Original Article Egyptian Journal of Health Care, 2021 EJHC Vol 12. No.

Assessment of Compliance for Postoperative Patients with

Bariatric Surgery

Ahmed Elsayed Ibrahiem1, Salwa Samir Ahmed2, Asmaa Abdel Rahman Abdel
Rahman,3 Amr Hamed Afifi4.
Assistant lecturer of Medical Surgical Nursing1, Professor of Medical Surgical Nursing2,
Assistant Professor of Medical Surgical Nursing3 Faculty of Nursing, Ain Shams University,
Lecturer of General Surgery4, Faculty of Medicine, Ain Shams University.

Abstract

Background: Obesity remains a continuing global health concern that associated

with increased risk of numerous chronic diseases. Bariatric surgery is indicated as a strategic
alternative for rapid weight loss, remission or improvement of co-morbidities. Aim: This
study aimed to assess compliance for postoperative patients with bariatric surgery. Design: A
descriptive study design was utilized to achieve the aim of this study. Setting: The study was
conducted in bariatric surgery outpatient clinic and bariatric surgery department at El-
Demerdash Hospital of Ain Shams University. Subject: A purposive sample of 104 patients
with postoperative bariatric surgery who are selected according to certain inclusion criteria.
Tools of data collection: (1) Postoperative bariatric surgery patients' interview questionnaire.
(2) Patients' compliance assessment questionnaire. Results: The results of this study showed
that 80 percent of the studied patients had poor level of compliance postoperative bariatric
surgery. Conclusion: The current study concluded that most of the studied patients had poor
level of compliance postoperative bariatric surgery. Recommendations: The current study
recommended that, developing of guidelines protocol regarding patients' compliance post-
operative bariatric surgery to maintain health and improve patients' outcomes.
Key words: Assessment, Postoperative Bariatric Surgery, Patients' Compliance.

Introduction productivity and social disadvantages

(Blüher, 2019).
Obesity negatively affects health
outcomes and increases the risk of Body Mass Index (BMI) is defined
metabolic diseases (for example type 2 as the extent to which body weight,
diabetes mellitus and fatty liver disease), muscle and fat are congruent to height,
cardiovascular diseases (hypertension, frame, gender and age. It can be
myocardial infarction and stroke), calculated by dividing a persons' weight
musculoskeletal disease (osteoarthritis), by the height square (kg/m2) (Moorhead
Alzheimer disease, depression and some et al., 2018).
types of cancer (for example, breast,
ovarian, prostate, liver, kidney and colon). According to BMI, general
In addition, obesity might lead to reduced population is classified in five categories:
quality of life, unemployment, lower underweight BMI < 18.5 kg/m2, normal
weight BMI 18.5-24.9 kg/m2, class I

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obesity - overweight BMI 25.0-29.9 All current clinical guidelines

