KIDNEY TRANSPLANTATION Predictors of Self-Management among Kidney Transplant Recipients Somayeh Khezerloo1, Hosein Mahmoudi2 , Hamid Sharif Nia3, Zohreh Vafadar*4 Purpose: Self-management among kidney transplant recipients is a key factor in long-term survival. The present study aims to determine the predictors of self-management among kidney transplant recipients in Iran. Materials & Methods: This cross-sectional analytical study was conducted on 360 kidney transplant recipients who were selected from six transplantation clinics affiliated to six major universities of medical sciences in Iran. The data were collected using a demographic and clinical characteristics questionnaire and the Persian version of the 24-item Self-Management Scale for Kidney Transplant Recipients. Result: The mean score of the participants’ self-management was 62.39±8.04. Multiple regression analysis revealed that the significant predictors of self-management among kidney transplant recipients were age (B = -0.319), gender (B = -1.70), pre-transplantation dialysis duration (B = 0.256), dialysis type (B = 3.060), duration after transplantation (B = 0.08), and marital status (B = 4.44) (model R2 = 0.444). Conclusion: This study showed that kidney transplant recipients in Iran have a moderate self-management status. The significant predictors of their self-management were age, gender, marital status, pre-transplantation dialysis type and duration, and the length of time passed after transplantation. The findings of this study provide a basis for developing interventions to improve self-management among kidney transplant recipients. Keywords: self-management; transplantation; kidney INTRODUCTION Kidney transplantation is the best treatment for end-stage renal disease.(1) In 2014, 17107 kidney transplantations were performed and more than 100000 patients were still on the waiting list in the United States. The number of candidates for kidney transplan- tation increases by 3000 annually.(2) In Iran, 2700 kid- ney transplantations are performed each year. In other words, 48% of the patients with end-stage renal disease in Iran receive kidney transplant, while the global rate is 20%. These statistics denote the good status of kidney transplantation in Iran.(3) Self-management is among the most important factors behind transplant survival and outcomes.(4) By defini- tion, self-management is the ability to manage symp- toms, treatments, physical and mental complications, and lifestyle behaviors in relation to a chronic condi- tion.(5) Currently, self-management is considered as a main aspect of successful healthcare delivery. It sig- nificantly improves patients’ health status and quali- ty of life and reduces the rate of re-hospitalization.(6,7) Self-management has three main components, namely medical management, emotional management, and new 1Ph.D. Ph.D. Student of Nursing, Baqiyatallah University of Medical Sciences, Faculty of nursing, Tehran, Iran. E-mail: khezerloos@yahoo.com 2Associate Professor, trauma Research Center and Faculty of nursing, Baqiyatallah University of Medical Sciences, Tehran, IR Iran. 3Ph.D. Assistant Professor, Amol Faculty of Nursing and Midwifery, Mazandaran University of Medical Sciences, Sari, Iran. 4Assistant Professor, Health Management Research Center, medical-surgical group. Nursing faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran. Zohrehvafadar@gmail.com. *Correspondence: Assistant professor, Health Management Research Center, medical-surgical group. Nursing faculty, Baqiyatallah University of Medical Sciences, Tehran, Iran. Mobile: +98 917 3117 227. E mail: Zohrehvafadar@gmail.com. Received February 2019 & Accepted July 2019 life roles management.(8) Accordingly, self-manage- ment behaviors among kidney recipients may include adherence to the following: medications, regular mon- itoring of transplant rejection symptoms, regular medi- cal visits, adequate fluid intake, adequate sun exposure protection, undergoing cancer screening tests, and a low-salt low-fat diet.(9) Limited self-management may result in transplant re- jection.(10) Unhealthy lifestyle behaviors predispose transplant recipients to infection and other complica- tions. These complications may result in psychological problems and thereby, undermine self-management ability.(11) On the other hand, transplant recipients need immunosuppression in order to prevent transplant re- jection.(12) The success of immunosuppression largely depends on adherence to immunosuppressive regimens. (13) Poor treatment adherence among transplant recipi- ents increases the risks of renal failure and transplant rejection by seven times and increases the likelihood of hospitalization mostly due to infections.(14) Yet, esti- mates show that 30% of transplant recipients have poor treatment adherence(5–7). In addition, another study con- ducted in Iran has shown that the rate of poor treatment adherence is as high as 57.8%.