Thi Nguyet - Nguyen - Thesis

Queensland University of Technology
SELF-MANAGEMENT PROGRAM FOR PEOPLE WITH CHRONIC KIDNEY
DISEASE IN VIETNAM: A PRAGMATIC RANDOMISED CONTROLLED TRIAL
Nguyet Thi Nguyen
RN, BN, MSN
Submitted in fulfilment of the requirements for the degree of
Doctor of Philosophy
Institute of Health and Biomedical Innovation
School of Nursing
Faculty of Health
Queensland University of Technology
2018
Abstract
Background: Globally, chronic kidney disease (CKD) is a major problem, and in
Vietnam it is increasing rapidly. Active involvement in self-management can prevent
further deterioration of kidney function and slow the progression of CKD. Self-
management education programs that focus on improving CKD knowledge and self-
efficacy have been shown to improve self-management behaviours and health-related
quality of life, although most of these studies have been conducted in end-stage kidney
disease. Few studies have been done in earlier, pre-dialysis stages of CKD. In Vietnam,
very little education is provided by healthcare providers to patients with a chronic
disease, and no previous studies of CKD self-management have been undertaken in this
country. This thesis reports on a three-phase study.
Aims: The aims of Phases 1 and 2 were to translate, validate, and psychometrically
evaluate two instruments (kidney disease knowledge survey [KiKS] and CKD self-
management [CKD-SM]) in Vietnamese prior to the main phase. Phase 3 sought to test
the effectiveness of a self-management intervention designed for pre-dialysis CKD
patients attending renal clinics in Vietnam.
Methods: Phase 1 involved forward and back-translation of the two instruments with
four independent translators and then the Vietnamese versions were tested for content
validity by an expert panel (n = 10). Phase 2 used a test/retest design to psychometrically
evaluate the Vietnamese versions of both instruments for measuring self-management and
knowledge of people with CKD. The retest was one to two weeks later. Analysis of the
first two phases involved assessment of content validity, reliability, and internal
consistency.
Self-management program for people with chronic kidney disease i

In Phase 3, a pragmatic randomised controlled trial (pRCT) was conducted in the
outpatient renal clinics at Bach Mai Hospital, Vietnam. Participants were diagnosed with
CKD (stages 3–5) and not yet receiving dialysis, ≥ 18 years old, able to communicate in
Vietnamese, and able to be contacted by phone. Exclusion criteria consisted of
participants who were unwilling to participate, had cognitive impairment, were seriously
unwell, were enrolled in another clinical trial, or were undertaking dialysis. Participants
were randomly allocated into either the intervention or control group. Social cognitive
theory informed the intervention, which was delivered over 16 weeks. The intervention
group received face-to-face education and telephone support provided by a nurse
researcher, in addition to usual care. The comparison group received usual care only.
Primary outcomes were knowledge and self-management behaviour measured by the
instruments translated and tested in the previous phases. Secondary outcomes were self-
efficacy, health-related quality of life, and blood pressure control. Vietnamese versions of
the self-efficacy for managing chronic disease (SECD) and health-related quality of life
(SF-36v2) instruments were used to measure self-efficacy and health-related quality of
life, respectively. Blood pressure data were extracted from hospital records. All outcome
data were collected for both groups by blinded outcome assessors at baseline, 8 weeks
and 16 weeks. An intention-to-treat analysis and linear mixed models were used to
evaluate the effectiveness of the intervention at each time point and treatment interactions
with time and group.
Results: Phase 1 found that the Vietnamese versions of both the knowledge and self-
management instruments (V.KiKS and V.CKD-SM, respectively) demonstrated good
content validity. Scale and item content validity average scores for the V.KiKS and
V.CKD-SM were .97 and .99, respectively. In Phase 2, 158 people (51.3% women) aged
between 18–84 years completed both instruments. Most had CKD stage 5 (68.3%). The
ii Self-management program for people with chronic kidney disease

reliability testing of the V.KiKS Kuder-Richardson-20 was .58 and the V.CKD-SM
Cronbach’s alpha was .93. Retesting found good intra-class correlation coefficients of .82
for the V.KiKS and .84 for the V.CKD-SM. The results from Phases 1 and 2 supported
the validity and reliability of these instruments.
A total of 135 participants were enrolled into the pRCT, with 68 receiving the
intervention and 67 receiving usual care. There were no significant differences in
demographic and renal data between the groups at baseline. The average age of
participants in the intervention group was 48.8 years (standard deviation [SD] = 13.7),
which was similar to the control group (48.9 years, SD = 13.9). Most participants (67%)
were in either CKD stage 3B or 4. Glomerulonephritis was the main cause of CKD in
both groups (60%). There were no significant differences in knowledge, self-management
behaviour, and self-efficacy between the intervention and control groups at baseline.
Linear mixed models showed treatment effects of time and group on participants’
knowledge, self-management behaviour, and self-efficacy were significant, with p values
< .01. At 8 weeks’ follow-up, compared to usual care, the intervention group showed
improvement in knowledge (mean change = 5.71, 95% confidence interval [CI] = 4.80,
6.62), self-management behaviour (mean change = 12.44, 95% CI = 7.48, 17.40), and
self-efficacy (mean change = 1.02, 95% CI = 0.49, 1.55). At 16 weeks, large effect sizes
for improved knowledge (mean change = 7.43, 95% CI = 6.50, 8.36), self-management
behaviour (mean change = 18.13, 95% CI = 13.14, 23.11), and self-efficacy (mean
change = 1.43, 95% CI = 0.90, 1.96) were detected. A small effect change was observed
for health-related quality of life in the intervention group [physical health component
summary (mean change = 6.91, 95% CI = 1.22, 12.60) and mental health component
summary (mean change = 7.83, 95% CI = 1.88, 13.78)]. There was no significant change
found between groups for blood pressure when the study concluded.
Self-management program for people with chronic kidney disease iii

Conclusion: The V.KiKS and V.CKD-SM are now validated patient-reported outcome
measures suitable for clinical practice and research in Vietnamese-speaking populations.
The findings of the main study, the first RCT in Vietnam to test a CKD self-management
program targeting pre-dialysis stages of CKD, found that the education program was
effective in improving patients’ knowledge, self-management, and self-efficacy.
However, further research of longer duration is needed to establish whether the program
preserves kidney function. Nurses in Vietnam could deliver this short patient education
program in hospital wards or outpatient clinics and also in the commune hospitals during
health promotion activities. Finally, this study contributes to nursing knowledge to
improve patient care in the earlier stages of CKD.
Keywords: blood pressure, chronic kidney disease, health-related quality of life,
knowledge, pragmatic randomised controlled trial, self-efficacy, self-management, social
cognitive theory
iv Self-management program for people with chronic kidney disease

Table of Contents
Abstract ........................................................................................................................ i
List of Figures ........................................................................................................... xii
List of Tables ........................................................................................................... xiii
List of Abbreviations ................................................................................................xv
Statement of Original Authorship ......................................................................... xvi
Acknowledgements ................................................................................................ xvii
Chapter 1: Introduction .......................................................................................1
1.1 Introduction .........................................................................................................1
1.2 Chronic Kidney Disease ......................................................................................2
1.2.1 Definition ...................................................................................................2
1.2.2 Prevalence ..................................................................................................3
1.2.3 Risk Factors and Causes ............................................................................5
1.2.4 Management and Treatment.......................................................................8
1.2.5 Healthcare in Vietnam .............................................................................10
1.3 Significance of the Research .............................................................................13
1.4 Research Aims ...................................................................................................13
1.5 Research Questions ...........................................................................................14
1.6 Thesis Overview ................................................................................................14
Chapter 2: Literature Review ............................................................................17
2.1 Introduction .......................................................................................................17
2.2 Impact of Chronic Kidney Disease....................................................................17
2.2.1 Physical Impact ........................................................................................17
2.2.2 Psychological Impact ...............................................................................19
2.2.3 Social Impact............................................................................................19
Self-management program for people with chronic kidney disease v

2.2.4 Health-Related Quality of Life ................................................................21
2.3 Self-Management and Self-Care in Chronic Disease ........................................22
2.3.1 Self-Care ..................................................................................................22
2.3.2 Self-Management .....................................................................................23
2.4 Chronic Kidney Disease Self-Management ......................................................29
2.4.1 Skills.........................................................................................................30
2.4.2 Components of Chronic Kidney Disease Self-Management ...................31
2.5 Chronic Kidney Disease Self-Management Research .......................................35
2.5.1 Critical Appraised of Chronic Kidney Disease Self-Management

Systematic Reviews .................................................................................35
2.5.2 Summary of Included Randomised Controlled Trials in Chronic Kidney

Disease Self-Management........................................................................45
2.5.3 Gaps in Chronic Kidney Disease Self-Management Research ................56
2.6 Chapter Summary ..............................................................................................57
Chapter 3: Theoretical Framework ..................................................................59
3.1 Introduction .......................................................................................................59
3.2 Social Cognitive Theory ....................................................................................61
3.2.1 Person, Behaviour, and Outcome .............................................................65
3.2.2 Self-Efficacy ............................................................................................66
3.2.3 Information Sources .................................................................................66
3.2.4 Outcome-Expectation...............................................................................70
3.2.5 Summary of Social Cognitive Theory .....................................................71
3.3 Social Cognitive Theory and Chronic Kidney Disease Self-Management .......71
3.4 Social Cognitive Theory Fit with Vietnam Context ..........................................73
3.5 Chapter Summary ..............................................................................................76
Chapter 4: Methods ............................................................................................77
4.1 Introduction .......................................................................................................77
4.1 Research Questions ...........................................................................................79
vi Self-management program for people with chronic kidney disease

4.2 Phase 1: Translation and Validation ..................................................................79
4.2.1 Instruments ...............................................................................................80
4.2.2 Process of Translation ..............................................................................81
4.2.3 Data Analysis ...........................................................................................83
4.3 Phase 2: Psychometric Evaluation.....................................................................84
4.3.1 Design ......................................................................................................84
4.3.2 Setting ......................................................................................................84
4.3.3 Sample ......................................................................................................84
4.3.4 Eligibility Criteria ....................................................................................85
4.3.5 Data Collection ........................................................................................85
4.3.6 Procedure .................................................................................................85
4.3.7 Data Analysis ...........................................................................................86
4.4 Phase 3: A Pragmatic Randomised Controlled Trial .........................................87
4.4.1 Design ......................................................................................................87
4.4.2 Participants ...............................................................................................88
4.4.3 Intervention ..............................................................................................89
4.4.4 Length of Follow-up ..............................................................................100
4.4.5 Outcomes ...............................................................................................100
4.4.6 Sample Size Estimation .........................................................................105
4.4.7 Randomisation .......................................................................................106
4.4.8 Sequence Generation..............................................................................106
4.4.9 Allocation Concealment .........................................................................106
4.4.10 Blinding ...............................................................................................107
4.4.11 Recruitment .........................................................................................107
4.4.12 Data Management and Analysis ..........................................................109
4.5 Research Ethics ...............................................................................................112
4.6 Chapter Summary ............................................................................................113
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Chapter 5: Results ............................................................................................115
5.1 Introduction .....................................................................................................115
5.2 Phase 1 Results ................................................................................................115
5.2.1 Translation .............................................................................................115
5.2.2 Translation Process ................................................................................116
5.2.3 Instrument Validation Results................................................................118
5.3 Phase 2 Results ................................................................................................120
5.3.1 Sample Characteristics ...........................................................................121
5.3.2 Renal Clinical Characteristics ................................................................124
5.3.3 Instrument Summary Results .................................................................127
5.3.4 Instrument Responses ............................................................................127
5.3.5 Instrument Reliability ............................................................................134
5.3.6 Test/Retest Reliability ............................................................................135
5.3.7 Pair Items Correlations...........................................................................136
5.3.8 Testing Normal Distribution of Outcome Variables ..............................140
5.3.9 Correlation between Test and Retest .....................................................140
5.3.10 Comparison of Outcome Variables Results by Demographic

Characteristics ........................................................................................141
5.3.11 Feasibility of Using Two Instruments .................................................145
5.4 Phase 3 Results ................................................................................................147
5.4.1 Participant Flow .....................................................................................147
5.4.2 Recruitment ............................................................................................151
5.4.3 Baseline Data .........................................................................................151
5.4.4 Test of Normality Continuous Variables ...............................................159
5.4.5 Baseline Associations between Socio-Demographic and Primary

Outcomes ...............................................................................................159
5.4.6 Effect of the Self-Management Program on Outcome Variables ..........163
5.4.7 Ancillary Analyses .................................................................................177
viii Self-management program for people with chronic kidney disease

5.4.8 Participant Evaluation of the Self-Management Program .....................181
5.4.9 Harms .....................................................................................................181
5.5 Chapter Summary ............................................................................................182
Chapter 6: Discussion .......................................................................................183
6.1 Introduction .....................................................................................................183
6.2 Theoretical Framework ...................................................................................183
6.2.1 Culture and Context ...............................................................................184
6.2.2 Mechanisms of Behaviour Change ........................................................187
6.3 Phase One: Translation and Validation of Instruments ...................................191
6.3.1 Vietnamese Kidney Disease Knowledge ...............................................192
6.3.2 Vietnamese Chronic Kidney Disease Self-Management .......................193
6.4 Phase Two: Psychometric Testing of Instruments ..........................................194
6.4.1 Vietnamese Kidney Disease Knowledge ...............................................194
6.4.2 Vietnamese Chronic Kidney Disease Self-Management .......................195
6.5 Phase Three: Effectiveness of a Chronic Kidney Disease Self-Management

Program .....................................................................................................................197
6.5.1 Knowledge .............................................................................................198
6.5.2 Self-Efficacy ..........................................................................................200
6.5.3 Self-Management Behaviour .................................................................201
6.5.4 Health Related Quality of Life ...............................................................203
6.5.5 Blood Pressure Control ..........................................................................205
6.6 Chapter Summary ............................................................................................207
Chapter 7: Conclusions ....................................................................................209
7.1 Introduction .....................................................................................................209
7.2 Strengths of the Study .....................................................................................209
7.3 Limitations of the Study ..................................................................................211
7.4 Implications of the Study.................................................................................213
Self-management program for people with chronic kidney disease ix

7.4.1 Implications in Clinical Practice ............................................................213
7.4.2 Implications in Nursing Education ........................................................214
7.4.3 Implications for Research ......................................................................215
7.4.4 Implications for Healthcare Organisations ............................................216
7.5 Thesis Conclusions ..........................................................................................218
References ................................................................................................................219
Appendices ...............................................................................................................254
Appendix 1. Author’s Permission for Using Original version of the KiKS .............254
Appendix 2. Author’s Permission for Using Original version of the CKD-SM .......255
Appendix 3. Original English Kidney Disease Knowledge Survey (E.KiKS) .........256
Appendix 4. English Version of the Chronic Kidney Disease Self-Management ....257
Appendix 5. Phase 1 and 2 − QUT Ethics Approval ................................................258
Appendix 6. Phase 1 and 2 − Bach Mai Hospital Approval .....................................259
Appendix 7. Phase 2 − Participant Demographic Information Questionnaire..........260
Appendix 8. Phase 2 − Kidney Disease Knowledge Survey ....................................262
Appendix 9. Phase 2 − Chronic Kidney Disease Self-Management Instrument ......266
Appendix 10. Phase 2 – Clinical Characteristics (from patients’ medical records) .270
Appendix 11. Permission to use the ‘Living with Reduced Kidney Function’ ........272
Appendix 12. Permission to use the ‘Living Well with Chronic Kidney Disease’ ..273
Appendix 13. Chronic Kidney Disease Booklet .......................................................274
Appendix 14. Agreement to use SF-36v2 .................................................................330
Appendix 15. Phase 3 − QUT Ethics Approval ........................................................331
Appendix 16. Phase 3 − Bach Mai Hospital Approval .............................................332
Appendix 17. Registration ANZCTR Number .........................................................333
Appendix 18. Phase 3 − Kidney Disease Knowledge Survey ..................................334
Appendix 19. Phase 3 − Chronic Kidney Disease Self-Management Instrument ....338
Appendix 20. Phase 3 − Self-Efficacy for Managing Chronic Disease Instrument .343
x Self-management program for people with chronic kidney disease

Appendix 21. Phase 3 − Health Related Quality of Life (SF-36v2) .........................345
Appendix 22. Phase 3 − Participant Demographic Information Questionnaire .......360
Appendix 23. Phase 3 – Renal Clinical Characteristics (Patients’ Medical Records)362
Appendix 24. Phase 3 − Patients’ Comorbidity ........................................................364
Appendix 25. Phase 3 − Scoring of Patients’ Comorbidities ...................................366
Appendix 26. Phase 3 − Evaluation of the Intervention Program ............................367
Appendix 27. Problematic words and phrases from Forward Translation of KiKS .369
Appendix 28. Problematic words and phrases from Forward Translation of CKD-SM373
Appendix 29. Comparison of English and Back-Translated of Vietnamese KiKS ..381
Appendix 30. Comparison of English and Back-Translated of Vietnamese CKD-SM387
Appendix 31. Assessment Tool for Panel .................................................................392
Appendix 32. Revision made for items that the Suggested by Panellists .................407
Appendix 33. Histograms, Normal Q-Q plots, and Box plots of Variables .............411
Appendix 34. Normality testing of Outcome Variables at each time point ..............421
Appendix 35. Participant Evaluation of Self-Management Program .......................422
Self-management program for people with chronic kidney disease xi

List of Figures
Figure 2.1. PRISMA flow diagram of included systematic reviews. .........................37

Figure 3.1. Triadic reciprocal causation (Bandura, 1989, 1997, 2004b, 2012). .........62
Figure 3.2. Social cognitive theory (Bandura, 1977, 2002; Lenz & Shortridge-
Baggett, 2002; Shortridge-Baggett & van der Bijl, 1996). ...........................64
Figure 4.1. Study phases. ............................................................................................78
Figure 4.2. Translation process adapted from Sousa and Rojjanasrirat (2011)..........83
Figure 4.3. Framework of the self-management intervention program. .....................90
Figure 5.1. Phase 2 research process. .......................................................................120
Figure 5.2. Consolidated standards of reporting trials 2010 participant flow
diagram. ......................................................................................................150
Figure 5.3. Mean [95% CI] of knowledge scores over time for the control and
intervention groups. ....................................................................................165
Figure 5.4. Mean [95% CI] self-management scores over time for the control and
Figure 5.5. Mean [95% CI] self-efficacy scores over time for the control and
Figure 5.6. Mean [95% CI] PCS scores at baseline and week 16 for the control and
Figure 5.7. Mean [95% CI] MCS scores at baseline and week 16 for the control and
Figure 5.8. Mean [95% CI] SBP at baseline and week 16 for the control and
Figure 5.9. Mean [95% CI] DBP at baseline and week 16 for the control and
xii Self-management program for people with chronic kidney disease

List of Tables
Table 1.1. Chronic Kidney Disease Classification .......................................................3

Table 1.2. Risk Factors for Chronic Kidney Disease ...................................................5
Table 2.1. Systematic Reviews of Chronic Kidney Disease Self-Management
Research .......................................................................................................41
Table 4.1. Face-to-Face Self-Management Education Program................................95
Table 4.2. Follow-up Self-Management Education Program .....................................98
Table 5.1. Demographic Characteristics of Expert Panel ........................................118
Table 5.2. Scale and Item Content Validity Average of Instrument Variables for
Content Validity and Readability................................................................119
Table 5.3. Demographic Characteristics of Participants .........................................122
Table 5.4. Renal Clinical Characteristics.................................................................125
Table 5.5. Means and Standard Deviations for two Instruments .............................127
Table 5.6. Vietnamese Kidney Disease Knowledge Correct Results ........................129
Table 5.7. Vietnamese Chronic Kidney Disease Self-Management Responses
Results .........................................................................................................131
Table 5.8. Summary of Internal Reliability for Instrument Variables and Subscale
Variables .....................................................................................................135
Table 5.9. Intra-class Correlation Coefficients for Instrument Variables................136
Table 5.10. Paired Samples Correlations for Vietnamese Kidney Disease
Knowledge ..................................................................................................137
Table 5.11. Paired Samples Correlations for Vietnamese Chronic Kidney Disease
Self-Management ........................................................................................138
Table 5.12. Testing Normal Distribution of Instrument Variables ...........................140
Table 5.13. Results of Mann-Whitney U Test for Vietnamese Kidney Knowledge
Variable by Demographic Characteristics .................................................142
Table 5.14. Results of t–tests for Vietnamese Chronic Kidney Disease Self-
Management Variables by Demographic Characteristics .........................144
Table 5.15. Information Required to Document the Flow of Participants through
each Stage of the Main Study......................................................................148
Table 5.16. Baseline Sociodemographic Characteristics .........................................152
Table 5.17. Baseline Related Renal Characteristics ................................................154
Self-management program for people with chronic kidney disease xiii

Table 5.18. Baseline Renal Clinical Test Results .....................................................155
Table 5.19. Baseline Characteristics of Participants Lost to Follow-Up ................157
Table 5.20. Baseline Internal Reliability for Instrument Variables and Subscale
Variables .....................................................................................................158
Table 5.21. Baseline Association of Socio-demographic Characteristics on Primary
Outcomes Variables ....................................................................................161
Table 5.22. Mean Scores of Knowledge Subgroups between two Groups at Each
Time Point ...................................................................................................166
Table 5.23. Comparison of Primary Outcomes Variables at Each Time Point
Showing Post-hoc Test for Control and Intervention Groups ....................169
Table 5.24. Mean Scores of Self-management Subscales between two Groups at
Each Time Point .........................................................................................170
Table 5.25. Comparison of Secondary Outcome Variables at Each Time Point
Showing Post-hoc Test for Control and Intervention Groups ....................176
Table 5.26. Comparison of Knowledge Mean Scores between Unadjusted and
Adjusted Baseline Socio-demographic Variables in the Intervention Group178
Table 5.27. Comparison of Self-management Mean Scores between Unadjusted and
Adjusted Baseline Socio-demographic Variables in the Intervention Group180
xiv Self-management program for people with chronic kidney disease

List of Abbreviations
BMI Body mass index

BP Blood pressure
CCM Chronic care model
CI Confidence interval
CKD Chronic kidney disease
CKD-SM Chronic kidney disease self-management
d Cohen’s d
DBP Diastolic blood pressure
eGFR Estimated glomerular filtration rate
ESKD End stage kidney disease
HD Haemodialysis
HRQoL Health related quality of life
IQR Interquartile range
KiKS Kidney disease knowledge survey
KRT Kidney replacement therapy
LMM Linear mixed models
M Mean
MCS Mental health component summary
Mdn Median
PCS Physical health component summary
PD Peritoneal dialysis
pRCT Pragmatic randomised controlled trial
ps p values
RCTs Randomised controlled trials
SBP Systolic blood pressure
SCT Social cognitive theory
S-CVI Scale content validity index
SD Standard deviation
SECDS Self-efficacy for managing chronic disease scale
V.CKD-SM Vietnamese Chronic kidney disease self-management
V.KiKS Vietnamese Kidney disease knowledge
V.SECD Vietnamese Self-efficacy for managing chronic disease
V.SF-36v2 Vietnamese Health-related quality of life
Self-management program for people with chronic kidney disease xv

Statement of Original Authorship
The work contained in this thesis has not been previously submitted to meet requirements
for an award at this or any other higher education institution. To the best of my
knowledge and belief, the thesis contains no material previously published or written by
another person except where due reference is made.
QUT Verified Signature

Signature:
Date: 15/06/2018
xvi Self-management program for people with chronic kidney disease

Acknowledgements
First, I would like to express my gratitude to my respectful supervisory team, Prof Ann
Bonner and Assoc Prof Clint Douglas, for their high-quality supervision. Special thanks
to Prof Bonner for her unwavering support, guidance, and encouragement from the
inception of this thesis to its completion. Her significant contribution to chronic kidney
disease nursing, nationally and internationally, has also inspired me in a number of
different ways. I also thank Ann for her enormous patience and support in reading and
editing this thesis. Without her support, I could not have completed this thesis.
Second, I would like to give my greatest thanks and appreciation to Prof Genevieve Gray
for helping me to receive a scholarship to start my research journey, and her ongoing
encouragement and support throughout my PhD. Her significant contribution to
developing nurse teachers in Vietnam has inspired me in working and learning. My
thanks also go to Assoc Prof Tuyen Do and the staff in the Nephro-Urology Department
at Bach Mai Hospital, Hanoi, Vietnam, for their support of this study. I would also like to
thank all of the patients who agreed to participate in this research, which made an
enormous contribution to the completion of the research findings.
Tremendous thanks are extended to my parents, parents-in-law, sisters and brothers for
their love and encouragement. Special thanks to my Mom and Dad, thank you for all of
your sacrifices. Without your support, I could not have completed this thesis. Above all
my special thanks to my husband Dr Minh Pham, for his enormous and unwavering
support over these years, and to my daughter Michelle Pham, who was born in Australia
during my PhD and my son Vu Pham who has lived and breathed my studying. I hope
that I will inspire you in learning and your success in the near future.
Self-management program for people with chronic kidney disease xvii

Thank you to my friends, Assoc Prof Peter Lewis and his wife Christine Lewis, Colette
Wembenyui, and Huong Tran, who have been a great source of support throughout this
PhD. My thanks also to my director Assoc Prof Binh Ta and colleagues at Hanoi Medical
College for their support and encouragement.
Other thanks to: Lee Jones, Research Methods Group, for her statistics support and advice
which solved my statistical puzzles; Emma Kirkland in the Health Research Services
Team for her ongoing support; and Dr Martin Reese, for his academic language support,
as this thesis is written in my second language.
Lastly, thanks to the professional editor, Dr Gillian Ray-Barruel, who provided
copyediting and proofreading services according to university-endorsed guidelines and
the Australian Standards for editing research theses.
My dream of undertaking a PhD degree abroad would not be possible without generous
financial support of Australia Awards Scholarships (AAS).
I dedicate my success to all of you.
xviii Self-management program for people with chronic kidney disease

Chapter 1: Introduction
1.1 Introduction
The global burden of chronic disease is increasing, with chronic disease-related mortality
growing from 60% (31 million) in 2000 to 68% (38 million) in 2012 (WHO, 2015). Chronic
kidney disease (CKD) is a significant contributor to this burden in both developed and
developing nations, with approximately 80% of people with CKD living in low to middle
income countries (Mills et al., 2015). The disease is classified into stages according to the
estimated glomerular filtration rate (eGFR) with stage five also termed end-stage kidney
disease (ESKD) when kidney replacement therapy (KRT) is required to sustain life
(Webster, Nagler, Morton, & Masson, 2017). Recognised as one of the worldwide public
health problems, CKD is burdensome on individuals and families because of its effects on
daily life and the extensive and long-term healthcare required. For individuals, managing
CKD is a complex task that requires day-to-day self-management through adherence to
medication, blood pressure (BP) management, healthy eating, and exercise. Improved CKD
self-management is known to slow the progression of the disease and to improve health
outcomes (Bonner et al., 2014; Lee, Wu, Hsieh, & Tsai, 2016; Lin, Liu, Hsu, & Tsai, 2017;
Lopez-Vargas, Tong, Howell, & Craig, 2016; Welch et al., 2014). However, in developing
countries such as Vietnam, where health resources are stretched and almost non-existent
primary healthcare service provided by general practitioners care available, effective
strategies are needed to better support people to engage in CKD self-management.
This chapter first describes CKD: its definition, prevalence, risk factors, causes, and
management. This is followed by a discussion about the healthcare system in Vietnam, the
Chapter 1: Introduction 1
significance of this research, research aims, and research questions. Lastly, an overview of
this thesis is presented.
1.2 Chronic Kidney Disease
1.2.1 Definition
Chronic kidney disease (CKD) is defined globally as either kidney damage with urine,
imaging, and histologic abnormalities, or a low estimated glomerular filtration rate (eGFR) ≤
60 mL/min/1.73m² for 3 months or longer (Johnson et al., 2013; Webster et al., 2017). The
impairment of kidney function in CKD is irreversible (Johnson et al., 2013; Webster et al.,
2017), and the reduction in kidney function is classified into five stages based on eGFR (see
Table 1.1). The first stage is when eGFR is normal or increased to equal or greater than 90
mL/min/1.73m². Stage 2 refers to normal or slightly decreased eGFR, with ranges from 60 to
89 mL/min/1.73m². Stage 3 is sub-divided into 3A, mild-moderate decrease, and 3B,
moderate-severe decreased (range in eGFR 45–59 mL/min/1.73m² and 30–44
mL/min/1.73m², respectively). In stage 4, eGFR is severely reduced (15–29
mL/min/1.73m²), and stage 5 is when eGFR is less than 15 mL/min/1.73m². This stage is
also called end-stage kidney disease (ESKD) (Johnson et al., 2013; Webster et al., 2017).
2 Chapter 1: Introduction
Table 1.1. Chronic Kidney Disease Classification
Classification eGFR (mL/min/1.73 m²) Descriptions
Stage 1 ≥ 90 Normal or increased eGFR
Stage 2 60−89 Slightly decreased eGFR
Stage 3A 45−59 Mild-moderately decreased eGFR
Stage 3B 30−44 Moderate-severe decrease eGFR
Stage 4 15−29 Severely reduced eGFR
Stage 5 < 15 ESKD-nondialysis
Stage 5D and 5T ESKD-dialysis and Kidney transplantation
(Johnson et al., 2013; Webster et al., 2017)

