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Effect of education based on
“PRECEDE” model on self‑care
behavior in hemodialysis patients
Fariba Mosavi, Fatemeh Aliakbari, Leili Rabiei1
Website:
www.jehp.net
Abstract:
DOI:
10.4103/jehp.jehp_534_19 BACKGROUND AND OBJECTIVE: Patients undergoing hemodialysis due to multiple drug therapies,
special diet plans, and need to acquire the ability to adapt to physical and mental disabilities require
special monitoring. The PRECEDE‑PROCEED model is a process for behavior change and can
lead to the promotion of self‑care behavior. The aim of this study was to evaluate the effect of a
health promotion program based on the PRECEDE‑PROCEED model on self‑care behaviors in
hemodialysis patients.
METHODS: This was a clinical trial study that was performed on 67 patients undergoing hemodialysis
in Lordegan Hospital that has been distributed in two groups randomly. Data were collected using
self‑care assessment form according to the PRECEDE‑PROCEED model. Based on the results of
this questionnaire, five educational sessions were held in the fields of knowledge, attitude, enabling
factors, reinforcement, and behavioral factors for the samples. Data were analyzed using descriptive
and analytical statistics with SPSS version 21 software.
RESULTS: According to statistical analysis before intervention, no significant difference was observed
between the mean scores of self‑care among the two groups. However, instantly and 3 months after
intervention, the mean score of self‑care (P = 0/03), knowledge, attitude, reinforcement factors, and
behavioral factors (P < 0.05) significantly increased in the experimental group.
CONCLUSION: Based on the results of this study PRECEDE‑PROCESS model, the health promotion
program increased the mean self‑care score of hemodialysis patients. This program has been able to
improve their self‑care behaviors by changing knowledge, attitudes, and reinforcement and behavioral
factors of patients and is recommending as an application in the nursing of these patients.
Keywords:
Hemodialysis patient, PRECEDE model, self‑care behavior
Community Oriented
Research Center in
Midwifery and Nursing Introduction Unfortunately, chronic renal failure, due
Sciences, Shahrekord to its high morbidity and mortality, is

C
University of Medical recognized as a major health problem in
hronic advanced renal failure is a
Sciences, Shahrekord,
progressive and irreversible kidney recent years, affecting approximately 11%
1
Health School,
Shahrekord University
disease. At this stage, the body’s ability to of the world’s adult population, that a
of Medical Science, maintain metabolism and balance water large percentage of them will be needed to
Shahrekord, Iran and electrolytes destroyed, resulting in replacement therapies.[3]
uremia.[1] This kidney dysfunction causes
Address for many problems in patients’ lives, and when Although dialysis prolongs the life span of
correspondence: these patients, it will have many problems
the kidneys fail to perform their duties
Dr. Fatemeh Aliakbari,
Community Oriented properly, kidney replacement therapies and complications that affect the quality of
Research Center in such as hemodialysis, transplantation, and life in these patients.[4]
Midwifery and Nursing peritoneum dialysis are used.[2]
Sciences, Shahrekord The prevalence and incidence of renal
University of Medical This is an open access journal, and articles are disease worldwide in 2105 is about 242 cases
Sciences, Shahrekord, distributed under the terms of the Creative Commons
Iran. Attribution‑NonCommercial‑ShareAlike 4.0 License, which
E‑mail: aliakbarifa@ allows others to remix, tweak, and build upon the work How to cite this article: Mosavi F, Aliakbari F,
gmail.com non‑commercially, as long as appropriate credit is given and Rabiei L. Effect of education based on “PRECEDE”
the new creations are licensed under the identical terms. model on self-care behavior in hemodialysis patients.
Received: 16‑09‑2019 J Edu Health Promot 2020;9:69.
Accepted: 04‑11‑2019 For reprints contact: [email protected]

© 2020 Journal of Education and Health Promotion | Published by Wolters Kluwer - Medknow 1
 Mosavi, et al.: PRECEDE model on self-care behavior in hemodialysis patients

per million people, with 8% of annual incidence, or factor that affects the quality of life in hemodialysis
about 29,000, that 14,000 of them are treated with patients. Finally, the researchers argue that we should
hemodialysis.[3] seek strategies to increase the self‑care ability of patients
to improve the quality of life.[13]
According to statistics available in Iran, averages
of 1200–1400 people develop kidney failure each Growing evidence suggests that theory‑based
year. According to statistics from the Department of interventions are effective programs for health education,
Transplantation and Special Diseases of the Ministry of and the PRECEDE model is one of them. This model is
Health in 2013, approximately 32,686 kidney patients used to identify health education needs and analyze
have been identified in the country, and the number of health problems and factors affecting peoples’ health
hemodialysis patients in the country will double in the status. This model emphasizes on two components of
next 5 years.[5] intervention and evaluation.[14]

