with the Helsinki Declaration of 1964, as revised in 2013, concerning human and animal rights. Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: the authors acknowledge the support of department of hemodyalisis the Luwuk Regional Hospital of Banggai Regency and Anutapura Regional Hospital in Central Sulawesi, Master of Nursing study program Faculty of Nursing Hasanuddin University. Received: 18 September 2024. Accepted: 21 October 2024. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13(s1):13122 doi:10.4081/hls.2024.13122 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 8] [Healthcare in Low-resource Settings 2025;13(s1):13122] problem, intensive efforts to increase adherence to diet therapy and fluid restrictions are needed. Education can alter behavior to enhance health outcomes. A limited understanding of health information, such as about the flu vaccine, may lead to hesitation in getting vaccinated.9 A pilot study demonstrated that an educational and supportive approach effec- tively improved health outcomes in stroke patients, particularly in increasing muscle strength and joint range of motion.10 A literature review found that applying the transtheoretical model of learning effectively changed low-salt diet behaviors in patients with hyper- tension.11 Additionally, the use of technology to educate patients and improve health literacy has grown in recent years.12 Some of the above diseases are chronic diseases that require special atten- tion by providing a more educational approach to change the patient’s behavior which can improve their condition, such as hemodialysis patients who need education to change their behavior in terms of diet and fluid restriction. Education can enhance adherence to diet therapy and fluid restrictions in patients undergoing HD. Research indicates that providing health education positively impacts adherence levels for these guidelines.13 A holistic approach that incorporates both social support and education is crucial for helping patients with HD maintain adherence to diet and fluid restrictions.14 Education about diet and fluid restriction has been ongoing in the hospital. The edu- cation model used still uses the lecture method with leaflet media. However, patients are still not compliant with diet and fluid restric- tion, this can be seen from weight gain and symptoms of shortness of breath that appear when patients undergo HD. This is because the model and media used for education do not support changing the behavior of HD patients. Therefore, there needs to be an edu- cation model that focuses more on changing behavior. One effec- tive method to improve understanding and behavior is the Information-Motivation-Behavioral skills (IMB) model. This model emphasizes the need for relevant information, strong moti- vation or support, and the necessary behavioral skills to foster health behavior changes.15 It suggests that achieving optimal health behavior change requires patients to have access to these elements to avoid risky behaviors.16 However, the implementation of the IMB education model has never been applied to HD patients. Therefore, implementing the IMB model can enhance understand- ing and lead to behavioral changes in patients undergoing HD. The IMB model comprises three main components. First, the information component provides patients with accurate and rele- vant details about their conditions, potential consequences, and treatment options. Second, motivation is crucial for driving behav- ior change, and within the IMB framework, researchers or health professionals use interviews to motivate patients. Third, behavioral skills focus on teaching practical and strategic skills that facilitate behavior change.17 From the explanation above, it can be conclud- ed that these three components are a single unit in the process of providing education which aims to change patient behavior and attitudes By integrating these components, the IMB model offers targeted education aimed at improving adherence to diet therapy and fluid restrictions in patients undergoing HD.16 Numerous studies have explored the application of the IMB model for addressing various health issues. For instance, a study18 found that IMB-based interventions effectively increased involve- ment and quality of preventive behaviors among community- dwelling older adult. Similarly, a different study19 demonstrated that IMB-based programs were useful and effective in promoting preventive