Abbreviation: eGFR, estimated glomerular filtration rate; ESKD, end-stage kidney disease;
D, dialysis, T, transplantation
1.2.2 Prevalence
Global
As previously identified, CKD is a public health concern of both developed and developing
nations because of its serious consequences, such as premature death and poor quality of life.
The global prevalence of CKD in all adults is estimated at between 10% to 16% (Dienemann
et al., 2016), with the majority of people in stages 3–5 (10.6%) (Hill et al., 2016). The
estimated prevalence of CKD varies considerably and this may be due to whether the disease
has been diagnosed and also the methods for collecting national data for reporting in
registries.
In the United States (U.S.), the number of people with ESKD has more than tripled from
209,000 in 1991 to 660,000 patients in 2015 (National Kidney Foundation, 2016). The U.S.
Centers for Disease Control and Prevention recently estimated that about 30 million adults or
15% of U.S. adults were likely to have CKD (CDC, 2017). There are similar estimates of
CKD for England and Canada (Arora et al., 2013; Roderick, Roth, & Mindell, 2011).
In Australia, the problem of CKD is also on the rise, which is reflected in the number of
people progressing to ESKD and requiring kidney replacement therapy including dialysis
and transplant (ANZDATA Registry, 2016). In 2014, there were estimates of 2,600 new
patients of treated ESKD, with seven new treated patients per day (AIHW, 2016b).
Australian Institute of Health and Welfare (2016b) also reported that the estimated number
of dialysis-treated ESKD and transplant-treated people was 22,100, with 55% on dialysis and
45% living with a functioning transplant. According to ANZDATA Registry (2016), this
increased to 23,012 in 2015.
Asia
The prevalence of CKD is also increasing in Asian nations (Abraham et al., 2016; Wild,
Roglic, Green, Sicree, & King, 2004). For example, the prevalence of CKD was 17.5% in
Thailand, 13.3% in North India (Delhi), 13% in Japan, 13% in China (Beijing), 12.5% in
Indonesia, and 12% in Taiwan (Li et al., 2011; Nasution, Sulaiman, & Shafie, 2013). In
Korea, according to the Korean National Health and Nutritional Examination Survey from
2011 to 2013, an estimated 8.2% of adults were living with CKD, with the majority in stages
1–3 (8.0%) and stages 4–5 (0.2%) (Park, Baek, & Jung, 2016). According to the Singapore
Renal Registry (2018), an estimated 2.3% of the adult population have CKD, and five people
are newly diagnosed with CKD each day.
Vietnam
In Vietnam, the number of people with CKD is increasing rapidly. According to Tuyen
(2011), it is estimated that there are 100 to 150 new patients with CKD per million of
population per annum, and about 10,000 patients with ESKD are on haemodialysis. Hyodo et
al. (2017) estimated that six million people have CKD, which is about 6% of the total
Vietnamese population. Moreover, in 2013, Hyodo et al. (2017) estimated that 80,000 people
had ESKD (although many do not receive dialysis), and each year a further 8,000 people are
newly diagnosed with ESKD. The growing number of people with CKD has led to an
increased need for healthcare services.
1.2.3 Risk Factors and Causes
Risk factors
Globally the major risk factors for CKD are diabetes (particularly type 2 diabetes),
cardiovascular disease, hypertension, smoking, and obesity (AIHW, 2009, 2016a; CDC,
2017). The risk factors for CKD can be grouped into three main categories: namely, non-
modifiable, modifiable behavioural, and biomedical (AIHW, 2009, 2016a; CDC, 2017) (see
Table 1.2).
Table 1.2. Risk Factors for Chronic Kidney Disease
Non-modifiable Modifiable Behavioural Biomedical
Family history and genetics Tobacco smoking Diabetes
Increasing age Physical inactivity High blood pressure
Previous kidney disease or injury Poor nutrition Cardiovascular disease
Low birth weight Overweight and obesity Systemic kidney

inflammation
Male gender
(AIHW, 2009, 2016a; CDC, 2017)
In addition, socio-economic factors, such as income, education, and environmental factors
may also affect the incidence, prevalence, and progression of CKD. Researchers in the
United Kingdom (U.K.), the U.S., India, and Taiwan have found that having a low income
has a considerable effect on the development of CKD compared to a high income (Drey,
Roderick, Mullee, & Rogerson, 2003; Singh et al., 2013; Wen et al., 2008; White et al.,
2008).
In Vietnam, risk factors for CKD are known to be increasing due to the ageing population,
increasing prevalence of hypertension and obesity, and the high rates of tobacco and alcohol
use (Ito et al., 2008). In addition, the preferential consumption of foods that are high in
sodium and/or in saturated and partially hydrogenated fats (Hoy, Rao, Nhung, Marks, &
Hoa, 2013; Nguyen, 2009) is also contributing to the growing problem of CKD.
Understanding the risk factors could help healthcare providers (nurses and medical
practitioners) to assist patients to reduce the risk for developing CKD, and once it is
established, to more effectively self-manage CKD.
Causes
Diabetes and hypertension are both risk factors for and causes of CKD. Diabetes is the
leading cause of CKD in most countries (Abboud & Henrich, 2010; Hung et al., 2017; Jha,
Wang, & Wang, 2012; Orantes-Navarro et al., 2017). Diabetes causes structural and
functional changes in the kidneys, mostly due to glomerulosclerosis (Lim, 2014) that directly
increases glomerular permeability and worsening albuminuria (Toth-Manikowski & Atta,
2015). Diabetic nephropathy accounts for about 30% to 45% of ESKD cases worldwide,
with 44% in the U.S. (CDC, 2017) and 37% in 2015 in Australia (ANZDATA Registry,
2017).
Hypertension is another common cause of CKD, as high BP causes damage to the kidney’s
arterial blood vessels (Huan, Cohen, & Townsend, 2015). Hypertension can also be a
complication of CKD (Thomas, Kanso, & Sedor, 2008). The kidneys have a vital role in BP
homeostasis, so that when kidney function deteriorates, the kidneys are less able to help
regulate BP. Therefore, as the prevalence of hypertension increases in both developed and
developing countries, so does the prevalence of CKD. For example, in the U.S., hypertension
accounts for 29% of new cases of ESKD (CDC, 2017). In Australia, hypertension is
estimated to cause 13% of ESKD (ANZDATA Registry, 2017).
Glomerulonephritis (GN) is another major cause of CKD (Abraham et al., 2016; Jha et al.,
2013). Glomerulonephritis results from infections, autoimmune responses, and exposure to
drugs and toxins (Jha et al., 2013; Levey & Coresh, 2012). In Asian countries, nephrotoxic
herbal medications, environmental toxins (e.g., some pesticides, inadequate water supply),
infectious diseases (HIV or IgA nephropathy), and the use of unregulated food additives can
result in renal impairment (Imai & Matsuo, 2008; Jha et al., 2013). It should be noted that
GN is no longer the leading cause of CKD in developed nations, although it is cited as a
common cause in many countries in Asia and South Asia. For instance, the results from
several studies indicate that GN is the significant leading cause of ESKD in China,
Bangladesh, Taiwan, Japan, and the Philippines with 47.3%, 25.5%, 25%, 21%, and 20%,
respectively (Abraham et al., 2016; Iseki, 2008; Jha et al., 2013; Nakai et al., 2004; Zhang et
al., 2008).
In Vietnam, where access to healthcare is limited (see also section 1.3) and accurate data
collection is problematic, the prevalence and causes of CKD are likely to be highly
underestimated (Nguyen, 2013; Nguyen, 2014). As both diabetes and hypertension have
increased dramatically in Vietnam, there will be a rise in CKD. In one study conducted in a
large hospital in Hanoi (Bach Mai Hospital), glomerular diseases accounted for 26.1% of
people with CKD (Vuong & Tran, 2013). Hyodo et al. (2017) found that the main causes of
ESKD in patients receiving haemodialysis were diabetic nephropathy (74%) and chronic GN
(9%). The prevalence of GN is high because Vietnamese people rely on traditional medicines
that can be toxic to the kidneys (Duong, Olszyna, Nguyen, & McLaws, 2015). Other risk
factors such as inadequate water supply, use of pesticides, and labouring in hot, humid
conditions are also likely to cause renal failure, which is often not diagnosed or treated.
These risk factors are causing a CKD epidemic in other countries where the disease is
classified as CKD of unknown origin (Orantes-Navarro et al., 2017).
1.2.4 Management and Treatment
Early intervention to manage CKD by using appropriate therapies is extremely important to
reduce the impact and progression of the disease (Johnson et al., 2013; Sharaf El Din, Salem,
& Abdulazim, 2016). There are two main methods to manage the early stages of CKD: non-
pharmacological and pharmacological (Johnson et al., 2013). However, when the eGFR
decreases to less than 15 mL/min/1.73m², kidney replacement therapy (KRT) (including
haemodialysis, peritoneal dialysis, and kidney transplantation) is essential.
Non-pharmacological therapy is used for managing the early stages of CKD, and includes
dietary changes and lifestyle modifications (Johnson et al., 2013; Turner, Bauer,
Abramowitz, Melamed, & Hostetter, 2012). Dietary changes include adopting a healthy
eating plan that involves sodium and fat reduction. Lifestyle modifications are weight
reduction, increased physical activity (i.e., exercise and brisk walking), moderation of
alcohol consumption, and smoking cessation (Tuot, Plantinga, et al., 2013; Welch et al.,
2014). These interventions are known to delay the progression and prevent the consequences
of CKD (Johnson & Mathew, 2007), particularly through controlling BP, cholesterol and
blood glucose (Johnson et al., 2013). Moreover, lifestyle modifications, discussed in Chapter
2 (see section 2.4.2), are important even if medication interventions are also implemented.
Pharmacological treatment is used to control BP, blood glucose and cholesterol levels as
crucial interventions to slow the progression of CKD and avoid cardiovascular morbidity and
mortality (Nicholas, Vaziri, & Norris, 2013; Norris & Nicholas, 2015). The goal of
pharmacological treatment is to work towards achieving clinical targets for BP less than
140/90 mmHg, or if albuminuria is present BP should be less than 130/80 mmHg (Nicholas
et al., 2013; Norris & Nicholas, 2015). Targets for glycosylated haemoglobin (HbA1c) and
serum cholesterol are less than 7.0% and less than 4.0 mmol/L, respectively (Kidney Health
Australia, 2015).
The focus of this thesis is on people with CKD stages 3–5 who are not receiving KRT, and
therefore lifestyle modifications as well as adherence to medications are very important to
slow the progression of kidney disease. Lack of awareness of having a kidney problem in
people with CKD is high in many countries. Plantinga et al. (2008) found that less than 6%
of patients with CKD stage 3 and less than 30% with CKD stages 4–5 reported never seeing
a renal medical practitioner. Vassalotti, Li, McCullough, and Bakris (2010) in a national
screening study in the U.S. of 90,000 adults at high risk of CKD found that being aware of
having CKD was very low in all ethnic groups. For instance, only 6.3% of African
Americans, 6.8% of Native Americans, 8.6% of Caucasians, 11.1% of Hispanics, and 11.9%
of Asians and Pacific Islanders were aware that they had CKD (Vassalotti et al., 2010). In
Asian countries, awareness is also low. For instance, Hwang, Tsai, and Chen (2010)
indicated that 3.5% to 9.7% of Taiwanese with CKD were aware that they had the disease. In
a study of 2,576 adults in China, awareness of CKD was only 1.0% (Lu et al., 2010). This
highlights the need to improve awareness of CKD and kidney disease-specific knowledge in
those at risk for or who do have CKD.
1.2.5 Healthcare in Vietnam
Healthcare services
Vietnam has a population of about 90 million people (Shillabeer, 2016; Tuan, 2015) and up
to 80% of the population live in rural areas (Hyodo et al., 2017). The changing disease
pattern towards greater mortality due to chronic diseases and an increase in the older
population is creating more pressure on the Vietnamese healthcare system (Tuan, 2015;
Tuyen, 2011). For instance, hospital admissions due to chronic disease increased from 39%
in 1986 to 68% in 2002 (Minh, Huong, & Giang, 2008). The Vietnamese health
infrastructure is overwhelmed with overcrowded hospitals, where it is common that hospital
beds accommodate two or more patients in the same bed (Tuan, 2015).
The healthcare system in Vietnam is complicated by the administrative structure, regulations,
and a lack of coordination among different sectors. The Vietnamese health service comprises
four tiers. The lowest level are commune health centres in local communities, then
polyclinics and general hospitals, provincial hospitals, and national hospitals (Shillabeer,
2016). People usually seek primary health care at commune-level healthcare centres and are
then referred up through the tiers until they reach a national hospital (Shillabeer, 2016),
although there is great reluctance to use the lower tiers as these services are poorly equipped
and the staff have very little training. General practitioners (family doctors) are rare in
Vietnam and are just beginning to emerge. National hospitals, such as Bach Mai Hospital,
are specialised centres, although most people bypass lower level services to be seen by a
medical practitioner working in a more prestigious hospital.
The complicated healthcare system contributes to the fact that more than 70% of all sick
people do not seek care from any formal healthcare source (Ha, Berman, & Larsen, 2002).
They often wait for the illness to go away, or purchase medication for self-treatment from
private pharmacies or drug sellers who do not have any medical qualifications, or they
follow the advice of family members (Giang & Allebeck, 2003). Self-medication is highly
prevalent in Vietnam (Ha et al., 2002), as most medications can be purchased without a
medical practitioner’s prescription. However, self-medication can lead to the risk of
developing serious complications, such as adverse effects on kidney function, risk of
cardiovascular events, and hepatic injury (Berardi, 2005).
One of the main reasons for avoiding healthcare services is that about 28 million people are
too poor to pay hospital fees. Vulnerable groups (such as the poor, the elderly, and those in
rural areas) will generally choose to ignore their illness or undertake self-treatment (Thuan,
Lofgren, Lindholm, & Chuc, 2008), delaying seeking medical advice until the disease is in
an advanced stage.
The cost of CKD treatment is an example, and the cost of haemodialysis is very expensive.
Currently, the average income per person is US$1,730 per annum, but the average cost for
thrice-weekly haemodialysis per year is US$3,600 (US$25 per session) (Duong et al., 2015).
The Vietnamese government does provide a national health insurance system and will pay
80% of the dialysis treatment cost or up to 100% for certain patient groups (i.e., determined
on being below the poverty line, revolutionary contributors, and social protection group)
(Duong et al., 2015); however, all patients need to find the money to pay for 20% or more of
the treatment fee as well as other costs. For instance, transportation, food, and
accommodation after each treatment session are also a financial burden on patients. For these
reasons, haemodialysis treatment is too expensive for most people (Bui, 2007). There is also
a lack of specialist renal medical practitioners, and dietitians as a discipline are just
beginning to emerge in Vietnam. It is not until 2020 when hospitals will be required to have
a kitchen and provide meals to patients. Consequently, there is very little support for patients
to adhere to a management plan to slow the progression of CKD.
Nursing care
In Vietnam, nursing care in hospitals is mainly focused on technical nursing care, which is
often not centred on the needs of patients and families (Ha & Nuntaboot, 2016; Harvey,
Calleja, & Phan, 2013). Nurses are still viewed as medical assistants and are not permitted to
make independent nursing decisions (Pron, Zygmont, Bender, & Black, 2008), even though
they may have completed a 3- or 4-year Bachelor of Nursing qualification. These courses,
however, are mainly taught by medical practitioners using a medical model, with the nursing
content largely provided as teaching a limited range of skills. Medical practitioners’ orders
direct nursing interventions (Gallagher, Partridge, Tran, Lubran, & Macrae, 2017). One
example is that medication dosages are calculated by medical practitioners rather than nurses
prior to administering to patients (Pron et al., 2008). Family members have a vital role in
delivering direct nursing care to patients, such as attending to the hygiene needs of the
patient and bringing food (Khuu, 1999; Pron et al., 2008). Discharge planning is not
provided, and patient education is provided only by medical practitioners (Pron et al., 2008).
These examples illustrate the low social status and current practice of nurses in Vietnam.
However, a recent study examined how nurses provided health promotion to patients with
diabetes and CKD (Pham & Ziegert, 2016). This study found that nurses do have an
important role in health promotion, and they do this by creating positive relationships with
patients, supporting patients to make lifestyle modifications, and also educating patients and
families on health, disease, and self-care (Pham & Ziegert, 2016). The study findings further
highlight that nurses can provide patient education in clinical settings to help patients to
better manage their chronic disease.
1.3 Significance of the Research
This research is significant for three main reasons. First, CKD is rising globally and is a
major problem in developing countries such as Vietnam (Hyodo et al., 2017). It is a disease
that progresses to a point where very costly KRT is required to sustain life, thus increasing
the burden on individuals, families, and societies. Slowing the progression of CKD to avoid
needing dialysis and to reduce the risk of death due to cardiovascular complications requires
urgent attention in Vietnam due to the already overstretched healthcare system. Second, there
is increasing evidence that supporting patients to undertake self-management is an effective
approach to managing CKD and to slow the disease progression. Self-management is about
getting a person to be actively involved in looking after their disease. Providing patient
education to engage in self-management behaviour is therefore warranted to reduce the
disease burden and improve quality of life. Third, a number of studies have occurred in
ESKD for those receiving HD regarding improving adherence to treatment including that of
self-management, but less research has been undertaken for those with earlier stages of
CKD. Finally, this is the first randomised controlled trial (RCT) of a CKD self-management
intervention conducted in Vietnam.
1.4 Research Aims
This research aims to address the gap in knowledge and self-management for people with
CKD stages 3–5 (i.e., non-dialysis CKD). This research has three phases. The aims of Phase
1 and 2 are to translate, validate, and psychometrically evaluate two instruments in the
Vietnamese language. The instruments are needed to measure key outcomes (knowledge and
self-management) in Phase 3. The final phase aims to test the effectiveness of a self-
management intervention designed for pre-dialysis CKD patients attending renal clinics in
Vietnam.
1.5 Research Questions
The research questions are as follows:
Phase 1 and 2
1. Is the Vietnamese version of the kidney disease knowledge instrument reliable and
valid to measure knowledge of people with CKD?
2. Is the Vietnamese version of the CKD self-management instrument a reliable and
valid measure of self-management behaviour among people with CKD?
Phase 3:
3. Among Vietnamese people with CKD stages 3–5, does a self-management
intervention improve knowledge, self-efficacy, and self-management behaviour
compared to standard care in a hospital renal clinic?
intervention improve blood pressure control and health-related quality of life
1.6 Thesis Overview
This thesis comprises seven chapters. The first chapter has examined CKD, healthcare in
Vietnam, significance of the research, research aims and questions. The next chapter
provides a literature review of the impact of CKD, self-management and self-care in chronic
disease, particularly CKD self-management, and research of CKD self-management, and
significant gaps in CKD self-management research. Chapter 3 critically examines social
cognitive theory (SCT) as the theoretical foundation for a CKD self-management
intervention. Chapter 4 presents the research methods to address the research questions and
is divided into three phases. Phase 1 involves translation and validation of the CKD
knowledge (KiKS) and self-management (CKD-SM) instruments into Vietnamese. Phase 2
is a test/retest of these instruments in people with CKD in Vietnam. Phase 3 is a pragmatic
randomised controlled clinical trial (pRCT) of a self-management intervention. The results of
these phases are presented together in Chapter 5. Chapter 6 then discusses and compares the
study findings with the current literature. The final chapter reviews the strengths, limitations,
implications, and the main conclusions of the research.
Chapter 2: Literature Review
2.1 Introduction
This chapter will begin with a review of the literature related to the impact of CKD on
physical, psychological, and social domains. This chapter will then review the literature
developing the argument for differences in self-care and self-management. This is
followed by a critical appraisal of existing systematic reviews that included randomised
controlled trials of CKD self-management interventions. The chapter then concludes with
an argument for the significant gaps in knowledge and why this research is warranted.
2.2 Impact of Chronic Kidney Disease
The following section describes the physical, psychological, and social impact of CKD.
These three domains are associated with an individual’s health-related quality of life
(HRQoL). Therefore, these three domains are interconnected, and CKD-related
symptoms or problems in one domain will impact on the other domains.
2.2.1 Physical Impact
Chronic kidney disease significantly increases the risk of morbidity and mortality and
also decreases a person’s quality of life (AIHW, 2016b; Chin et al., 2008). Chronic
kidney disease is associated with a reduction in physical functioning and can cause
several complications, including cardiovascular disease, anaemia, metabolic imbalances,
and malnutrition (Almutary, Bonner, & Douglas, 2013; Almutary, Douglas, & Bonner,
2016; Bonner & Douglas, 2014; Thomas, Kanso, et al., 2008; Wright & Hutchison,
2009).
Chapter 2: Literature review 17

A range of physical CKD symptoms seem to impact substantially on people. For
example, two systematic reviews indicated that people with CKD, particularly in the later
stages, experience symptoms such as fatigue/tiredness, pain, pruritus, dry skin,
constipation, nausea, sleep disturbance, dyspnoea and restless legs (Almutary et al., 2013;
Murtagh, Addington-Hall, & Higginson, 2007). Fatigue is one of the most prevalent and
distressing symptoms in people with CKD (Almutary, Bonner, & Douglas, 2016). It has
been reported as affecting up to 90% of people (Almutary et al., 2013). Fatigue can
influence everyday life due to tiredness and reduced energy levels to undertake daily
activities (Finnegan-John & Thomas, 2013). A number of studies have shown that fatigue
has major repercussions on functioning and HRQoL (Bonner, Caltabiano, & Berlund,
2013; Jhamb et al., 2013; Picariello, Moss-Morris, Macdougall, & Chilcot, 2017b). Those
with higher fatigue levels have lower physical health and mental well-being (Bonner et
al., 2013). In a recent study in which individual symptoms were shown to cluster
together, fatigue was strongly connected to all five symptom clusters (Almutary, Douglas,
et al., 2016). This highlights the need for increased support for people with CKD to
reduce their levels of fatigue.
However, CKD is usually asymptomatic and often unrecognised until an advanced stage
of kidney failure. The lack of debilitating symptoms may mean that people are less
inclined to believe that they have CKD (Braun, Sood, Hogue, Lieberman, & Copley-
Merriman, 2012; Picariello, Moss-Morris, Macdougall, & Chilcot, 2017a), and could
reduce their engagement in self-management behaviours, particularly those related to
lifestyle modifications. Providing support is therefore essential to assist people in
knowing what CKD is, how to identify early symptoms, and how to take steps to manage
their disease.
18 Chapter 2: Literature review

2.2.2 Psychological Impact
Chronic kidney disease also has a significant impact on the psychological well-being of
people because of the decline in kidney function and the burden of long-term treatment
(White & McDonnell, 2014). In a systematic review, Almutary et al. (2013) found that
people with CKD stage 4 reported having more psychological problems in comparison to
those with stage 5. Psychological problems include feeling anxious, worrying, feeling
sad, depression, denial, loss of control, and fear of death (Almutary, Bonner, et al., 2016;
Bonner & Douglas, 2014). The psychological problems influence an individual’s life and
impact on other roles such as maintaining employment and sustaining social relationships
(Renkema et al., 2011). Thus, providing patient education may also assist psychological
well-being.
2.2.3 Social Impact
The social consequences of CKD are enormous due to the effects on individuals, family
members, and the government. The consequences include role changes within the family,
employment status, financial status, ability to continue education, reduced social network
and activities, change in residential location, and holiday and recreation (Bonner &
Douglas, 2014; Jansen, Rijken, Heijmans, Kaptein, & Groenewegen, 2012; Kidney
Health Australia, 2009). Having poor health, fatigue, anaemia, and pain are some reasons
why having CKD also impacts on social aspects of a person’s life. People with CKD have
difficulties taking part in other activities because of the burden of time spent visiting
medical practitioners, and adhering to medications and dialysis treatment schedules
(Jansen et al., 2012; Kidney Health Australia, 2009). People with CKD are involved in a
life-long commitment to treatment in order to delay CKD progression, as this disease
cannot be cured. Consequently, the families of people with CKD may experience

financial difficulties as a consequence of reduced work leading to a loss of income to care
for a family member, and other health costs (Ramachandran & Jha, 2013). People often
live with their family members or significant others; therefore, entire families also feel
the impact of CKD (Hoang, Green, & Bonner, 2018).
Chronic kidney disease causes a significant economic burden on health and social care
services (Mills et al., 2015). The cost of treatment and caring for people with CKD and
the associated consequences are increasing every year. According to World Kidney Day
(2015), treatment of CKD in the U.S. was estimated at $48 billion per year. In England,
the cost of CKD in 2009 and 2010 was estimated to be £1.44 to £1.45 billion, and costs
related to the consequences of CKD are also rising, estimated at £174 to £178 million
(Kerr, Bray, Medcalf, O'Donoghue, & Matthews, 2012). A recent study conducted with
data from Europe, North America, and Australasia reported that the annual hospital costs
for people with CKD ranges from £403 (stages 1 to 3B) to £525 (stage 5 but not on
dialysis) (Kent et al., 2015). However, the annual hospital cost is significantly increased
for those receiving dialysis and it also depends on how long they are receiving it. For
example, it ranges from £18,986 for those in the year of initiation to £23,326 for the
following years (Kent et al., 2015). A recent systematic review indicates that effective
interventions to slow the decline in renal function would have saved US$33 billion
between 2000 to 2010, and the amount saved would be even higher if interventions were
initiated in those with earlier stages of CKD (Vanholder et al., 2017).
In summary, the impact of CKD on the physical, psychological, and social domains of
life contributes to the reduced HRQoL of those with CKD (Almutary, Douglas, &
Bonner, 2017). There is, however, limited research on the impact of CKD on people in
Vietnam. The impact of haemodialysis does create a significant economic burden for

Vietnamese households due to the gap in costs for haemodialysis and medications
(Duong et al., 2015). The family may need to spend all of their savings, borrow from
neighbours, or sell family possessions to seek health care treatment at the hospital (Minh,
Huong, Giang, & Byass, 2009; Pron et al., 2008). This leads to patients reducing the
amount of dialysis they receive (Duong et al., 2015). Thus, slowing the progression of
CKD and improving the care needed to sustain life for people living with CKD is crucial
in countries such as Vietnam. Providing patients with self-management education is
therefore important to prevent further deterioration of kidney function and reduce the
disease’s impact on their health-related quality of life.
2.2.4 Health-Related Quality of Life
Health-related quality of life is one indicator of the overall well-being of an individual. It
refers to the person’s quality of life impacted by health-related problems, and it can
provide important information concerning how the individual is coping with their CKD
(Ibrahim, Teo, Che Din, Abdul Gafor, & Ismail, 2015; Pagels, Söderkvist, Medin,
Hylander, & Heiwe, 2012). Being diagnosed with CKD affects all the aspects of life
reviewed in the previous section, and HRQoL is known to be compromised not only in
advanced CKD stages but also in earlier stages of the disease (Aggarwal, Jain, Pawar, &
Yadav, 2016; Cruz et al., 2011; Pagels et al., 2012). For instance, Ibrahim et al. (2015)
found that a lower HRQoL was associated with a higher risk of kidney function
reduction, and the consequences were increasing mortality and need for hospitalisation.
Improving HRQoL in people with CKD is essential to prevent the negative impact of the
disease on physical, psychological, and social domains (Aggarwal et al., 2016). Self-
monitoring and managing the disease, adhering to treatment, and responding to changes is
likely to maintain an individual’s HRQoL (Barlow, Wright, Sheasby, Turner, &

Hainsworth, 2002). Jordan and Osborne (2007) suggest that the purpose of chronic
disease self-management education programs is to empower people through providing
information and teaching of skills to better self-manage their condition, which is then
likely to affect their overall health and wellbeing. Hence, providing self-management
education could reduce the burden of symptoms and improve HRQoL in the earlier stages
of CKD.
2.3 Self-Management and Self-Care in Chronic Disease
In chronic disease, the goal is to keep the illness under the best possible control,
preventing deterioration and complications of the disease on physical, psychological, and
social functioning (Clark, 2003). In order to achieve this goal, people need to have skills
to perform health-related tasks to manage their illness, which includes self-care and self-
management. The concepts of self-care and self-management are often used
interchangeably in the existing literature although there are differences in meaning
(Kralik, Price, & Telford, 2010; Wilde & Garvin, 2007). The following sections discuss
the concepts of self-care and self-management.
2.3.1 Self-Care
Self-care refers to the everyday activities that an individual undertakes to maintain their
physical and mental health. These activities are focused on maintaining good health by
preventing illness rather than managing an existing illness (Barlow et al., 2002; Clark et
al., 1991; Ryan & Sawin, 2009). Daily activities include eating, drinking, sleeping,
personal hygiene, and other activities that can be considered relevant in daily life (i.e.,
working, meeting with friends). Self-care is therefore something that all people do (or
ought to do).

2.3.2 Self-Management
Self-management in chronic disease refers to the positive efforts of individuals to manage
and to be actively involved in their healthcare in order to optimise health, prevent
complications, control symptoms, and follow treatment regimens (Novak, Costantini,
Schneider, & Beanlands, 2013; Von Korff, Gruman, Schaefer, Curry, & Wagner, 1997).
In other words, self-management is about activities that are needed in addition to self-care
to control an existing chronic disease. For the remainder of this thesis, the term self-
management is used.
Chronic disease self-management has been discussed for over four decades in the
literature (Corbin & Strauss, 1985; Lorig & Holman, 2003; Novak et al., 2013). Corbin
and Strauss (1985; 1988) explain that self-management is: (1) work to care for the disease
(taking medication, medical appointments, exercising or eating a special diet), (2) work to
maintain a normal life (e.g., chores, social contacts, hobbies), and (3) emotional work
required to deal with feelings (such as frustration, anger, depression). People with chronic
disease need to be responsible for their disease management in order to improve clinical
symptoms and HRQoL (Grady & Gough, 2014; Lorig & Holman, 2003; Novak et al.,
2013). The following sections discuss skills and required components in self-
management.
Skills
While early research in chronic disease self-management focused on adherence to
medical treatments, the research has moved towards a much broader understanding of
skills required to improve an individual’s ability to self-manage their chronic disease
(Grady & Gough, 2014; Lorig, 2002; Lorig & Holman, 2003; Novak et al., 2013). These

skills are confidence and knowledge (Lorig, 2002; Mackey, Doody, Werner, & Fullen,
2016).
First, confidence is the ability to engage in necessary actions to manage a chronic disease.
Several authors (Lorig, 2002; Lorig & Holman, 2003; Riegel & Dickson, 2008) describe
this as a person who is an active participant in their treatment, and who is able to deal
with problems, make decisions, and maintain their own health. Individuals’ confidence in
identifying problems related to their illness and seeking solutions is important in
developing self-management skills to maintain their health (Mackey et al., 2016). It is
because a person knows themselves better than others do, and they are also the best judge
of what are achievable goals (Lorig, 2002). Lorig (2002) also suggested that individuals
need confidence to be able to make an action plan that works best for them to achieve
their goals. Schwarzer (2014) has shown that when patients are confident in their ability
to manage their disease, they achieve better health outcomes.
Living with chronic disease, people need to have a strong belief in their ability (self-
efficacy) to be confident in certain behaviours needed to manage their disease (Freund,
Gensichen, Goetz, Szecsenyi, & Mahler, 2013; Lorig & Holman, 2003; Ludman et al.,
2013). In other words, improvements in self-efficacy could therefore lead to improved
confidence to figure out solutions when new problems arise while living with chronic
disease (Lorig & Holman, 2003; Ludman et al., 2013). What is crucial is that healthcare
providers are instrumental in supporting patients to acquire that confidence (Lorig, 2002).
Self-management education can build confidence in patients to maintain their health by
supporting them to engage in activities such as managing their medical treatment and
psychological well-being (Lorig, 2002; Lorig & Holman, 2003).

Knowledge, particularly disease-related knowledge, is the second skill needed for
effective self-management. Having knowledge to manage symptoms or select and/or
adhere to an appropriate treatment is essential to reduce the impact of disease and to
improve HRQoL (Lorig & Holman, 2003; Novak et al., 2013). A recent review (Mackey
et al., 2016) indicates that disease-related knowledge is integral to self-management
because having adequate knowledge is needed for active engagement in making
decisions. Two further systematic reviews indicate that providing self-management
education is vital in improving patients’ knowledge of their disease, which helps to
prevent complications and improve their quality of life (Bhurji, Javer, Gasevic, & Khan,
2016; Dinh, Bonner, Clark, Ramsbotham, & Hines, 2016). However, two recent studies
indicate that many people with chronic disease have inadequate knowledge about their
disease, medications they take, medicine side effects, and required activities to manage
their disease and promote their health (Gallagher, Warwick, Chenoweth, Stein-Parbury,
& Milton-Wildey, 2011; Song et al., 2013). For example, in a study conducted in China
with a sample of people known to have a chronic disease (n = 925), Song et al. (2013)
found that few were aware that they had a chronic disease. In another study conducted in
Australia of 118 participants with chronic illnesses who were assessed on their
medication knowledge found that participants’ medication knowledge was low [(mean =
47.61, SD = 18.73) out of a potential 100] (Gallagher et al., 2011).
In summary, improving self-management skills, namely confidence and knowledge, in
those with a chronic disease is needed to help individuals maintain their health, which in
turn may slow disease progression (Lorig & Holman, 2003), result in less symptom
burden and complications (Cramm & Nieboer, 2012), and lead to a better quality of life
(Ludman et al., 2013). Education is one strategy to improve chronic disease knowledge
and to improve confidence in self-managing that disease.