kg/m2, class II obesity - BMI 30.0-39.9 indicate that bariatric patients should be
kg/m2, class III obesity - extreme obesity regularly evaluated after surgery and that
BMI > 40 kg/m2 (De Lorenzo et al., a long-term commitment from both the
2016). patient and the bariatric surgical team is
required. The frequency of follow-up
Bariatric surgery is now visits should be adapted to the procedures,
considered the first management option patients compliance and lifestyle change
for failure of medical treatment in (Maleckas et al., 2016).
severely obese subjects and the most
effective method for sustained long-term Patients are required to commit to
weight loss. Bariatric surgical options following lifelong healthy lifestyle and
may be grouped into three main behavioral modification postoperative
categories: malabsorptive, restrictive, and bariatric surgery such as eating, physical
mixed procedure. Malabsorptive activity habits and medical follow-up. So,
procedures reduce the size of the stomach, patients may be required to undergo
although they function primarily by monthly visits for 3, 6, or 12 months to
creating malabsorption. They effectively maintain or lose a specific amount of
reduce nutrient absorption in small bowel body weight. In addition to, close follow-
which leads to weight loss (Funes et al., up of the glycaemic control, blood lipid
2020; Rothrock, 2015). Four common profile, obstructive sleep apnea, gastro
types of procedures are Gastric Bypass, esophageal reflux disease, body weight,
Gastric Banding, Sleeve Gastrectomy, quality of life, eating behavior and bone
Biliopancreatic Diversion with Duodenal health (Varban & Dimick, 2019;
Switch (Dewit & Kumagai, 2013; Shah Busetto et al., 2017).
et al., 2016).
Significance of the study:
The number of bariatric surgery
procedures performed worldwide Proposed causes of weight regain
increased from 146,000 to 340,000 or insufficient weight loss post-surgery
between 2003 and 2011, with Roux-en-Y include inadequate follow-up support by
gastric bypass and sleeve gastrectomy the multidisciplinary team, maladaptive
type which accounts for approximately eating and lifestyle behaviors, non
75 % of all procedures (Thorel et al., compliance to therapeutic regimen
2016). physical side effects of surgery, low
patient knowledge, psychological
The specialist bariatric nurse disorders, use of medications associated
should give support to the nursing staff with weight gain. Better assessment of
caring for bariatric patients to ensure these behavioral factors, can help identify
policies and protocols are adhered to and patients at risk for sub-optimal outcomes.
a high quality of evidence-based care is
delivered. In order to provide continuity Aim of the Study:
of care for the surgical patient after
discharge from the hospital, the nurse
need to consider what type of assistance This study aimed to assess
the patient requires in the home setting compliance of patient's postoperative
according to their individual needs bariatric surgery.
(Martinez, 2014).
Research question:

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To what extent the patient with 1- Postoperative bariatric surgery

postoperative bariatric surgery is patients' interview questionnaire: It was
compliant with therapeutic regimen? developed by the researcher in an Arabic
language based on review of relevant
Subjects and Methods: literatures as (Centers for Disease
Control and Prevention, 2017; Wicker
A- Research design: & Dalby, 2017; American Society for
Metabolic and Bariatric Surgery, 2016;
A descriptive exploratory research Linton, 2016; DeMaria & Ansari, 2016)
design was conducted to achieve the aim and it includes two parts:
of this study. Part I: It was concerned with
assessment of demographic
B- Setting: characteristics of patients under study
such as age, gender, residence, level of
The study was conducted in education, marital status and occupational
bariatric surgery outpatient clinic and state.
bariatric surgery department at El-
Demerdash Hospital affiliated to Ain Part II: It was concerned with the
Shams University. assessment of patients' clinical data such
as present medical history, past medical
C- Subject: history and family history.
A purposive sample of 104
postoperative bariatric surgery patients 2- Patients' compliance assessment
was selected according to certain questionnaire: This tool was used to
inclusion criteria. With type I error with assess patients' compliance with diet,
significant level alpha (  ) = 0.05 medication, physical activity, sleeping,
(confidence level 95%). stress management and follow-up
postoperative bariatric surgery. It was
Inclusion criteria: developed in an Arabic language using
the following related literatures
The study subject was selected (American Society for Metabolic and
according to the following criteria: Bariatric Surgery 2018; Still etal., 2018;
Kumar & Gomes 2017; Lim, Baker &
 Postoperative patients with Jones, 2015 and Rothrock, 2015).
bariatric surgery.
This tool was divided into four
parts:
 Age over 18 years.
Part I: patients' compliance to
 Willing to participate in the
post operative bariatric surgery
study.
instructions: This part was used to assess
patients' compliance post-operative
 Both sexes. bariatric surgery. It includes 54
statements which were grouped into 5
 Patients with obesity related co- sections that include diet post-operative
morbidity. bariatric surgery (20 items), physical
activity (14 items), sleeping and rest post-
D-Tools of data collection operative bariatric surgery (7 items),
smoking post-operative bariatric surgery