In the US Centers for Medicare and Medicaid Services The framework of this model defines intervention as a
guidelines (2009), patients treated with dialysis are systematic process and identifies health problems and
considered as a member of their care team. Based on their determinants.[15]
this definition of caring for these patients, rather than
focusing on the words obedience and adherence, the In 2005, Greene and Crotter point out that this model
patients’ self‑care should be emphasized and created a is flexible, measurable, committed to the principle of
new paradigm in the care of dialysis patients.[6] participation and has a process structure.[16] In order
to improve the self‑care behaviors of hemodialysis
Patients undergoing hemodialysis require special and patients, it is necessary to investigate the factors related
continuous monitoring because of their multiple drug to their behaviors. In this regard, it is recommended
treatments, specific nutritional plans, and the need to to use behavior study models, which PRECEDE is one
acquire the capacity to adapt to physical and mental of the most applicable and appropriate models in this
disabilities. Furthermore, it is important to increased field. Components of this model include predisposing
patient compliance with self‑care behaviors in all structures (individual and social characteristics that
possible ways.[7] motivate health behavior), reinforces (physical and
spiritual rewards that reinvigorate and sustain health
These people are not fully capable for resolving their behavior), and enablers (environmental characteristics
self‑care deficits and need to increase their awareness that facilitate the emergence of health behaviors or any
about hemodialysis process and ways to prevent skill in the individual).[17]
complication through careful and continuous assessment
of patients’ health needs and health literacy.[8] In educational‑environmental diagnostics and
evaluation, the predisposing factors are factors that
Self‑care activities in patients undergoing dialysis can prioritize behavior change and provide motivation for
play a significant role in adapting patients to the disease behavior (knowledge, attitudes, beliefs, and values).
process, promoting quality of life, reducing the frequency Enabling factors are necessary for behavioral or
and length of hospital stay, and reducing medical costs environmental change that allows for the realization of an
and mortality rate.[9] Studies show that people with environmental motivation or policy (access to resources,
desirable self‑care abilities have a greater ability to accessibility, rules, and skills). Reinforcement factors are
rehabilitate and maintain their independence.[8] the factors that guide behavior and provide ongoing
rewards for maintaining behavior (such as family,
In Carrillo Algarra and Díaz study in Colombia, only peers, teachers, employers, and health workers).[18] On
half of the patients treated with peritoneal dialysis had the other hand, the selection of educational model is the
suitable self‑care ability.[10] Unsar et al. in Turkey reported first step in educational planning process. Therefore, this
that patients’ self‑care ability was moderate.[11] study aimed to design and evaluate a health promotion
program based on the PRECEDE‑PROCESS model on
Limited studies have been done on the self‑care self‑care behaviors of patients undergoing hemodialysis.
ability of patients undergoing hemodialysis in Iran.
Atashpeikar et al. (2012) reported that 78.3% of patients Methods
have undesirable self‑care ability.[9] Self‑care ability has
been shown to be directly related to patients’ quality of The present study is a double‑blind clinical trial
life, and the higher degree of self‑care leads to a better conducted on 67 patients undergoing hemodialysis
quality of life.[12] Malecian study (2013) points to the at Shohada‑ Hospital (Chaharmahal and Bakhtiari
importance of self‑efficacy in self‑care as an important Province) (IRCT20190301042872N1 clinical trial code).
2 Journal of Education and Health Promotion | Volume 9 | March 2020
 Mosavi, et al.: PRECEDE model on self-care behavior in hemodialysis patients

All patients were enrolled in the study by census method Furthermore, a model‑based researcher‑made
based on inclusion criteria. Based on a the previous questionnaire including items such as knowledge
study[18] and considering the following formula, with (8 questions), attitude (9 questions), enabling factors
95% confidence level and 80% test power and the given (10 questions), and reinforcing factors (10 questions)
sample loss, the sample size was estimated to be 70 (35 was designed by a researcher. The validity of the
in each group). questionnaire was confirmed by ten experts in health
education and it was validated by several lecturers of
 2( z1‑ + z1‑  )2 z 21‑  health education and nephrologist for validity of face
 2
n = R 2
+ ; and content, and their comments were used for validity.
 ∆ 2
4  The reliability of the questionnaire was measured using
 1 + (w − 1)  twenty of patients undergoing hemodialysis by internal
v 2
R= − correlation (α = 0.94) (this group was not included in the
 w [1 + (v − 1) ]  original study).