(15) Urology Journal/Vol 16 No. 4/ July-August 2019/ pp. 366-370. [DOI: http://dx.doi.org/10.22037/uj.v0i0.5061] A key prerequisite to self-management improvement is to determine its contributing factors. These factors (include donor factors, recipient factors, and immuno- logical factors), which greatly influence the outcome of kidney transplantation. Of these three factors, the factors associated with the recipient are related to the patients' self-management. In order to design a plan for improving of these patients' self-management, in the first step, it is necessary to understand the current status of self-management behaviors and the predictor varia- bles among kidney transplant recipients. However, in Iran, few studies have been done on these factors so far. Therefore self-management improvement interventions usually face different challenges and difficulties. Thus, the present study has been conducted to determine the predictors of self-management among kidney transplant recipients in Iran. MATERIALS & METHODS This cross-sectional analytical study was conducted from 2016 to 2017. The Study population consisted of the transplant recipients referring to the kidney trans- plantation clinics affiliated to six major universities of medical sciences in Iran situated in Tehran, Tabriz, Ur- mia, Mashhad, Kerman, and Hamadan. A random sam- ple of 360 kidney transplant recipients were selected through cluster random sampling. The inclusion criteria were: age above eighteen, ability to answer the study questionnaires, and having stable physical and mental conditions. Data Collection The data collection instruments were a demograph- ic and clinical characteristics questionnaire and the Self-Management Scale for Kidney Transplant Recip- ients. The items included in the first questionnaire (pre- dictors) were related to age, gender, educational level, marital status, employment status, financial status, di- alysis type (hemodialysis or peritoneal dialysis), daily fluid intake, comorbid conditions, organ source (live or cadaver), the amount of sleep per day, the pre-trans- plantation dialysis history, and the length of time after transplantation. In this study no potential confounders were detected. The Self-Management Scale for Kidney Transplant Recipients was developed in 2013 by Ko- saka et al.(16) Khezerloo et al. translated this scale into Persian, evaluated its psychometric properties, and re- ported that it had the four subscales of self-monitoring (eight items), self-care behaviors (six items), early de- tecting and coping with abnormalities (six items), and drug management (four items). They also reported a Cronbach’s alpha of 0.73 and an intraclass correlation coefficient of 0.9 for the scale.(17) The items of this scale are scored from 1 to 4, resulting in a possible total score of 24 to 96—the higher the score, the greater the patient self-management. Ethical Considerations This study was part of a PhD dissertation in nursing approved by the Ethics Committee of Baqiyatallah University of Medical Sciences, Tehran, Iran (code: IR.BMSU.REC.1395.304). The aim of the study was explained to the participants and written informed con- sents were received from them. All the participants had the freedom to voluntarily withdraw from the study. The study data are kept confidentially. Statistical Analysis The SPSS software (v. 25.0) was used for data analysis. Initially, the distribution of the self-management vari- able was evaluated through the Kolmogorov-Smirnov test. Then, the simple and the linear regression analyses were used to predict the participants’ self-management based on their demographic and clinical characteristics. Independent variables were entered into the regression Predictors of self-management -Khezerloo et al. Table 1. Participants’ demographic and clinical characteristics. Characteristics N (%) or Mean ± SD Gender Male 205 (56.9) Female 155 (43.1) Age (Years) 47.11±11.84 Marital status Single 122 (33.9) Married 283 (66.1) Educational status Below diploma 91 (25.3) Diploma 82 (22.8) Associate degree 10 (2.8) Bachelor’s degree 137 (38.1) Master’s degree and higher 40 (11.1) Employment status Unemployed 39 (10.8) Housewife 105 (29.5) Employee 138 (38.3) Self-employed 78 (21.7) Financial status Poor 114 (31.7) Moderate 191 (53.1) Good 55 (15.3) Dialysis type Peritoneal 139 (36.6) Hemodialysis 221 (61.4) History of dialysis (Month) 51.48±19.98 Duration after transplantation (Month) 43.76±23.27 Organ source Live donor 234 (65.0) Cadaver 126 (35.0) Number of sleeping hours a day Less than 7 108 (30) 7–9 169 (46.9) More than 9 83 (23.1) Daily fluid intake (Liter) Less than 1 91 (25.3) 1–2 204 (56.7) More than 2 65 (18.1) Kidney Transplantation 367 model using the hierarchical method (backward model). Multicollinearity was evaluated through variance infla- tion factor and tolerance value. The variance inflation factor values greater than 10 and the tolerance values of .1 or less were considered problematic.