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(8 items) and follow-up post-operative questionnaire was calculated and were

bariatric surgery (5 items). categorized as follow:

 0-3 was considered non-

adherent.
Scoring system
 4-6 was considered partially
This part consisted of 54 adherent.
statements, the response to each statement
were either with Yes (given one grade) or  7-10 was considered adherent.
No (given zero).
Part III: Perceived Stress Scale
- The total score for every section (PSS): This scale was adopted from
was calculated by summing the patients' (Cohen et al., 1983). This scale was used
responses, and then the total scores for to assess patients' stress level post-
the entire questionnaire were calculated. operative bariatric surgery. Patients were
asked about their feelings and thoughts
- The total scores for every item during the past month and they have to
and the total score of the questionnaire indicate how often they felt or thought a
were categorized into good, fair and poor certain way in response to 10 questions.
compliant as follow:
Scoring system:
 < 50% was considered poor
compliance. Perceived Stress Scale (PSS) items
was rated on a scale from zero to 4 where
 50%- 75% was considered fair zero mean (never), 1 mean (almost never),
compliance. 2 mean (sometimes), 3 mean (fairly often),
and 4 mean (very often). Questions
 ≥ 75% was considered good number 1, 2, 3, 6, 9, 10 are negative
compliance. statements, while questions number 4, 5, 7,
8 are positive statements. Four items were
Part II: Medication Adherence reverse coded, and all items were summed
Rating Scale (MARS): This scale was to obtain total scores as the following:
adopted from (Thompson et al, 2000). It
includes 10 statements to assess patients' 0-13 was considered low stress.
compliance to medication post-operative
bariatric surgery. Patient who responds by  14-26 was considered moderate
"NO" to the questions from 1- 6 and stress.
questions from 9 -10 and by "YES" to
questions 7 and 8 are considered  27-40 was considered high
compliant to medication. perceived stress.

Scoring system Part IV: Bariatric Analysis and

Reporting Outcome System (BARO)
This scale includes 10 statements. and Moorehead-Ardelt quality of life
The response to the statement is by either Questionnaire: this questionnaire was
Yes (given one grade) or No (given zero). adapted from (Moorehead et al., 2003) to
The total score for every statement was assess changes in quality of life after
calculated first and then the score for the treatment. It includes five domains
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expressed by graphic symbols, each one A pilot study was carried out on
of them had scoring point as follow; self- 10% (10) of patients to test the
esteem (-1 to +1), physical activity (-0.5 applicability of the study and to test
to +0.5), social life (-0.5 to +0.5), work clarity of the designed tool, as well as to
conditions (-0.5 to +0.5) and sexual estimate the time needed for each tool.
activity (-0.5 to +0.5). Points are added or The modifications were done for the used
subtracted according to changes in these tools then the final form was developed.
domains. Patients of the pilot study were excluded
from the study subjects.
Total questionnaire scoring
system: Field Work:

 One point or less was considered - To carry out the study, an approval
failure. was obtained from the hospital
directors and nursing directors of
 > 1 to 3 points was considered bariatric surgery outpatient clinic and
fair. bariatric surgery department at Ain
Shams University Hospital. A letter
 > 3 to 5 points was considered was issued to them from the faculty of
good. nursing Ain Shams University
explaining the aim of the study in
 > 5 to 7 points was considered order to obtain permission and
very good. cooperation to conduct the study.