Research units were randomly divided into intervention After completing the researcher‑made questionnaires
and control groups using random allocation software. in the pretest phase, the results of questionnaire were
Criteria for entering the study were agreeing to analyzed by the researcher. The training program was
participate in the study, passing more than 6 months designed according to the results and approved by five
from the first hemodialysis session and no verbal, nephrologists and ten faculty members of the School of
psychological, and hearing impairment. Nursing and Health. In the context of these models, low
self‑care ability of hemodialysis patients was considered
In the case of dissatisfaction or going for transplantation, as the most important health problem and individual,
the sample was excluded from the study. This study behavioral, and environmental factors considered
was approved by the Ethics Committee of Shahrekord as factors that affecting this condition. Careful diet
University of Medical Sciences (IR.SKUMS.REC.1397.167). observance has been identified as a target behavior in
All the participants fill the informed consent form, and the behavioral diagnosis stage.
after the intervention, the educational content of the
intervention group was provided to the control group. Then, in the educational and ecological diagnostic
stage, predisposing factors (including patient
Data were collected using demographic questionnaire, awareness and attitudes), reinforcing (including
standard questionnaire of self‑care ability in hemodialysis encouragement, family and health‑care worker
patients, and researcher‑made questionnaire based on support, self‑esteem, autonomy, and awareness of
the PRECEDE model constructs. A standard self‑care educational resources), and enabling factor (including
questionnaire was also used. The modified version of access to educational resources and health‑care
the Chinese version of this scale was originally designed facilities) have been investigated. according to results
by Ors et al. in 1989 and has 24 items with a score of 1–5 the specific objectives of program designed and after
based on the Likert scale. preliminary investigations and coordination, the
training program was designed in accordance with
The self‑care ability of research units was divided into the designed content for the intervention group in five
three levels of good (100–175.1), moderate (75–50.1), and 40‑min training sessions.[19,20]
poor ≥) 50%). In the study of Vosoughi et al. (2015), the
reliability of the instrument was confirmed by test–retest Four training sessions were held for hemodialysis
method with Spearman’s correlation coefficient of 0.85. patients and one training session for family members
The internal consistency of the instrument was confirmed that are responsible for patient care as influencing
by Cronbach’s alpha of 0.83.[7] factors (to enhance reinforcement factors) Table 1. In

Table 1: Educational sessions for hemodialysis patients based on the PRECEDE model
Educational session Session topic Factors Educational strategy
First session Increased awareness of self‑care behaviors (diet, physical Predisposing Lecture, group discussion, and
activity, sleep, improved home environment, and ways to factors question and answer
cope with stress).
Second session Changing attitudes (the benefits of a change in lifestyle Predisposing Group discussion and brainstorming
and its costs and obstacles) factors and group problem solving
Third session Understanding the associations and organs that help Enabling Lecture, group discussion, and
patients and how to get proper education in the disease factors question and answer
Fourth session Training sessions with family caregivers of Reinforcing Lecture, group discussion, and
patients (training on how to care for patients) Factors question and answer

Journal of Education and Health Promotion | Volume 9 | March 2020 3

 Mosavi, et al.: PRECEDE model on self-care behavior in hemodialysis patients

the present study, educational resources including tests (t‑test, Mann–Whitney, repeated measures analysis,
educational pamphlets, educators, educational classes, and Friedm an) [Figure 1].
a CD, educational photos, and slides were used through
lecture methods, group discussions, and questions and Results
answers with families.
The mean age of the participants was 24.7 ± 51.35 years.
Patients were given daily checklists to enhance There was no significant difference between the
their behavioral goals. In the designed intervention, experimental and control groups in terms of age (P = 0.25).
discussions on promoting knowledge and attitude Other demographic characteristics of patients are listed
were considered as predisposing factors. Topics include in Table 2.
diet, physical activity, sleep, improving your home
environment, and ways to cope with stress. Totally, both the groups were similar in background
characteristics. Statistical tests did not find any
During the intervention, achieving goals was evaluated differences between the two groups (P > 0.05).
regularly, which enabled the training program to
continue in accordance with learners’ needs and in line There was no significant difference between the two groups
with predetermined goals. During the follow‑up period, in terms of mean score of self‑care before intervention, but
patients were evaluated for behavioral changes, and immediately after and 3 months after the intervention, there
self‑care levels were assessed immediately and 3 months was a significant difference between the two groups; the
after the intervention. self‑care score in the intervention group was significantly
higher than the control group (P < 0.001) [Table 3].
After intervention and follow‑up, the educational
content of the intervention group was given to the The results showed that there was no significant
control group. Posttest questionnaires were completed difference between the two groups in the mean scores
by the researcher immediately after the intervention of knowledge, attitude, reinforcing factors, behavioral,
and 3 months after the intervention, and the data were and self‑care before the intervention.
analyzed using SPSS software version 21(SPSS Inc.,
Chicago, IL, USA) and descriptive tests (mean, standard However, this difference was significant at immediately
deviation, frequency, and percentage) and analytical and 3 months after the intervention on the independent