behaviors in women with osteoporosis. Building on this, the present study aims to evaluate the effectiveness of the IMB model in improving adherence to diet therapy and fluid restrictions in patients undergoing HD. Materials and Methods Research design This quasi-experimental study employed a pretest and posttest design with a control group (Figure 1). Population and sample The study population comprised patients undergoing HD at HD Departements in hospital X. A total of 84 patients were includ- ed and divided into two groups: intervention and control, each with 42 participants. The sample was obtained when patients arrived for their scheduled dialysis sessions. Consecutive sampling was used for recruitment. Inclusion criteria were: undergoing routine HD, having been on HD for more than 3 months, age >18 years, and being in a stable condition during the education period. Exclusion criteria included cognitive disturbances or mental health issues, conditions requiring emergency treatment, HD more than twice a week, and high adherence rates. Two participants from each group were excluded due to requiring admission to the intensive care unit (Figure 2). Data collection Study instruments The attitude scale for diet therapy of hemodialysis patients was used to measure adherence to diet therapy of patients undergoing Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13122] [page 9] Figure 1. Theoretical framework of the study.Information–motivation–behavioral skills model of education for adherence to diet therapy and fluid restrictions. HD.20 This questionnaire has undergone validity and reliability tests, with Cronbach’s alpha calculated in three subscales (n=381), which confirmed the reliability of these subscales and the high internal validity.21 The questionnaire was translated at the Hasanuddin University Makassar Language Center, back-translat- ed, and subjected to validity and reliability tests. In the face valid- ity test, the agreement value was 94.4 with a Content Validity Index (CVI) of 0.94; in the reliability test, Cronbach’s alpha was 0.93. The fluid control in hemodialysis patient scale was used to assess adherence to fluid restrictions in patients undergoing HD.22 This questionnaire has undergone validity and reliability tests, with Cronbach’s alpha coefficient of 0.88, and Cronbach’s alpha for the subdimensions were 0.92, 0.80, and 0.67, respectively. The test and re-test correlation value was 0.94 (p<0.001), indicating a sig- nificantly moderate correlation (r=0.58, p<0.001).23 The question- naire was translated at the Hasanuddin University Makassar Language Center, back-translated, and then subjected to validity and reliability tests. In the face validity test, the agreement value was 98.8, with a CVI of 0.98. In the reliability test, Cronbach’s alpha was 0.94. Objectively, dietary compliance and fluid restric- tion can be seen from weight gain between dialysis sessions. In this study, weight was needed to ensure the results of the dietary com- pliance and fluid restriction questionnaires. Special issue Pathways of Change Figure 2. Flowchart of the study. Information–motivation–behavioral skills model of education for adherence to diet therapy and fluid restrictions. [page 10] [Healthcare in Low-resource Settings 2025;13(s1):13122] Study procedures Intervention group A total of four education sessions were conducted over 4 weeks. During the information stage, patients gathered after dialy- sis sessions received information about diet therapy and fluid restrictions for 15 minutes. In the motivation stage, motivational interviews provided personalized support to each patient, lasting no more than 15 minutes per session. The behavioral skills stage involved teaching participants how to plan their diet and fluid intake at home, with their adherence monitored through logbook entries during HD sessions (Figure 2). Control group The education intervention followed the hospital’s Standard Operating Procedures (SOP). The educational SOP implemented uses a mass education system, where education is provided simul- taneously. This is different from IMB (Information-Motivation- Behavioral Skills) which provides education personally, consisting of three main components, namely information, motivation, and behavioral skills. Four sessions were conducted, one per week, with each session lasting 30 minutes. All participants were assem- bled after HD sessions for these educational meetings. Data