 > 7 to 9 points was considered - The researcher started by selecting the

excellent. patients who performed bariatric
surgery and met the inclusion criteria.
Tools validity and reliability The researcher explained the aim and
nature of the study to patients prior to
 Validity was tested through a data collection in order to take their
jury of seven experts from medical approval to participate in the study.
surgical nursing department, faculty of - The studied patients were recruited
nursing and faculty of medicine, Ain from bariatric surgery outpatient
Shams University (2 professors in nursing, clinic and bariatric surgical
3 assistant professors in nursing and 2 department.
medical lecturers). The experts reviewed - The patient interview questionnaire
the tools for clarity, relevance, that includes demographic
comprehensiveness, simplicity, characteristics, patient's clinical data,
understanding and applicability. Minor and family history was filled in by the
modifications were done. Testing researcher or the patients or family
reliability of the developed tools was member according to their level of
done statistically by using Alpha education.
Cronbach test. Total compliance was - Patient's compliance tool was filled in
0.766, total medication adherence rating by the researcher or the patients or
scale was 0.848, total perceived stress family member according to their
scale was 0.722 and for total BARO score level of education. It takes about 30-
was 0.661. 45 minutes to be filled in for every
patient.
 Pilot Study:
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- Data collection was done on Sunday Crop. Quantitative data were presented as
and Tuesday of each week because mean, standard deviation. Qualitative data
these days are determined for bariatric were presented as percentages. The
patients in the out-patient clinic. Data observed differences and association were
was collected in the morning and considered as follows:
afternoon shifts, for a period of six
months, starting at December 2018  Non-significant at P > 0.05
until the end of April 2019.  Significant at P ≤ 0.05

Administrative Design: Limitation of the study

An official letter was issued from 1- The time available for data collection
the Faculty of Nursing, Ain Shams was not enough, as most of patients
University to the director of inpatient come from far cities and need to leave
bariatric surgery department and bariatric hospital as early as possible.
surgery outpatient clinics at which the
study was conducted, explaining the 2- Unsuitable environment and the
purpose of the study to obtain their interview were held in the outpatient
permission to conduct this study. clinic where there was too much noise
and lack of privacy.
Ethical Considerations:
Results
 The research approval was
obtained from the ethical committee of Regarding demographic
faculty of nursing before initiating the characteristics of the studied patients,
study work. table (1) shows that mean age was
32.57±6.18. Regarding patients' gender, it
 The researcher clarified the was found that, 75.0% of the studied
objectives and aim of the study to patients patients were females. As regards to
included in the study. residence, it was found that 72.1% were
living in urban area. Regarding
 Patients' oral consent to educational level, the result shows that
participate in the study was obtained. 49% of the studied patients had diploma
education. As well, 77.9% of the studied
 The researcher assured patients weren't working. In relation to
maintaining anonymity and marital status of the studied patients, it
confidentiality of subjects` data. was found that 64.4% were married.

 Patients were informed that they Table (2) demonstrates that, 93.3%,
are allowed to withdraw from the study at 76.5%, 62.5% of the studied patients had
any time without giving any reasons and poor compliance regarding physical
without penalties. activity, stop smoking, diet after bariatric
surgery. While, 49.0% of them were good
Statistical Design: compliance regarding follow-up visits
after bariatric surgery.
The data were collected, coded
and entered into a suitable excel sheet. Table (3) illustrates that, 41.3% of
Data were transferred into SPSS for the studied patients were non adherent to
window, version 20.0 Armonk, NY: IBM medication postoperative bariatric
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surgery. While, 39.4% of the studied post operative bariatric surgery. While,
patients were partially adherent and 53.8%, 45.2% and 32.7% of them had the
19.3% of them were adherent to same level of compliance regarding self-
medication postoperative bariatric esteem, sexual activity, social life
surgery. postoperative bariatric surgery.

Table (4) illustrates that, 56.7% of Table (6) reveals that there was
the studied patients had moderate level of statistically significant relation between
stress postoperative bariatric surgery. total patients' compliance and their
While, 32.7% of the studied patients had demographic characteristics post
high level of stress and 10.6% of them operative bariatric surgery that include
had low level of stress postoperative age, gender, level of education and
bariatric surgery. occupation with (P<0.05). While, there
was no statistically significant relation
Table (5) reveals that, 64.4% of between their compliance and residence
the studied patients had less labor level and marital state post operative bariatric
surgery (P>0.05).

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Table (1): Percentage distribution of the studied patients according to their

demographic characteristics (n=104).