Components
The successful management of chronic disease is when people have self-management
skills to be actively involved in taking activities needed to promote their health (Lorig,
2002; Lorig & Holman, 2003). However, self-management skills are not sufficient to lead
to better chronic disease self-management. Seminal researchers in chronic disease argue
that other required components including communication, partnership in healthcare, and
adherence (Grady & Gough, 2014; Holman & Lorig, 2000; Lorig, 2002) also contribute
to the success in self-managing chronic disease. In addition, self-integration, problem-
solving, social support, and taking action are also required to assist people to effectively
manage chronic illness (Audulv, Asplund, & Norbergh, 2012; Brooks, Andrade,
Middleton, & Wallen, 2014; Hill-Briggs, 2003; Lin, Anderson, Chang, Hagerty, &
Loveland-Cherry, 2008; Lorig & Holman, 2003; Whittemore, 2005).
First, communication is important component that enables individuals with chronic
disease to work effectively together with their healthcare providers (Beverly, Worley,
Court, Prokopakis, & Ivanov, 2016; Lorig, 2002; Schulman-Green, Jaser, Park, &
Whittemore, 2016). In other words, those with a chronic disease must feel able to report
symptoms, problems or any concerns to healthcare providers and, in turn, healthcare
providers need to listen and provide information, support, answers, and guidance to assist
the patients. Good communication that is appropriate for an individual patient’s needs and
circumstances is likely to assist with supporting self-management behaviours (Beverly et
al., 2016; Stuckey et al., 2015).
Second, partnership in healthcare is when patients and healthcare providers work together
in planning chronic disease treatments and making decisions (Grady & Gough, 2014;
Holman & Lorig, 2000; Lorig, 2002). A healthcare partnership works better when there is

effective communication between both patients and healthcare providers. However, in the
Vietnam context, the medical practitioner is still the dominant person in the partnership
and the patients defer to them. At this time, the Western view of partnership in healthcare
is not yet appropriate for Vietnam.
Adherence is another component of self-management. Adherence refers to patients’
behaviours which coincide with medical or health advice, including taking medication,
following a diet, lifestyle modifications, and attending clinics (McDonald, Garg, &
Haynes, 2002). Adherence is more likely if communication is effective and partnership in
care with healthcare providers is in place (Beverly et al., 2016). In Vietnam, if
information is provided by a medical practitioner or with support from a medical
practitioner, patients do try to adhere to treatment regimens.
Fourth, self-integration is a process in which self-management activities are assimilated
into daily life (Audulv et al., 2012; Lin et al., 2008). For example, it is about how a
person maintains and integrates a suitable diet, taking medications, participating in other
lifestyle modifications, and adhering to other treatments in everyday life. An analysis of
the literature indicates that integration is necessary for self-management (Whittemore,
2005). Nursing interventions such as providing education, symptom recognition and
management, alleviating uncertainty, promoting self-management, providing assistance
with daily living activities, and developing community resources assist patients to
integrate chronic disease treatment into their lives (Whittemore, 2005).
Problem-solving, which refers to the process of using the self-management skills and
activities needed to problem-solve (Hill-Briggs, 2003; Lorig & Holman, 2003). In other
words, a person is able to identify problems and generate possible solutions to maintain
behaviours to manage their disease. People with chronic disease can be taught to identify

problems related to their disease, be provided with possible solutions based on their
problems, and should be assisted with selecting the most suitable solution and with the
evaluation of results (Lorig & Holman, 2003). Abazarian, Baboli, Abazarian, and
Ghashghaei (2015) suggest that providing education about problem-solving skills will
result in reducing symptom burden in people with chronic disease.
Social support refers to the support that a person receives from family members, friends,
significant others, and healthcare providers in order to manage their chronic disease
(Brooks et al., 2014; Gallant, 2003; Langford, Bowsher, Maloney, & Lillis, 1997).
Reviews from literature have shown that social support affects people’s health behaviours
and their health outcomes (Gallant, 2003; Holt-Lunstad, Smith, & Layton, 2010). Social
support can help to reinforce people to maintain their confidence to adhere to their
treatment plans and to perform healthy behaviours (DiMatteo, 2004; Gopinath, Harris,
Burlutsky, & Mitchell, 2013). However, inadequate social supports, including poor
communication with medical practitioners, low family support, and financial problems
have often been recognised as barriers to active self-management among people with
chronic disease (Jerant, Friederichs-Fitzwater, & Moore, 2005).
Taking action is also an important component whereby individuals learn how to integrate
changes in behaviour to care for themselves (Lorig & Holman, 2003; Novak et al., 2013).
For instance, learning how to incorporate healthy eating into everyday life, remembering
to take medications, stopping smoking, and being more active are all behaviours
important in preventing complications and improving quality of life in people with
chronic conditions. Education programs that support people to take action are required. In
Vietnam, as previously described in Chapter 1, nurses work under the direction of
medical practitioners (Pron et al., 2008) and consequently are restricted to providing very

little chronic disease education in either inpatient wards or outpatient clinics. Moreover,
medical practitioners are only able to provide limited patient education (Pham & Ziegert,
2016). In addition, patients may see different healthcare providers each hospital visit,
which makes it more difficult for patients to manage their disease. This is because
different providers may provide conflicting advice (Riegel & Carlson, 2002). Thus, it is
difficult for patients with chronic disease to take action and to engage in effective self-
management. Simple, easy-to-deliver, self-management education in Vietnam could be
effective in supporting patients to take action in managing their chronic disease.
In conclusion, successful self-management requires the integration of skills and required
components to manage the work of living with chronic health conditions in everyday life
and to deal with the psychosocial aspects of the conditions (Lorig, Sobel, & Gonzalez,
2012). When people believe in their ability to take action to overcome daily challenges in
managing their chronic disease, they are more likely to perform it frequently, and this in
turn is likely to achieve better health outcomes. People with chronic disease could master
self-management with guidance and support from healthcare providers, particularly
nurses helping patients learn skills to be active in care, acquire confidence in seeking
support and utilising resources to master problems, making decisions about their care, and
adhering to recommended treatment regimens. In the following section, the skills and
relevance components of self-management are specifically described in the context of
CKD.
2.4 Chronic Kidney Disease Self-Management
Chronic kidney disease self-management has a substantial number of daily tasks that a
person needs to perform to manage the impact of the disease and to slow its progression
(Curtin, Mapes, & Thomas-Hawkins, 2001; Lin, Wu, Wu, Chen, & Chang, 2012; Ong,

Jassal, Porter, Logan, & Miller, 2013). The following sections review the previously
described skills in the context of the CKD self-management. Finally, a review of
relevance required components of self-management for people with CKD is discussed
including communication, partnership in healthcare, adherence, self-integration, problem
solving, social support, and taking action.
2.4.1 Skills
Self-management skills requires both a better understanding of kidney disease and
confidence to take steps to manage the disease. Confidence is one of the important skills
in self-management of CKD. Three recent studies of CKD self-management have
examined people’s confidence through self-efficacy (Joboshi & Oka, 2016; Kazawa &
Moriyama, 2013; Lin, Tsai, Lin, Hwang, & Chen, 2013). The main focus of using self-
efficacy in these studies was to enhance participants’ confidence in improving their
lifestyle, such as maintaining a healthy weight and BP. When people have confidence in
their ability to achieve goals, they are more likely to maintain their lifestyle to manage
CKD (Kazawa & Moriyama, 2013). Education therefore can assist the improvement of
self-efficacy (confidence).
Knowledge in CKD refers to information about kidney disease, treatment options,
medications, diet, and lifestyle modifications. Previous research indicates that in earlier
stages CKD, prior to starting KRT, people have a lack of understanding of CKD and its
treatment (Finkelstein et al., 2008; Wright, Wallston, Elasy, Ikizler, & Cavanaugh, 2011).
For example, Finkelstein et al. (2008) measured perceived knowledge among people with
CKD stages 3–5 (n = 676) and found that more than a third (35%) of participants reported
that they had very limited or no understanding of their CKD and their treatment options.
Another study of 399 patients with CKD, all of whom were pre-dialysis, found that more

than half reported having little or no knowledge related to medications that helped the
kidneys (72%), medications that hurt the kidneys (63%), foods they should avoid when
their kidney function was low (61%), symptoms of CKD (61%), and the functions of the
kidney (51%) (Wright Nunes et al., 2011).
Studies have also shown that people with CKD want and need more CKD-specific
knowledge to support their self-management behaviours (Costantini et al., 2008; Havas,
Douglas, & Bonner, 2017; Lewis, Stabler, & Welch, 2010). Thus, improving people’s
kidney disease-related knowledge is important for early symptoms, taking prescribed
medications, and adhering to other management strategies. Patient education has been
shown to be extremely important in improving CKD knowledge in five recent systematic
reviews in CKD self-management (Bonner et al., 2014; Lee et al., 2016; Lin et al., 2017;
Lopez-Vargas et al., 2016; Welch et al., 2014). A more detailed examination of these
systematic reviews occurs in section 2.5.
In conclusion, previous research has shown that people with higher self-efficacy and
adequate kidney knowledge have better self-management of adherence to medication
regimens, partnership in health care, open communication, and kidney function compared
to those with lower self-efficacy and inadequate kidney knowledge (Curtin et al., 2008;
Devraj et al., 2015). Increased CKD self-management skills requires both a better
understanding of kidney disease and confidence to manage the disease, which in turn,
may prevent further deterioration of kidney function, and also to maintain their overall
health and well-being.
2.4.2 Components of Chronic Kidney Disease Self-Management
Seminal research in CKD have indicated that the required components to contribute to the
success in self-managing kidney disease. The components include communication,

partnership in healthcare and adherence have been identified in the initial research in
ESKD for those receiving dialysis (Curtin, Mapes, Schatell, & Burrows-Hudson, 2005).
First, communication is a respectful, two-way, meaningful conversation between patients
and healthcare providers (Curtin et al., 2005). Several studies have examined
communication in CKD (Lederer et al., 2015; Walker et al., 2017; Washington,
Zimmerman, & Browne, 2016). These studies have found that there are minimal
discussions of CKD. For instance, Lederer et al. (2015) in a study conducted in the U.S.
(n = 32) found that 38% of participants relied on their medical practitioners to provide
kidney disease information. This finding highlights that participants perceived their role
as a listener, a passive partner in the communication process. By being passive, CKD
knowledge and understanding of medical practitioners’ explanations may not improve
(Lederer et al., 2015). Thus, effective communication between patients and healthcare
providers is crucial to help patients with self-management activities such as home BP
monitoring, weight management, and dietary changes (Lederer et al., 2015; Lopez‐Vargas
et al., 2014) to slow the disease progression and improve HRQoL.
Second, using partnership in healthcare was reported in a number of studies of CKD self-
management (Byrne, Khunti, Stone, Farooqi, & Carr, 2011; Choi & Lee, 2012; Kazawa
& Moriyama, 2013; Walker, Marshall, & Polaschek, 2013; Williams, Manias, Walker, &
Gorelik, 2012). In these studies, the main focus of partnership is on building a good
relationship between patients and healthcare providers. Thereby, patients can share their
experiences and concerns with healthcare providers. In turn, healthcare providers
encourage and support patients to enhance their engagement in daily activities to manage
their disease. Lifestyle modifications of diet (avoiding added salt, eating high salt foods,
avoid high-fat food), taking regular physical activity, limiting alcohol consumption,

controlling body weight, and cessation of smoking are all important daily activities (see
also Chapter 1, section 1.2.4). Previous research in CKD self-management integrates
lifestyle modifications as part of various interventions. To avoid repetition, this research
is reviewed in the following section.
Third, adherence is important to CKD self-management, as for other chronic disease
previously discussed in section 2.3.2. However, adherence, particularly medication
adherence, remains a challenge in CKD with some studies suggesting the prevalence of
low adherence to prescribed medications is 30% or higher (Burnier, Pruijm, Wuerzner, &
Santschi, 2015; Sontakke, Budania, Bajait, Jaiswal, & Pimpalkhute, 2015). In addition, a
recent narrative review indicates that levels of adherence to diet, medication, and
treatment ranges from 20% to 70% (Beto, Schury, & Bansal, 2016). In Vietnam,
adherence with CKD treatment is unknown; however, it has been reported in people with
ESKD for those receiving haemodialysis. For example, 27% miss medications, 39%
struggle to adhere to renal diets, and 42% miss one or more haemodialysis sessions
(Duong et al., 2015). Similar to lifestyle modification, adherence is a common outcome in
CKD self-management research, which is reviewed in the following section.
In addition, Lin et al. (2012) and Ong et al. (2013) have indicated other components also
needed in self-management in people with CKD. Lin et al. (2012) used Lorig and Holman
(2003) components of self-integration, problem solving, social support, and taking action.
Ong et al. (2013) described the components as food management, BP management, blood
results management, and medication management. Ong et al. (2013) is in fact describing
what daily activities need to be done, and these have already been examined above.
Self-integration in CKD self-management reflects a person’s ability to integrate treatment
regimens and daily activities to manage their disease (Lin et al., 2012). Previous studies

of CKD self-management integration have examined nutrition (i.e., label reading,
identification of food containing salt or protein) (Campbell, Ash, & Bauer, 2008; Chen et
al., 2011; Kazawa & Moriyama, 2013), lifestyle modifications (Chen et al., 2011; Joboshi
& Oka, 2016; Kazawa & Moriyama, 2013), self-monitoring (Kazawa & Moriyama, 2013;
Lin et al., 2013), and making efforts to adjust to living with CKD (Blakeman et al., 2014).
The main focus in these studies is providing self-management education to enhance
participants’ integration to learn to maintain lifestyle modifications. In these studies,
participants have integrated monitoring their BP at home, physical activity and cooking
healthy meals. Thereby, participants’ integration in daily lifestyle which leads to their
decision to take action is discussed below.
Problem-solving in CKD self-management is the ability to seek a variety of resources and
actively learn knowledge of CKD in order to manage their kidney disease (Lin et al.,
2012). Several CKD self-management studies have used problem-solving skills to assist
patients (Blakeman et al., 2014; Joboshi & Oka, 2016; Lin et al., 2013; Teng, Yen, Fetzer,
Sung, & Hung, 2013; Williams et al., 2012). In these studies, problem-solving was part of
the patient education to assist patients to select appropriate food, remember to take
medication, or list ways of overcoming their problems to change their behaviour to
manage their disease. For example, Lin et al. (2013) in a study conducted in Taiwan
involving those with early stages of CKD (n = 37), participants were instructed to identify
possible problems in their daily activities, such as the overconsumption of high-fat foods
and salty foods, and how it impacted on their kidney function. The problems were then
discussed during the education program, and participants developed skills/strategies to
use to solve problems (Lin et al., 2013).

Social support is also important in CKD self-management. For example, Ibrahim et al.
(2015) in study conducted in Malaysia (N = 200) examined the influence of social support
on HRQoL, finding that higher social support was associated with improved medication
adherence, reduced hospitalisations, and a better HRQoL. Self-management education
may also be important for family members of those with CKD.
Taking action is when people believe in their capacity for self-managing, and they start
setting realistic goals for themselves and developing strategies to achieve their goals.
Taking action has been previously studied in CKD self-management (Byrne et al., 2011;
Joboshi & Oka, 2016; Kazawa & Moriyama, 2013; Lin et al., 2013). In these studies,
goals were typically about controlling BP and maintaining lifestyle modifications, and the
provision of education helped with developing an action plan. Taking action is based on
self-efficacy theory, which will be discussed in Chapter 3.
In summary, the literature shows that the skills and required components of self-
management have been used in the context of CKD to slow the progression of the disease
and to contribute to better health outcomes. What follows is a critique of the CKD self-
management research.
2.5 Chronic Kidney Disease Self-Management Research
This section critically appraises exisiting systematic reviews of CKD self-management
research. It then identifies the gaps in CKD self-management research.
2.5.1 Critical Appraised of Chronic Kidney Disease Self-Management Systematic
Reviews
Normally a systematic review is needed to search for existing studies in the substantive
area however as two existing systematice reviews had already been found (Bonner et al.,

2014; Welch et al., 2014), a search was performed to find if there had been any other
systematic reviews of CKD self-management studies. First MEDLINE, CINAHL,
ScienceDirect, ProQuest, and EbscoHost databases were searched by using the keywords
‘self-management’; ‘education’; ‘intervention’; ‘programme’; ‘chronic kidney disease’;
‘systematic review’; ‘meta-analysis’; ‘literature review’ for the period 2010−2017 in
English or Vietnamese language. A PRISMA flow diagram is provided as Figure 2.1.

Identification Records identified through database
searching (n = 2,164)
- MEDLINE (n = 75)
- CINAHL (n = 776)
- ScienceDirect (n = 1,176) Additional records identified
- ProQuest (n = 35) through other sources
- EbscoHost (n = 102) (n = 1)
Records after duplicates removed

(n = 630)
Screening
Records screened Records excluded

(n = 1,535) (n = 1,530)
Eligibility
Full-text Full-text
systematic reviews systematic reviews
assessed for eligibility excluded
(n = 5) (n = 0)
Included
Systematic reviews
included in quantitative
synthesis
(n = 5)
Figure 2.1. PRISMA flow diagram of included systematic reviews.

The search found five recent systematic reviews of quantitative studies (Bonner et al.,
2014; Lee et al., 2016; Lin et al., 2017; Lopez-Vargas et al., 2016; Welch et al., 2014).
Table 2.1 summarises the key findings of the systematic reviews. Two systematic reviews
included studies only in the pre-dialysis stages of CKD (i.e., stages 1–4), published in
English regardless of quantitative design (Bonner et al., 2014; Welch et al., 2014). Both
systematic reviews identified similar studies of which five were randomised controlled
trials (RCTs) (Byrne et al., 2011; Campbell et al., 2008; Chen et al., 2011; Flesher et al.,
2011; Williams et al., 2012). The other three systematic reviews (Lee et al., 2016; Lin et
al., 2017; Lopez-Vargas et al., 2016) included only RCTs of CKD self-management
interventions in either pre-dialysis patients or in those already receiving dialysis. Lee et
al. (2016) included two RCTs involving pre-dialysis patients (Campbell et al., 2008; Chen
et al., 2011), both of which were also reported by Bonner et al. (2014) and Welch et al.
(2014) in their systematic reviews. Lopez-Vargas et al. (2016) included 11 RCTs,
although only six were relevant to this thesis (Campbell et al., 2008; Chen et al., 2011;
Flesher et al., 2011; Paes-Barreto et al., 2013; Teng et al., 2013; Williams et al., 2012).
However, of these six studies, four had already been included in the other systematic
reviews (Bonner et al., 2014; Welch et al., 2014), leaving only two RCTs relevant to this
thesis (Paes-Barreto et al., 2013; Teng et al., 2013). The fifth systematic review (Lin et
al., 2017) included two pre-dialysis studies, of which one was published in Chinese,
leaving only Blakeman et al. (2014) suitable for inclusion in this literature review.
Additional search of included studies in the five systematic reviews was performed in
Google Scholar and the Queensland University of Technology library to obtain the
articles in full texts. From these five systematic reviews involving 1,011 patients with
CKD who were not on dialysis, eight RCTs examined CKD self-management
interventions (Blakeman et al., 2014; Byrne et al., 2011; Campbell et al., 2008; Chen et

al., 2011; Flesher et al., 2011; Paes-Barreto et al., 2013; Teng et al., 2013; Williams et al.,
2012). Since the systematic reviews have been published there has been one further RCT
(Joboshi & Oka, 2016), included in Table 2.1. What follows is a synthesis of the nine
previous RCTs that have reported on a CKD self-management intervention with a total of
1,076 participants.

Table 2.1. Systematic Reviews of Chronic Kidney Disease Self-Management Research
Systematic Years of Number of Study design Country Theoretical Intervention Outcomes Gaps in research
reviews and included studies RCT or Non (number) frameworks content/format/ assessed
new study studies (total RCT delivery/length
and year participants (number of
of new [n]) studies
study involving CKD
stages 3–5
participants
[non-dialysis])
Bonner et al. 2003 – 5 (n = 274)  3 RCTs  Australia  American  SM education on kidney  CKD  Lack of theory-
(2014) 2013 (stages 3–5)  Canada Dietetic knowledge, nutrition, knowledge base to inform
 2 non RCTs  Taiwan (2) Association cooking, exercise  SM the intervention
(stages 3–4)  Korea framework  Face-to-face, telephone  HRQoL  Varied strategies
 Nurses, medical  Nutritional to improve SM
practitioners, dietitian, status  Inconsistency in
cook educator, certified  eGFR the delivery,
exercise physiologist  BP duration, format
 12 weeks to 12 months  Cholesterol of the SM
 Urinary sodium education
 Urinary  Varied
protein assessment of
outcomes
Welch et al. 2010 – 7 (n = 376)  3 RCTs  Australia  Social cognitive  SM education on kidney  CKD  Theories were
(2014) 2013 (stages 1–4)  New Zealand theory knowledge, lifestyle, knowledge used in 4 studies
 4 non RCTs  Canada  Self-regulation exercise  SM to inform the
(stages 2–4)  U.K. theory  Face-to-face, telephone,  Self-efficacy intervention
 Taiwan  Health belief home visit, email  HRQoL  Varied strategies
 Korea model  Nurses, medical  Exercise to improve SM
 Japan practitioners, dietitian,  Nutritional  Inconsistency in
cook educator, certified status the delivery,
exercise physiologist  Medication duration, format

of new [n]) studies
study involving CKD
stages 3–5
participants
[non-dialysis])
 8 weeks to 12 months adherence of the SM
 eGFR education
 Creatinine  Varied
 BP assessment of
 Cholesterol outcomes
 Biochemistry  Flaws in
 Hb reporting
 HbA1c
Lee et al. 2002 – 7 (n = 423)  2 RCTs  Australia  Cognitive  SM education on kidney  eGFR  Theories were
(2016) 2014 (stages 3–5)  Brazil behavioural knowledge, nutrition,  BMI used in 3 studies
 1 non RCT  Taiwan (4) therapy skills to better self-  HRQoL to inform the
(stages 3–4)  Korea  Self-efficacy management intervention
 4 RCTs theory  Face-to-face, telephone  Varied strategies
(ESKD-  Nurses, medical to improve SM
dialysis) practitioners, dietitian  Limited outcome
 8 weeks to 12 months measures
Lin et al. 2003 – 18  18 RCTs (only  U.K. (5)  Cognitive  SM education on  Medical  Lack of theory-
(2017) 2017 (n = 1,647) 2 included  Brazil behavioural medical, role, and management base to inform
CKD non-  Iran therapy emotional management,  Self-efficacy the intervention
dialysis  India  Self-efficacy and quality of life  Anxiety in a number of
participants  Taiwan (4) theory  Face-to-face, telephone,  Depression studies
[stages 1–4]; 1  Hong Kong (2)  Four-Cs interactive website  HRQoL  Varied strategies
article in  China (4) model of  Delivery was not to improve SM
English and 1 chronic care reported  Limited

of new [n]) studies
study involving CKD
stages 3–5
participants
[non-dialysis])
in Chinese,  Health belief  4 weeks to 6 months outcomes
therefore only model assessed
1 RCT
included)
Lopez- 1996 – 26  11 RCTs  Australia (3)  Social cognitive  Education on kidney  CKD  Lack of theory-
Vargas et al. 2015 (n = 5,403) (stages 2–5,  Canada (4) theory knowledge, nutrition, knowledge base to inform
(2016) although only  Brazil  Self-regulation exercise, lifestyle  SM the intervention
6 studies  New Zealand theory modification, dietary  Self-efficacy in a number of
focused on  The  Health belief skills, skills to better  HRQoL studies
stages 3–5) Netherlands model SM  Medication  Varied strategies
 15 non RCTs  Sweden  Trans-  Face-to-face, telephone, adherence to improve SM
(stages 1–5)  Spain (3) theoretical home visit, email  Hospital-  Inconsistency in
 U.S. (2) model  Nurses, medical isations the delivery,
 Korea practitioners, dietitian  Exercise duration, format
 Japan  8 weeks to 24 months  Diet of the SM
education
 China modification
 eGFR  Varied
 Taiwan (7)
 Creatinine assessment of
 Biochemistry outcomes
 Glucose
 BP
 Weight
 BMI

of new [n]) studies
study involving CKD
stages 3–5
participants
[non-dialysis])
Joboshi and 2009 – − RCT with 1:1  Japan  Self-efficacy  SM education on  SM  Theories used but
Oka (2016) 2011 allocation into 2  Health treatment plan, lifestyle,  Self-efficacy not clearly
groups (n = 65) promotion skills for better SM,  BP explained why 3
model setting goals to foster  Creatinine theories were
 An interaction self-efficacy  eGFR needed to
model of  Face-to-face, telephone,  Serum improve SM
client health email, outpatient visit potassium  Limited
behaviour  Nurses  Hb outcomes
 12 weeks assessed
 Lack of using
standardised
instruments
 Example
instrument items
not provided
Abbreviation: CKD, chronic kidney disease; RCT, Randomised controlled trial; non RCT, Non-randomised controlled trial; SM, Self-management; BP, Blood pressure;
HRQoL, Health-related quality of life; eGFR, estimated glomerular filtration rate; BMI, Body mass index; Hb, Haemoglobin; U.K., United Kingdom; U.S., United States.

2.5.2 Summary of Included Randomised Controlled Trials in Chronic Kidney Disease
Self-Management
Of the nine studies, two were conducted in Australia (Campbell et al., 2008; Williams et
al., 2012), two in the U.K. (Blakeman et al., 2014; Byrne et al., 2011), two in Taiwan
(Chen et al., 2011; Teng et al., 2013), and one each in Canada (Flesher et al., 2011),
Brazil (Paes-Barreto et al., 2013) and Japan (Joboshi & Oka, 2016). Five of the studies
used a theory to inform the development of the intervention. These were: Social cognitive
theory (SCT) (Byrne et al., 2011), the Health belief model (Williams et al., 2012),
American Dietetic Association framework (Campbell et al., 2008), Transtheoretical
model (Teng et al., 2013), and the fifth study by Joboshi and Oka (2016) used a
combination of self-efficacy, an interaction model of client health behaviour, and a health
promotion model, although it was unclear how these three theories conceptually linked to
the study. Of these, only SCT was used in more than one study (Byrne et al., 2011;
Joboshi & Oka, 2016) although it was unclear how this theory informed the intervention.
The remaining four studies (Blakeman et al., 2014; Chen et al., 2011; Flesher et al., 2011;
Paes-Barreto et al., 2013) did not report using a theoretical framework to guide the
research.
As the interventions across the nine studies differed in terms of CKD content area,
format, delivery, and duration of the intervention, as well as outcomes measured, these
will be examined in more detail below.
Content of self-management interventions
The content of the interventions across the nine studies varied considerably. The content
included education about kidney knowledge (Blakeman et al., 2014; Byrne et al., 2011;

Chen et al., 2011), nutrition and a healthy diet (Campbell et al., 2008; Chen et al., 2011;
Flesher et al., 2011), physical activity (Flesher et al., 2011), medication (Blakeman et al.,
2014; Byrne et al., 2011; Chen et al., 2011; Williams et al., 2012), ways to measure and
control BP (Byrne et al., 2011; Williams et al., 2012), lifestyle modifications (Flesher et
al., 2011; Joboshi & Oka, 2016), and planning and self-management techniques to
achieve goals (Joboshi & Oka, 2016).
Format of self-management interventions
The format of the self-management interventions also varied in a number of ways. Face-
to-face education was the most frequently used format (Byrne et al., 2011; Campbell et
al., 2008; Chen et al., 2011; Flesher et al., 2011; Joboshi & Oka, 2016; Paes-Barreto et
al., 2013; Teng et al., 2013). Other formats used were telephone support (Blakeman et al.,
2014; Campbell et al., 2008; Chen et al., 2011; Paes-Barreto et al., 2013; Teng et al.,
2013), group discussion (Byrne et al., 2011; Chen et al., 2011), home visit (Williams et
al., 2012), clinic visit (Joboshi & Oka, 2016; Teng et al., 2013), emails (Joboshi & Oka,
2016), and interactive website (Blakeman et al., 2014). Williams et al. (2012) also
reported the use of Digital Versatile Disc (DVD) to enhance people’s confidence in
taking medications by focusing on their beliefs that when they took medication, they
would be able to control their BP and improve their health. Only Byrne et al. (2011)
reported that a friend or relative could also attend for support.
The majority of studies used written resources during the education intervention. The
resources were learning modules (Byrne et al., 2011), kidney information guidebook
(Blakeman et al., 2014), CKD cookbook (Flesher et al., 2011) or recipes to replace salt
(Paes-Barreto et al., 2013), and a BP booklet (Williams et al., 2012). However, the
provision of written education resources was not reported in three studies (Campbell et

al., 2008; Chen et al., 2011; Joboshi & Oka, 2016). By providing easily useable resources
such as printed materials, patients can review the material at home or they can read and
discuss it together with their family, which may in turn improve the effect of the CKD
self-management program.
Delivery of self-management interventions
Across the studies, the interventions were mostly delivered by nurses (Byrne et al., 2011;
Chen et al., 2011; Flesher et al., 2011; Joboshi & Oka, 2016; Williams et al., 2012). Other
studies used dietitians (Campbell et al., 2008; Chen et al., 2011; Flesher et al., 2011;
Paes-Barreto et al., 2013), cook educator (Flesher et al., 2011), staff and students at a
university (Blakeman et al., 2014), peers and volunteers (Chen et al., 2011), or trained
research assistants (Teng et al., 2013). In the clinical setting, these studies indicate that
nurses have a vital role in providing self-management education.
Duration of self-management interventions
The duration of the interventions in studies varied from 3 months (Campbell et al., 2008;
Joboshi & Oka, 2016), 5 months (Paes-Barreto et al., 2013), 6 months (Blakeman et al.,
2014; Byrne et al., 2011), to 12 months (Chen et al., 2011; Flesher et al., 2011; Teng et
al., 2013; Williams et al., 2012). Due to the heterogeneity of the studies, it is not possible
to identify the ideal duration of a CKD self-management education program. One study
reported that the investigators experienced difficulty with recruitment and retention of
people with CKD during a 6-month follow-up (Byrne et al., 2011).
In conclusion, previous research shows that self-management interventions vary widely,
and there is no consistency in the program content, format, and duration.

Outcomes assessed of self-management interventions
The effectiveness of CKD self-management interventions has been assessed in terms of
patient-reported and clinical outcomes, which are examined below.
Patient-reported outcomes
Knowledge
Knowledge was the most frequently assessed outcome, although only in three of the
studies (Blakeman et al., 2014; Chen et al., 2011; Teng et al., 2013). Chen et al. (2011)
measured knowledge and found that patients received the intervention had improved their
knowledge regarding kidney function, diet, treatment, and medication compared with the
control group when the study completed at 12 months. Knowledge was assessed at only
two time points (baseline and 12 months) although overall effect change of the
intervention on improved knowledge was not reported. In addition, it is unknown whether
knowledge improved during the first few weeks or months or only at the end of the study.
Teng et al. (2013) assessed knowledge at five time points—baseline, 3, 6, 9 and 12
months—using the Renal Protection Knowledge (RPK) checklist, which measures
participants’ knowledge of renal function protection, knowledge of using Chinese herbs
related to renal function, and CKD diet (Yen, Huang, & Teng, 2008). However, the
checklist is not available in English. The study measured knowledge at three repeated
time points at months 6, 9 and 12 when the study completed. The results indicated that
participants’ knowledge had improved over time. However, it is unclear how much
improvement between groups as overall knowledge scores of the two groups were
presented in a graph and no accurate numbers such as effect size of the overall

intervention on knowledge, mean scores, and standard deviation for each group at each
time point were reported in the publication.
The third study measured medication knowledge at 6 months by using the Medication
Knowledge and Medication Motivation subscales from the Modified Morisky Medication
Adherence Scale (Blakeman et al., 2014). This instrument was developed by Morisky,
Green, and Levine (1986) to test knowledge of hypertension medication. Blakeman et al.
(2014) found that medication knowledge of participants was not different between groups
at 6 months (study completion) in the intervention group versus control group. This result
may be due to the limitations of the intervention format and delivery as previously
discussed.
Participant knowledge was not measured in the other six studies (Byrne et al., 2011;
Campbell et al., 2008; Flesher et al., 2011; Joboshi & Oka, 2016; Paes-Barreto et al.,
2013; Williams et al., 2012). Lack of measuring knowledge in these studies may be due
to different study designs, as two studies tested the feasibility of the intervention (Byrne
et al., 2011; Williams et al., 2012), while the other four studies focused on different
intervention topics. Knowledge is an important skill in self-management behaviour as
previously argued in this chapter. Measuring knowledge is therefore crucial to assessing
how much people understand about their kidney disease; however, having sufficient
understanding does not indicate that a person can or will put this knowledge into practice.
Hence, measuring other outcomes such as self-efficacy and self-management behaviour at
the same time may help to explain that acquisition of disease-specific knowledge
improves confidence and that knowledge has been transferred into routine CKD self-
management behaviours.