analysis The Wilcoxon test, paired t-test, and Friedman test were used to assess changes in adherence to diet therapy and fluid restrictions over eight dialysis sessions. To assess the differences between the two groups, the Mann- Whitney test, independent t-test, and Kruskal–Wallis test were employed to evaluate variations in diet therapy compliance and adherence to fluid restrictions. Results Data collection took place between December 2023 and January 2024. The intervention group received IMB model-based education across four sessions over 4 weeks, while the control group received education following the hospitals’ standard operat- ing procedures. Characteristics of the respondents Eighty respondents were divided equally into the intervention group (n=40) and the control group (n=40). The chi-square test revealed no significant differences in the characteristics of respon- dents between the two groups (Table 1). Changes in adherence to diet therapy and fluid Special issue Pathways of Change Table 1. Demographic characteristics of the participants of the intervention and control groups. Variable Intervention group (n=40) Control group (n=40) p* n (%) n (%) Age Mean±SD 51.7±12.6 51.9±10.6 0.948b Min-max 24-72 26-74 Sex Male 21 (45.5) 25 (62.5) 0.366a Female 19 (47.5) 15 (37.5) Educational attainment Elementary school 8 (20) 5 (12.5) 0.175a Junior high School 6 (15) 5 (12.5) Senior high School 14 (35) 13 (32.5) Diploma 3 (7.5) 0 (0) Bachelor 7 (17.5) 16 (40) Magister 2 (5) 1 (2.5) Work Government employed 8 (20) 9 (22.5) 0.124a Self-employed 8 (20) 15 (37.5) Unemployed 24 (60) 16 (40) Marriage status Married 31 (77.5) 31 (77.5) 0.161a Single 1 (2.5) 2 (5.0) Divorced 4 (10) 7 (17.5) Duration of Hemodialysis <1 year 9 (22.5) 13 (32.5) 0.117a 1-5 years 17 (42.5) 20 (50) >5 years 14 (35) 7 (17.5) Comorbid diseases Hypertension 22 (55) 19 (47.5) 0.909a Diabetes mellitus 12 (30) 13 (32.5) Kidney stones 3 (7.5) 4 (10) Gouty arthritis 3 (7.5) 4 (10) p<0.05; aChi-square test; bMann-Whitney test; SD-Standard Deviation [Healthcare in Low-resource Settings 2025;13(s1):13122] [page 11] restrictions in the intervention and control groups Significant improvements in adherence to diet therapy were observed in both the intervention group (p=0.001) and the control group (p=0.005). Similarly, significant changes in adherence to fluid restrictions were noted in the intervention group (p=0.001) and the control group (p=0.002; Table 2). Differences in adherence to diet therapy and fluid restrictions before and after the intervention in the intervention and control groups There were no significant differences in pre-intervention diet therapy adherence between the intervention and control groups (p=0.221), nor were there significant differences in adherence to fluid restrictions (p=0.146). However, a significant difference in post-intervention diet therapy adherence was observed between the two groups (p=0.001), as well as significant differences in adher- ence to fluid restrictions (p=0.001; Table 3). Discussion In this study, we evaluated the impact of IMB model-based interventions on patients undergoing HD in terms of their adher- ence to diet therapy and fluid restrictions. The findings indicate that these interventions considerably enhance the adherence of HD patients to both diet therapy and fluid restrictions. This study employed various methods to help patients under- stand adherence to diet therapy and fluid restrictions. Motivational interviews were conducted to build patients’ trust in nurses, boost motivation, and promote changes in behavior, attitudes, and cogni- tion for self-management. Patients were also taught practical skills to develop and master, effectively altering their behavior toward diet and fluid restrictions. Overall, these findings demonstrate that IMB model-based educational interventions can effectively improve adherence to diet therapy and fluid restrictions in patients undergoing HD, providing personalized and patient-centered healthcare. Nurses can utilize this approach to manage patients with chronic diseases, including those undergoing HD. This study utilized the theoretical IMB model, which, unlike other educational models, integrates behavior-changing interven- tions into three main components: information, motivation, and behavioral skills. Information pertains to the knowledge base about diseases, motivation seeks to alter attitudes and foster the desire for change, and behavioral