Studied patients
Items
N %
Age
18 < 30 17 16.3
30 < 40 64 61.5
40 < 50 17 16.3
≥ 50 6 5.9
Mean ±SD 32.57±6.18
Gender
Male 26 25.0
Female 78 75.0
Residence
Rural 29 27.9
Urban 75 72.1
Educational level
Can't read and write 22 21.2
Diploma education 51 49.0
Higher education 31 29.8
Occupational state
Free work 7 6.7
Governmental work 14 13.5
Not working 81 77.9
Others 2 1.9
Marital status
Single 27 26.0
Married 67 64.4
Widow/ Divorced 10 9.6

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Table (2): Percentage distribution of total compliance among studied patients

post operative bariatric surgery (n=104)

Good Fair Poor

Items of compliance
N % N % N %
Compliance to diet after bariatric surgery 11 10.6 28 26.9 65 62.5
Compliance to physical activity 0 0.0 7 6.7 97 93.3
Compliance to sleep and rest instructions
40 38.5 30 28.8 34 32.7
after bariatric surgery
Compliance to smoking cessation after
0 0.0 4 23.5 13 76.5
bariatric surgery
Compliance to follow-up after bariatric
51 49.0 34 32.7 19 18.3
surgery
Total compliance 1 1.0 19 18.3 84 80.8

Table (3): Percentage distribution of total patients' compliance with medication post
operative bariatric surgery (n=104)

Total Medication
N %
Adherence
Adherent 20 19.3
Partially adherent 41 39.4
Non adherent 43 41.3

Table (4): Percentage distribution of total patients' perceiving of stress post

operative bariatric surgery (n=104)

Total perceived Stress Scale N %

High stress 34 32.7
Moderate stress 59 56.7
Low stress 11 10.6

Table (5): Percentage distribution of patients' compliance regarding quality of

Life post operative bariatric surgery (n=104).

Much less Less The same More Much more

Items
N % N % N % N % N %
Self-esteem 0 0.0 37 35.6 56 53.8 10 9.6 1 1.0
Physical
29 27.9 23 22.1 32 30.8 15 14.4 5 4.8
activities
Social life 22 21.2 25 24.0 34 32.7 13 12.5 10 9.6
Labor (work
12 11.5 67 64.4 25 24.0 0 0.0 0 0.0
condition)
Sexual 0 0.0 5 4.8 47 45.2 52 50.0 0 0.0

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Table (6): Relation between patients' total compliance and their demographic
characteristics post operative bariatric surgery (n=104).

Total compliance
Items
Good Fair Poor Chi-square
N % N % N % X2 P-value
18 < 30 1 1 0 0 16 15.4
age 30 < 40 0 0 13 12.5 51 49.0
40 < 50 0 0 3 2.9 14 13.4 12.773 0.047*
≥ 50 0 0 3 2.9 3 2.9
Gender Male 1 1 11 10.6 14 13.5
17.076 <0.001**
Female 0 0 8 7.6 70 67.3
Residence Rural 0 0 5 4.8 24 23.0
0.430 0.807
Urban 1 1 14 13.5 60 57.7
Level of Can't read and
0 0 1 1.9 21 20.1
education write
Middle level
1 1 3 2.9 47 45.2 27.651 <0.001**
education
High
0 0 15 14.4 16 15.4
education
Occupation Free work 0 0 3 2.9 4 3.8
Governmental
0 0 8 7.6 6 5.7
work 72.472 <0.001**
Not working 0 0 8 7.6 73 70.1
Others 1 1 0 0 1 1
Marital status Single 1 1.9 2 1.9 24 23
Married 0 0 11 10.6 56 53.9 2.517 0.642
Widow/
0 0 6 5.8 4 3.8
Divorced
Non significant p>0.05 * Statistical significant P<0.05