Self-efficacy
Self-efficacy, or confidence in the ability to do something, is one of the most important
skills in CKD self-management. Byrne et al. (2011) described evaluating self-efficacy
although no instrument was identified, and neither were any results reported. Only
Joboshi and Oka (2016) measured self-efficacy as a primary outcome. This study
measured participants’ self-efficacy at baseline and at 3 months when the study ended.
Efforts to foster self-efficacy were included in the study, such as encouragement from
nurses to clarify lifestyle issues and determine self-management skills needed for a
healthier lifestyle. In addition, this intervention group was provided with further support
through outpatient visits, telephone calls, or emails. Joboshi and Oka (2016) found that
there was an increase in self-efficacy in the intervention group as they have improved
confidence in taking healthy actions to self-maintain health compared to the control
group. The confidence that participants gained from the intervention is crucial to improve
their lifestyle practice, which helps to self-manage CKD and prevent further deterioration
of kidney function. However, the self-efficacy instrument used in this study had been
developed by Kim, Shimada, and Sakano (1996) and was in Japanese. Joboshi and Oka
(2016) did not provide information regarding how this instrument assessed self-efficacy.
In the remaining seven studies (Blakeman et al., 2014; Campbell et al., 2008; Chen et al.,
2011; Flesher et al., 2011; Paes-Barreto et al., 2013; Teng et al., 2013; Williams et al.,
2012), self-efficacy was not an outcome. Self-efficacy is an important aspect of
improving self-management behaviour that will be explored further in the next chapter.
Self-management
Improvement in CKD self-management was the aim of all nine studies although
surprisingly it was measured in only six studies, using six different instruments. Flesher et

al. (2011) used the chronic disease self-management instrument developed by Stanford
School of Medicine Patient Education Research Centre to assess self-management at
baseline, 6 months, and 12 months. However, only participants’ answers at baseline and
12 months were used to compare and report for the effect of the intervention program.
Flesher et al. (2011) found that participants who received the self-management program
showed improvement in their exercise frequency, concern over their health condition, and
frequency of visits to healthcare providers and hospitalisation; however, unclear in
reporting how much improvement in the intervention compared to the control group were
provided in the publication.
Williams et al. (2012) assessed participants’ self-management by using a therapeutic level
of medication adherence instrument. Change in medication adherence was measured
using the four Item Morisky Medication Adherence Scale (Morisky et al., 1986),
however, there is an inconsistency in their findings regarding medication adherence.
Participants in both groups reported that they did not have any problem remembering to
take prescribed medications, but at the same time they forgot to take medication
(Williams et al., 2012). Although these authors found that an average of 87% of the
intervention group adhered in recording their BP daily; however, no result from the
control group was reported. Williams et al. (2012) also found that participants in the
intervention group (30.6%) did not routinely check their blood pressure although they
reported that they already owned self-monitoring blood pressure machines. These
findings indicate the important of measuring self-management behaviour and knowledge
at the same time to have better demonstration of whether participants’ knowledge is
transferred into daily activities to manage CKD.

The Health Promoting Lifestyle Profile-II Chinese version (HPLP-IIC) instrument was
used to measure diet and exercise self-management behaviours in the study by Teng et al.
(2013). This study found that physical activity in the intervention group had improved
over time, compared to the control group. This study also found a large increased (60%)
in being action or maintenance stage of dietary behaviour in the intervention group,
whereas only a small increased (13%) was found in the control group. This finding
highlights that participants who received the education have begun adhering to a healthy
diet to self-manage their kidney disease and maintain health such as they had steeper
decline in nutrition scores, although no difference between groups was found.
Paes-Barreto et al. (2013) measured participants’ self-management through a checklist of
protein intake using a 24-hour food method at four visit time points [first visit (4–6
weeks), second visit (8–10 weeks), third visit (12–14 weeks), and fourth visit (16–20
weeks)]. The study found that participants who received the intervention had decreased
protein intake values between baseline and fourth visit (Paes-Barreto et al., 2013). This
finding indicates that those received the intervention have turned their understanding into
action to reduce the consumption of protein to manage CKD.
Blakeman et al. (2014) measured CKD self-management as a secondary outcome using
the Summary of Diabetes Self-Care Activities (SDSCA) instrument, which was
developed to measure self-management behaviour in people with type 2 diabetes
(Toobert, Hampson, & Glasgow, 2000). Self-management was assessed at baseline and at
the study end (6 months later). Blakeman et al. (2014) found that participants in the
intervention group showed an improvement in self-management activities compared to
the control group, although no theory was used to demonstrate the intervention effects on
improving self-management in the intervention group.

Joboshi and Oka (2016) measured CKD self-management through an instrument the
authors created, based on the CKD Medical Practice Guide of the Japanese Society of
Nephrology. The instrument, written in Japanese, had been validated prior to this study.
The instrument assessed medication adherence, BP, body weight, test data management,
drinking and smoking, nutrition, exercise, and infection prevention (Joboshi & Oka,
2016). Self-management was measured at baseline and at the completion of the study (12
weeks later), and found that participants who received the self-management intervention
had improved self-management behaviour compared to those who did not. The result has
been demonstrated that the intervention is effective in improving participants’ self-
management behaviour as those received the self-management support indicated more
confidence in taking action to achieve their goals or adjust their behaviours to manage
CKD.
Participants’ self-management was not measured in the remaining three studies (Byrne et
al., 2011; Campbell et al., 2008; Chen et al., 2011), although all studies aimed to examine
the impact of self-management program on people with CKD.
Health-related quality of life
Improvement in HRQoL is one indicator of the beneficial effects of improved self-
management, although HRQoL was only assessed in two studies (Blakeman et al., 2014;
Campbell et al., 2008). Blakeman et al. (2014) used the EuroQoL to measure HRQoL in
both groups, finding that the intervention group showed improved in HRQoL, compared
to the control group. Although unclear in reporting of the finding was found regarding the
effect change of the overall intervention on HRQoL, which therefore limited the ability to
explain the effects of the intervention and compare with other studies. Campbell et al.
(2008) used the Kidney Disease Quality of Life Short Form version 1.3 (KDQoL-SF

v1.3) found that compared to the control group, the intervention group showed improved
symptoms, cognitive functioning, and vitality. However, participants’ health-related
behaviours and knowledge related to information given in the intervention program were
not assessed in the study by Campbell et al. (2008), which may be limited the
demonstration of how the intervention improve their HRQoL. The other seven studies
(Byrne et al., 2011; Chen et al., 2011; Flesher et al., 2011; Joboshi & Oka, 2016; Paes-
Barreto et al., 2013; Teng et al., 2013; Williams et al., 2012) did not assess this outcome.
Clinical outcomes
The purpose of CKD self-management is to assist people to have better health and to slow
the progression of CKD. The most frequently assessed outcomes have been kidney
function (eGFR) and BP control. Other renal clinical tests and health-related outcomes
such as potassium, cholesterol, haemoglobin, urinary protein, urinary sodium, body
weight, and body mass index (BMI) were less frequently assessed. Smoking status was
not measured in any of the nine studies.
Evaluation of eGFR was reported in five studies (Chen et al., 2011; Flesher et al., 2011;
Joboshi & Oka, 2016; Paes-Barreto et al., 2013; Williams et al., 2012); however, there
were mixed findings across the studies. Chen et al. (2011) found that eGFR had improved
over time in the intervention group, compared to those in the control group. By contrast,
eGFR of participants in the intervention group did not improve compared to those who in
the control group in the other three studies (Flesher et al., 2011; Joboshi & Oka, 2016;
Paes-Barreto et al., 2013). One further study, Williams et al. (2012), did attempt to
measure eGFR as an outcome, but due to missing data they were unable to report this
result. In two studies, Campbell et al. (2008) and Teng et al. (2013), eGFR was only
measured at baseline and was not a study outcome. The remaining two studies did not

measure eGFR (Blakeman et al., 2014; Byrne et al., 2011). As self-management programs
are designed to assist people to improve or maintain their kidney function, assessing
whether eGFR changes overtime is a useful outcome; however, as change in eGFR is
likely to take a long time (months or years) and could also be affected by other factors
(e.g., cause of CKD, comorbid diseases, etc.), a long study duration over serveral years is
required.
Blood pressure control (BP) was another clinical outcome measured in four studies
(Blakeman et al., 2014; Flesher et al., 2011; Joboshi & Oka, 2016; Williams et al., 2012);
however, equivocal findings of BP were found. Only Blakeman et al. (2014) found an
improved in BP at the end of the study between the intervention and control groups,
whereas other studies did not (Flesher et al., 2011; Joboshi & Oka, 2016; Williams et al.,
2012). Three studies did not measure BP (Byrne et al., 2011; Campbell et al., 2008; Chen
et al., 2011). Byrne et al. (2011) did attempt to measure BP; however, there were no
results provided in the publication.
Other outcomes such as serum creatinine, potassium, cholesterol, haemoglobin, urinary
protein, urinary sodium, body weight, and BMI varied across the nine studies. Serum
creatinine was reported in four studies, and no difference was found in Joboshi and Oka
(2016), Chen et al. (2011), and Paes-Barreto et al. (2013), while Williams et al. (2012)
found improvement in the intervention group but they were unable to compare to the
control group. Joboshi and Oka (2016) and Paes-Barreto et al. (2013) also reported
unchanged in serum creatinine between the intervention and control groups at the end of
their respective studies. Cholesterol, urinary protein, urinary sodium were measured by
Flesher et al. (2011), who found that only urinary sodium had changed between groups at
the study end. Potassium was measured in two studies (Joboshi & Oka, 2016; Paes-

Barreto et al., 2013), and no difference was detected in either study. Haemoglobin (Hb)
was only assessed by Joboshi and Oka (2016) who found no difference between groups.
Urea, glucose, phosphorus, albumin, body weight and BMI were assessed by Paes-
Barreto et al. (2013), and no differences between groups were found for any of these
outcomes. However, Paes-Barreto et al. (2013) found that at the fourth visit compared to
baseline, the intervention group had decreased in albumin, urea, body weight, and BMI.
The other two studies did not report any of these clinical outcomes in their respective
results (Blakeman et al., 2014; Byrne et al., 2011).
In conclusion, self-management education is to support people to understand kidney
disease and improve confidence in making behaviour change to manage their disease in
everyday life. Knowledge is an integral part of self-management as people need to
understand what CKD is, how to identify early symptoms, and how to take steps to
manage their disease. Knowledge and self-management behaviour are therefore important
outcomes and ought to be measured in behavioural studies. In addition, measuring self-
efficacy, HRQoL, and clinical outcomes such as BP control are also needed to evaluate
the effects of the self-management education on enhancing patients’ confidence in taking
actions to manage the disease and reduce the impacts of CKD on HRQoL and health
outcomes.
2.5.3 Gaps in Chronic Kidney Disease Self-Management Research
Even though there have been nine previous RCTs, there are several gaps in CKD self-
management research. First, no studies have been undertaken in Vietnam. Second, due to
the small number and heterogeneity of studies conducted thus far, further research
informed by behavioural theories is warranted to test whether self-management
interventions work in different contexts. Third, strategies to improve self-management

have varied according to content, format, delivery, and resources used. Fourth, there is
little consistency in the type of outcomes assessed. Self-management behaviour has been
measured using different instruments and culturally relevant instruments need to be used.
In addition, given the focus on improving self-management both patient-reported and
clinical outcomes ought to be measured. It seems obvious that, at a minimum, a person’s
knowledge of CKD and whether they believe they are self-managing should be primary
outcomes for this type of intervention study. Lastly, flaws in reporting were found, and
only three studies adhered to the CONSORT guidelines. Given these gaps, a study in
Vietnam where minimal CKD patient education is provided is clearly warranted.
2.6 Chapter Summary
Chronic kidney disease is a major problem globally and creates a number of impacts on
the physical, psychological and social aspects of a person’s life. Providing self-
management education is essential to assisting people to understand what CKD is, how to
identify early symptoms, and how to take steps to self-manage their disease. Effective
self-management behaviours are known to slow the progression of CKD and improve
people’s HRQoL although the findings from nine previous RCTs indicate a gap in
knowledge. These previous studies have: limitations with methodology; substantial
variations in the content, format, delivery, and duration of the intervention; measure a
variety of outcome using inconsistent methods so as to preclude a meta-analysis; and are
inconsistently report. In the next chapter, social cognitive theory (SCT) as the theoretical
framework to guide this study is described, and this is followed by a detailed description
of the three phases for this study in Chapter 4.

Chapter 3: Theoretical Framework
3.1 Introduction
There are a number of theories identified in the literature which have been used to explain
health behaviour, such as the Theory of Planned Behaviour (Ajzen, 1991), the
Transtheoretical Model (Prochaska, DiClemente, & Norcross, 1992), the Health Belief
Model (Pender, Murdaugh, & Parsons, 2015), and Social Cognitive Theory (SCT)
(Bandura, 1989). The Theory of Planned Behaviour is used to predict the occurrence of a
specific behaviour through four components such as attitude toward behaviour, subjective
norms, perceived behavioural control, and intention (Ahmad et al., 2014); however, the
gap between intensions and behaviour are difficult to classify (Munro, Lewin, Swart, &
Volmink, 2007; Rich, Brandes, Mullan, & Hagger, 2015). The Transtheoretical Model
explains how individuals make and internalise behaviour change through five stages;
namely the pre-contemplation, contemplation, preparation, action, and maintenance
stages (Cassidy, 1999; Prochaska et al., 1992). However, the Transtheoretical Model is
limited because it does not demonstrate how individuals change their behaviour and why
only few individuals succeed (Munro et al., 2007). The Health Belief Model consists of
six key constructs, perceived susceptibility, perceived severity, perceived benefits,
perceived barriers, cues to action, and self-efficacy, to explain how individuals change
their health behaviours (Sadeghi, Tol, Moradi, Baikpour, & Hossaini, 2015). This model
has similarities to SCT although it is unclear these constructs combine to explain
behaviour change (Munro et al., 2007). Among these theories, SCT provides the most
comprehensive understanding of why and how individuals change their health behaviour
Chapter 3: Theoretical framework 59

and the factors that influence them (McAlister, Perry, & Parcel, 2008; Munro et al.,
2007).
Social cognitive theory emphasises the interaction between people and their
environments, and their capacities for learning and adaptation to perform the desired
behaviour (Bandura, 2004b, 2012; McAlister et al., 2008). Behaviour is a result of
individual learning experiences within particular environmental situations and utilising
intellectual and physical capacities (Bandura, 2004b, 2012; McAlister et al., 2008). Thus,
an individual’s behaviour can be changed through new learning experiences, their
perception of the environment, and their motivation for the development of capacities
(McAlister et al., 2008).
Increasing self-efficacy is commonly seen as the most effective way of changing
individual behaviour (Bandura & Adams, 1977; Koopman-van den Berg & van der Bijl,
2001; Tsay, 2003; Wierdsma, van Zuilen, & van der Bijl, 2011; Wu et al., 2011).
Moreover, at least one additional contribution made by SCT, compared with other health
behavioural theories, is the use of four major sources of information to enhance
confidence (self-efficacy) in the process of changing behaviour (McAlister et al., 2008;
Rosenstock, Strecher, & Becker, 1988). Social cognitive theory also provides a structure
and processes to inform the development of an intervention that can improve the level of
self-efficacy in an individual (Lenz & Shortridge-Baggett, 2002; van de Laar & van der
Bijl, 2001). Hence, SCT is recognised as one of the most frequently used theories in
studying health behaviour in people with chronic disease (Dang, Deoisres,
Keeratiyutawong, & Baumann, 2013; Dao, 2012; Ha, Hu, Petrini, & McCoy, 2014; Wu et
al., 2007; Yoo, Kim, Jang, & You, 2011), including those with CKD (Balaga, 2012;
60 Chapter 3: Theoretical framework

Byrne et al., 2011; Kazawa & Moriyama, 2013; Tsay, 2003; Weng, Dai, Huang, &
Chiang, 2010; Wierdsma et al., 2011).
This chapter justifies the theoretical framework used to guide this study. First, SCT and
its components are explained. Second, existing research among people with CKD,
informed by SCT, is reviewed. Third, how SCT is a good fit with the context of Vietnam
is discussed.
3.2 Social Cognitive Theory
Social cognitive theory is based on the principles of social learning theory, which
explains that people learn certain behaviours from vicarious learning experiences, such as
imitation and recognition (Bandura, 1989, 1997, 2004b; Price & Archbold, 1995).
According to Bandura (1989, 1997, 2004b, 2012), human behaviour is understood as a
product of the interaction between personal factors (P), environmental factors (E), and the
attribution of the behaviour itself (B). Bandura terms this as triadic reciprocal causation
(see Figure 3.1). Personal factors are an individual’s attitudes, knowledge, and
expectations; environmental factors are social norms, access to community, and influence
on others; and behavioural factors are skills and practice (Bandura, 1989, 1997, 2004b,
2012). In addition, Bandura (1989) states that “people are both products and producers of
their environment” (p. 4). A change in one element will create an impact on other
elements, as shown in Figure 3.1. Thus, SCT attempts to explain individuals’ behaviour
and how this is influenced by the environment around them, as well as by their own
personal circumstances.

Personal (P)
Behavioural (B) Environmental (E)
Figure 3.1. Triadic reciprocal causation (Bandura, 1989, 1997, 2004b, 2012).
Person and Behaviour
Personal factors and behaviour reflect the interaction between thought, affect, and action
(Bandura, 1989, 2004b). People’s thinking, beliefs, and feelings all affect their
behaviours (Bandura, 1986, 2004b). For instance, people think that they may not be able
to overcome difficult situations, so they do not feel competent to take action, while those
who judge themselves competent to successfully overcome challenges are more likely to
perform a new behaviour. In those with CKD, their thoughts may affect their behaviour,
for example, when they avoid doing exercise because they think they are unable to
perform it regularly. However, those who believe in their abilities to perform it could do
so regularly. Furthermore, not only people’s thoughts but also their physical and
psychological attributes affect behaviour (Bandura, 1989, 2004b). In other words,
individual characteristics, including age, gender, race, and health conditions can also
influence behaviour and quality of life.
Behaviour and Environment
The two-way interaction between behaviour and the environment is presented in the
construct of SCT (see Figure 3.1). Bandura (2004b) asserts that people’s behaviour can
alter environmental conditions and environmental conditions can alter behaviour.
Environmental factors provide a wide range of conditions that can have a reciprocal effect

on people’s behaviour. For example, if individuals with CKD ought to exercise regularly,
they need a suitable environment that is conducive to do so. In Vietnam, exercise is more
commonly seen in urban areas than in rural areas. People often engage in exercise, often
tai chi, in the streets or nearby parks with their friends or relatives.
Environment and Person
The environment and the person also interact (Bandura, 1997). Environmental factors
such as temperature or rainfall could affect a person. For example, Bui et al. (2015)
reported that in Vietnam people are more likely to more exercise in the dry season than in
the wet season.
Since SCT was developed, Bandura and his colleagues have continued to develop this
theory further by explaining components that influence changing behaviour (see Figure
3.2). These components are person, behaviour, efficacy-expectations (self-efficacy) and
four information sources, outcome-expectations, and outcome. According to SCT,
providing sufficient and appropriate self-efficacy is a crucial way to influence human
behaviour, and by increasing self-efficacy, a person can be assisted to change certain
behaviours. The following section explains the components of SCT.

Person Behaviour
Characteristics: age,  Start
 Energy Outcome
gender, race, education
 Frequently
Efficacy-expectations Outcome-expectation
 Difficulty  Physical
 Conviction  Social
 Generality  Self-evaluative
Information sources
 Performance accomplishment
 Vicarious experience
 Verbal persuasion
 Self-appraisal
Environment
Figure 3.2. Social cognitive theory (Bandura, 1977, 2002; Lenz & Shortridge-Baggett,
2002; Shortridge-Baggett & van der Bijl, 1996).

3.2.1 Person, Behaviour, and Outcome
Person
A person is an individual, who they are, and their characteristics. These characteristics
can include age, gender, race, current relationship, education, employment status, and
health conditions (Bandura, 1989).
Behaviour
Behaviour are the sorts of actions (or activities) that a person does all of the time or most
of the time. Some of these behaviours could be described as good (or appropriate)
behaviours, such as healthy eating, exercise, weight control, smoking cessation (Tuot,
Plantinga, et al., 2013; Welch et al., 2014). Other behaviours which are not appropriate
are unhealthy behaviours, particularly when it comes to maintaining good health. These
behaviours could be, for example, drinking alcohol or smoking cigarettes (Kidney Health
Australia, 2015). In Vietnam, particularly in men, unhealthy behaviours are common,
such as smoking, consuming a lot of alcohol, having unhealthy diets, and being
physically inactive (Minh et al., 2009). These unhealthy behaviours could affect chronic
disease self-management, including CKD.
Outcome
Outcome is a result from the changed behaviour. Lenz and Shortridge-Baggett (2002)
suggest that when individuals are motivated to perform certain behaviours, it is often
related to the belief that they will produce better outcomes. When a person achieves a
positive health outcome that in turn affects the environment (i.e., family around them),
the person is convinced to keep up that behaviour. For example, an individual with CKD

adheres to a diet plan to reduce sodium intake as they know it is good for their kidney
function. Their confidence (self-efficacy) convinces the families to avoid adding salt
while preparing and cooking food for them. Thus, outcomes such as better BP or stable
kidney function could come through a feedback loop (see Figure 3.2), and this in turn
reinforces confidence to continue with that behaviour (adhere to diet plan) to promote
their HRQoL.
3.2.2 Self-Efficacy
Social cognitive theory uses the concept of self-efficacy to get a person to change their
behaviour. Self-efficacy is an individual’s belief in their ability to perform certain
behaviour (Bandura, 1997, 2012). Self-efficacy influences a person’s ability to learn and
perform a task, and it reinforces their belief that they will maintain that behaviour
(Lunenburg, 2011; McAlister et al., 2008). For instance, if someone needs to lose weight,
then their confidence must be high for them to follow a weight-reduction diet. Higher
levels of self-efficacy will overcome barriers to follow a diet to reduce weight. A person
with CKD who has a low level of self-efficacy towards implementing lifestyle changes,
such as adhering to a low salt diet, is unlikely to change their behaviour and may worsen
their kidney function through continued hypertension. On the other hand, those with high
self-efficacy who believe they can reduce their salt intake are likely to perform that
behaviour. In CKD, when a person believes in their capacity to change or improve certain
behaviour, they are more likely to continue to do it.
3.2.3 Information Sources
According to Bandura (1997, 2004a, 2012), people acquire confidence in changing
behaviour from four information sources. These are performance accomplishment,

vicarious experience, verbal persuasion, and self-appraisal. The four information sources
of self-efficacy are discussed below.
Performance accomplishment
Performance accomplishment is the confidence that comes from within a person when
they feel a sense of success, particularly if they believe that they have mastered that
behaviour (or experience) (Bandura, 1997, 2012; Benight & Bandura, 2004; Hayden,
2009; Luszczynska & Schwarzer, 2005). An experience such as learning a new skill may
increase or decrease a sense of self-efficacy, and this depends on whether the experience
was a success or failure (Bandura, 2012; Lenz & Shortridge-Baggett, 2002). If an
individual is able to establish high levels of self-efficacy early, then she or he will be able
to generalise that experience to another one. Thus, experience of success and failure in
managing behaviour are vital to enhancing self-efficacy levels. When an individual with
CKD is doing an activity, such as following a diet, taking medication, or doing some
exercise, and they feel that is helping their health, then they feel a sense of personal
accomplishment, which further increases their confidence in self-managing their kidney
disease.
Vicarious experience
Vicarious experience refers to the observation of others as another source of acquiring
self-efficacy (Bandura, 1997, 2012; Lenz & Shortridge-Baggett, 2002). Observing people
similar to themselves who successfully perform a task can influence another person’s
self-efficacy (Bandura, 1997, 2012; Hayden, 2009; Holloway & Watson, 2002; Lenz &
Shortridge-Baggett, 2002). By contrast, if people observe someone similar to themselves
fail, this could diminish their self-efficacy (Bandura, 1997; Hayden, 2009; Holloway &
Watson, 2002; Lenz & Shortridge-Baggett, 2002; Luszczynska & Schwarzer, 2005).

Observing a role-model who is able to perform a difficult behaviour can enhance another
person’s level of self-efficacy through vicariously experiencing that behaviour.
According to Lenz and Shortridge-Baggett (2002), individuals do learn through the
experiences of others, which they can then use to modify their own behaviour. For
example, if a person with CKD observes others with CKD succeed in managing their
adherence to a low-salt diet, this could influence their confidence to also reduce salt in
their diet. However, in Vietnam, people are often reticent with sharing experiences with
each other, thus learning through vicarious experience in a CKD outpatient clinic is
problematic and alternative methods will be needed.
Verbal persuasion
Verbal persuasion refers to verbally giving instructions, suggestions, and advice to
individuals to convince them to perform new (or modified) behaviours (Bandura, 1997,
2012; Hayden, 2009; Lenz & Shortridge-Baggett, 2002). Self-efficacy derived from
verbal persuasion is the most often used information source because it is easy to use,
although it is less effective than the information sources of performance accomplishment
or vicarious experience (Bandura, 1997, 2012; Lenz & Shortridge-Baggett, 2002). This
may in part explain why it may not work when healthcare providers try to convince
patients that they can change their behaviours to manage their kidney disease. If verbal
persuasion is used in a positive way, it may be more likely to assist individuals to make
more effort (i.e., have greater confidence) to achieve certain actions or behaviours. For
example, if nurses or medical practitioners encourage patients with CKD to manage their
dietary behaviour and inform them about how to choose appropriate food, patients are
likely to put more effort into following their diet. However, if verbal persuasion is

provided in a negative way, it may lead patients to doubt their own capabilities and will
therefore lower chances of success (Bandura, 1997; Lenz & Shortridge-Baggett, 2002).
In Vietnam, difficulties with overcrowding and a lack of staff and health resources occurs
in most hospitals (Pron et al., 2008), which is likely to impact on the ability of healthcare
providers to provide further support in chronic disease management. This is particularly
the situation when nurses are focused mainly on administering medications and technical
skills rather than providing patient education (Pham & Ziegert, 2016). So, it is important
therefore to develop suitable verbal persuasion strategies for Vietnam.
Self-appraisal
Self-appraisal is the final information source of self-efficacy. Self-appraisal refers to self-
evaluation of one’s own physiological and emotional states (Bandura, 1997; Hayden,
2009; Lenz & Shortridge-Baggett, 2002; Luszczynska & Schwarzer, 2005). Confidence
derived from self-appraisal is often used to support the other information sources
(Bandura, 1997; Lenz & Shortridge-Baggett, 2002). People rely on information from their
physical and emotional states to judge their abilities to desire or avoid performing a
particular behaviour (Bandura, 1997, 2012; Lenz & Shortridge-Baggett, 2002). Self-
appraisal is necessary so that physical and emotional well-being is improved and negative
emotional states are lowered.
Vietnamese people are reluctant to reveal to others when something is difficult to do, as
they want to appear as having a strong character (Shanahan & Brayshaw, 1995). They are
also unlikely to express their concerns or difficulties in changing behaviour, such as
struggling with adjusting their diet or barriers to treatment adherence. Hence, providing
support that could involve patients in expressing and sharing their concerns or difficulties
is crucial for the success in enhancing their self-efficacy to manage CKD. Providing a

supportive environment in which it becomes normal and comfortable to verbalise CKD
self-management difficulties is important in developing self-appraisal skills. Patients may
feel less anxious or confronted to discuss their situation, which may in turn have a
positive effect on self-efficacy.
Among the four information sources of self-efficacy, performance accomplishment is the
most powerful source, as it is based on direct information obtained by individuals as they
learn something new (Lenz & Shortridge-Baggett, 2002). However, Bandura (1997)
recommends that all four information sources should be used together to enhance self-
efficacy because each of the sources have a vital role in the process of changing health
behaviour in a person, as explained above.
3.2.4 Outcome-Expectation
The other factor influencing a person’s behaviour is outcome-expectation. Outcome-
expectation is a person’s beliefs about the possible outcomes that could result from a
given behaviour (Bandura, 1977, 1997; Luszczynska & Schwarzer, 2005). Outcome-
expectation can be physical, social, and self-evaluative (Bandura, 1977, 1997;
Luszczynska & Schwarzer, 2005). Positive or negative expectations can be incentives or
disincentives, respectively. For instance, some physical outcome-expectations of people
with CKD might be breathlessness, pruritus (itching), or trouble sleeping, and these might
provide the motivation to change behaviour (e.g., reducing salt, adhering to medications).
Social and self-evaluative outcome expectations act in a similar way as physical ones
(Bandura, 1997; Luszczynska & Schwarzer, 2005). Therefore, in order to perform an
optimal behaviour for a long period, people have to overcome their physical, social, and
self-evaluative expectations of that behaviour.