skills involve training patients to learn and master skills that can effectively modify their behavior.23 The core part of the IMB model is information. This involves providing patients with accurate and relevant details about their disease, its consequences, and the available treatment options. Information can be conveyed through various methods, such as educational materials, health services, and digital platforms. As patients gain more knowledge and understanding, they can make informed decisions and take appropriate actions to manage their health condition effectively.17 In this study, the three components of Information Motivation Behavior Skill were applied in this study which was conducted during 8 dialysis sessions and the provision of IMB model educa- tion was given to each patient during the dialysis session. Where each patient gets an education session from the three components. With details of the three components of the IMB Information Motivation Behavior Skill model, each 15 minutes. In the informa- tion, patients will be provided with a diet and fluid restriction guidebook. The patient’s motivation will talk about their motiva- tion during the dialysis session with the researcher and in the next Special issue Pathways of Change [page 12] [Healthcare in Low-resource Settings 2025;13(s1):13122] Ta bl e 2. C ha ng es in a dh er en ce to d ie t t he ra py a nd fl ui d re st ric tio ns in th e in te rv en tio n an d co nt ro l g ro up s. Va ria bl e I nt er ve nt io n gr ou p C on tr ol g ro up Pr e- te st P os t-t es t M ea n p * P re te st P os tte st M ea n p * (n =4 0) (n =4 0) d iff er en ce (n =4 0) ( n= 40 ) d iff er en ce M ea n± SD M ed ia n (m in -m ax ) M ea n± SD M ed ia n (m in -m ax ) M ea n± SD M ed ia n (m in -m ax ) M ea n± SD M ed ia n (m in -m ax ) A dh er en ce 4 1. 40 ±2 .9 9 40 .0 0 5 1. 37 ±3 .5 4 5 2. 00 9 .9 7 0 .0 1a 4 0. 57 ±2 .9 2 4 0. 00 4 1. 70 ±3 .6 4 4 0. 00 1 .1 3 0 .0 5a to di et th er ap y ( 37 -4 8) (3 9- 58 ) ( 35 -4 6) (3 6- 50 ) A dh er en ce 4 4. 10 ±4 .7 0 4 4. 0 5 3. 45 ±3 .6 0 5 3. 50 9 .3 5 0 .0 1b 3 9. 55 ±6 .6 5 3 9. 50 4 1. 52 ±4 .9 5 4 0. 00 1 .9 7 0 .0 2b to fl ui d (3 5- 43 ) ( 46 -6 0) ( 26 -5 4) (3 3- 54 ) re str ic tio ns p< 0. 05 ; a < W ilc ox on te st ; b P ai re d t-t es t; SD -S ta nd ar d D ev ia tio n. session the researcher provides motivation to change their behav- ior of compliance with treatment including diet and fluid restric- tions. The patient’s Behavior Skill will be taught to compile a daily food menu which will be recorded on the monitoring sheet and will be evaluated at the next dialysis session, whether the menu that has been compiled is consumed while at home. The three components become one education session. The findings obtained from the implementation of the IMB model education showed a significant increase in dietary compli- ance and fluid restriction, but in the control group there was no sig- nificant change in dietary compliance and fluid restriction. The challenge is how to provide behavioral skills in managing diet and fluids between dialysis sessions. The findings obtained that the motivational component is a more dominant component of the three components in changing behavior. Motivation plays an important role in encouraging behavioral change. In the IMB model, researchers or health professionals often conduct motiva- tional interviews with patients. The purpose of this interview is to understand the patient’s personal motivations and the social con- text that influences them, build trust, and increase their motivation and willingness to change behavior. Motivation can be strength- ened by empowering patients, setting realistic goals, and highlight- ing the benefits of behavioral change. Motivation plays a crucial role in initiating behavior change. Within the IMB model framework, researchers or health profes- sionals often conduct motivational interviews with patients. These interviews aim to understand patients’ personal motivations and social factors, build trust, and stimulate a desire to change behav- ior. Motivation can be enhanced by empowering patients, setting achievable goals, and emphasizing the benefits of behavioral change.17 Behavioral skills focus on teaching patients practical and strategic skills to facilitate behavior change. This involves educat- ing patients on using useful tools, developing self-management techniques, overcoming challenges, and adopting healthier behav- iors. Behavioral