Enrollment Assessed for eligibility

(n = 140)

Excluded (n = 29)
• Not meeting inclusion criteria
(n = 21)
• Declined to participate (n = 20)
• Other reasons (n = 0)

Randomized (n = 70)

Allocation
Allocated to intervention (n = 35) Allocated to control group (n = 35)
• Received allocated intervention (n = 35) • Received allocated intervention (n = 35)
• Did not receive allocated intervention • Did not receive allocated intervention
(n = 0) (n = 0)

Follow-Up
Lost to follow-up (death) (n = 1) Lost to follow-up (going for kidney
transplantation) (n = 2)

Analysis
Analysed (n = 34) Analysed (n = 33)
• Excluded from analysis (n = 1) • Excluded from analysis (n = 2)

Figure 1: Effect of education based on “PRECEDE” model on self‑care behavior in hemodialysis patients

4 Journal of Education and Health Promotion | Volume 9 | March 2020

 Mosavi, et al.: PRECEDE model on self-care behavior in hemodialysis patients

t‑test (P < 0.05). The variance with repeated measures Discussion

showed a significant difference in the process of mean
score change in the three measurement stages (before the The present study aimed to investigate the
intervention, immediately after the intervention, and effect of PRECEDE‑based education on self‑care
3 months after the intervention) (P < 0.001). Whereas, behaviors of patients undergoing hemodialysis. This
for the variables of enabling factors, analysis of variance model is one of the planning models in health education
that is used to identify needs and promote health.[21]
with repeated observations showed that the mean score
changes in the three measurement stages were not Based on the educational and ecological diagnostic stage
significant P = 0.21 [Table 4]. of model, predisposing, enabling, and reinforcing factors
are potentially effective factors on a health problem. In this
Table 2: Demographic characterization of participants study, the awareness and attitude of patients undergoing
Variable Group Intervention, Control, P hemodialysis were considered as predisposing factors.
n (%) n (%)
Sex Male 21 (61.8) 19 (57.6) χ2=3.72 Before the intervention, the two groups were at a poor
Female 13 (38.2) 14 (42.4) P=0.16 level of the educational and ecological diagnostic stage
Total 34 (100) 33 (100)
of the PRECEDE model (knowledge, attitude, enabling
Married Single 1 (34.3) 1 (8.6) χ2=3.97
status and reinforcing factors, and behavioral causes).
Married 33 (665.5) 33 (91.4) P=0. 11
Total 34 (100) 33 (100) Therefore, these results emphasize the necessity of
Education Illiterate 26 (77.8) 20 (58.8) χ2=1.06 intervention for increasing the knowledge of patients
level Primary school 5 (18.5) 11 (23.4) P=0. 31 about improving safe behaviors. Umeukeje et al. in their
Less than high school 3 (3.7) 2 (5.9) study reported that lack of awareness about self‑care
Diploma 0 1 (2.9) in patients can lead to numerous problems and even
Total 34 (100) 33 (100) death in them.[20]

Table 3: Comparison of changes in mean self‑care scores in the two groups before and after the intervention
Self‑care Mean±SD Independent t‑test
Control group (n=33) Intervention group (n=34)
Before intervention 32.3±6.55 35.61±8.86 t=0.31, P=0.35
After intervention 33.31±8.45 45.21±10.17 t=2.36, P=0.022
3 months after intervention 33.83±9.58 41.87±8.86 t=1.92, P=0.059
ANOVA F=2.36
Repeated measure P=0.033
SD=Standard deviation