(18) The level of significance was set at less than.05. RESULTS The participants were mostly male (56.9%) and mar- ried (66.1%), had received hemodialysis (61.4%), had received kidney transplant from live donors (65%), and aged 47.11±11.84 years on average. The mean age among the male and the female participants were 46.41±10.54 and 48.1±13.35 years, respectively (Ta- ble1). The mean score of the participants’ self-management was 62.39 ± 8.04 (in the range of 24 to 96). The mean scores of the male and the female participants’ self-man- agement were 61.45 ± 9.09 and 63.63 ± 6.19, respec- tively. Table 2 shows the mean scores of self-manage- ment and its four subscales. Multiple linear regression showed that the significant predictors of self-management among kidney transplant recipients were age (B = -.319), gender (B = -1.70), pre-transplantation dialysis duration (B =.256), dialysis type (B = 3.060), the length of time after transplanta- tion (B =.08), and marital status (B = 4.44) (model R2 = .444). Accordingly, older age, masculinity, shorter pre-transplantation dialysis duration, receiving dialysis through the peritoneal route, shorter post-transplanta- tion time, and singularity were associated with poorer self-management (all P <.05) (Table 3). DISCUSSION This study aimed to determine the predictors of self-management among kidney transplant recipients. The findings revealed that the mean score of the par- ticipants’ self-management was 62.39 ± 8.04 (ranging from of 24 to 96), which indicates moderate self-man- agement. Similarly, an earlier study had found that only a few kidney transplant recipients had good self-man- agement status in areas such as fluid intake, physical exercise, and adherence to treatment and dietary regi- mens.(19) However, another study reported that kidney transplant recipients had great self-management.(6) This contradiction may be due to the differences in the set- tings, samples, and the contexts of the studies. The study also shows that age is one of the significant predictors of self-management among kidney trans- plant recipients; older age was associated with poorer self-management. Greater self-management among the younger participants may be due to their unfamiliari- ty with serious health conditions, fear of the unknown, fear of the long-term effects of not adhering to the treat- ments and the greater support they receive from their Table 2. The mean scores of self-management and its subscales. Subscales Min-Max Mean ± SD Number of items Subscale mean Self-monitoring 8-25 17.22 ± 5.43 8 2.15 Self-care behavior 12-24 18.34 ± 3.31 6 3.056 Early detecting and coping with abnormalities 7-22 12.55 ± 4.12 6 2.091 Drug management 9-16 14.27 ± 1.68 4 3.56 Total 44-74 62.39 ± 8.04 24 —— Predictor Unadjusted model* Adjusted model* Tolerance VIF B [95% CI] P B [95% CI] P Age (Years) .10 [0.03 ,.17] .005 –.31 [–.39, –.24] <.001 .488 2.051 Sex Male –2.18 [–3.85 , –.51] .01 –1.70 [–3.07, –.32] .016 .845 1.184 Female 1 - - - - - Marital status Single 1 - - - - - Married 6.23 [4.62, 7.90] <.001 4.44 [2.96, 5.92] <.001 .797 1.255 Educational status Below 0.46 [–0.16, 0.99] 0.16 - - - - diploma Diploma 1 - - - - - Associate 1 - - - - - degree Bachelor’s 1 - - - - - degree Master’s 1 - - - - - degree and higher Dialysis type Peritoneal 1 - - - - - Hemodialysis –1.92 [–3.62, –.22] .02 3.06 [1.40, 4.71] <.001 .604 1.656 History of dialysis (Month) .202 [.16 , 0.23] <.001 0.256 [0.19, 0.31] <.001 .282 3.542 Duration after .14 [.11,.17] <.001 .087 [.05,.12] <.001 .604 1.654 transplantation (Month) Organ source Live donor 1 - - - - - Cadaver –5.83 [–7.74, –4.19] .88 - - - - *Univariate Linear Regression and Multiple Linear Regression were used to Analyze the Association between multiple determinants of self-management. Table 3. Predictors for Effective factors on the self-management among kidney transplant recipients. Predictors of self-management -Khezerloo et al. Vol 16 No 04 July-August 2019 368 families and peers. However, contrary to the findings of the present study, the previous studies have report- ed greater self-management among older kidney trans- plant recipients.(20, 21) This contradiction may be due to the differences among different societies regarding cultural characteristics and health literacy. Culture and health literacy are among the significant factors affect- ing self-management among the patients with chronic conditions.(22) Gender was another significant predictor of self-man- agement in the present study; the female participants had greater self-management than their male counter- parts. Earlier studies reported that female organ recip- ients had better infection prevention and sun exposure protection behaviors(4,23), while male organ recipients were better at drug management.