skills training can include activities such as goal setting, problem-solving, self-monitoring, and practicing new behaviors. Ultimately, the interaction of all the model compo- nents—information, motivation, and behavioral skills—leads to a change in behavior.17 Applying the IMB model to patients undergoing HD can enhance positive behaviors by improving adherence to diet therapy and fluid restrictions, as the model is designed to facilitate behav- ior change. According to the IMB model, achieving behavior change for optimal health requires providing relevant information, offering strong support and motivation, and helping patients devel- op the necessary skills while avoiding risky behaviors.16 By incor- porating information, motivation, and behavioral skills, the IMB model effectively promotes understanding and behavior change.24 Integrating these three components into a cohesive educational approach can lead to improved adherence to diet and fluid restric- tions among HD patients. Personalized management by nurses for patients with kidney diseases is crucial. A healthy and balanced diet includes the proper proportions of proteins, carbohydrates, fats, vitamins, and miner- als. To ensure optimal health, a varied and balanced diet is essen- tial. The kidneys play key roles related to eating patterns, including excreting body wastes, regulating fluid volume, and controlling blood pressure. After food intake, the body utilizes necessary sub- stances and removes excess ones as waste through urine. If kidney function declines, waste can accumulate in the blood, leading to various complications.25 Fluid management is crucial for maintaining fluid and elec- trolyte balance in the body, involving the monitoring and measure- ment of fluid intake and output. In patients undergoing HD, increased fluid intake can be influenced by several factors, with thirst being a significant one. Thirst often occurs after consuming high-salt foods, as excessive salt levels can activate the thirst mechanism in the brain, prompting a desire to drink more fluids to maintain sodium balance.26 Dietary compliance and fluid restriction can be maintained by consistently implementing the IMB education model in providing education in the HD department, emphasizing the motivational component because it is in accordance with existing findings that motivation is the most dominant component in changing behavior. The results of this study can serve as a reference for empower- ing nurses to implement educational programs based on the IMB model and develop comprehensive care plans for patients undergo- ing HD. This approach aims to enhance adherence to diet therapy and fluid restrictions. Additionally, addressing these aspects is cru- cial as other complications may exacerbate the condition of patients undergoing HD. Conclusions The IMB education model has been proven to improve dietary compliance and fluid restriction. This study provides valuable insights into the benefits of health education interventions for man- aging patients undergoing HD. By focusing on personalized inter- ventions that address patients’ information needs, motivation, and Special issue Pathways of Change [Healthcare in Low-resource Settings 2025;13(s1):13122] [page 13] Table 3. Differences in pretes and posttest adherence to diet therapy and fluid restrictions in the intervention and control groups. Variable Intervention group Control group Mean difference p* (n=40) (n=40) Mean ± SD Median (min-max) Mean ± SD Median (min-max) Pre-test Adherence to diet therapy 41.40±2.99 40.00(37-48) 40.57±2.92 40.00(35-46) −0.83 0.221a Adherence to fluid restrictions 44.10±4.70 44.0(35-43) 39.55±6.65 39.50(26-54) −4.55 0.146b Post-test Adherence to diet therapy 51.37±3.54 52.00(39-58) 41.70±3.64 40.00(36-50) 9.67 0.01a Adherence to fluid restrictions 53.45±3.60 53.50(46-60) 41.52±4.95 40.00(33-54) 12.23 0.01b p<0.05; aMann–Whitney test; bIndependent t-test; SD, standard deviation. behavioral skills, this educational model enables nurses to develop comprehensive care plans tailored to each patient’s needs. For fur- ther research, it is hoped that media can be added to support the education process, such as applications for monitoring diet and flu- ids between dialysis sessions. References 1. Bello AK, Okpechi IG, Osman MA, et al. Epidemiology of haemodialysis outcomes. Nat Rev Nephrol 2022;18:378-95. 2. Htay H, Bello AK, Levin A, et al. Hemodialysis use and prac- tice patterns: an international survey study. Am J Kidney Dis 2021;77:326-335.e1. 