Table 4: Descriptive‑analytic comparison of mean scores of educational and ecological diagnostic stage of
PRECEDE‑PROCESS and self‑care model before, 1, and 3 months after intervention in the two study groups
Stage Group Mean±SD ANOVA Repeated measure
Before intervention Instant after intervention 3 month after intervention
Knowledge Intervention 9.33±1.24 10.73±1.47 10.21±2.65 F=3.45
Control 9.62±2.14 9.64±1.94 9.01±2.46 P=0.041
Independent t‑test t=0.31, P=0.35 t=2.36, P=0.022 t=1.92, P=0.059
Attitude Intervention 26.85±4.14 28.21±4.43 29.21±3.84 F=5.10
Control 25.12±4.22 26.01±4.73 27.18±4.91 P=0.005
Independent t‑test t=2.41, P=0.095 t=2.41, P=0.016 t=2.06, P=0.043
Enabling Intervention 7.67±1.36 7.61±1.55 7.29±1.29 F=16.1
factors Control 7.34±1.61 7.72±1.36 7.9±1.62 P=0.21
Independent t‑test t=0.84, P=0.41 t=0.96, P=0.66 t=1.92, P=0.059
Reinforcing Intervention 2.72±1.25 3.32±1.99 3.21±1.15 F=3.06
factors Control 2.51±0.87 2.72±0.46 2.78±0.91 P=0.05
Independent t‑test t=0.76, P=0.44 t=2.43, P=0.018 t=1.97, P=0.52
Behavioral Intervention 1.14±0.65 1.47±0.74 1.41±0.82 F=3.06
factors Control 1.06±0.49 1.09±0.45 1.03±0.58 P=0.03
Independent t‑test t=0.61, P=0.54 t=2.49, P=0.015 t=2.18, P=0.033
SD=Standard deviation

Journal of Education and Health Promotion | Volume 9 | March 2020 5

 Mosavi, et al.: PRECEDE model on self-care behavior in hemodialysis patients

The results of this study showed that patients’ self‑care quality of life of chronic patients, including hemodialysis
was significantly related to their self‑care awareness, patients. Furthermore, the findings of this study can
which was also increased with their self‑care awareness, be used by nurses in the clinic and can eliminate the
which is consistent with similar studies.[22‑24] educational needs of patients.

Self‑care is one of the most important factors in Conclusion

enhancing the quality of life for patients with chronic
illnesses, so they can increase their quality of life despite Based on the results of this study, the health education
the many long‑standing problems that they are involved program based on the PRECEDE model can improve the
with. These results are in line with the results of the self‑care of patients undergoing hemodialysis.
study by Lii et al.,[25] He et al.,[26] Azizzadeh Pormehr and
Shojaezadeh,[27] and Rahimi et al.[28] In summary, this program increases the knowledge
and attitude score of participants, so it had a positive
A similar study about the impact of an education program effect on the predisposing factors, and by reinforcing
based on the PRECEDE model on the self‑care ability of the predisposing and reinforcing factors, this model
patients undergoing hemodialysis was not found. In increased the self‑care ability of participants.
similar studies on patients with beta‑thalassemia, this
model has a positive effect on lifestyle of these patients.[29] Researchers hope that regarding the positive effects of
this program on enhancing the self‑care ability of patients
In another study by Yuxue et al. in an article entitled undergoing hemodialysis, health authorities, planners,
“The Effect of Using the PRECEDE Model‑on Diabetic and research centers can implement and evaluate the
patients,” seventy patients were divided into two health education programs through defined stages of
intervention and control groups. Intervention groups this model.
received education about blood sugar control according
to the PRECEDE model after need assessment. Acknowledgments
This article was part of a master thesis with the approval
This study proposes the PRECEDE model as a very useful code IR.SKUMS.REC.1397.167 of Ethics Committee
health promotion model in the control of hyperglycemia of Shahrekord University of Medical Sciences. The
of chronic diabetes.[30] authors would like to extend our gratitude to thank all
participants who wholeheartedly participated in this
The results of the study by Rastgarimehr et al. with regard research.
to improving the quality of life of elderly patients in
Tehran have reported similar results.[31] Financial support and sponsorship
This study was part of a MS thesis supported by
In the present study, the PRECEDE model focuses not
Shahrekord University of Medical Sciences.
only on predisposing factors but also examines other
behavioral factors including reinforcing and enabling
factors. In a Zendehtalab study (2012), the effect of
Conflicts of interest
There are no conflicts of interest.
implementing a program based on the PRECEDE
model on adolescents’ mental health scores after the
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