(23,24) Women seem to have poorer adherence to their medications due to their fear of the side effects of immunosuppressive agents on their appearance. Moreover, they are more adherent to sun protection due to the effects of sun exposure on their beauty and appearance. However, a study reported that women usually have better health-related knowledge; therefor, they have better self-monitoring and greater self-protection against health risk factors.(25) This con- tradiction may be due to the fact that the present study has assessed all the aspects of self-management, while the other one has only considered some of its aspects. Marital status was another significant predictor of self-management in the present study. The findings show that married participants have better self-manage- ment than their single counterparts. Previous studies re- ported the same finding, too.(25) Spousal and emotional support may be significant factors behind married par- ticipants’ greater self-management. A previous study reported a positive relationship between social support and self-management among transplant recipients.(26) Moreover, spouses usually share their health-related knowledge with each other and help each other select appropriate health-related behaviors. In addition, the findings of the present study revealed that pre-transplantation dialysis type and duration were significant predictors of self-management among kid- ney transplant recipients. The participants with a longer dialysis period and a history of hemodialysis had sig- nificantly greater self-management compared to those with a shorter dialysis period and a history of perito- neal dialysis. The patients with a longer dialysis period and a history of hemodialysis might have experienced more difficulties. Therefore, they might as well have attempted to more closely adhere to self-management behaviors in order to avoid returning to their difficult pre-transplantation conditions. Similarly, a previous study indicated that due to the significant effects of hemodialysis on the patients’ lives and autonomy, the patients who were receiving hemodialysis had poorer quality of life compared to those who were receiving peritoneal dialysis.(27) The other predictor of self-management in the present study was length of time passed after transplantation— the longer the duration, the greater self-management. This factors lead to self-management improvement due to the acquisition of better coping and self-management abilities over time.(23) Contrarily, several earlier studies reported reduction in drug self-management over time. (20,28,29) This contradiction may be due to the difference in the side effects of immunosuppressive agents expe- rienced by the participants in these studies. The side effects of immunosuppression are a significant factor affecting self-management among kidney transplant re- cipients—the more the side effects, the poorer medica- tion adherence and self-management.(20) Another justifi- cation regarding self-management variation over time, may be the fact that the present study assessed all the components of self-management, while the other ones have only evaluated some. To the best of our knowledge, this was the first study conducted in Iran on the prediction of self-management among kidney transplant recipients. One limitation of the study was that sampling was done among kidney transplant recipients who were over eighteen. There- fore, the study provides little information, if any, on self-management predictors among children and ado- lescents. CONCLUSIONS This study showed that kidney transplant recipients in Iran have moderate self-management status. The sig- nificant predictors of their self-management are age, gender, marital status, pre-transplantation dialysis type and duration, and the length of time passed after trans- plantation. The findings of this study provide a basis for developing interventions to improve self-management among kidney transplant recipients. ACKNOWLEDGEMENT Hereby, the authors appreciate all the kidney transplant recipients who participated in this study, as well as the whole staffs of the kidney transplant centers who con- tributed to data collection. CONFLICT OF INTEREST The authors declare that they had no conflict of interest. REFERENCES 1. Schmid-Mohler G, Schäfer-Keller P, Frei A, Fehr T, Spirig R. A mixed-method study to explore patients' perspective of self- management tasks in the early phase after kidney transplant. Prog Transplant. 2014;24:8- 18. 2. NKF. Organ Donation and Transplantation Statistics. available at https://wwwkidneyorg/ news/newsroom/factsheets/Organ-Donation- and-Transplantation-Stats.March 28, 2017. 3. Farhangnews. Available at http:// w w w f a r h a n g n e w s i r / c o n t e n t / 1 8 5 0 5 2 . September 27, 2016. 