3.2.5 Summary of Social Cognitive Theory
Social cognitive theory accounts for different people, their personal characteristics, and
behaviour. In SCT, human behaviour can be altered when a person starts doing a new
action; it may generate positive thoughts or even physical energy to continue to perform
that action, which in turn may become regular behaviour (Bandura, 1986). Self-efficacy
and information sources are the central components of SCT (Bandura, 2004a, 2006). Self-
efficacy is a belief in the ability to successfully perform a behaviour, and the four
information sources are strategies to enhance a person’s self-efficacy.
3.3 Social Cognitive Theory and Chronic Kidney Disease Self-Management
A systematic searching process was used to identify if any previous studies in CKD had
been guided by SCT. The searching process involved MEDLINE, CINAHL,
ScienceDirect, ProQuest, and EbscoHost databases using the keywords ‘social cognitive
theory’; ‘self-efficacy model’; ‘self-management’; ‘chronic kidney disease’; ‘chronic
kidney failure’; ‘earlier stages of kidney disease’; ‘pre-dialysis stages of kidney disease’;
‘end-stage kidney disease’; ‘dialysis’; ‘haemodialysis’; ‘kidney transplant’. In the CKD
literature, there have been 14 studies informed by SCT. These studies have been
conducted in the U.S. (Curtin et al., 2008; Patterson, Umstattd Meyer, Beaujean, &
Bowden, 2014; Wells & Anderson, 2011), Netherlands (Wierdsma et al., 2011), U.K.
(Boothby & Salmon, 2013; Byrne et al., 2011; Clarke et al., 2015), Philippines (Balaga,
2012), Japan (Joboshi & Oka, 2016; Kazawa & Moriyama, 2013), Taiwan (Tsay &
Healstead, 2002; Tsay, 2003; Weng et al., 2010), and Iran (Moattari, Ebrahimi, Sharifi, &
Rouzbeh, 2012). Six studies involved an intervention and the remaining studies were
descriptive studies. Of those, three were intervention studies of CKD self-management in
earlier stages of CKD (Byrne et al., 2011; Joboshi & Oka, 2016; Kazawa & Moriyama,

2013), while the intervention studies involved dialysis and kidney transplant patients
(Moattari et al., 2012; Tsay, 2003; Wierdsma et al., 2011).
In the three studies involving people in the earlier stages of CKD, one study was a quasi-
experimental one-group design (Kazawa & Moriyama, 2013) and two were RCTs (Byrne
et al., 2011; Joboshi & Oka, 2016). While the two RCTs were reviewed in the previous
chapter, SCT is examined in more detail below.
Kazawa and Moriyama (2013) examined the effects of a self-management skills-
acquisition program to improve self-efficacy and quality of life in people with CKD
stages 3–4 (N = 30) in Japan. The study used SCT to guide the development of the self-
management program, with the main focus being on the approaches for improving
participants’ self-efficacy and required knowledge to foster good communication between
participants and nurses to engage in self-management of kidney disease. The study
provided goals and structure of the self-management program with approaches to
improved self-efficacy. However, how and when the four information sources were used
to enhance self-efficacy were not described.
Byrne et al. (2011) in an RCT (control group = 41, intervention group = 40) purported
using SCT to inform a structured educational intervention designed to improve
knowledge and self-management skills. However, it was unclear how SCT had been
applied in this study. In addition, the use of the self-efficacy and four information sources
were not described.
In a recent RCT, Joboshi and Oka (2016) evaluated the effectiveness of the Encourage
Autonomous Self-Enrichment program for people with CKD (stages 1–5) not receiving
dialysis. In the study, only self-efficacy was selected from SCT as one of the core
concepts of the self-management program. Action plans and specific goal setting were

used in the study to foster self-efficacy. The study, like other previously discussed CKD
self-management studies, claimed using SCT, but the study did not use any of the four
information sources to enhance self-efficacy.
The concept of self-efficacy of SCT and its relationships with self-management
behaviours in people with CKD has also been reported in eight descriptive studies
(Balaga, 2012; Boothby & Salmon, 2013; Clarke et al., 2015; Curtin et al., 2008;
Patterson et al., 2014; Tsay & Healstead, 2002; Wells & Anderson, 2011; Weng et al.,
2010). However, seven studies involved people with ESKD receiving dialysis and/or who
had a kidney transplant. Only Clarke et al. (2015), who used qualitative methods
involving people with CKD stages 1–5 (N = 36), sought to understand the barriers,
motivators, and beliefs held by participants towards exercise. The study suggested that
clear goal setting and guidance from healthcare providers were important to support
people with CKD to overcome barriers and improve confidence in exercising (Clarke et
al., 2015). The analysis identified three themes compatible with the triadic reciprocal
causation of SCT, including personal factors, behavioural factors, and environmental
factors. Clarke et al. (2015) found that when participants perceived that previous exercise
had improved their health, they appeared more confident in their ability to exercise
regularly and expressed greater confidence in achieving exercise goals.
Overall, previous CKD self-management studies have used SCT or self-efficacy to
inform an education intervention, although the reporting of how SCT was used and the
benefits of using SCT requires further research.
3.4 Social Cognitive Theory Fit with Vietnam Context
There are several reasons to explain why SCT is a good fit with the context of Vietnam.
First, there have been a number of studies that used SCT as the conceptual model to

understand CKD self-management behaviours. These studies have occurred in Western
countries (Boothby & Salmon, 2013; Byrne et al., 2011; Clarke et al., 2015; Curtin et al.,
2008; Patterson et al., 2014; Wells & Anderson, 2011; Wierdsma et al., 2011) and in non-
Western countries (Balaga, 2012; Joboshi & Oka, 2016; Kazawa & Moriyama, 2013;
Moattari et al., 2012; Tsay & Healstead, 2002; Tsay, 2003; Weng et al., 2010),
demonstrating the suitability of the constructs of SCT to differing cultures. These studies
indicate the positive relationship between self-efficacy and self-management behaviours.
Second, two Vietnamese studies have been informed by SCT (Dang et al., 2013; Dao,
2012). Dao (2012) conducted a descriptive study to examine the factors influencing self-
management behaviours of people with type 2 diabetes (N = 198). This study has shown
that diabetes knowledge, belief in treatment effectiveness, healthcare providers’ support,
and diabetes management self-efficacy affected self-management behaviours. Dang et al.
(2013) also conducted an intervention study to evaluate the effectiveness of a self-
management education for people with type 2 diabetes in Vietnam (control group = 44,
intervention group = 42). Self-efficacy was used to guide the development of the study
intervention. The findings showed that participants who received the self-management
intervention had significant improvement in diabetes self-care behaviours and diabetes
self-efficacy when compared to those who did not (p values < .01). Dang et al. (2013)
found that participants in the intervention group showed significantly improved self-care
behaviours compared to the control group at 3 months and 6 months (Ms = 4.78 and 5.20,
SDs = 0.69 and 0.55 versus Ms = 4.15 and 4.02, SDs = 0.79 and 0.88), respectively.
Participants in the intervention group also showed significant improvement in self-
efficacy compared to the control group at 3 months (M = 4.15, SD = 0.40 versus M =
3.70, SD = 0.28) and at 6 months (M = 4.44, SD = 0.62 versus M = 3.70, SD = 0.28)

(Dang et al., 2013). Findings of these two studies highlight that SCT fits with people who
have chronic disease in Vietnam.
Third, self-efficacy is a core concept in SCT and is used to improve a person’s
confidence. Confidence is a person’s belief in their ability to succeed, and people all want
to have confidence to do their work, take care of others, and to take care themselves. Self-
efficacy should fit with all people regardless of location or type of chronic disease.
Fourth, a systematic review indicated that behavioural interventions using sources of
information as learning strategies can effectively assist people with chronic disease to
acquire knowledge of the disease, and to become more confident in their ability to better
self-manage their disease (Jang & Yoo, 2012). Welch et al. (2014) in another systematic
review of CKD studies also concluded that information assists with self-management
behaviours. Thus, information sources to enhance self-efficacy could meaningfully fit
with people living in Vietnam.
Despite several strengths to indicate that SCT can be used in the Vietnamese context, the
healthcare context in Vietnam may also be a challenge to using SCT. As previously
discussed in Chapter 1, patient education is not valued and rarely provided by nurses. In
addition, SCT largely focuses on a person’s belief in their ability and confidence to
change behaviour. However, in Vietnam, behaviour is influenced by many cultural
practices. One practice involves everyone sharing meals together, often as a big group, so
reducing salt and avoiding fried foods will be a challenge for a self-management
intervention.
The strengths of using SCT, however, far outweigh the limitations. Thus, SCT is
recognised as a useful theory to guide the intervention to improve health outcomes of
people with CKD in Vietnam. In this study, the individual’s health outcome, such as

better BP control, could through a feedback loop provide more confidence to a person to
continue with certain behaviours.
3.5 Chapter Summary
Social cognitive theory has been widely used to inform studies of changing behaviour in
people with chronic disease. This theory provides a framework for researchers to create
robust interventions to enhance the self-efficacy of people with chronic disease to engage
in self-management behaviour. In this research, SCT was used in Phase 3: an intervention
to improve self-management behaviour of people with CKD stages 3–5 who were not
receiving dialysis. The self-efficacy information sources in the intervention program are
described in more detail in Chapter 4. The next chapter explains the research methods for
all three phases.

Chapter 4: Methods
4.1 Introduction
In this chapter, the methods for conducting each phase are described. Phase 1 was
undertaken to translate and validate the Kidney Disease Knowledge Survey (KiKS) and
Chronic Kidney Disease Self-Management (CKD-SM) instrument from English into
Vietnamese according to the process of Brislin (1970). Phase 2 psychometrically
evaluated these two instruments using a test/retest design in Vietnam. The aim of Phases
1 and 2 was to prepare instruments for the main study, Phase 3, a pragmatic randomised
controlled trial (pRCT) of a self-management intervention to support people with CKD
(stages 3–5) in Vietnam. The phases are presented in Figure 4.1 and the methods for each
are presented below. In this thesis, the term “the researcher” refers to the PhD candidate.
If other personnel were involved in recruitment or data collection, these are identified by
their role.
Chapter 4: Methods 77
Phase 1: Translation and validation of Phase 2: A psychometric evaluation of
instruments includes the KiKS and CKD-SM the instruments in Vietnamese context
Phase 3: Pragmatic RCT of a self-management intervention program
Increase: knowledge and self-efficacy
Improve: self-management behaviour
Outcomes
 Better blood pressure control
 Better health-related quality of life
Figure 4.1. Study phases.
78 Chapter 4: Methods
4.1 Research Questions
The research questions are:
Phase 1 and 2 research questions:
1. Is the Vietnamese version of the kidney disease knowledge instrument reliable
and valid to measure knowledge of people with CKD?
2. Is the Vietnamese version of the CKD Self-Management instrument reliable and
valid measure of self-management behaviour among people with CKD?
Phase 3 research questions:
intervention improve knowledge, self-efficacy, and self-management behaviour
intervention improve blood pressure control and health-related quality of life
4.2 Phase 1: Translation and Validation
Using valid instruments is crucial to measuring outcomes of research. Translation and
validation of instruments are often required when a study uses instruments that have been
developed in another language. In this study, these instruments are the Kidney Disease
Knowledge Survey (KiKS) and the Chronic Kidney Disease Self-Management (CKD-
SM). The KiKS (Wright et al., 2011) is available in English and had not been translated
into Vietnamese. The CKD-SM instrument was developed by Taiwanese researchers (Lin
et al., 2012) and had been used to measure self-management behaviours in people with
early stages of CKD in Taiwan. The CKD-SM instrument also had not been translated
into Vietnamese. In this phase, the two instruments were translated according to the
Brislin’s (1970) translation model.
Brislin’s translation model has been globally recognised as one of the most reliable
methods for translating research instruments for use in cross-cultural research
environments (Sousa & Rojjanasrirat, 2011). It is a process of forward and backward
translation of the instrument to ensure equivalent meaning to the original version (Sousa
& Rojjanasrirat, 2011). The differences in linguistic use, such as sentence structure, word
phrases, colloquialisms or idioms, and culture are commonly distorted in the translation
of the instrument process (Yu, Lee, & Woo, 2004). Thus, after the translation process, it
is necessary to test the validity and reliability in the context where the instrument will be
used (Yu et al., 2004).
4.2.1 Instruments
Prior to translating both instruments, permission to translate and adapt these instruments
was provided by the instrument developers (see Appendices 1 and 2).
Kidney disease knowledge survey
The KiKS was developed to assess the knowledge related to kidney disease management,
such as kidney functions, treatment options for kidney failure, signs and symptoms of
disease progression, potential medications that harm or benefit the kidney, BP targets, and
other information related to preserving kidney function (Wright et al., 2011). This
instrument contains 28 items, with 23 items requiring a dichotomous Yes/No answer and
five multiple choice items (see Appendix 3). According to Wright et al. (2011), this
instrument has good reliability with a Kuder-Richardson-20 coefficient of .72. This
instrument also has been tested in Australia (Wembenyui, 2017).
Chronic kidney disease self-management instrument
The CKD-SM instrument includes 29 items divided into four factors: self-integration,
problem-solving, seeking social support, and adherence to recommended treatment
regimen (Lin et al., 2012). These factors align with Lorig and Holman (2003) (see
Chapter 2, p. 33). Participants indicate how often they perform each behavioural
statement on a scale of 1 to 4 (1 = never, 2 = sometimes, 3 = usually, 4 = always) (see
Appendix 4). Cronbach’s alphas range from .77 to .92 (Lin et al., 2012). Three items were
added for this study, including one item about medication [item 30: I take my medications
even when I am not at home] and two items about problem-solving [item 31: I take action
when my early warning signs and symptoms get worse; item 32: When I have questions
about my kidney disease, I discuss what to do with my doctors or nurses]. These three
items were added with permission from the instrument developer because the original
CKD-SM instrument did not include these aspects of self-management. Therefore, a 32-
item CKD-SM instrument was used in Phases 1 and 2. This instrument has been tested in
an English-speaking country [Australia, Wembenyui (2017)].
4.2.2 Process of Translation
The purpose of the translation process in this study is to convert the KiKS and CKD-SM
instruments from English into Vietnamese; however, the meaning of the instrument items
in the Vietnamese culture should be maintained.
While there are no standard guidelines for instrument translation from the source
language to the target language (Maneesriwongul & Dixon, 2004), the most frequently
used method in cross-cultural studies is one-way translation (Weeks, Swerissen, &
Belfrage, 2007). However, using this method often results in low level of validity and
reliability of the study instruments (Erkut, Alarcón, Coll, Tropp, & García, 1999; Sperber,
Devellis, & Boehlecke, 1994). Hence, the preferred and recommended approach should
involve at least forward translation, back-translation, and testing among target language
subjects (Maneesriwongul & Dixon, 2004).
Among the translation methods, Brislin’s model (1970) is a well-known method for
translating and back-translating instruments (Jones, Lee, Phillips, Zhang, & Jaceldo,
2001). A disadvantage of Brislin’s translation model is that it requires many independent
bilingual translators to blindly translate an instrument from the source language to the
target language, and conversely from the target language to the source language until
content equivalence is achieved between the source and the translated versions. As a
result, it is difficult for researchers to estimate how many independent bilingual
translators are needed to satisfy the above process (Cha, Kim, & Erlen, 2007). Moreover,
several factors may influence the selection of the translation methods, such as the study
objectives, availability of translators, budget, and time (Maneesriwongul & Dixon, 2004).
Thus, an adaptation of the translation method is warranted. Sousa and Rojjanasrirat
(2011) recommend a 4-step process.
The first step was the forward translation of the KiKS and CKD-SM from English (source
language [SL]) into Vietnamese (translated language [TL]) by two bilingual healthcare
professionals. Step 2 was the blind back-translation (BT) of the instruments into English
by two bilingual healthcare professionals. Step 3 was the comparison of the original
version and the back-translated version of the KiKS and CKD-SM. The final step was the
review of the instruments by an expert panel. The expert panel comprised a renal medical
practitioner, two renal nurses, a general medical practitioner, and two general nurses to
assess the content validity of the instruments. The panel also included two primary school
level teachers to assess whether the level of language was appropriate, and two older
adults to assess whether the language could be understood by an older population who are
often less literate. The translation process is summarised in Figure 4.2.
Step 1 Step 2 Step 3 Step 4
TL1 BT1
Compare Modify as TL for

Compare Compare
SL BT1 and per the expert
TL1 and TL2 with SL
BT2 comments panel
TL2 BT2
Figure 4.2. Translation process adapted from Sousa and Rojjanasrirat (2011).
Notes. SL refers to source language; TL refers to translated language; BT refers to back translation
4.2.3 Data Analysis
Data was entered into and analysed using Microsoft Excel 2010. To assess the validity of
the Vietnamese version of the two instruments, the data generated from the panel review
of both instruments (V.KiKS and V.CKD-SM) was used to calculate the scale and item
content validity average scores (S-CVI/Ave), which is calculated as an average of the
item-level content validity (I-CVI) by summing the rating and dividing the number of
items (Polit & Yang, 2016).
4.3 Phase 2: Psychometric Evaluation
4.3.1 Design
The design of Phase 2 was a test/retest of study instruments using a convenience sample
of patients with CKD in Hanoi, Vietnam.
4.3.2 Setting
The study was conducted in the Department of Nephro-Urology, Bach Mai Hospital.
Bach Mai Hospital is located in the centre of Hanoi and is one of the largest hospitals in
Vietnam. The hospital was established in 1911 during the French colonial rule. It plays an
important role in the healthcare system of Vietnam and is one of three highly specialised
hospitals for internal medicine. Currently, Bach Mai Hospital has nearly 2,000 beds,
although it typically has 3,000 inpatients (i.e., in Vietnam there are often 2–3 patients per
bed). Many people with CKD from Hanoi or surrounding provinces attend this hospital
for treatment.
4.3.3 Sample
According to Kline (2013), the sample size for test and retest reliability and to measure
the internal consistency reliability should contain at least 100 participants to minimise
statistical error. In this phase, 158 adults with CKD completed both instruments. In the
retest, it is recommended that the study should include at least 20% of the sample (Sousa
& Rojjanasrirat, 2011). Thus, 52 participants from the initial sample (33%) were retested.
A period of one to two weeks is also recommended (EMGO+ Institute for Health and
Care Research, 2010). In addition, due to time constraints for this PhD, the retesting was
conducted one to two weeks after the initial testing.
4.3.4 Eligibility Criteria
This study recruited 158 participants who had been diagnosed with CKD (any stage),
aged ≥ 18 years, and able to speak, read and understand Vietnamese language. Exclusion
criteria consisted of participants who were unwilling to participate, had cognitive
impairment, serious illness (e.g., cancer, stroke, and dementia) determined by treating
medical practitioner.
4.3.5 Data Collection
Data was collected from participants and medical records. Participants completed three
self-report instruments: i) Demographic data was collected on age, gender, marital status,
individual and household incomes, level of education, and occupation using a researcher-
developed questionnaire (see Appendix 7); ii) V.KiKS, and iii) V.CKD-SM (see
Appendices 8 and 9, respectively). Data was extracted from medical records for current
medications and renal clinical characteristics (see Appendix 10).
4.3.6 Procedure
First, Queensland University of Technology ethics approval was obtained, which
included permission from the Director of Bach Mai Hospital (see Appendices 5 and 6).
Second, internal approval was received from the Head of Department of Nephro-Urology
in this hospital. Third, potential participants with CKD were selected by convenience
sampling. The researcher explained the purpose and method of the study, explained their
right to participate or withdraw from the study, and sought written informed consent if
they were willing to participate in the study. For the testing of instruments, data was
collected in the waiting area at the Department of Nephro-Urology. The instruments were
evaluated in person for the initial testing while the participant was in the renal
department, and the retest instruments were administered by post. In the retest,
participants indicated on their consent form whether or not they agreed to complete both
instruments. For those who indicated their willingness to do the retest, instruments were
distributed by post one to two weeks after the completion of the first survey. Instruments
were completed at home and sent back, using another pre-paid envelope to the researcher
(her office at Hanoi Medical College, Hanoi). These instruments took approximately 20–
30 minutes to complete on each occasion. Clinical data was collected by the researcher.
4.3.7 Data Analysis
Data was entered into and analysed using IBM SPSS version 22 (IBM Corporation, NY,
USA). To measure the psychometric properties, internal consistency, and test/retest
reliability were calculated using Kuder-Richardson-20 coefficient (KR20), Cronbach’s
alpha (Cronbach’s α), and Pearson/Spearman’s rho correlation coefficients, intra-class
correlation coefficient, and paired sample t-test. The Mann-Whitney U Test and
independent sample t–tests were used to compare the results of outcome variables for
demographic characteristics and results. The analysis was divided into four steps:
Step 1: Descriptive statistics including means (Ms), standard deviations (SDs), number (n)
and percentage (%) distribution were calculated to describe demographic characteristics,
renal clinical characteristics of the participants and individual item scores of the two
instruments.
Step 2: The data quality, internal consistency and correlations between items and the sum
of the other items were assessed. Data quality was assessed in terms of mean for each
item with standard deviation, median, percentage of missing data. Internal consistency of
the V.CKD-SM instrument was assessed by using Cronbach’s alpha and
Pearson/Spearman’s rho correlation coefficients. For the V.KiKS, the internal consistency
was assessed by using KR20.
Step 3: Test/retest reliability of 52 participants was assessed using intra-class correlation
coefficient and paired sample t-test.
Step 4: Comparison of the V.KiKS and V.CKD-SM scores by demographic
characteristics were assessed by using Mann-Whitney U Test and independent-samples t–
tests, respectively.
4.4 Phase 3: A Pragmatic Randomised Controlled Trial
4.4.1 Design
Randomised controlled trials (RCTs) are generally recognised to be the “gold standard”
for evaluating an intervention program on measured outcomes (Relton, Torgerson,
O'Cathain, & Nicholl, 2010; Saturni et al., 2014). However, using the “gold standard” has
limitations in everyday clinical practice (Concato, Shah, & Horwitz, 2000; Herland,
Akselsen, Skjønsberg, & Bjermer, 2005; Saturni et al., 2014; Ware & Hamel, 2011). For
example, the use of rigorous patient selection based on inclusion and exclusion criteria
could result in a study population that differs from the actual patient population (Ware &
Hamel, 2011). A pragmatic RCT (pRCT) design is useful to evaluate interventions in
routine clinical care (Saturni et al., 2014). In CKD, using a pRCT enables a broader range
of patients to be included to test an intervention applicable to patient care and to measure
relevant patient-centred outcomes, thus enhancing external validity and the translation of
results into clinical care (de Boer et al., 2016). The design of this phase was, therefore, a
single-blind pRCT with 1:1 allocation into control and intervention groups. This trial
consisted of a self-management education program provided to the intervention group of
people with CKD stages 3–5 who were not yet receiving dialysis. The control group
received standard care.
4.4.2 Participants
Patients with CKD attended outpatient hospital clinics for regular appointments with
renal medical practitioners. Participants in this phase were not involved in Phase 2.
Inclusion criteria
Participants were diagnosed with CKD (stages 3–5) and not expected to start dialysis
during the study, aged ≥ 18 years, able to speak, read, and understand Vietnamese
language. They also had to be contactable via telephone for follow-up.
Exclusion criteria
Participants were excluded if they were enrolled in other clinical trials, unable or
unwilling to provide informed consent, undertaking peritoneal dialysis or haemodialysis,
had cognitive impairment, or were seriously unwell.
Settings and Locations
The study was conducted in the department of Nephro-Urology, Bach Mai Hospital. The
hospital provides treatment for people who live in Hanoi City, as well as other provinces
in the north of Vietnam.
The Nephro-Urology Department comprises an 80-bed inpatient ward (over 3,563
patients per year) and outpatient clinics (approximately 18,000 patients visit per year)
(Tuyen, 2011). Typically, 50 people attend the Nephro-Urology outpatient clinics or are
admitted to the hospital each day. There are two areas where outpatient clinics are based:
the Nephro-Urology Department and general Outpatient Department. Both departments
are standard places for patients to receive blood test results and a completed record made
by the medical practitioners. The patient takes these documents home and brings them
back at subsequent clinic appointments. There are no hospital records for outpatient
clinics.
4.4.3 Intervention
Control group
Participants randomised to the control group in this study received standard CKD care
from their healthcare providers, which is focused on taking medications and receiving
basic healthcare advice. Participants attend outpatient appointments every 1–3 months,
although this depends on the level of renal function. The participants in the control group
were provided with a CKD booklet at the completion of the study.
Intervention group
Participants randomised to the intervention group received both the standard CKD care
from their healthcare providers, and a 12-week self-management intervention guided by
SCT delivered by this researcher who is a nurse. Participants received a CKD booklet and
a handout that summarised the intervention topics before participating in an individual
face-to-face educational session and two follow-up phone calls. The four information
sources of self-efficacy were used to guide the delivery of the face-to-face session and
follow-up phone calls (see below). The flow chart of the intervention group in this study
is presented in Figure 4.3.
Self-management intervention program
Face-to-face session by using the Follow up phone calls of 20 to 30

four information sources (60 mins
minutes)  Follow up two priorities goals
 Planning and suggestions: health by using verbal persuasion and
diet, food labels, salt intake, renal self-appraisal together with
clinical test results, and exercise performance accomplishment
 Identify two main goals related to and vicarious experience
self-management
Increase knowledge and self-efficacy levels
Improve self-management behaviour
 Better blood pressure control

 Improve health-related quality of life
Figure 4.3. Framework of the self-management intervention program.
Chronic kidney disease booklet
The CKD booklet was adapted (with permission) from Kidney Health Australia’s (2008)
Living with Reduced Kidney Function handbook (see Appendix 11) and American Kidney
Fund’s (2010) Living Well with Chronic Kidney Disease handbook (see Appendix 12).
The topics included in the English version of the CKD booklet were discussed by the
researcher with her supervisory team to make the content culturally relevant and at a
suitable level of Vietnamese speaking patients with CKD. The English CKD booklet was
then translated into Vietnamese by the researcher. The Vietnamese version was sent to a
graphic designer to design the booklet for patients. The Vietnamese CKD booklet
explains the functions of the kidneys, the early signs and symptoms of CKD, and
strategies for managing or delaying the progression of CKD, such as the benefits of
maintaining a healthy lifestyle and adherence to medications. It also contained a diary for
participants to record medication side effects, monitor their clinical data, treatment plan,
and questions for medical appointments. The handout summarised the main points in the
CKD booklet and important self-management skills, such as taking medications, nutrition
and exercise, smoking cessation, understanding renal clinical results, and using available
resources to self-manage CKD. All intervention materials were prepared for a primary
school reading level (see Appendix 13).
Face-to-face education session
The intervention started with a 1-hour face-to-face session, focused on improving CKD
knowledge and self-management by utilising the four self-efficacy information sources
(see Table 4.1). As knowledge is vital in improving self-management behaviour (Curtin,
Sitter, Schatell, & Chewning, 2004), and other studies have found that people with CKD
have little or no knowledge related to medication, foods, and symptoms of CKD
(Finkelstein et al., 2008; Wright Nunes et al., 2011), the content of the face-to-face
session focused on explaining these topics. The four information sources of self-efficacy,
performance accomplishment, vicarious experience, verbal persuasion, and self-appraisal
(Bandura, 1997; Lenz & Shortridge-Baggett, 2002) were used. The following sections
explain how each self-efficacy information source was used in the face-to-face session.
Performance accomplishment is the confidence when individuals believe that they have
mastered that behaviour and it is the most important strategy to assist participants to
actually engage in performing self-management behaviour (Bandura, 1997). Participants
were asked to identify CKD-related problems and set two realistic achievable goals based
on their priorities. These goals were recorded in their CKD booklet and monitored at each
follow-up. By doing that, the researcher assisted participants to review problems or issues
related to their kidney disease management and to improve their self-management skills
to overcome it.
Vicarious experience can increase self-efficacy through observation of people similar to
oneself successfully performing a task (Bandura, 1997). In Vietnam peer learning through
vicarious experience in renal clinics is not common. Hence, local images and pictures
throughout the CKD booklet were used to show food labels, healthy foods to eat, and
unhealthy foods to avoid. In addition, two written scenarios of people who successfully
overcome challenges to self-manage their kidney problems were developed to assist
participants to learn about other people’s experience of managing CKD.
Verbal persuasion was also used to enhance participants’ self-efficacy. Verbal
suggestions and advice were provided to each individual to promote understanding about
their kidneys and to self-manage their disease. Although knowledge alone does not
change behaviour, the goal was to increase individual self-efficacy levels and support
participants to start taking action. The researcher used the CKD booklet and
encouragement to help individuals develop achievable goals and identify strategies to
have better self-management of kidney disease.
Self-appraisal, the final information source, was used to encourage participants to
identify where they were succeeding with self-management such as adhering to
medications, and also to express their concerns or difficulties in managing CKD, for
instance struggling with reducing salt in their diet. Participants were then supported to
identify possible solutions to achieve their goals.
Follow-up education sessions
Participants received two follow-up phone calls of 20−30 minutes at weeks 4 and 12 by
the nurse researcher to reinforce the self-management action plan and to review progress
towards goals. The focus was to identify improvements and to encourage participants to
continue behaviour change through positive reinforcement. Structured around the CKD
booklet topics, the discussion supported participants to build on small changes and to use
problem-solving skills to overcome daily challenges. For instance, the researcher asked
participants to read and self-monitor their renal clinical test report after seeing the renal
medical practitioners. Participants were asked to continue to use the CKD booklet at
home and encouraged to seek family and social support for long-term behavioural
change. Performance accomplishment was also used in follow-up phone calls to assist
participants to monitor their goals. The first goal was reviewed at the first follow-up
(week 4). If participants achieved the first goal, they were asked to start working on the
second goal. However, those who did not succeed in the first goal would then be
encouraged to re-adjust the first goal, and the researcher re-assessed that goal at the next
follow-up 12 weeks later. Participants were also asked to review the two scenarios and
discuss with the researcher via telephone call follow-up. The phone call follow-up also
allowed time for participants to ask any questions they may have (see Table 4.2).
Table 4.1. Face-to-Face Self-Management Education Program
(Week 0: 60 mins)
Topics SCT Information Mins Contents Goals for Methods Main focus
sources participants
Pre-intervention 5 Review current disease condition of Comfort and  Face-to-face Understanding
participant ready for a face- communication participant
to-face session
Identifying  Performance 5–7 Identify one major problem/issue of Be able to Progressive goal Focusing on
problems/issues accomplishment concern for: identify the setting: problems/issues
 CKD knowledge problem/issue  Invite participant related to disease-
for CKD to identify specific
 CKD self-management
knowledge and problem/issue knowledge and
CKD self- CKD self-
 Prioritise 1 to 2
management management
main goals to
deal with 1 to 2
major
problems/issues
Understanding of  Verbal persuasion 20 Summary of the CKD booklet: Understand the  Provide a Focusing on
CKD specific  Vicarious CKD knowledge: importance of handout knowledge and
knowledge and experience CKD knowledge  Face-to-face tasks which
 Kidney function
the importance of and CKD self- education participants
CKD self-  CKD symptoms management in should know and
 Questions and
management CKD self-management: the CKD booklet able to perform
answers
 CKD control [e.g., BP control,
medicines, healthy lifestyles]
 Share two scenarios from the
CKD booklet
 Understand main renal clinical
results [e.g., eGFR, urea, Hb]
 Seeking information to self-
manage kidney problems
Identifying self-  Performance 5  Identify two priority goals related Be able to state  Documentation Focusing on
management’s accomplishment to self-management behaviours two achievable of the goals importance of
goals personal self- CKD control to
management motivate
goals participants for
self-management
to slow the
progress of
kidney disease
and maintain BP
control
Planning:  Verbal persuasion 5–8 Option topics linked to individual Understand the Handout focused on: Focusing on tasks
 Diet  Vicarious goals [for example]: important tasks  Good diet which participants
 Medications experience  Meal planning for healthy diet: of CKD self- are able to
 Example of
 Physical salt/fluid balance, potassium, management perform
 Self-appraisal reading renal
activity phosphate, calcium intake clinical test
 Read the renal clinical test results results
 Physical activity
 Exercise safety
Understanding 5  One on one teaching about food Persuade the
food labels of labels and salt intake participant to read
different products  Share experience of choosing food labels before
healthy food and reading food buying and eating
labels using local images and
pictures
Suggestions on  Verbal persuasion 5–10  Slowing progression of CKD by Promote discussion:

following up the  Self-appraisal maintaining healthy lifestyles  Questions and
self-management  Positive reinforcement in answers
program response to participants’ concerns  Provide positive
 Participants to identify two reinforcement
priority self-management goals
(which will be followed up during
telephone calls)
 Provide nurse researcher’s phone
number so that participants can
call to ask questions
Note. SCT, Social cognitive theory; CKD, Chronic kidney disease; BP, Blood pressure; Hb, Haemoglobin, eGFR, estimated glomerular filtration rate.
Table 4.2. Follow-up Self-Management Education Program
(Weeks 4 and 12: 20–30 mins)
Time Topics SCT Information Mins Contents Goals for Methods Main Focus
sources Participants
Follow-up via Discussion:  Verbal persuasion 10–15  Discuss positive Understand and  Feedback on  Focusing on
telephone call  Review the physiological and be able to participant’s the first
or in the clinic first goal psychological responses perform better success in priority self-
(Week 4) from Week 0 to healthy eating and the first priority following the management
physical activity self- healthy eating goal which
 Move to the
management and physical identify in the
second goal
goal and start activity face-to-face
if the first
 Self-appraisal 10–15  Discuss two priority self- working on the  Encourage session
goal was
management goals as second self- participants to  Re-adjustment
achieved  Performance
listed above on the face- management achieve their of the first
 Reinforce accomplishment
to-face session goal goals goal if needed
CKD  Vicarious
knowledge experience  Provide exercise safety  Exhibit empathy  Some
booklet tips for home use in the and caring information
CKD booklet will also be
 Enhance the participant to  Incorporate reinforced, and
talk and get helps from problem-solving allow time to
family members, friends, activities ask questions
and significant others or concerns
Follow-up via Discussion:  Verbal persuasion 10–15  Discuss positive Understand and  Feedback on  Focusing on
telephone call  Re-assess the physiological and be able to participant’s the second
or in the clinic first goal if psychological responses perform better success in priority self-
(Week 12) needed in to healthy eating and the second following the management
Week 4 physical activity priority self- healthy eating goal which
management and physical identify in the
 Review the
goal and activity face-to-face
second goal
maintain the session
from Week 0  Self-appraisal 10–15  Discuss two priority self-  Encourage
management goals as first goal participants to  Re-adjustment
 Reinforce  Performance
listed above on the face- achieve their of the second
Time Topics SCT Information Mins Contents Goals for Methods Main Focus
sources Participants
CKD booklet accomplishment to-face session goals goal if needed
 Vicarious  Provide exercise safety  Exhibit empathy  Some
experience tips for home use in the and caring information
CKD booklet will also be
 Enhance the participant to  Incorporate reinforced, and
talk and get helps from problem-solving allow time to
family members, friends, activities ask questions
and significant others or concerns
Note. SCT, Social cognitive theory; CKD, Chronic kidney disease.
4.4.4 Length of Follow-up
As previously identified in Chapter 2 (see section 2.5.2) the duration of the CKD self-
management interventions varied in the length of the follow-up period. For this research,
16 weeks’ duration with two follow-up education phone calls at week 4, week 12 and two
follow-up repeated measures at weeks 8 and 16 was deemed suitable and feasible.
Previous literature reported that behaviour changes in people with CKD showed good
improvement in the first 6 months, with most of the improvement seen by 3 months
(Kazawa & Moriyama, 2013; Lin et al., 2013; Tsay, 2003). This could be because new
habits have formed. In addition, improving participants’ self-efficacy about their ability to
implement care successfully is a crucial step in promoting active self-management
(Ismail, Winkley, & Rabe-Hesketh, 2004; Wu et al., 2008). Moreover, according to
Bandura (2004b), people need support to be confident in their ability to learn a new
behaviour and rehearse what they have learnt to achieve better outcomes.
In Vietnamese context, little research has been conducted in caring for people with CKD,
particularly for those with CKD at outpatient clinics in hospitals. This study is an initial
step in providing a self-management intervention to support people with CKD. For
feasibility reasons, a longer follow-up period was not possible for this PhD study.
4.4.5 Outcomes
The primary outcomes of kidney disease knowledge (V.KiKS) and self-management
behaviour (V.CKD-SM), along with self-efficacy (V.SECD), were measured at baseline,
weeks 8 and 16. Secondary patient outcomes including health-related quality of life
(V.SF-36v2) and BP control were measured at baseline and upon completion of the
follow-up period at week 16. Additional measurements including demographic