3. Indonesian Renal Registry. 11th report Of Indonesian renal registry 2018. Indones Ren Regist 2018;14-5. 4. Riskesdas. Laporan Riskesdas Provinsi Sulawesi Tengah. Kesehat Provinsi, Sulawesi Tengahesehatan Provinsi, Sulawesi Teng. 2018;399. 5. Hunter EG, Shukla A, Andrade JM. Barriers to and strategies for dietary adherence: a qualitative study among hemodialy- sis/peritoneal dialysis patients and health care providers. J Ren Nutr 2023;33:682-90. 6. Ozen N, Cinar FI, Askin D, et al. Nonadherence in hemodial- ysis patients and related factors: A multicenter study. J Nurs Res 2019;27:1-11. 7. Herlina, Santi, Rosaline MD. Kepatuhan Pembatasan Cairan Pada Pasien Hemodialisis. Dunia Keperawatan J Keperawatan dan Kesehat 2021;9:46. 8. Özkan, İlknur, Taylan S. Diet and fluid restriction experiences of patients on hemodialysis: a meta-synthesis study. Rev Nefrol Dial y Traspl 2022;42:22-40. 9. Xie W, Xiao J, Chen J, et al. Impact of health education on pro- moting influenza vaccination health literacy in primary school students: a cluster randomised controlled trial protocol. BMJ Open 2024;14:1-7. 10. Sjattar EL, Megawati I, Irwan AM, Majid S. Development of supportive-educative range of motion exercise for post-stroke patients: a pilot study. Home Heal Care Manag Pract 2022;34:92-100. 11. Hasriani, Sjattar EL, Arafat R. The effect of educational inter- vention based on transtheoretical model for a low-salt diet among hypertension patients: a literature review. Indones J Public Heal 2022;17:331-43. 12. Adapa K, Jain S, Kanwar R, et al. Augmented reality in patient education and health literacy: a scoping review protocol. BMJ Open 2020;10:e038416. 13. Başer, Esra, Mollaoğlu M. The effect of a hemodialysis patient education program on fluid control and dietary compliance. Hemodial Int 2019;23:392-401. 14. Sukarrini T, Efendi F, Putri NS. A phenomenological study to explore patient experience of fluid and dietary restrictions imposed by hemodialysis. J Vasc Nurs 2022;40:105-11. 15. Puji, Lestari K, Ayu Putri Anggraini D, et al. Edukasi Kesehatan Berbasis Model Information Motivation Behavior Skill Meningkatkan Pengetahuan Dan Perilaku Perawatan Antenatal Pada Ibu Hamil Risiko Tinggi. Jambi Med J 2021;234-45. 16. Chang SJ, Choi S, Kim SA, Song M. Intervention strategies based on information-motivation-behavioral skills model for health behavior change: A systematic review. Asian Nurs Res (Korean Soc Nurs Sci) 2014;8:172-81. 17. Xu, Handong, Wang J. An information-motivation-behavioral skills model-based intervention for patients with epilepsy. Epilepsy Behav 2023;147:109408. 18. Lee, Hye M, Park YH. The effectiveness of the information- motivation-behavioral skills model-based intervention on pre- ventive behaviors against respiratory infection among commu- nity-dwelling older adults. Patient Educ Couns 2021;104:2028-36. 19. Yeongsuk, A LP, PhD DHK. A preliminary study on the effects of an osteoporosis prevention program based on an Information-Motivation-Behavioral skill model in older adult women: A cluster randomized controlled trial. Geriatr Nurs. 2022;45:55-63. 20. Özer ZBTGYKE. Attitude scale for the dietary therapy of hemodialysis patients: Turkish validity and reliability study. nternational Urol Nephrol 2023;55:769-76. 21. Onbe, Hiromi, Kanda K. Development and testing of the Attitude Scale for the Dietary Therapy of Hemodialysis Patients. Japan J Nurs Sci 2018;15:39-49. 22. Cosar A, Arife, Cinar Pakyuz S. Scale development study: The Fluid Control in Hemodialysis Patients. Japan J Nurs Sci 2016;13:174-82. 23. Peng X, Li Z, Zhang C, et al. Assessing determinants of online medical services adoption willingness of general hospital physicians using the information-motivation-behavioral skills model: a multi-group structural equation modeling approach. J Multidiscip Healthc 2021;14:3453-62. 24. Sulistianingsih A, Saputri N. Kehamilan bebas anemia : pen- dekatan menggunakan information motivation behavior (IMB) skill Model. M.Pd ATH, editor. Padang: Rumahkayu Pustaka; 2020. 25. Donnelly P, Dunne H, Conlon PPJ. Kidney Disease A Guide For Patients 4Th Edition. Irish Kidney Association. Beaumont Hospital. 2019. 26. Siregar CT. Buku Ajar Manajemen Komplikasi Pasien Hemodialisa. Reni Asmara Ariga, editor. Yogyakarta: Deepublish CV Budi Utama; 2020. Special issue Pathways of Change [page 14] [Healthcare in Low-resource Settings 2025;13(s1):13122]