Discussion 34.5 years. While the result is

contradicted with Susmallian et al.,
Regarding demographic (2019) who found that the mean age of
characteristics of the studied patients, the the study group was 67.92 years old.
result of the present study revealed that,
about two thirds of the studied patients, As regards to gender, the result
their age ranged from 30 < 40 years old clarified that, three quarters of the studied
with mean age 32.57±6.18. This is may patients were females. This may be due to
be due to that this age is called early that females are caring more about their
adulthood during which people are care body image and appearance than men, in
about their body image and general addition to that female patients in this
appearance. study had sedentary lifestyle and they
reported higher intake of sugars and fatty
This finding is consistent with Lin foods that predispose them to obesity and
and Tsao (2018) who revealed that the other chronic diseases. This result is
average age of the studied participant was agree with Carbajo et al. (2018) who

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found that nearly three quarters of studied Regarding marital status,

patients were females. approximately two thirds of the studied
patients were married. The studied
Regarding residence, the current patients clarified that they are following
study revealed that, nearly three quarters sedentary lifestyle, didn’t practice any
of the studied patients were from urban physical activities, watching television
areas. This may be due to the nature of for long time and had hormonal changes
industrial life in the urban area where the due to pregnancy, all these issues can lead
fast food restaurants present, people using to unhealthy weight gain. This finding
elevator instead of climbing stairs, lack of goes in the same line with Vieira et al.,
activity and more social activities where (2020) who stated that more than half of
people usually prepare large amounts of the studied patients were married.
high fat foods. All these issues reflect the
unhealthy lifestyle of people living in As regards total patients'
urban areas which make them more prone compliance, the current study reveals that,
to obesity. most of the studied patients had poor
level of physical activity postoperative
This result is consistent with bariatric surgery. This may be due to that
Bergmann and Tabone (2015) who the studied patients didn’t received
found that the majority of the studied instructions on how to perform physical
patients were from non-rural dwelling exercise as well as didn’t given guidelines
residence. for lifestyle modification post-operative
bariatric surgery. This result is
In relation to educational level, cotradicted with Coen et al., (2018) who
approximately half of the studied patients revealed that two thirds of the studied
were diploma education. This finding patients successfully completed the
may explain the average social standard recommended physical exercise
for patients who are receiving treatment intervention at the first six months after
at El-Demerdash hospital which is bariatric surgery which reflect positive
considered a governmental hospital that significant association between physical
provide its services at low price. This exercise and weight loss outcomes.
result is supported by Twells et al., (2017)
who reported that three quarters of the As regards to smoking cessation
studied patients was post-secondary after bariatric surgery, more than three
education. While this finding is quarters of the studied patients didn’t quit
contradicted with Zhu, Norman and smoking. This is may be due to that
While (2013) who found that nearly half patients need to be more knowledgeable
of the studied patients were bachelor about the benefits to stop smoking, they
degree. should try to change their daily habits in
order to reduce their reliance on cigarettes
Regarding occupational state, as much as possible to avoid its harmful
majority of the studied patients are not effect after surgery.
working. This is may be due to that three
quarters of the studied patients were This result is supported by Lent et
females and are house wives. This result al. (2013) who reported that smoking
is consistent with El-dawoody (2016) habits score did not change after surgery
who found that more than half of the in either bariatric procedure and current
studied patients are not working. smokers did not quit smoking.

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The current study represented that, medication adherence tends to be good in