4. Hedayati P, Shahgholian N, Ghadami A. Nonadherence Behaviors and Some Related Factors in Kidney Transplant Recipients. Iran J Nurs Midwifery Res. 2017 ;22:97-101. 5. Yusoff SSM, Ishak NH, Rahman RA, Kadir AA. Diabetes self-care and its associated factors among elderly diabetes in primary care. J T U med sc. 2017. 6. Weng LC, Dai YT, Huang HL, Chiang YJ. Self‐efficacy, self‐care behaviours and quality of life of kidney transplant recipients. J Adv Nurs. 2010;66:828-38. 7. Dawkes S. Self-management of coronary Predictors of self-management -Khezerloo et al. Kidney Transplantation 369 heart disease in angina patients after elective percutaneous coronary intervention: A mixed methods study: Doctoral dessertation, Edinburgh Napier University; 2014. 8. Novak M, Costantini L, Schneider S, Beanlands H, editors. Approaches to self‐ management in chronic illness. Seminars in dialysis; 2013: Wiley Online Library. 9. Jamieson NJ, Hanson CS, Josephson MA, Gordon EJ, Craig JC, Halleck F, et al. Motivations, Challenges, and Attitudes to Self- management in Kidney Transplant Recipients: A Systematic Review of Qualitative Studies. Am J Kidney Dis. 2016;67:461-78. 10. Meier‐Kriesche HU, Schold JD, Kaplan B. Long‐Term Renal Allograft Survival: Have we Made Significant Progress or is it Time to Rethink our Analytic and Therapeutic Strategies? Am J Transplant. 2004;4:1289-95. 11. Weng LC, Dai YT, Wang YW, Huang HL, Chiang YJ. Effects of self‐efficacy, self‐ care behaviours on depressive symptom of Taiwanese kidney transplant recipients. J Clin Nurs. 2008;17:1786-94. 12. Lamb K, Lodhi S, Meier‐Kriesche HU. Long‐Term Renal Allograft Survival in the United States: A Critical Reappraisal. Am J Transplant. 2011;11:450-62. 13. Group KDIGOTW. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(Suppl 3):S1-S157. 14. Medscape. Kidney Transplantation Patients Have High Readmission Rates. October 3, 2016:Available at http://www.medscape.com/ viewarticle/772950. 15. Shabany-Hamedan M, Mohmmad-Aliha J, Shekarabi R, Hosseini A. The relationship between medication adherence and quality of life in Renal Transplant Patients. IJN. 2010;23:29-34. 16. Kosaka S, Tanaka M, Sakai T, Tomikawa S, Yoshida K, Chikaraishi T, et al. Development of Self-Management Scale for Kidney Transplant Recipients, Including Management of Post-Transplantation Chronic Kidney Disease. ISRN Transplantation. 2013;2013. 17. khezerloo S, Mahmoudi H, Vafadar Z. Evaluating the psychometric properties of the Persian Self-Management Scale for Kidney Transplant Recipients. Urol J. 2019;16: 72-78. 18. Orme JG, Combs-Orme T. Multiple regression with discrete dependent variables: Oxford University Press; 2009. 19. Gordon EJ, Prohaska TR, Gallant M, Siminoff LA. Self-care strategies and barriers among kidney transplant recipients: a qualitative study. Chronic Illn. 2009;5:75-91. 20. Prendergast MB, Gaston RS. Optimizing medication adherence: an ongoing opportunity to improve outcomes after kidney transplantation. Clin J Am Soc Nephrol. 2010;5:1305-11. 21. Estabrooks PA, Nelson CC, Xu S, King D, Bayliss EA, Gaglio B, et al. The frequency and behavioral outcomes of goal choices in the self-management of diabetes. Diabetes Educ. 2005;31:391-400. 22. Shaw SJ, Huebner C, Armin J, Orzech K, Vivian J. The role of culture in health literacy and chronic disease screening and management. J Immigr Minor Health. 2009;11:460-7. 23. Germani G, Lazzaro S, Gnoato F, Senzolo M, Borella V, Rupolo G, et al., editors. Nonadherent behaviors after solid organ transplantation. Transplant Proc; 2011: Elsevier. 24. Gheith O, El-Saadany S, Abuo DS, Salem Y. Compliance with recommended life style behaviors in kidney transplant recipients: does it matter in living donor kidney transplant? Iran J Kidney Dis. 2008;2:218-26. 25. August KJ, Sorkin DH. Marital status and gender differences in managing a chronic illness: The function of health-related social control. Soc Sci Med. 2010;71:1831-8. 26. Chen YC, Chang LC, Liu CY, Ho YF, Weng SC, Tsai TI. The Roles of Social Support and Health Literacy in Self‐Management Among Patients With Chronic Kidney Disease. J Nurs Scholarsh. 2018;50:265-75. 27. Theofilou P. Quality of life in patients undergoing hemodialysis or peritoneal dialysis treatment. J Clin Med Res. 2011;3:132. 28. Shimaya M, Watanabe M, Azumi M, Shichiri K, Tomiyama C, Tanabe M, et al. A Questionnaire Survey in Kidney Transplant Outpatients: Factors Associated with Good Self-Management. Health J. 2015;7:589. 29. Massey EK, Tielen M, Laging M, Beck DK, Khemai R, van Gelder T, et al. The role of goal cognitions, illness perceptions and treatment beliefs in self-reported adherence after kidney transplantation: a cohort study. J Psychosom Res. 2013;75:229-34. Predictors of self-management -Khezerloo et al. Vol 16 No 04 July-August 2019 370