characteristics, comorbidities, renal and clinical data were obtained to understand the
characteristics of the study sample. Outcome data was measured by two research
assistants. Both research assistants were newly graduated nurses, had no association with
the clinical service, and were employed the researcher. Research assistant 1 (RA1)
recruited and collected baseline data from participants. Research assistant 2 (RA2)
measured repeated outcomes of the study. The RA2 first contact with participants was at
week 8 and then again at week 16 via phone or in the renal clinics to measure outcome
data. The RA2 did not have access to the coding sheet or the interpretation of the code
and was blinded to group allocation.
Self-management affects a number of outcomes, including both short- and long-term
(Ryan & Sawin, 2009). Thus, outcome data required repeated measures at weeks 8 and 16
to assess the effectiveness of the self-management education program on participants’
knowledge, self-management, and self-efficacy. Repeated measures also helped to
examine the trend of the outcomes data after delivering the intervention compared to
those in the control group, and to explore the overall treatment effects of groups × time
interaction on outcome variables. In addition, repeated measures enabled comparison to
the existing literature.
Primary outcomes
Knowledge
Knowledge was measured by using the Vietnamese Kidney Disease Knowledge
instrument (V.KiKS) that was assessed for validity and reliability in Phase 1 and Phase 2.
The V.KiKS is a self-report instrument comprising 28 items that measure the participant’s
knowledge related to kidney disease management, such as kidney function, treatment
options for kidney failure, signs and symptoms of disease progression, potential

medications that harm or benefit the kidney, BP targets, and other information related to
preserving kidney function (Wright et al., 2011). The V.KiKS takes approximately 10
minutes to complete. The items are scored as 1 = correct, or 0 = incorrect, and total scores
range from 0 to 28. The higher score the participants receive, the better their knowledge
of CKD. The Kuder-Richardson-20 reliability coefficient of the V.KiKS was .58.
Moreover, the test/retest analyses showed that the V.KiKS was relatively stable because
the intra-class correlation coefficient (ICC) was .82 (p < .01), and this was above the
acceptable cut-point of .70 (see Table 5.9). The V.KiKS was measured at baseline, week
8, and at the end of the intervention (week 16) (see Appendix 18).
Self-management behaviour
Self-management behaviour was measured by using the Vietnamese Chronic Kidney
Disease Self-Management instrument (V.CKD-SM) that was assessed for validity and
reliability in Phases 1 and 2. The V.CKD-SM self-report instrument comprises 32 items
and measures whether participants perform a range of self-management behaviour
factors, including self-integration (11 items); problem-solving (11 items); seeking social
support (5 items); and adherence to recommended regimen (5 items). The subscales are
constructed by summing the scores on the separate items belonging to the subscale.
Respondents answer each item on a Likert scale from 1–4; 1 = never, 2 = sometimes, 3 =
usually, 4 = always. Total scores of the V.CKD-SM are also constructed by summing the
scores on the four subscales and range from 32 to 128. High scores indicate a high level
of self-management behaviour in managing CKD. The instrument takes about 15 minutes
to complete. The Cronbach’s alpha of the V.CKD-SM was .93 and the one to two-week
test/retest Pearson correlation was .98 (p < .01). The Cronbach’s alphas for the four
subscales were .87 (self-integration), .87 (problem-solving), .67 (seeking social support),

and .67 (adherence to recommended regimen) (see Phase 2 Results, Table 5.8). The
V.CKD-SM instrument was measured at baseline, at weeks 8 and 16 (see Appendix 19).
Secondary outcomes
Self-efficacy
Participants’ self-efficacy was measured by using the Vietnamese Self-efficacy for
Managing Chronic Disease 6-item Scale (V.SECDS). Developed by Lorig et al. (1989),
the short form of self-efficacy chronic disease scales (SECDS) contains six items and
measures the level of confidence with undertaking a range of chronic disease-related
activities. Participants indicate a score from 1 to 10 (1 = not at all confident, 10 = totally
confident). Higher scores indicate greater levels of self-efficacy. This instrument is
widely used in chronic disease studies and was tested on 605 participants with chronic
disease (Lorig, Sobel, Ritter, Laurent, & Hobbs, 2001) and the Cronbach’s alpha was .91.
Given the scope of this phase, it was decided to forward-translate this instrument with
two independent bilingual translators. The V.SECDS was measured at baseline, weeks 8
and 16 (see Appendix 20).
Health-related quality of life (HRQoL) is important to measure because of the impact of
CKD on quality of life (see also section 2.2.4), and it is also needed to determine whether
improved self-efficacy has led to an outcome (see diagram of SCT on p. 64). The SF-
36v2 (McHorney, Ware, & Raczek, 1993) was used to measure HRQoL in this study.
This instrument was selected because it measures participants’ perceptions of their own
physical and mental function. Each sub-scale is scored between 0 and 100 and a higher
score indicates a better level of HRQoL in that domain. In addition, the SF-36v2 has been

translated into several languages, including Vietnamese (Bullinger et al., 1998; Le, Vu, &
Schelling, 2014; Ware et al., 2008). Le et al. (2014), in a study of 1,800 people in Hanoi,
measured the consistency of the Vietnamese SF-36v2 (V.SF-36v2). The V.SF-36v2 has
high reliability with Cronbach’s alpha coefficients for the subscales ranging from .75 to
.88 (Le et al., 2014). The V.SF-36v2 is available for free to PhD students (see Appendix
14). The V.SF-36v2 was measured at baseline and at week 16 when the study ended (see
Appendix 21).
Blood pressure control
A manual BP cuff was used to measure BP at each clinic appointment. The result was
routinely recorded in the medical record. Both systolic pressure (SBP) and diastolic
pressure (DBP) in mmHg were obtained at baseline and at week 16 (see Appendix 23). A
target of BP of < 140/90 mmHg is recommended for patients with nondiabetic CKD;
however, for those with proteinuria a BP < 130/80 mmHg is normally suggested (Tsai et
al., 2017).
Additional measurements
Demographic characteristics
Demographic data were age, gender, marital status, individual and household incomes,
level of education, and occupation, health insurance, family size, length of time of CKD
diagnosis, and Google search on kidney problems. This information was collected at
baseline only, using a researcher-developed questionnaire (see Appendix 22).

Renal and clinical data
This data was obtained from patients’ medical records and comprised the main cause of
renal failure, weight and height (or BMI), blood results (sodium, potassium, phosphate,
calcium, bicarbonate, blood glucose level, HbA1c, creatinine, urea, eGFR, albumin,
haemoglobin, cholesterol, high-density lipoprotein and low-density lipoprotein, iron), and
a list of current medications. The renal clinical data were obtained at baseline (see
Appendix 23).
Charlson comorbidity index
The Charlson comorbidity index (CCI) was used to assess the presence of other chronic
disease in study participants (see Appendix 24). The CCI is widely used in research
(Quan et al., 2011). The CCI consists of 16 items and the severity of comorbidity was
classified into three levels according to the score (see Appendix 25). Mild CCI is a score
of 1–2; moderate CCI is a score of 3–4, and severe CCI is a scores ≥ 5 (Charlson,
Szatrowski, Peterson, & Gold, 1994; Charlson, Pompei, Ales, & MacKenzie, 1987; You-
qun et al., 2014). As data was verbally collected by the RA1, there was no need to
translate the CCI into Vietnamese. The CCI was measured at baseline.
4.4.6 Sample Size Estimation
The sample size was calculated using G*power 3.1. The pRCT aimed to improve
participants’ self-management behaviour. Hence, the sample size was calculated
assuming 80% power (1-beta = .8), a type 1 error rate (alpha) of .05 (two-tailed), and a
medium effect size (Cohen’s d = 0.5) on improved self-management reported by Bonner
et al. (2014) in other CKD studies where participants were not receiving dialysis. A
minimum of 134 participants (67 participants per group) were required. The study was

conducted from November 2015 to February 2016 to recruit this number of participants
and then follow-up participants until June 2016.
4.4.7 Randomisation
Eligible participants were randomised into two groups, using sequentially numbered,
opaque sealed envelopes. All investigators and participants were blinded to group
allocation until after recruitment, consent, and baseline data were completed.
4.4.8 Sequence Generation
The randomisation sequence was developed by the researcher by generating a random
number table in Microsoft Excel to eliminate selection bias. The table with the random
numbers was checked to ensure there was a balance in the number of participants
allocated to control and intervention groups. The opaque sealed envelopes were then
coded by the researcher according to the random-number table.
4.4.9 Allocation Concealment
Allocation concealment was used to prevent selection bias (Moher et al., 2010). The
researcher placed a code into the envelopes before sealing. RA1 was blinded to the
coding and the envelopes were opaque and unable to be read when held to the light. The
coding sheet and the interpretation of the code were then given to RA1 to use to randomly
allocate the study participants into the control or intervention groups.
Research assistant 1 assessed eligible participants, discussed the purpose and methods of
the study with each eligible participant, obtained consent, and enrolled the participant in
the study. Baseline data was collected by the RA1 before the participant chose their
envelope for group allocation. Participants who were randomly assigned to the

intervention group then met with the researcher to receive the education materials (a CKD
booklet and a handout that summarised the intervention topics) before participating in the
face-to-face education session.
4.4.10 Blinding
Due to the nature of the intervention it was difficult to achieve blinding in this study.
Only research assistants who collected data at baseline (RA1) and follow-up (RA2) were
blinded to group allocation to minimise bias. Renal medical practitioners and clinic
nurses could not be blinded in this study; however, they did not have access to the coding
sheet or a list of participants in both the intervention and control groups. Neither the
researcher who provided the intervention nor the participants with CKD were blinded.
4.4.11 Recruitment
The follow steps describe the process of recruitment.
Step 1: the RA1 met with a renal medical practitioner who was able to identify eligible
potential participants who were pre-dialysis (i.e., CKD stages 3–5). Then the RA1 met the
renal nurse at the clinic patient registration desk to ask the renal nurse to give the
recruitment flyers to potential eligible participants to read and learn about the main study.
It was possible for the renal nurse to identify potential participants after completing the
clinic patient registration procedure. After reading the recruitment flyer, if a patient was
willing to speak with a research assistant, the renal nurse referred the patient (potential
participant) to the RA1 who was sitting in the waiting room. It took about 5 minutes to
complete this step.
Step 2: the RA1 would then meet eligible participants with CKD in the waiting room at
the clinic, introduce themselves, the purpose and methods of the study and invite them to

participate. Potential participants could ask the RA1 questions about the study, and also
read the Participant Information Sheet before providing written consent. Participants
could decide to sign the consent form immediately after understanding the study or take
as long as necessary (because they are in the clinics for 3 to 4 hours). Alternatively, a
participant could take the Participant Information Sheet home to discuss with their family
or friends and the RA1 spoke with them when they next came to the clinic.
Step 3: participants were invited to complete the self-reported instruments before being
randomly assigned into either the control group or the intervention group. The RA1
assisted them to complete the baseline self-reported instruments. It took about 30 to 40
minutes to complete step 3. Also at this time the RA1 collected renal clinical data from
their medical record.
Step 4: each participant selected one of the opaque envelopes, opened it and gave their
number to the RA1. The RA1 checked the code number with the coding sheet to
randomly allocate the participant to either the control or intervention group. Those in the
intervention group were referred to the principal researcher by the RA1 (approximately 5
minutes).
Step 5: each participant in the intervention group was provided with a 60-minute face-to-
face session delivered by the principal researcher. Participants in the control group did
not attend this session.
Step 6: at weeks 8 and 16 the RA2 collected data from both groups.
As the renal outpatient clinics operate daily, the process was repeated every day (9 am to
4 pm, Monday to Friday) during the study time from November 2015 to June 2016.

4.4.12 Data Management and Analysis
Data management
First, a coding manual for each variable of a participant’s outcome measure was
developed. Second, all returned outcome measures from the sample were reviewed by the
researcher before entering the data into SPSS to assess for missing data, any errors or
invalid response codes. Third, categorical variables (education, occupation, causes of
CKD, stage of CKD based on eGFR, etc.) were coded, and continuous values (age,
individual and family incomes, total V.KiKS, total V.CKD-SM, etc.) were entered.
Among these variables, eGFR required calculation before entering into SPSS. According
to the National Kidney Foundation (2015), eGFR was individually calculated for each
participant using age, gender, and serum creatinine level by using the CKD-EPI formula.
Then, 20% of the returned participant outcome measures were randomly checked for a
second time for any errors and unusual responses. The completed database was then
checked in SPSS, using frequency analysis to investigate any errors or missing numbers
and the distribution of all variables for normality. Following that, unusual responses, any
missing data, or errors in the data were checked with the original versions of participants’
outcome measures.
The results indicated that there were no missing items or errors in the socio-demographic
data, related renal characteristics, and outcome measures at all time points. However,
renal clinical test results showed several missing values because not all participants were
required to have testing at the time they participated in the study. Therefore, the common
available renal clinical data from all participants (eGFR, potassium, haemoglobin, BP,
urea, sodium, and blood glucose) were used.

Data analysis
There were 135 participants involved in this study at baseline. However, 15 participants
dropped out because they started dialysis, did not complete the repeated measures, or
were not contactable. As a result, there were some missing values from these participants.
An intention-to-treat analysis was performed using the available outcome data from all
participants, as recommended in the literature (Gupta, 2011; Little & Kang, 2015; Polit &
Gillespie, 2009). Following Consolidated Standards of Reporting Trials (CONSORT)
2010 guidelines (Moher et al., 2010), data from 67 participants in the control group and
68 in the intervention group were included in the final analysis.
Participant responses in the outcome measures were scored before being entered into
IBM SPSS Statistics version 23 software. Descriptive statistics including histograms, Q-
Q Plots, boxplots, skewness and kurtosis were examined to evaluate normal distribution
of all continuous variables at baseline and each time point. Continuous variables with
normal distribution (age, BMI, eGFR, BP, etc.) were described as means (Ms) and
standard deviations (SDs), while medians (Mdn) and interquartile range (IQR) were used
to report those that were abnormally distributed (incomes, blood glucose, sodium, etc.).
Non-continuous variables were expressed in number (n) and percentage (%) (gender,
education, occupation, marital status, cause of CKD, etc.). Baseline characteristics were
compared for control and intervention groups, and lost to follow-up using independent t–
tests or Mann Whitney U tests for continuous variables. Chi-square or Fisher Exact tests
were used to examine any baseline differences in categorical variables.
Primary outcomes were knowledge (V.KiKS) and self-management behaviours (V.CKD-
SM), and secondary outcomes were self-efficacy (V.SECD), HRQoL (V.SF-36v2), and
BP control. Linear mixed models were used to test the effectiveness of the intervention at

each time point and to test whether treatment interacts with time and group (Brown &
Prescott, 2015). There are three main reasons for using linear mixed models (LMM) to
analyse the results of this study. First, LMM is a standard method of analysing
longitudinal data, such as data from an RCT, because this method can incorporate both
fixed and random effects and permit different covariance structures (Peduzzi, Henderson,
Hartigan, & Lavori, 2002). Hence, it helps to examine how the response of the individual
participant changes over time. Second, the random effects allow covariate coefficients to
vary randomly from one individual participant to another, thereby providing a trajectory
response from each individual over time (Ma, Mazumdar, & Memtsoudis, 2012). Third,
LMM are models for non-ignorable missing data (Hesser, 2015; Peduzzi et al., 2002). In
this study, the missing data was not replaced because LMM include every data point
available and all participants were included in the data analysis at three time points.
Linear mixed models were used to examine the effectiveness of the self-management
intervention program on primary and secondary outcome variables between groups
(intervention vs. usual care control), and the interactions between group and time.
Outcome variables were first checked to meet the requirements to run the models, which
required residual analysis to ensure that the assumptions of the models needed to be valid.
Residuals were normally distributed, had a mean of zero, and had a constant variance
(Tabachnick & Fidell, 2013).
Group, time, and group × time were included in each of the models as fixed effects. In
order to account for correlation between patients’ repeated measures over time, patient-
level random effects were also included in each model. The group × time interaction was
examined to determine the overall treatment effects between groups over time. Each
variable of participants’ demographic characteristics at baseline was then adjusted to the

model to compare with the unadjusted analyses.
Cohen’s d effect size was used to calculate the magnitude of the treatment effect of the
intervention group compared to the control group. Cohen’s d was calculated as the
difference between the means of intervention group (week 16) and control group
(baseline) divided by the pooled standard deviation (SDpooled). Values of Cohen’s d are
small, medium, and large effect (0.2, 0.5, and 0.8, respectively; Cohen, 1988).
4.5 Research Ethics
Ethics approval for the first two phases was obtained from Queensland University of
Technology Human Research Committee (Approval Number 1400000667) (see
Appendix 5) and permission from Bach Mai Hospital in Hanoi was sought (see Appendix
6). Ethics approval for Phase 3 (pRCT) was also obtained from Queensland University of
Technology Human Research Committee (Approval Number 1500000678) (see
Appendix 15) and permission from Bach Mai Hospital in Hanoi was sought (see
Appendix 16).
For the first two phases, the researcher explained the aims of the study, research
procedure, benefits, and safety of this study to participants before obtaining their consent.
In Phase 3, RA1 explained the purpose, methods, research procedure, benefits, and safety
of the pRCT to each participant before obtaining their consent. During all phases,
participants were assured that they had the right to refuse to participate or to withdraw
from the study at any time, and if they refused or withdrew from the project there would
be no effect on the healthcare they received. Confidentiality was assured, and no personal
information was disclosed to any other person. All data were stored in a secure area and
only utilised for the purpose of the research. The results were reported as group data, and
no names or other forms of identity were disclosed.

The trial was also registered in the Australian New Zealand Clinical Trials Registry
(ANZCTR), recorded as ACTRN12616000038493 (see Appendix 17).
4.6 Chapter Summary
This chapter described the methods for all three phases of this PhD study. In Phase 1, the
translation process of two instruments was conducted. Phase 2 assessed the reliability of
these instruments and tested and retested these instruments. The aim of these phases was
to provide valid and reliable instruments in Vietnamese to measure the outcomes of Phase
3. Phase 3 was a pRCT of a 16-week CKD self-management intervention with
participants randomly assigned into one of 2 groups. The results of each phase are
presented in the next chapter.

Chapter 5: Results
5.1 Introduction
The overall aim of this study was to test the effectiveness of the self-management
intervention program for people with CKD stages 3–5 in a Vietnamese sample. The self-
management program was guided by SCT. Prior to commencing the pRCT, preliminary
phases were required. Phase 1 translated and validated two instruments, the KiKS and
CKD-SM, from English into Vietnamese according to the processes described in the
previous chapter. Phase 2 involved the testing and retesting of the instruments for
psychometric properties. The final phase was the pRCT. All three phases were conducted
in Vietnam.
5.2 Phase 1 Results
5.2.1 Translation
The translation process of the two English versions of the KiKS and CKD-SM involved
four steps (see Figure 4.2). The translation process was completed by four bilingual nurse
academics who were each qualified at Master’s degree or higher, had a minimum of
English language capability of International English Language Testing System (IELTS)
6.5 or above, and had been involved in translating previous written material into
Vietnamese. In addition, they had many years of teaching experience in universities and
colleges in Vietnam.
Chapter 5: Results 115

5.2.2 Translation Process
Forward translation
The English versions of the two instruments were sent separately to two bilingual
translators to translate into Vietnamese. Then the Vietnamese versions were sent back to
the researcher for comparison to finalise the Vietnamese version, which involved
comparing words, phrases, and structures. The differences between the two versions were
discussed in a supervisor team meeting.
There were some problematic words or phrases in the forward-translated KiKS. These
were “đúng or không đúng” [correct or incorrect] used instead of “có or không” [yes or
no] for many of the answers because in Vietnamese this is the preferred way to answer a
closed-ended question. The phrase “chạy thận nhân tạo” [haemodialysis] (item 5) was
retained as it was in the original version and it is the most common form of dialysis
modality in Vietnam. The phrase “Sút cân (Giảm cân)” [weight loss] was also retained
because it is a common phrase. The comparison between the original, both translations,
and agreed terms of the KiKS are presented in Appendix 27.
The forward-translated CKD-SM also had some problematic words or phrases. For
example, “self-management” in the title of the instrument was translated into Vietnamese
as “tự quản lý [self-management]” by one translator and the other translator used “tự
chăm sóc [self-care]”. However, the phrase “tự quản lý [self-management]” was used
because the meaning is closer to the meaning of the [self-management] term. Other
problematic words were “dietitian” (item 8), which had been translated as “nhà dinh
dưỡng [nutritionist]” or “chuyên gia dinh dưỡng [nutritional specialist]”. The word
“pharmacist [dược sĩ]” (items 30 & 32) was deleted because medical practitioners
(doctors) or nurses provide this care for patients; and the word “health professionals”
116 Chapter 5: Results

(items 13, 15 & 17) is not used, so the phrase “bác sĩ và điều dưỡng [doctors or nurses]”
was used instead. Lastly the word “church [nhà thờ]” (items 24 & 28) was deleted
because the majority of people in Vietnam have no religion. In Vietnam, people believe
in ancestors-worship and almost all Vietnamese homes have an ancestors’ altar.
Ancestor-worship, while not a religion, is a belief which is embedded in the historical and
cultural traditions of Vietnamese which has been respected and acknowledged by the
communist government (Thuy & Hong, 2017). Appendix 28 contains the comparison
between the original, both translations, and agreed terms of the CKD-SM.
Back-translation
The draft Vietnamese versions of the KiKS and CKD-SM were then provided to a further
two bilingual translators, who were not involved in the forward translation, to translate
from Vietnamese back into English. These translators did not have access to the original
English versions. The back-translation process was similar to the forward translation
process. There were some problematic words and phrases identified in the back
translation, such as verb tense use and word choices. One translator used a singular verb
form for almost all of the questions while the other translator used a plural verb form.
Comparison of the English instrument and its back-translated version
The researcher reviewed and compared the back-translated versions of these instruments
with the original versions. Then the researcher made notes of any differences in word use,
phrases, sentence structures, and meanings to discuss in a supervisory team meeting. The
differences in word use, tense, and phrase were adjusted to achieve meanings close to
those of the original version. The comparisons of the two back-translated versions of the
KiKS and CKD-SM can be found in Appendices 29 and 30, respectively. Both translated
versions of the CKD-SM and KiKS were now ready to be validated by an expert panel.

5.2.3 Instrument Validation Results
Content validity and instrument readability assessments
To assess content validity of the translated KiKS and CKD-SM, 10 people were invited to
review the instruments. The demographic characteristics of the panel members are
presented in Table 5.1. Each panel member separately scored each item and sub-item
between 1–4 for relevance (1 = not relevant, 2 = major change to be relevant, 3 = minor
change to be relevant, 4 = very relevant), clarity (1 = not clear, 2 = major change to be
clear, 3 = minor change to be clear, 4 = very clear), and appropriateness and adequacy
(1 = not appropriate, 2 = major change to be appropriate, 3 = minor change to be
appropriate, 4 = very appropriate). Comprehensiveness was scored as either 1 or 2 (1 =
should be deleted, 2 = should be retained) (see Appendix 31). Panel members were also
asked to provide their comments on any item that they thought should be revised to be
made clearer, simpler, or easier for people with low literacy levels (see Appendix 32).
Table 5.1. Demographic Characteristics of Expert Panel
Occupation Age Gender

Renal medical practitioner 34 Male
Renal nurse 51 Female
Renal nurse 48 Female
General medical practitioner 26 Female
General registered nurse 23 Female
General registered nurse 23 Female
Primary school level teacher 39 Male
Primary school level teacher 42 Male
Home worker 58 Female
Home worker 57 Female

Scale and item content validity average
The results for scale and item content validity average (S-CVI/Ave) and instrument
readability are presented in Tables 5.2. The panel members rated 28 items of the
translated KiKS and 32 items of the translated CKD-SM. The data generated from the
panel review of both instruments was used to calculate the scale and item content validity
(S-CVI). The S-CVI/Ave of each instrument was calculated as an average of the item-
level content validity (I-CVI) by summing the rating and dividing by the number of items
(Polit & Yang, 2016). The recommended standard for the S-CVI/Ave should be .90 or
higher (Polit & Yang, 2016). In this study, the overall S-CVI/Ave (content validity and
readability) of the translated KiKS was .97 and the translated CKD-SM was .99. These
results indicate that the translated KiKS and translated CKD-SM instruments achieved
sufficient content validity in regard to relevance, clarity, comprehensiveness,
appropriateness, and adequacy. Thus, both instruments demonstrated good content
validity.
Table 5.2. Scale and Item Content Validity Average of Instrument Variables for Content
Validity and Readability
Variables Relevance Clarity Comprehensiveness Adequacy Overall
V.KiKS: .97 .98 .97 .97 .97

S-CVI/Ave
V.CKD-SM: 1.00 1.00 .98 1.00 .99

S-CVI/Ave
Abbreviations: S-CVI/Ave, Scale and item content validity average; V.KiKS, Vietnamese Kidney disease
knowledge instrument; V.CKD-SM, Vietnamese Chronic kidney disease self-management instrument.

In addition, the panel members’ written comments about problematic words and phrases
were collated and then discussed with the supervisory team. Appendix 32 presents the
problematic words and the outcomes from the discussions with the supervisory team. The
final Vietnamese versions of both the KiKS and CKD-SM were then ready for
psychometric testing (Phase 2). Both Vietnamese versions of the CKD-SM and KiKS are
referred as the V.CKD-SM and V.KiKS, respectively in the remainder of this thesis.
5.3 Phase 2 Results
Phase 2 used a test/retest design conducted at one nephrology department in which a total
of 158 participants were recruited. Of these, 70 participants agreed to complete the retest,
and of these 52 returned both instruments and 18 participants return only one instrument.
It is unknown why both instruments were not returned, and because no participant
telephone numbers were obtained, no further follow-up occurred. Figure 5.1 summarises
the Phase 2 research process.
Informed consent for testing instruments (n = 158)
Agreed to complete retest (n = 70)
Excluded due to missing data (n = 18)
Completed retest (n = 52)
Figure 5.1. Phase 2 research process.

5.3.1 Sample Characteristics
There was a nearly equal distribution between males (48.7%) and females (51.3%).
Participant ages ranged from 18 to 84 years (M = 44.0, SD = 16.2). Among these
participants, the majority of them were between the ages of 20 and 39 (40.5%) and only
one participant (0.6%) was over 80 years of age. Most of the participants (88.6%) were
married. Participants who had completed primary school, secondary school, and high
school comprised 24.1%, 40.5%, and 23.4% of the total, respectively. The occupation of
the majority of participants was farmer (43.7%). The average monthly individual income
and monthly family income ranged from 0 to 10 million VND/month (M = 2.74, SD =
1.6) and 0.5 to 17.5 million VND/month (M = 6.10, SD = 3.16), respectively. Of those
participants who had no income, they were either farmers or home workers. The majority
of participants lived with three to four family members (62.1%). Participant
characteristics are summarised in Table 5.3.

Table 5.3. Demographic Characteristics of Participants
Characteristics n %
Age (years), range: 18–84, M (SD) 44.0 (16.2)
≤ 19 5 3.2
20–39 64 40.5
40–59 52 32.9
60–79 36 22.8
≥ 80 1 0.6
Gender
Male 77 48.7
Female 81 51.3
Marital status
Married 140 88.6
Single 15 9.5
Widowed 2 1.3
Divorced 1 0.6
Education
Primary school 38 24.1
Secondary school 64 40.5
High school 37 23.4
Certificate degree (2 years) 5 3.1
Certificate degree (3 years) 2 1.3
Bachelor degree 12 7.6
Occupation
Officer and officer worker 12 7.6
Farmer 69 43.7

Characteristics n %
Industrial worker 19 12.0
Seller 26 16.5
Home worker 5 3.1
Retired 18 11.4
Other jobs 9 5.7
Monthly individual income (million VND), range: 0–10, M (SD) 2.74 (1.6)
< 1.5 40 25.3
1.5–3.0 47 29.8
3.1–4.5 53 33.5
4.6–6.0 12 7.6
≥ 6.1 6 3.8
Monthly family income (million VND), range: 0.5–17.5, M (SD) 6.1 (3.16)
< 3.0 16 10.1
3.0–6.0 65 41.1
6.1–9.0 54 34.2
9.1–12.0 14 8.9
≥ 12.1 9 5.7
Number of family members, range: 1–11, M (SD) 4.15 (1.35)
≤ 2 people 10 6.3
3–4 people 98 62.1
5–6 people 44 27.9
≥7 6 3.7
Note. N = 158.
Abbreviations: M, Mean; SD, Standard deviation; VND, Viet Nam Dong.

5.3.2 Renal Clinical Characteristics
More than half of the participants were in CKD stage 5 but not yet receiving dialysis (n =
86; 54.4%), while the rest were in stage 1 (5.7%), stage 2 (9.5%), stage 3A (3.8%), stage
3B (3.2%), and stage 4 (9.5%). Approximately 14% of the participants were receiving
dialysis. Only 25.9% had a normal BP of < 120/80 mmHg. Other clinical data included
cholesterol, HbA1c, potassium, calcium, phosphate, haemoglobin (Hb), body mass index
(BMI), and total number of medications (see Table 5.4). All participants had eGFR, BP,
potassium, Hb and BMI recorded in their hospital records. However, there were large
numbers who had not been tested for cholesterol, HbA1c, calcium, and phosphate. The
majority (n = 109; 69%) had a normal serum potassium level. The BMI results indicated
that more than half of the participants (n = 104; 65.8%) had a normal weight and only 15
(9.5%) had a BMI level greater than 25. Nearly two thirds of the participants (n = 98;
62%) had an Hb level lower than 100 g/L, and around 67% (n = 105) had a low serum
calcium level. In regard to the total number of medications prescribed, 26 (16.4%) had to
take at least three different types of medication, 102 (64.6%) took between four and six
medications, and 30 (19%) were prescribed more than seven different types of
medication.

Table 5.4. Renal Clinical Characteristics
Clinical test results n %

CKD Stage [eGFR (mL/min/1.73 m²)], M (SD) 23.65 (30.27)
Stage 1 (≥ 90) 9 5.7
Stage 2 (60–89) 15 9.5
Stage 3A (45–59) 6 3.8
Stage 3B (30–44) 5 3.2
Stage 4 (15–29) 15 9.5
Stage 5 (< 15) 86 54.4
Stage 5D 22 13.9
Blood pressure (mmHg)
< 120/80 41 25.9
120–139/80–89 66 41.8
140–159/90–99 37 23.4
≥ 160/100 14 8.9
Haemoglobin (g/L), M (SD) 97.57 (21.6)
< 100 98 62.0
100–120 38 24.1
> 120 22 13.9
Potassium (mmol/L), M (SD) 3.88 (0.69)
< 3.5 43 27.2
3.5–5.0 109 69.0
> 5.0 6 3.8
Cholesterol (mmol/l), M (SD) 6.38 (3.69)
< 3.6 14 8.9
3.6–5.2 49 31.0
> 5.2 49 31.0
No test 46 29.1
HbA1c (%), M (SD) 5.89 (1.03)
4.2–6.4 12 7.6
> 6.4 5 3.2
No test 141 89.2
Calcium (mmol/L), M (SD) 2.05 (0.29)
< 2.2 105 66.5

Clinical test results n %
2.2–2.6 37 23.4
> 2.6 3 1.9
No test 13 8.2
Phosphate (mmol/L), M (SD) 1.9 (0.53)
< 1.45 6 3.8
1.45–1.9 17 10.8
> 1.9 15 9.5
No test 120 75.9
BMI, M (SD) 21.12 (3.4)
< 18.5 39 24.7
18.5–24.9 104 65.8
25–29.9 11 7.0
≥ 30 4 2.5
Medications used
≤3 26 16.4
4–6 102 64.6
≥7 30 19.0
Note. N = 158.
Abbreviations: M, Mean; SD, Standard deviation; eGFR, estimated glomerular filtration rate; D, dialysis;
HbA1c, Glycosylated haemoglobin; BMI, Body mass index.