more than two thirds of the studied the early post-surgery period, 90% of
patients were not compliance to diet patients taking supplements daily.
postoperative bariatric surgery. This may
be due to that the studied patients didn’t Regarding stress perceiving
received necessary instructions on the management, the present study finding
importance of compliance to diet post clarified that more than half of the studied
operative bariatric surgery. This result is patients had moderate level of stress. This
consistent with Maghrabi et al. (2019) explained that patients didn’t received
who reported that patients need additional instructions on how to manage stress they
educational sessions to ensure adequate face after bariatric surgery and how to
communication and learning of all core practice stress relieving measures. This
recommendations regarding eating after result is agree with Boniecka, et al.,
bariatric surgery. (2017) who reported that, near half of the
studied patient had a moderate level of
The current study illustrated that stress.
approximately half of the studied patients
had good compliance with follow-up post Regards quality of life, more than
postoperative bariatric surgery. This may two thirds of the studied patients had less
be due to the clarification of the level of work condition post operative
importance of follow up visits to improve bariatric surgery. This may be due to
weight loss outcomes, identify insufficiency of health status which
complications early and lead to better affects patients' work performance after
health outcomes after bariatric surgery. bariatric surgery that helps in improving
This study finding comes in agreement the quality of life. This finding is
with Dagan et al. (2017) who reported contradicted with Alkassis et al., (2019)
that most of studied patients attend to who found that there was a significant
follow-up visit after surgery. While, this improvement in patients' quality of life
finding is contradicted with Kob et al., domains after surgery and no patient had
(2015) who revealed that more than half a very poor or poor quality of life score.
of the studied patients were not attend to
follow-up after surgery when feel better. Regarding the relation between
patients' total compliance and their
As regards to total medication demographic characteristics, the result of
adherence, the current study findings the current study revealed that there was
showed that near half of the studied statistically significant relation between
patients were non adherent to medication total studied patients' compliance and
after bariatric surgery and little of them their demographic characteristics post
were adherent to medication. This is operative bariatric surgery that include
clarified by Modi et al., (2013) who age, gender, level of education and
stated that patients unable to eat solid occupation. This may be due to that
foods for several weeks after operation demographic characteristics are one of
that hinder their ability to swallow a large the factors that affect positively on
multivitamin pill, and even a chewable patients' compliance after bariatric
vitamin may not be as palatable surgery.
postoperatively as it was preoperatively
This finding is consistent with
This result is consistent with Hood Belo et al., (2018) who reported that
et al., (2016) who reported that there is no significance association

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between follow up adherence and  Further researches are

patients' age, gender, level of education recommended to study the factors
and occupation. affecting patients' compliance post-
operative bariatric surgery. As well as
Conclusion more intervention researches are needed
to develop a cohesive and comprehensive
The study revealed that most of body of evidence upon which to base
the studied patients had poor level of bariatric nursing care to improve patients'
compliance postoperative bariatric outcomes.
surgery and more than half of them had
moderate level of stress. In addition, near References
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adherent to medication postoperative Alkassis, M., Haddad, F. G., Gharios, J.,
bariatric surgery. Moreover, there was a Noun, R., & Chakhtoura, G. (2019).
statistically significance relation between Quality of Life before and after Sleeve
studied patients' compliance and their Gastrectomy in Lebanese
Population. Journal of Obesity, 2019, 1-6.
demographic characteristics. doi: 10.1155/2019/1952538

Recommendations American Society for Metabolic and

Bariatric Surgery (2016).Benefits of
The result of this study projected Bariatric Surgery. Retrieved from
the following recommendations: https://asmbs.org/. Accessed on 11April
2018 at 11:20pm
I – for patient:
American Society for Metabolic and
Bariatric Surgery (2018). Life after
 Bariatric surgery modules, Bariatric Surgery. Available at:
pamphlets and simple booklet should be https://asmbs.org/patients/life-after-
available for patients to illustrate and bariatric-surgery. Accessed on 16 August
simply explain lifestyle modification 2018 at 11: 17 am
post-operative bariatric surgery.
Belo, G. D. Q. M. B., Siqueira, L. T. D.,
 Lifestyle modification module Melo Filho, D. A. A., Kreimer, F.,
should be applied in all bariatric surgery Ramos, V. P., & Ferraz, Á. A. B. (2018).
Predictors of Poor Follow-up after
units and bariatric surgery clinical
Bariatric Surgery. Revista do Colégio
outpatients and updated periodically to Brasileiro de Cirurgiões, 45(2), 1-8. doi:
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