5.3.3 Instrument Summary Results
The maximum possible total score of the V.KiKS is 28. In this study, the scores ranged
from 11 to 23 (M = 17.67, SD = 2.61). For the V.CKD-SM, the possible minimum and
maximum scores were 32 and 128, respectively. In this study, the scores ranged from 47
to 115 (M = 72.20, SD = 10.17) (see Table 5.5).
Table 5.5. Means and Standard Deviations for two Instruments
Instruments Number of items Potential range Actual range M (SD)
V.KiKS 28 0–28 11–23 17.67 (2.61)
V.CKD-SM 32 32–128 47–115 72.20 (10.17)
Note. N = 158
Abbreviations: M, Mean; SD, Standard Deviation; V.KiKS, Vietnamese Kidney disease knowledge
instrument; V.CKD-SM, Vietnamese Chronic kidney disease self-management instrument.
5.3.4 Instrument Responses
A summary of those participants who responded correctly to each of the V.KiKS items is
presented in Table 5.6. The five highest items answered correctly were item 19 (99.4%),
item 2 (98.7%), item 10 (98.7%), item 11 (96.8%), and item 7 (96.2%). However, more
than 80% of participants did not know why it is not good for the kidneys when there is
too much protein in the urine (item 3). The majority of participants could not identify one
medication from the list that they should avoid (item 4), what “eGFR” stood for (item 6),
blood glucose (item 16), and the fact that some people with CKD may have no symptoms
at all (item 28). None of the participants were informed of the results of the first test
scores of the V.KiKS.
A summary of participant responses to the V.CKD-SM is presented in Table 5.7. Items
having the highest mean scores included item 8 (M = 3.06, SD = 0.59), item 17 (M = 3.54,

SD = 0.58), item 27 (M = 3.29, SD = 0.59), and item 30 (M = 3.42, SD = 0.53). By
contrast, items with the lowest mean scores included item 2 (M = 1.63, SD = 0.70), item 5
(M = 1.37, SD = 0.53), item 6 (M = 1.60, SD = 0.62), item 16 (M = 1.66, SD = 0.73), item
29 (M = 1.58, SD = 0.66), and item 32 (M = 1.65, SD = 0.69). None of the participants
were informed of the results of the first test scores of the V.CKD-SM.

Table 5.6. Vietnamese Kidney Disease Knowledge Correct Results
Items Correct
(%)
1 On average, your blood pressure should be maintained 76.6
2 Are there certain medications your doctor can prescribe which is useful 98.7
for your kidneys?
3 Why it is not good for kidneys when there is too much protein in the 17.1
urine?
4 Select the ONE MEDICATION from the list below that a person with 5.1
CHRONIC kidney disease should AVOID:
5 If the kidney(s) fail, treatment might include (FOR THIS QUESTION 86.7
you can CHOOSE up to TWO ANSWERS):
6 What does “GFR” stand for? 8.9
7 Does CHRONIC kidney disease have different stages? 96.2
8 Does CHRONIC kidney disease increase risks of heart attack for 86.1
people?
9 Does CHRONIC kidney disease increase risks of mortality for people? 94.9
This part will ask about WHAT KIDNEY DOES. Please choose one answer for
each of the following questions
10 Does the kidney make urine? 98.7
11 Does the kidney clean blood? 96.8
12 Does the kidney keep bones healthy? 54.4
13 Does the kidney keep a person from losing hair? 47.5
14 Does the kidney help keep red blood cell counts normal? 91.1
15 Does the kidney help keep blood pressure normal? 89.2
16 Does the kidney help keep blood glucose normal? 19.0
17 Does the kidney help keep potassium levels in the blood normal? 45.6
18 Does the kidney help keep phosphorus levels in the blood normal? 38.6

Items Correct
(%)
This section is about SYMPTOMS. Please select from the list, all of the symptoms a
person might have if they have chronic kidney disease or kidney failure.
19 Increased fatigue? 99.4
20 Shortness of breath? 91.8
21 Metallic taste / bad taste in the mouth? 79.7
22 Abnormal itching? 60.1
23 Nausea and/or vomiting? 86.1
24 Hair loss? 46.2
25 Increased difficulty in sleeping? 91.8
26 Weight loss? 32.3
27 Confused? 21.5
28 No symptoms at all? 7.0
Note: N = 158

Table 5.7. Vietnamese Chronic Kidney Disease Self-Management Responses Results
Items M SD
Factor 1: Self-integration
7 To prevent the increased workload on my kidneys, I am able to control what I eat 2.96 0.57
8 I follow the diet which was recommended by my doctors or nurses. 3.06 0.59
11 I integrate closely my treatment of kidney disease into my daily life 2.41 0.57
12 I quit habits which worsen my kidney function (for example smoking, drinking alcohol, salty diet) 2.54 0.63
15 I follow health professionals’ recommendations about eating a balanced diet. 2.93 0.55
17 I follow health professionals’ recommendations about not smoking 3.54 0.58
18 I have changed my lifestyle to prevent my kidney disease from getting worse 2.47 0.56
20 I keep my kidney healthy by keeping my general health condition 2.44 0.52
21 I stop bad habits which might harm my kidneys (for example: smoking, eating salty food, drinking) 2.58 0.65
25 I can adjust my daily activities based on my kidney disease treatment plan when I am not at home (for 2.28 0.49
example: on travel, retreat)
28 I feel I am able to attend social activities (wedding, party), even though I have kidney disease. 2.19 0.47

Factor 2: Problem solving
2 I will ask about the reasons which might cause the decrease of my kidney function 1.63 0.70
5 I understand results of laboratory tests which were used to evaluate my kidney’s function (for example: 1.37 0.53
creatinine, eGFR)
6 When my blood pressure increases (more than 140/90), I try to find out any possible cause for this. 1.60 0.62
9 I solve problems related to my kidney disease by using different sources of information (for example: 1.58 0.68
calling my doctors or nurses, using internet, Google, group of supporting patients with kidney diseases)
14 I monitor my early warning signs and symptoms (for example: blood glucose, weight, shortness of breath, 2.11 0.59
foot swelling)
16 I asked doctors or nurses questions to understand clearly the plan of treating my kidney disease 1.66 0.73
22 I take steps to understand the risk factors associated with chronic kidney disease (such as high blood 1.98 0.44
pressure, diabetes, smoking, obesity).
26 When my body has new or worsen symptoms (for example: foot swelling, severe headache, urinate 2.11 0.47
frequently at night), I tried to find reasons
29 I search for information about chronic kidney disease from different sources (for example internet, leaflet, 1.58 0.66
manual, kidney disease patient peer group)
31 I take action when my early warning signs and symptoms get worse 2.16 0.54
32 When I have questions about my kidney disease, I discuss what to do with my doctors or nurses. 1.65 0.69

Factor 3: Seeking social support
1 When I have questions of my kidney disease, I discuss what I have to do with my family and friends 2.25 0.57
3 I inform my family and friends about my kidney treatment plan (such as, medications changes, lifestyle 1.89 0.54
changes).
4 I share my personal experience about kidney disease with other kidney disease patients 1.97 0.58
10 When I feel uncomfortable or disappointed, I discussed with someone about my emotion 1.98 0.46
19 I seek help from others when I am feeling upset or frustrated. 2.04 0.53
Factor 4: Adherence to recommended regimen
13 I follow healthcare professionals’ recommendations of doing exercises 1.85 0.64
23 I control my weight based on doctors or nurses’ advice 2.37 0.64
24 I make good choices about the type and amount of food I eat when I am not at home (for example: in 2.28 0.55
restaurant, party, eating out)
27 I still take all of my medications even when I am not at home 3.29 0.59
30 I take my medications as prescribed by my doctors. 3.42 0.53
Note. N = 158
Abbreviations: M, Mean; SD, Standard deviation.

5.3.5 Instrument Reliability
Reliability testing used the Kuder-Richardson-20 (KR20) for the KiKS and Cronbach’s
alpha for the V.CKD-SM and V.CKD-SM’s subscales. The KR20 of the V.KiKS was .58
compared to the English KiKS (E.KiKS) of .72 (Wright et al., 2011). The Cronbach’s
alpha of V.CKD-SM was .93 compared to the original version of .95 (Lin et al., 2012).
The subscale coefficients of the V.CKD-SM alphas ranged from .67 to .87, compared to
the originals which ranged from .77 to .92. The results of the reliability of these two
instruments and the subscales of the V.CKD-SM are presented in Table 5.8.

Table 5.8. Summary of Internal Reliability for Instrument Variables and Subscale
Variables
Variables Subscales KR20 Cronbach’s α
English KiKSª .72
V.KiKSᶜ .58
Original CKD-SMᵇ .95
Self-integration .92
Problem-solving .91
Seeking social support .84
Adherence to recommended regimen .77
V.CKD-SMᶜ .93
Self-integration .87
Problem-solving .87
Seeking social support .67
Adherence to recommended regimen .67
Note. ª N = 401; ᵇ N = 252; ᶜ N = 158.

Abbreviations: V.KiKS, Vietnamese Kidney disease knowledge instrument; V.CKD-SM, Vietnamese
Chronic kidney disease self-management instrument; English KiKS (Wright et al., 2011); Original CKD-
SM (Lin et al., 2012); KR20, Kuder-Richardson-20.
5.3.6 Test/Retest Reliability
In this study, 52 participants completed the test/retest to measure the stability of the
instrument (i.e., reliability). None of the 52 participants were informed of the V.KiKS and
V.CKD-SM scores after completing either the first test or the retest.
Consistency testing of the V.KiKS and V.CKD-SM used ICC, a two-factor, mixed-effects
model and type of absolute agreement, to assess the degree of reliability. The ICC index
should be above .70 (McGraw & Wong, 1996; Shrout & Fleiss, 1979). The ICC for the

V.KiKS was .82 (p < .01) and for the V.CKD-SM was .84 (p < .01). There was not much
variability between the test and retest of the two instruments. The responses from 52
participants to both instruments seem to be consistent and relative to one another. The
V.KiKS and V.CKD-SM 95% confidence intervals (CIs) were [0.68, 0.90] and [0.78,
0.89], respectively. The ICC results are presented in Table 5.9.
Table 5.9. Intra-class Correlation Coefficients for Instrument Variables
Variables 95% CI
ICC
LL UL
V.KiKS .82 0.68 0.90
V.CKD-SM .84 0.78 0.89
Note. n = 52; All coefficients are significant at p < .01.

Chronic kidney disease self-management instrument; ICC, Intra-class correlation coefficient; CI,
Confidence interval; LL, Lower limit; UL, Upper limit.
5.3.7 Pair Items Correlations
Pair items correlations of the V.KiKS and V.CKD-SM instruments are described in
Tables 5.10 and 5.11, respectively. In the V.KiKS, 8 pairs (items 2, 3, 7, 10, 11, 20, 21,
and 28) could not be computed because the standard error of the difference was zero (see
Table 5.10). The remaining nine pairs of the V.KiKS had a correlation coefficient less
than .70. Twenty-eight pair items of the V.CKD-SM had a correlation coefficient greater
than .70, with a significance level less than .01 (see Table 5.11). Only four pairs of the
V.CKD-SM had a correlation coefficient less than .70.

Table 5.10. Paired Samples Correlations for Vietnamese Kidney Disease Knowledge
Pairs M SD Correlation
Pair 1 -0.38 0.19 .91**
Pair 2 ª
Pair 3 ª
Pair 4 0.19 0.14 .90**
Pair 5 -0.19 0.14 .94**
Pair 6 0.19 0.14 .92**
Pair 7 ª
Pair 8 0.77 0.33 .59**
Pair 9 0.38 0.28 .32*
Pair 10 ª
Pair 11 ª
Pair 12 0.12 0.32 .79**
Pair 13 -0.21 0.46 .54**
Pair 14 0.04 0.19 .85**
Pair 15 0.08 0.27 .63**
Pair 16 -0.08 0.33 .68**
Pair 17 0.17 0.43 .63**
Pair 18 0.17 0.47 .53**
Pair 19 -0.02 0.14
Pair 20 ª
Pair 21 ª
Pair 22 0.06 0.31 .79**
Pair 23 -0.02 0.14 .91**
Pair 24 -0.15 0.50 .46**
Pair 25 0.00 0.28 .62**
Pair 26 0.06 0.37 .73**
Pair 27 0.04 0.34 .71**
Pair 28 ª
Note. n = 52; ª The correlation cannot be computed because the standard error of the difference is 0;
* significant at p < .05; ** significant at p < .01
Abbreviations: M, Mean; SD, Standard deviation

Table 5.11. Paired Samples Correlations for Vietnamese Chronic Kidney Disease Self-
Management
Pair 1 -0.04 0.28 .92**
Pair 2 0.12 0.38 .90**
Pair 3 0.02 0.14 .98**
Pair 4 0.04 0.19 .97**
Pair 5 -0.02 0.14 .98**
Pair 6 0.21 0.46 .80**
Pair 7 0.02 0.24 .92**
Pair 8 0.08 0.33 .87**
Pair 9 0.02 0.14 .99**
Pair 10 0.08 0.27 .91**
Pair 11 0.08 0.27 .92**
Pair 12 0.19 0.40 .87**
Pair 13 0.06 0.24 .95**
Pair 14 0.02 0.14 .98**
Pair 15 -0.04 0.19 .95**
Pair 16 -0.06 0.31 .93**
Pair 17 -0.06 0.46 .61**
Pair 18 0.04 0.19 .96**
Pair 19 -0.04 0.28 .92**
Pair 20 0.00 0.20 .94**
Pair 21 0.10 0.30 .93**
Pair 22 -0.04 0.19 .95**
Pair 23 0.12 0.38 .84**
Pair 24 0.02 0.37 .86**

Pair 25 -0.02 0.31 .85**
Pair 26 -0.02 0.37 .79**
Pair 27 -0.08 0.65 .53**
Pair 28 0.00 0.40 .69**
Pair 29 0.04 0.39 .86**
Pair 30 0.00 0.59 .47**
Pair 31 0.17 0.47 .78**
Pair 32 0.02 0.46 .81**
Note. n = 52; ** All pairs significant at p < .01

Abbreviations: M, Mean; SD, Standard deviation

5.3.8 Testing Normal Distribution of Outcome Variables
The Kolmogorov-Smirnov was used to test for a normal distribution of outcome variables
for the V.KiKS, V.KiKS (retest), V.CKD-SM, and V.CKD-SM (retest), and the results
are presented in Table 5.12. According to Pallant (2013), a non-significant result (p ≥ .05)
indicates a normal distribution. The results from Table 5.12 showed that the scores of the
V.CKD-SM and V.CKD-SM (retest) were normally distributed, while the scores of the
V.KiKS and V.KiKS (retest) were not normally distributed (p < .05).
Table 5.12. Testing Normal Distribution of Instrument Variables
Variables M SD Kolmogorov-Smirnov
p
V.KiKSᶜ 17.67 2.61 < .01
V.KiKSᵈ (retest) 17.42 2.16 .02
V.CKD-SMᶜ 72.20 10.17 .05
V.CKD-SMᵈ (retest) 75.67 10.78 .20
Note. ᶜ n = 158. ᵈ n = 52; significant p < .05

Chronic kidney disease self-management instrument; M, Mean; SD, Standard deviation.
5.3.9 Correlation between Test and Retest
The correlation between the V.CKD-SM (test) and V.CKD-SM (retest) was measured
using Pearson correlation. There was a significant relationship between the V.CKD-SM
(test) and V.CKD-SM (retest) (r = .98, p < .01). The correlation result of the V.CKD-SM
was unusually high, and this may be due to the short interval of the test/retest period,
therefore, participants might have tried to remember how they answered in the test and
responded again in the retest.

5.3.10 Comparison of Outcome Variables Results by Demographic Characteristics
Vietnamese kidney disease knowledge
The Mann-Whitney U Test was used to compare the V.KiKS scores for demographic
characteristics and results which are shown in Table 5.13. This test is used to measure for
differences between two independent groups on a continuous measure (Pallant, 2013).
As shown in Table 5.13, participants with higher skilled jobs (Mdn = 20, n = 12) had
more kidney knowledge than those with lower skilled jobs (Mdn = 17, n = 146) and this
was statistically significant (U = 457, z = -2.77, p < .05). There were no statistical
differences in CKD knowledge by age, gender, education, individual income, family size,
CKD stage, and number of medications.

Table 5.13. Results of Mann-Whitney U Test for Vietnamese Kidney Knowledge Variable by Demographic Characteristics
Variables n Mdn U z p
Age ≤ 55 years 117 18 2135 -1.05 .29
> 55 years 41 17
Gender Male 77 17 2999 -0.42 .68
Female 81 18
Education Level 1 to 9 103 17 2372 -1.69 .09
Level 10 and above 55 18
Occupation High skilled jobs 12 20 457 -2.77 .01
Low skilled jobs 146 17
V.KiKS
Individual income ≤ 3.0 million VND 106 17 2335 -1.57 .12
> 3.0 million VND 52 18
Family size ≤ 3 people 48 18.50 2194 -1.70 .09
≥ 4 people 110 17
CKD Stage Stages 1–4 50 18 2442 -0.97 .33
Stages 5 and 5D 108 17
Medication ≤ 3 types of medication 114 18 2075 -1.69 .09
≥ 4 types of medication 44 17
Note. N = 158; significant p < .05
Abbreviations: Mdn, Median; V.KiKS, Vietnamese Kidney disease knowledge instrument; VND, Viet Nam Dong.

Vietnamese chronic kidney disease self-management
The independent sample t–tests were used to compare mean scores of the V.CKD-SM by
demographic characteristics (see Table 5.14). This test is used to assess differences in
mean scores between the groups (Pallant, 2013).
As shown in Table 5.14, participants aged ≤ 55 years (M = 73.30, SD = 10.70) reported
greater self-management behaviours than those aged over 55 (M = 69.05, SD = 7.77) and
this was statistically significant (t(156) = 2.72, p = .01). Participants who completed high
school or above (M = 76.87, SD = 10.89) reported greater self-management behaviours
than those with lower high school qualifications (M = 69.70, SD = 8.86). Those in highly
skilled jobs (M = 86.00, SD = 12.18) experienced better self-management behaviours than
those in lower skilled jobs (M = 71.06, SD = 9.15). Participants with an income over 3
million VND per month (M = 76.65, SD = 10.86) had greater self-management
behaviours than those with income equal to or less than 3 million VND per month (M =
70.01, SD = 9.10). All of these variables (education, occupation, and individual monthly
income) were all statistically significant (ps < .01). There were no other statistical
differences in self-management behaviours by gender, number of family members, CKD
stage, or number of medications.

Table 5.14. Results of t–tests for Vietnamese Chronic Kidney Disease Self-Management Variables by Demographic Characteristics
Variables n M (SD) Mean difference [95% CI] t(156) p

Age ≤ 55 years 117 73.30 (10.70) 4.25 [1.14, 7.35] 2.72 .01
> 55 years 41 69.05 (7.77)
Gender Male 77 70.57 (9.13) -3.17 [-6.34, .00] -1.98 .05
Female 81 73.74 (10.91)
Education Level 1 to 9 103 69.70 (8.86) -7.17 [-10.34, -4.00] -4.47 < .01
Level 10 and above 55 76.87 (10.89)
Occupation High skilled jobs 12 86.00 (12.18) 14.94 [9.37, 20.51] 5.30 < .01
Low skilled jobs 146 71.06 (9.15)
V.CKD-SM
Individual ≤ 3.0 million VND 106 70.01 (9.10) -6.64 [-9.89, -3.40] -4.04 < .01
income > 3.0 million VND 52 76.65 (10.86)
Family size ≤ 3 people 48 73.48 (12.42) 1.84 [-2.12, 5.81] 0.93 .36
≥ 4 people 110 71.64 (9.03)
CKD Stage Stages 1–4 50 72.94 (11.88) 1.09 [-2.35, 4.53] 0.62 .53
Stages 5 and 5D 108 71.85 (9.32)
Medication ≤ 3 types of medication 114 73.14(10.26) 3.39 [-0.15, 6.92] 1.89 .06
≥ 4 types of medication 44 69.75 (9.62)
Note. N = 158; significant p ≤ .01
Abbreviations: M, Mean; SD, Standard deviation; t, t value from the t–tests; CI, confidence interval; V.CKD-SM, Vietnamese Chronic kidney disease self-management
instrument; eGFR, estimated glomerular filtration rate; VND, Viet Nam Dong.

5.3.11 Feasibility of Using Two Instruments
Vietnamese version of kidney disease knowledge instrument
The V.KiKS instrument has 28 items and was administered to 158 people with CKD in
Vietnam. The time taken to complete this instrument was about 10 to 15 minutes. Each
item was scored as 1 = correct, or 0 = incorrect. With regard to the results of Mann-
Whitney U test of the V.KiKS, the results indicated that there was a significant difference
in the V.KiKS scores between people with highly skilled jobs and those with lower
skilled jobs, while those who had completed fewer than nine years of schooling and those
who had completed more than nine years of schooling was nearly significantly different
(p = .09) (see Table 5.13). High skilled jobs appeared to be related to greater levels of
kidney disease knowledge, and this finding could be due to those who have more
education having a greater chance to work as professionals. Working in these jobs may
have made it easier to search for information on the internet to understand more about
kidney disease. Item 6 [What does ‘eGFR’ stand for] contains a medical term requiring it
to be explained to improve clarity for people with low health literacy level.
Vietnamese version of chronic kidney disease self-management instrument
The V.CKD-SM instrument has 32 items and was also administered to 158 people with
CKD in Vietnam. The total time required to complete this instrument varied from 15 to
20 minutes. The 4-point Likert scale ranged from 1 (never) to 4 (always). Most of the
questions were not difficult for participants to answer. However, some phrases, such as
maintaining my overall health [giữ gìn sức khoẻ chung], controlling [kiểm soát], integrate
closely [kết hợp chặt chẽ], changed lifestyle [thay đổi lối sống], take steps [thực hiện các

bước], and take action [thực hiện hành động] were not clear to older participants. The
researcher provided examples of what was meant.
The results of the t–tests for the V.CKD-SM by demographic characteristics showed
above indicated that there were significant differences in the V.CKD-SM scores by age,
education, occupation, and individual income (p < .05). Gender was also closely
significantly different (p = .05) (see Table 5.14). The results revealed that people who
were younger, who had completed more than nine years of schooling, people with highly
skilled jobs, and people with high incomes had higher V.CKD-SM scores. In the Vietnam
context, these people often live in urban areas or better environments where health
authorities can provide sufficient facilities and resources for people who need to perform
self-management skills. Therefore, the findings from Phase 1 and Phase 2 indicated that
the demographic variables including age, gender, education, occupation, and individual
income may become confounding variables, which should be carefully determined in
Phase 3.

5.4 Phase 3 Results
This phase comprised a pRCT of a CKD self-management intervention program. The
research hypotheses were:
1. Participants who receive a self-management intervention will have greater self-
reported knowledge, self-reported self-efficacy, and self-reported self-
management behaviour compared to those receiving standard care in a hospital
renal clinic.
2. Participants who receive a self-management intervention will have better blood
pressure control and self-reported health-related quality of life compared to those
receiving standard care in a hospital renal clinic.
The pRCT used two patient-reported outcome measures which had been translated and
psychometrically evaluated during the previous two phases of this study. The pRCT was
also conducted in Bach Mai Hospital, Hanoi City, Vietnam (see Chapter 4).
5.4.1 Participant Flow
Flyers were distributed to people with CKD attending the clinics (n = 1,103) with 148
people self-identifying to the nurse as being interested in the study and accordingly
assessed for eligibility; however, 13 were excluded. Thus, a total of 135 agreed to
participate in the study. Baseline data were collected and participants were randomly
assigned to either the intervention group (n = 68) or control group (n = 67) (see Table
5.15).

Table 5.15. Information Required to Document the Flow of Participants through each Stage of the Main Study
Stage Number of people Number of people not Reasons for not included or excluded Number
included included or excluded
Enrolment 148 13 Not in stages 3–5 of CKD 10
Difficulty with speaking because of the consequence of stroke 1
Declined to participate because of the time requirements 2
Randomisation 135 0 A minimum of 134 participants were required; however, within
the time frame for data collection 135 participants recruited to
the trial.
Treatment 68 intervention group 0
allocation 67 control group 0
61 intervention group 7 Commenced dialysis at week 8 2
Did not complete the repeated measures at week 16 because 2
Follow-up unwell
Not contactable at week 16 3
59 control group 8 Commenced dialysis at week 8 2
Commenced dialysis at week 16 1
Did not complete the repeated measures at week 16 because 3
unwell and sudden fatigue
Not contactable at week 16 2
Analysis 68 intervention group 0
67 control group 0

Figure 5.2 presents the CONSORT flow diagram of the study. Of these in the intervention
group, 61 completed the study and seven did not. Of those in the control group, 59
completed the study and eight did not. Those who did not complete the study were
unwell, uncontactable, or reported being too fatigued to complete the repeated measures.
The high retention rate in both groups was maintained because all patients returned to the
clinics every 4 to 12 weeks depending on their condition to have repeated blood tests,
obtain oral medications and to have their clinical tests reviewed by a renal medical
practitioner.

Assessed for eligibility
Enrollment
(n = 148) Excluded (n = 13)
 Not meeting inclusion
criteria (n = 11)
 Declined to participate
(n = 2)
 Other reasons (n = 0)
Randomised (n = 135)
Allocated to standard care Allocated to intervention

Allocation
group (n = 67) (n = 68)
 Receive allocated standard  Received allocated
care (n = 67) intervention (n = 68)
 Did not receive allocated  Did not receive allocated
standard care (n = 0) intervention (n = 0)
Lost to follow-up (n = 8) Follow up Lost to follow-up (n = 7)

 Commenced dialysis during  Commenced dialysis during the
the intervention (n = 3) intervention (n = 2)
 Did not complete the repeated  Did not complete the repeated
measures (n = 3) measures (n = 2)
 Not contactable (n = 2)  Not contactable (n = 3)
 Discontinued intervention (n = 0)
Analysed (n = 67) Analysed (n = 68)

Analysis
 Excluded from analysis (n = 0)  Excluded from analysis (n = 0)
Figure 5.2. Consolidated standards of reporting trials 2010 participant flow diagram.

5.4.2 Recruitment
Eligible participants were recruited from November 2015 until February 2016. All of the
participants were followed for 16 weeks. The study concluded in June 2016.
5.4.3 Baseline Data
Baseline socio-demographic characteristics
Baseline socio-demographic characteristics of the control group (n = 67) and the
intervention group (n = 68) are presented in Table 5.16. There was no significant
difference in gender (p = .07), although there were more females in the intervention group
and more males in in the control group. The average age of participants in the
intervention group was 48.8 years (SD = 13.7), which was similar to the control group (M
= 48.9, SD = 13.9). There were no significant differences in other socio-demographic
characteristics between the two groups at baseline (p > .05).

Table 5.16. Baseline Sociodemographic Characteristics
Characteristics Intervention Control
n = 68 n = 67 p
Age (years), M (SD) 48.8 (13.7) 48.9 (13.9) .97ª
Gender, n (%) .07ᵇ
Male 29 (42.6) 39 (58.2)
Female 39 (57.4) 28 (41.8)
Marital status, n (%) .17ᵇ
Married 54 (79.4) 59 (88.1)
Single/Divorced/Widowed 14 (20.6) 8 (11.9)
Education, n (%) .55ᵇ
Primary school 8 (11.7) 11 (16.4)
Secondary school 18 (26.5) 17 (25.4)
High school 24 (35.3) 17 (25.4)
College/ University 18 (26.5) 22 (32.8)
Occupation, n (%) .89ᵇ
High skilled jobs 17 (25.0) 15 (22.4)
Low skilled jobs 34 (50.0) 33 (49.2)
Retired/Unemployed 17 (25.0) 19 (28.4)
Insurance status, n (%) .61ᵇ
100% reimbursed 18 (26.4) 13 (19.4)
Partly reimbursed 42 (61.8) 46 (68.7)
Self-paid 8 (11.8) 8 (11.9)
Internet searching to understand about kidney problems, n (%) .67ᵇ
Yes 26 (38.2) 28 (41.8)
No 42 (61.8) 39 (58.2)
Individual income (million VND), Mdn (IQR) 4.00 (4.0) 3.50 (3.60) .96ᶜ
Family income (million VND), Mdn (IQR) 10.0 (9.16) 8.00 (10.0) .30ᶜ
Number of family members, Mdn (IQR) 3.00 (3.0) 3.00 (2.0) .63ᶜ
Note. N = 135; ªIndependent t–tests; ᵇChi-square test; ᶜMann-Whitney U test

Abbreviations: M, Mean; SD, Standard deviation; Mdn, Median; IQR, Interquartile range; VND, Viet Nam
Dong.

Baseline related renal characteristics
Related renal characteristics at baseline included stages of CKD, cause of CKD,
medication used, comorbidities, body mass index (BMI), and length of time diagnosed
with CKD. There were no significant differences in the renal characteristics between the
two groups of participants at baseline (p > .05) (see Table 5.17). Approximately 70% of
the participants in both groups were in stages 3B and 4. The most common cause of CKD
in both groups was glomerulonephritis. Diabetes and hypertension accounted only for
11.8% and 10.5% in the intervention group and control group, respectively. There were
similarities in the total numbers of medications used and length of time diagnosed with
CKD in both control and intervention groups.

Table 5.17. Baseline Related Renal Characteristics
Characteristics Intervention Control

n = 68 n = 67 p
CKD Stage (mL/min/1.73m²), n (%) .82ᵇ
Stage 3A (45−59) 13 (19.1) 13 (19.4)
Stage 3B (30−44) 22 (32.4) 26 (38.8)
Stage 4 (15−29) 24 (35.3) 19 (28.4)
Stage 5 (< 15) 9 (13.2) 9 (13.4)
CKD Cause, n (%) .60ᵇ
Diabetes and Hypertension 8 (11.8) 7 (10.5)
Glomerulonephritis 43 (63.2) 38 (56.7)
Others 17 (25.0) 22 (32.8)
Medications used, n (%) .92ᵇ
≤ 3 medications 14 (20.6) 12 (17.9)
4–5 medications 36 (52.9) 36 (53.7)
≥ 6 medications 18 (26.5) 19 (28.4)
Comorbidities, n (%) .30ᵇ
3 comorbidities 24 (35.3) 30 (44.8)
4 comorbidities 34 (50.0) 32 (47.8)
≥ 5 comorbidities 10 (14.7) 5 (7.4)
Time diagnosed with CKD (years), n (%) .47ᵇ
≤1 20 (29.4) 17 (25.4)
> 1–5 33 (48.5) 29 (43.3)
>5 15 (22.1) 21 (31.3)
BMI, M (SD) 22.02 (3.38) 21.50 (2.65) .33ª
Note. N = 135; ªIndependent t–tests; ᵇChi-square test
Abbreviation: M, Mean; SD, Standard deviation; BMI, body mass index.

Baseline renal clinical test results
Baseline renal clinical test results included BP, potassium, blood glucose level, and
sodium. There were no statistically significant differences between groups for eGFR
results, potassium, haemoglobin, systolic blood pressure (SBP), diastolic blood pressure
(DBP), urea, and sodium results. Only one significant difference was found, blood
glucose level, between the intervention and control groups (p < .05) (see Table 5.18).
Table 5.18. Baseline Renal Clinical Test Results
Clinical Tests Intervention Control
n = 68 n = 67 p
eGFR (mL/min/1.73m²), M (SD) 30.62 (14.44) 31.30 (14.27) .79ª
Potassium (mmol/L), M (SD) 4.40 (0.52) 4.34 (0.64) .61ª
Haemoglobin (g/L), M (SD) 120.19 (20.02) 117.88 (16.95) .48ª
Blood pressure (mmHg)
Systolic Blood Pressure, M (SD) 128.28 (19.78) 129.46 (17.37) .71ª
Diastolic Blood Pressure, M (SD) 80.88 (10.51) 82.16 (11.52) .50ª
Urea (mmol/L), M (SD) 13.62 (7.21) 13.48 (7.28) .91ª
Blood glucose (mmol/L), Mdn (IQR) 5.40 (0.90) 5.15 (0.57) .02ᶜ*
Sodium (mmol/L), Mdn (IQR) 137.0 (3.0) 138.0 (3.0) .77ᶜ
Note. N = 135; ªIndependent t–tests; ᶜ Mann-Whitney U test,

*Significant at p < .05
Abbreviations: M, Mean; SD, Standard deviation; Mdn, Median; IQR, Interquartile range; eGFR, estimated
glomerular filtration rate.

Baseline characteristics of participants lost to follow-up
In total, 120 participants completed the entire study. Of the 15 who did not complete the
study (see Figure 5.2), there were no statistically significant differences between those
who dropped out and those who were followed until the end of the study time (see Table
5.19). An intention-to-treat analysis was used in this study, which involved all
participants who were randomly assigned.

Table 5.19. Baseline Characteristics of Participants Lost to Follow-Up
Characteristics Follow-up Drop-out
n = 120 n = 15 p
Age (years), M (SD) 49.0 (14.1) 48.0 (11.6) .79ª
Gender, n (%) .43ᵇ
Male 59 (49.2) 9 (60.0)
Female 61 (50.8) 6 (40.0)
Marital status, n (%) .27ᵈ
Married 102 (85.0) 11 (73.3)
Single/Divorced/Widowed 18 (15.0) 4 (26.7)
Education, n (%) .59ᵈ
Lower high school 47 (39.2) 7 (40.0)
High school and above 73 (60.8) 8 (60.0)
Occupation, n (%) .54ᵈ
Working status 89 (74.2) 10 (66.7)
Not working status 31 (25.8) 5 (33.3)
Health insurance status, n (%) .69ᵈ
Yes 106 (88.3) 13 (86.7)
No 14 (11.7) 2 (13.3)
Internet searching to understand about kidney problems, n (%) .58ᵇ
Yes 47 (39.2) 7 (46.7)
No 73 (60.8) 8 (53.3)
Note. N = 135; ªIndependent t–tests; ᵇChi-square test; ᵈ Fisher’s exact test

Abbreviation: M, Mean; SD, Standard deviation.

Instrument reliability at baseline
The Kuder-Richardson-20 (KR-20) and Cronbach’s alpha were used to analyse the
internal consistency of the V.KiKS, V.CKD-SM, V.SECD, and HRQoL (V.SF-36v2).
The Kuder-Richardson-20 of the V.KiKS was .57. The Cronbach’s alphas of the V.CKD-
SM and V.SECDS were .87 and .92. The Cronbach’s alphas of the HRQoL domains
ranged from .64 to .92 (see Table 5.20).
Table 5.20. Baseline Internal Reliability for Instrument Variables and Subscale Variables
Variables Subscale KR20 Cronbach’s α
V.KiKS .57
V.CKD-SM .87
V.SECD .92
V.SF-36v2
Physical health component summary .85
Physical functioning .86
Role physical .92
Bodily pain .89
General health .64
Mental health component summary .87
Vitality .72
Social functioning .81
Role emotional .91
Mental health .82
Note. N = 135
Abbreviations: KR20, Kuder-Richardson-20; Cronbach’s α, Cronbach’s alpha; V.KiKS, Vietnamese
Kidney disease knowledge; V.CKD-SM, Vietnamese Chronic kidney disease self-management; V.SECD,
Vietnamese Self-efficacy for managing chronic disease; V.SF-36v2, Health-related quality of life.

5.4.4 Test of Normality Continuous Variables
Continuous variables at baseline and outcome variables at each time point were tested for
a normal distribution. From a visual inspection of the histograms, normal Q-Q plots, and
box plots (see Appendix 33), the outcome variable scores at each time point were
approximately normally distributed with mean, median, standard deviation, skewness,
and kurtosis values (see Appendix 34). The other continuous variables (except for
individual income, family income, time diagnosed with CKD, blood glucose, and sodium
variables) at baseline were also approximately normally distributed, with mean, median,
standard deviation, skewness, and kurtosis values for each variable (see Appendix 34).
5.4.5 Baseline Associations between Socio-Demographic and Primary Outcomes
Independent t–tests and one-way ANOVAs were used to examine the association of
socio-demographic characteristics and the primary outcome variables including
knowledge (V.KiKS) and self-management behaviour (V.CKD-SM). The results of each
primary outcome variable are presented in Table 5.21.
Knowledge
The mean knowledge score was significantly associated with education, occupation, and
internet searching (p ≤ .01). Participants who completed high school or above (M = 18.74,
SD = 2.79) scored higher for knowledge than those with lower high school education
qualifications (M = 16.91, SD = 3.13). Regarding participant occupation, Levene’s test
revealed that the variances of the three occupation groups were not equal (p < .05). The
Welch and Brown-Forsythe tests indicated that at least one occupation group had
significant differences in the mean score of knowledge (p < .05). Post-hoc comparisons
using Tamhane’s test confirmed that the mean score for participants with high skilled jobs

was 1.92 points (95% CI = 0.43, 3.41) significantly higher than that of those with lower
skilled jobs (Tamhane’s test, p < .05), and only 0.86 points (95% CI = -0.67, 2.38) higher
than those with unemployed or retired participants, but no significant difference was
found (Tamhane’s test, p > .05). Participants or family members who did internet
searching to understand kidney problems (M = 19.09, SD = 2.84) were seen to have
significantly higher knowledge than those who did not (M = 17.28, SD = 2.99).
The mean self-management behaviour score was significantly associated with a number
of variables, including education, occupation, and internet searching on kidney problems.
Participants who completed high school or above (M = 88.32, SD = 14.83) reported
higher self-management scores than those with lower high school education qualifications
(M = 79.04, SD = 14.05). There was a statistically significant difference at the p < .01
level in self-management scores for the three occupation groups: F(2, 132) = 6.50, p =
.002. Participants with highly skilled jobs (M = 91.06, SD = 13.06) were significantly
different from those with lower skilled jobs (M = 80.30, SD = 14.77), p < .01, while the
unemployed group (M = 86.89, SD = 15.50) did not differ significantly from either of the
other groups (p > .05). Participants or family members of those who did internet
searching (M = 90.43, SD = 13.32) were significantly different from those who did not (M
= 80.73, SD = 15.17), p < .01.

Table 5.21. Baseline Association of Socio-demographic Characteristics on Primary Outcomes Variables
Variables Categories n Knowledge Self-management
Age (years) 18–39 36 17.67 ± 3.16 84.75 ± 14.54
40–59 62 18.11 ± 3.32 83.73 ± 15.61
≥ 60 37 18.16 ± 2.50 85.85 ± 15.33
Gender Male 68 17.88 ± 3.32 83.63 ± 17.02
Female 67 18.13 ± 2.78 85.60 ± 13.10
Marital status Married 113 18.18 ± 2.98 85.31 ± 14.84
Single/divorce/widow 22 17.14 ± 3.34 81.00 ± 16.69
Education Upper high school 81 18.74 ± 2.79 88.32 ± 14.83

** **
Lower high school 54 16.91 ± 3.13 79.04 ± 14.05
Occupation High skilled jobs 32 19.19 ± 2.58 91.06 ± 13.06

** **
Low skilled jobs 67 17.27 ± 3.33 80.30 ± 14.77
Unemployed/Retired 36 18.33 ± 2.54 86.89 ± 15.50
Individual income (million VND) <3 44 17.55 ± 3.34 83.34 ± 15.10
3–6 51 18.41 ± 2.80 85.29 ± 15.64
≥6 40 18.00 ± 3.05 85.13 ± 14.95
Family income (million VND) <6 39 17.62 ± 3.51 82.05 ± 15.13

Variables Categories n Knowledge Self-management
6–9 25 18.56 ± 2.62 81.96 ± 14.07
≥9 71 18.03 ± 2.94 86.94 ± 15.40
Insurance status 100% reimbursed 31 18.06 ± 3.18 89.03 ± 13.18
Partly reimbursed 88 18.20 ± 2.97 83.75 ± 15.66
Self-paid 16 16.81 ± 3.19 80.75 ± 15.05
Family size (people) ≤2 53 18.13 ± 3.07 84.34 ± 13.96
3–4 62 17.68 ± 3.20 82.76 ± 16.26
≥5 20 18.70 ± 2.49 91.05 ± 13.66
Internet searching Yes 54 19.09 ± 2.84 90.43 ± 13.32

** **
No 81 17.28 ± 2.99 80.73 ± 15.17
Note. N = 135; ** p < .01; Value are M ± SD

Abbreviations: VND, Viet Nam Dong

5.4.6 Effect of the Self-Management Program on Outcome Variables
The effectiveness of the intervention program was assessed using linear mixed models to
examine the change in participant outcomes over time, between groups, and group × time
interaction. The outcome variables included primary and secondary outcomes. Primary
outcomes were knowledge and self-management behaviour; secondary outcomes were
self-efficacy, health-related quality of life, and blood pressure control. The linear mixed
models accounted every data point and all participant responses were included in the data
analysis at each time point to perform final study findings. Following the CONSORT
2010 guidelines (see Figure 5.2), data from 67 participants in the control group and 68 in
the intervention group were used to analyse the outcomes of the study. The effectiveness
of the self-management intervention program on each outcome variable is presented
below.
Primary outcomes
The primary outcomes were knowledge and self-management behaviour.
Knowledge
Overall, the fixed effects results from the linear mixed models revealed that participants’
knowledge in the intervention group significantly improved over time compared to those
in the control group (F = 226.89, p < .001). The treatment effects of time and group on
knowledge were also significant with ps < .01. The effect size of the overall intervention
on knowledge was large with Cohen’s d = 2.86.
The post-hoc test illustrated that the effect of the self-management program on
participants’ knowledge in both intervention and control groups. At baseline, there was no

difference in mean scores for knowledge between the intervention and control groups.
The mean scores for knowledge in the control group were remained stable, while
increasing in the intervention group over time. There was a large improvement in mean
scores for knowledge of 5.71 (95% CI = 4.80, 6.62) after 8 weeks among participants in
the intervention group compared to those in the control group. At the study completion,
week 16, the mean scores for knowledge of participants who received the intervention
sustained improvement to 7.43 (95% CI = 6.50, 8.36) compared to those in the control
group (see Table 5.23).
The average score differences in knowledge subgroups between the two groups at weeks
8 and 16 were significant (ps < .001) (see Table 5.22). The major improvement of
knowledge in the intervention group related to kidney symptoms and other understanding
related to kidney knowledge, such as eGFR, medication, and kidney treatment. These
results indicated that receiving the self-management intervention program demonstrated
significant improvement in participants’ knowledge (see Figure 5.3).

28
C o n tr o l
In ter v e n tio n
K n o w le d g e s c o r e
21
14
0
0 8 16
T im e (w e e k s )
Figure 5.3. Mean [95% CI] of knowledge scores over time for the control and
intervention groups.
Note. CI, Confidence interval.

Table 5.22. Mean Scores of Knowledge Subgroups between two Groups at Each Time Point
Subgroups Time Control (n = 67) Intervention (n = 68)
M SD M SD p
Kidney functions T0 6.48 1.06 6.38 1.25 .63

(9 items)
T1 6.24 1.43 7.32 1.47 < .001
T2 5.67 2.36 7.21 2.53 < .001

Knowledge
Kidney symptoms T0 6.06 1.77 5.97 1.89 .78
(10 items)
T1 5.96 2.01 8.06 2.01 < .001
T2 5.49 2.57 7.74 2.91 < .001
Other kidney-related T0 5.63 1.40 5.50 1.33 < .59

knowledge (9 items)
T1 5.46 1.52 7.81 1.62 < .001
T2 4.97 2.11 7.93 2.74 < .001
Note. N = 135.
Abbreviations: M, Mean; SD, Standard deviation; T0, baseline; T1, 8 weeks follow up; T2, 16 weeks follow up

Overall, the fixed effects results from the linear mixed models illustrated that
participants’ self-management behaviour in the intervention group significantly improved
over time compared to their counterparts in the control group (F = 178.84, p < .001). The
treatment effects of time and group on self-management behaviour were significant (ps <
.01). The effect size of the overall treatment effects on self-management behaviour was
large with Cohen’s d = 1.25.
At baseline, the mean scores of participants’ self-management behaviour from both
groups were similar. There was a large improvement in mean scores for self-management
to 12.44 (95% CI = 7.48, 17.40) at week 8 in the intervention group compared to the
control group, a further improvement of 18.13 (95% CI = 13.14, 23.11) after 16 weeks
when the completed (see Table 5.23 and Figure 5.4). These results indicated the positive
effect of the intervention program in improving participants’ self-management behaviour.
Regarding each subscale of the V.CKD-SM, participants in the control group had slightly
higher mean scores on the adherence to recommended regimen subscale than those in the
intervention group at baseline, while no significant differences were found between
groups in other subscales, including self-integration, problem-solving, and seeking social
support. Over time, mean scores of the four subscales of the V.CKD-SM in the
intervention group were significantly higher compared to the control group at weeks 8
and 16, ps < .05 (see Table 5.24).

130
C o n tr o l
S elf-m a n a g e m e n t sc o r e
120
In ter v e n tio n
110
100
90
80
70
0
0 8 16
Figure 5.4. Mean [95% CI] self-management scores over time for the control and

Table 5.23. Comparison of Primary Outcomes Variables at Each Time Point Showing Post-hoc Test for Control and Intervention Groups
Variables M (SD)
Control (n = 67) Intervention (n = 68) Mean difference [95% CI]
T0 T1 T2 T0 T1 T2 ∆T0-∆T1 ∆T0-∆T2
Knowledge 18.16 (3.00) 18.23 (2.81) 18.26 (2.68) 17.85 (3.12) 23.94 (2.14) 25.69 (1.69) 5.71 [4.80, 6.62] 7.43 [6.50, 8.36]
Self- 84.93 (15.92) 84.71 (15.68) 84.62 (15.36) 84.29 (14.51) 97.15 (13.93) 102.74 (11.41) 12.44 [7.48, 17.40] 18.13 [13.14, 23.11]
management
Note. N = 135; mean difference [95% CI] differs significantly from control group.
Abbreviations: M, Mean, SD, Standard deviation; CI, Confidence interval; T0, baseline; T1, 8 weeks follow up; T2, 16 weeks follow up; ∆T0-∆T1, Mean difference at 8
weeks follow up; ∆T0-∆T2, Mean difference at 16 weeks follow up.

Table 5.24. Mean Scores of Self-management Subscales between two Groups at Each Time Point
Subscales Time Control (n = 67) Intervention (n = 68)
M SD M SD p
Self-integration T0 33.54 5.94 32.26 6.46 .24

(11 items)
T1 32.32 6.84 35.82 7.97 .01
T2 33.69 6.05 39.84 3.87 < .001

V.CKDSM
Problem-solving T0 24.81 7.82 25.87 6.69 .39
(11 items)
T1 24.08 8.39 28.90 8.25 .01
T2 23.85 6.63 29.97 6.01 < .001
Seeking social support T0 11.04 3.85 11.76 4.07 .29

(5 items)
T1 10.97 3.60 13.10 4.13 < .01
T2 12.08 3.40 14.30 2.90 < .001
Adherence to T0 15.54 2.63 14.40 2.88 .02

recommended regimen
T1 14.89 3.53 16.22 3.51 .03
(5 items)
T2 16.10 2.56 18.15 1.56 < .001
Note. N = 135.
Abbreviations: M, Mean, SD, Standard deviation; V.CKD-SM, Vietnamese Chronic kidney disease self-management instrument; T0, baseline; T1, 8 weeks follow up;
T2, 16 weeks follow up.

Secondary outcomes
Similar mixed models were used to examine the change in participants’ self-efficacy,
health-related quality of life, and blood pressure control over time, between groups, and
group × time interaction.
Self-efficacy
Overall, the fixed effects results indicated that self-efficacy of participants who received
the intervention was significantly increased over time compared to those who did not (F =
40.81, p < .001) and a large effect size of this treatment was found (d = 0.96). The
treatment effects of time and group on self-efficacy were significant (ps < .01). Table
5.25 and Figure 5.5 present the comparisons of self-efficacy mean scores between the
intervention and control groups at three time points, including baseline, weeks 8 and 16.
The mean scores of the self-efficacy in the control group were unchanged over weeks 8
and 16, while they were significantly increased in the intervention group. The mean
difference of participants’ self-efficacy between the two groups at weeks 8 and 16 were
1.02 (95% CI = 0.49, 1.55) and 1.43 (95% CI = 0.90, 1.96), respectively.

10
C o n tr o l
9
S e lf-e ffic a c y s c o r e
In ter v e n tio n
0
0 8 16
T im e (w e e k s )
Figure 5.5. Mean [95% CI] self-efficacy scores over time for the control and intervention
groups.
Table 5.25, Figures 5.6 and 5.7 present the comparisons of the two components summary
mean scores of HRQoL, including the physical health component summary (PCS) and
mental health component summary (MCS) between the intervention and control groups at
baseline and at the study completion. Participants who received the education program
improved their PCS and MCS when the study was completed compared to those with
usual care (ps < .05).
The fixed effects indicated that the overall treatment effects of group × time interaction
on the MCS was significant (F = 4.27, p < .05), while the PCS was not significant (F =
2.07, p = .15). The treatment effects of time and group on PCS were significant with F =
15.51, p < .001 and F = 4.01, p < .05, respectively. On the other hand, the effects of time
and group on MCS were not significant with ps > .05.

The mean difference scores of the PCS and MCS at week 16 between the intervention and
control group were 6.91 (95% CI = 1.22, 12.60) and 7.83 (95% CI = 1.88, 13.78),
respectively.
100
C o n tr o l
90
In ter v e n tio n
P C S sco re
80
70
60
50
0
0 16
T im e (w e e k s )
Figure 5.6. Mean [95% CI] PCS scores at baseline and week 16 for the control and
Note. PCS, Physical health component summary; CI. Confidence interval.

100
C o n tr o l
90
In ter v e n tio n
M C S score
80
70
60
50
0
0 16
T im e (w e e k s )
Figure 5.7. Mean [95% CI] MCS scores at baseline and week 16 for the control and
Note. MCS, Mental health component summary; CI. Confidence interval.
Blood pressure control
Comparison of results for systolic blood pressure (SBP) and diastolic blood pressure
(DBP) between the intervention and control groups are presented in Table 5.25, Figures
5.8 and 5.9. Participants in the intervention group had better SBP and DBP control
compared with participants in the control group, although it was not statistically
significant (p > .05). The fixed effects indicated that the overall treatment effects of group
× time interaction on SBP and DBP were not significant with ps > .05. The treatment
effects of time and group on SBP and DBP were also not significant (ps > .05).

150
C o n tr o l
140 In ter v e n tio n

S B P (m m H g )
130
120
110
0
0 16
T im e (w e e k s )
Figure 5.8. Mean [95% CI] SBP at baseline and week 16 for the control and intervention
groups.
Note. SBP, Systolic blood pressure; CI, Confidence interval.
100
C o n tr o l
In ter v e n tio n
D B P (m m H g )
90
80
70
0
0 16
T im e (w e e k s )
Figure 5.9. Mean [95% CI] DBP at baseline and week 16 for the control and intervention
groups.
Note. DBP, Diastolic blood pressure; CI, Confidence interval

Table 5.25. Comparison of Secondary Outcome Variables at Each Time Point Showing Post-hoc Test for Control and Intervention Groups
Variables M (SD)
Control (n = 67) Intervention (n = 68) Mean difference [95% CI]
T0 T1 T2 T0 T1 T2 ∆T0-∆T1 ∆T0-∆T2
Self-efficacy 6.14 (1.47) 6.12 (1.49) 6.17 (1.47) 6.53 (1.86) 7.14 (1.57) 7.60 (1.40) 1.02 [0.49, 1.55] 1.43 [0.90, 1.96]
PCS 62.52 (17.33) — 66.99 (15.39) 64.28 (16.65) — 73.90 (13.47) — 6.91 [1.22, 12.60]
MCS 68.17 (18.71) — 70.19 (14.66) 67.12 (19.12) — 78.01 (12.08) — 7.83 [1.88, 13.78]
SBP 129.46 (17.36) — 132.05 (14.15) 128.28 (19.77) — 127.57 (15.33) — 4.48 [-1.54, 10.49]
DBP 82.16 (11.52) — 81.85 (10.14) 80.88 (10.50) — 79.69 (9.87) — 2.16 [-1.59, 5.92]
Note. N = 135; mean difference [95% CI] differs significantly from control group.
Abbreviations: M, Mean; SD, Standard deviation; PCS, Physical health component summary; MCS, Mental health component summary; SBP, Systolic blood pressure;
DBP, Diastolic blood pressure; CI, Confidence interval; T0, baseline; T1, 8 weeks follow up; T2, 16 weeks follow up; ∆T0-∆T1, Mean difference at 8 weeks follow up;
∆T0-∆T2, Mean difference at 16 weeks follow up.

5.4.7 Ancillary Analyses
The results of Phase 2 suggested socio-demographic variables, including age, gender,
education, occupation, and individual income, could be confounding variables. Thus,
models were adjusted for the purpose of sub-group analysis to examine these
abovementioned variables as well as other related variables for Phase 3. These variables
were internet searching, marital status, family income, and health insurance, which might
have contributed to improvements in the primary outcomes. The findings from the
adjusted models are presented below.
Knowledge
All of these variables were individually included into the model of knowledge; however,
the fixed effects results from the linear mixed models revealed that no significant change
in the mean scores of knowledge were found for age, gender, marital status, individual
and family incomes, or health insurance (ps > .05). On the other hand, the fixed effects
results from the models indicated there were significant changes in the mean scores of
knowledge for education, occupation, and internet searching (ps < .05). However, the
change from unadjusted knowledge mean scores and adjusted knowledge mean scores
was very small [less than 10%; Braga, Farrokhyar, and Bhandari (2012)]; therefore, this
suggests that these abovementioned variables were not confounding variables in
knowledge found in this pRCT (see Table 5.26).

Table 5.26. Comparison of Knowledge Mean Scores between Unadjusted and Adjusted Baseline Socio-demographic Variables in the
Intervention Group
M (SEM)
Knowledge ∆⃰
Unadjusted Models Adjusted Models
T0 T1 T2 T0 T1 T2 ∆T0-∆T1 ∆T0-∆T2
Education 18.09 (0.33) 24.11 (0.33) 25.74 (0.35) -0.17 -0.05

17.85 (0.32) 23.94 (0.33) 25.69 (0.33)
Occupation 18.19 (0.32) 24.24 (0.33) 25.85 (0.34) -0.30 -0.16
Internet searching 17.97 (0.32) 24.02 (0.32) 25.65 (0.34) -0.08 0.04
Note. ∆ ⃰ , Change value of knowledge mean scores in the intervention group from unadjusted and adjusted baseline socio-demographic variables (%).
Abbreviations: M, Mean; SEM, Standard error of the mean; T0, baseline; T1, 8 weeks follow up; T2, 16 weeks follow up; ∆T0-∆T1, Change at 8 weeks follow up; ∆T0-∆T2,
Change at 16 weeks follow up.

The above-mentioned variables, age, gender, education, occupation, individual and
family incomes, internet searching, marital status, and health insurance, were individually
adjusted to the model to examine whether these variables affected the improvement of
self-management. However, the fixed-effects results from the linear mixed models
showed no significant change in mean scores of self-management for age, individual and
family incomes, ps > .05. By contrast, the models showed significant change in mean
scores of self-management for gender, education, occupation, internet searching, marital
status, and health insurance, ps < .05. However, the change from unadjusted mean scores
of self-management and adjusted mean scores of self-management was very small [less
than 10%; Braga et al. (2012)]; therefore, this suggests that these above-mentioned
variables were not confounding variables of the results in the pRCT (see Table 5.27).

Table 5.27. Comparison of Self-management Mean Scores between Unadjusted and Adjusted Baseline Socio-demographic Variables in the
Intervention Group
M (SEM)
Self-management ∆⃰
Unadjusted Models Adjusted Models
T0 T1 T2 T0 T1 T2 ∆T0-∆T1 ∆T0-∆T2
Gender 84.04 (1.76) 96.69 (1.79) 101.94 (1.86) 0.46 0.80
Marital status 82.03 (2.19) 94.47 (2.22) 99.69 (2.28) 2.68 3.05
Education 86.50 (1.73) 99.17 (1.76) 104.88 (1.83) -2.02 -2.14

84.29 (1.77) 97.15 (1.77) 102.74 (1.78)
Occupation 86.29 (1.77) 98.95 (1.80) 104.40 (1.87) -1.80 -1.66
Health insurance 82.51 (1.96) 95.13 (1.98) 100.53 (2.04) 2.02 2.21
Internet searching 85.33 (1.70) 97.96 (1.72) 103.61 (1.80) -0.81 -0.87
Note. ∆ ⃰ , Change value of self-management behaviour mean scores in the intervention group from unadjusted and adjusted baseline socio-demographic variables (%).
Abbreviations: M, Mean; SEM, Standard error of the mean; T0, baseline; T1, 8 weeks follow up; T2, 16 weeks follow up; ∆T0-∆T1, Change at 8 weeks follow up; ∆T0-∆T2,
Change at 16 weeks follow up.

5.4.8 Participant Evaluation of the Self-Management Program
An evaluation form was provided to participants in the intervention group at week 16
when the study completed (see Appendix 26). All participants reported they would
recommend the CKD self-management program to others. Almost all participants (90%)
agreed that the teaching strategies, including the CKD booklet, face-to-face session, and
phone calls, helped them in managing their disease. About 95% of them also agreed that
the booklet was easy to read and understand. All participants agreed that doctors (renal
medical practitioners) and nurses should provide the self-management program. Twenty
percent of participants also provided some suggestions to improve the self-management
program. Their suggestions mainly focused on providing more detail in an eating plan
(example of three meals per day) and listing the recommended Vietnamese foods suitable
for those with CKD, hypertension and diabetes. Appendix 35 presents the results of the
participant evaluation.
5.4.9 Harms
All of the participants in this study received the same care and treatment from nurses and
renal medical practitioners at the renal clinics. Participants who were randomly assigned
to the intervention group received the additional self-management program. Moreover,
participation in this study was optional. There were minimal risks associated with
participation in this study. For those in the control group, there was the potential for
emotional discomfort due to the time to complete the outcome measures at the clinic or
via telephone calls. Those in the intervention group also might experience emotional
discomfort due to the time to complete the outcome measures and also during the self-
management education session. All risks were minimised as much as possible as
participants were invited to take part in the study at a time convenient for them. In

addition, they could choose to withdraw from the study at any time, and they could seek
assistance from nurses or medical practitioners at the renal clinics in Bach Mai Hosptial.
At the conclusion of the study, the control group participants were provided with the
CKD booklet.
5.5 Chapter Summary
This chapter presented the findings from all three phases of the study. Phase 1 involved
translating and validating the two instruments in Vietnamese. There were initially some
problematic words and phrases, but these were resolved prior to testing. Phase 2 involved
testing both instruments in a sample of 158 people with CKD. One to two weeks later, 52
people completed both instruments again. Satisfactory reliability was established and
these instruments were used to measure CKD knowledge and self-management behaviour
in Phase 3. This last phase was a pRCT of a self-management program delivered to
people with CKD (stages 3–5) in Vietnam. The findings of the trial indicated significant
improvements in knowledge, self-management behaviour, self-efficacy, and health-
related quality of life domains among those in the intervention group compared to those
in the control group. However, there was not a signficant improvement in BP. The study
findings are discussed in the next chapter.

Chapter 6: Discussion
6.1 Introduction
The present study, conducted in three phases, was designed to examine the effectiveness
of an intervention program in improving knowledge and self-management behaviour
among people with CKD stages 3–5 in Vietnam. The goal of the first phase was to
translate and validate the kidney disease knowledge survey (KiKS) and the chronic
kidney disease self-management (CKD-SM) instrument. The goal of Phase 2 was to
conduct a test/retest of these instruments for psychometric testing. This phase was to
ensure that both instruments were valid and reliable to measure the primary outcomes of
Phase 3. The primary aim of Phase 3 was to evaluate the self-management intervention
program for people with CKD in Vietnam, based on social cognitive theory (SCT).
The previous chapter presented the findings for each phase of the study. The purpose of
this chapter is to interpret and discuss the key findings in the light of existing literature.
This chapter first discusses how the study was guided by SCT and its application in the
Vietnamese context. Second, the results from Phases 1 and 2 are discussed. Then Phase 3
findings, which showed the effectiveness of the self-management intervention program to
improve knowledge and self-management behaviour, and previous research are
examined. Strengths, limitations, and implications together with the conclusions of this
study are presented in the final chapter.
6.2 Theoretical Framework
This is the first study to apply SCT as a framework to target a self-management
intervention program for people with CKD in Vietnam. The intervention of this study
Chapter 6: Discussion 183

focused on the key sources of information for self-efficacy, which is the core concept of
SCT. Bandura (1997) asserts that self-efficacy is an individual’s belief in their ability to
change behaviours; therefore, the stronger the level of self-efficacy, the more likely that
people will perform self-management behaviour. Therefore, the study’s intervention
targeted increasing people’s self-efficacy in their ability to competently self-manage
kidney disease.
6.2.1 Culture and Context
Social cognitive theory is a useful behavioural modification theory to improve self-
management in those with chronic diseases (Bandura, 2004a; Jang & Yoo, 2012).
However, the social factors of SCT have not been well translated into self-management
interventions which still largely focus on the individual’s beliefs. Although, SCT has
changed over time and now places more attention on the social environment and the
impact on individual behaviour decisions (Bandura, 2012), it still tends to view people as
individuals who have the power to take actions to produce certain health behaviours, with
little focus on family (Bandura, 1999). As a result, many self-management programs
ignore families in chronic disease management, such as chronic obstructive pulmonary
disease (Jonsdottir, 2013) and CKD (Welch et al., 2014).
Increasing evidence indicates the value of the family in encouraging and continuing
support in chronic disease self-management. For example, the role of the family in
providing support was reported in two recent systematic reviews, which showed that
involvement of family members as facilitators was beneficial in helping those with
chronic disease to maintain a positive approach to self-management, such as physical
activity, diet, and medication (Schulman-Green et al., 2016; Whitehead, Jacob, Towell,
Abu-Qamar, & Cole-Heath, 2017). People with higher family support levels, which can
184 Chapter 6: Discussion

lead to higher confidence levels, seem to have better disease management (Rosland et al.,
2008; Stamp et al., 2016; Wen, Parchman, & Shepherd, 2004). It could be because the
family provides extra support in caring for people with illness, particularly for those with
chronic disease and needing regular follow-up. For example, the family members provide
direct support to take their family member living with a chronic illness to have a health
assessment if they experience symptom exacerbation.
Many people with chronic disease engage in key tasks to manage their condition in a
family context, including eating, medication management, and treatment regimen. For
example, the family may be involved in providing further support for people with daily
activities to self-manage chronic illness (Whitehead et al., 2017) and reminding people to
take their medication (Flynn et al., 2013; Samuel-Hodge et al., 2000). This highlights that
self-management is not only an individual issue, but should be considered in the broader
family context, where the family is often involved in supporting and creating a good
environment that helps in maintaining everyday activities to manage CKD (Chen et al.,
2018). For example, families often provide support to their family member who has CKD
to eat the correct food and to take their medication. The support from family members is
an important aspect in each individual’s disease management; therefore, healthcare
providers should recognize this and include family members in self-management
education sessions (Thirsk & Clark, 2014).
Vietnamese culture is strongly influenced by familial relationships, and everyday
activities may be affected by the family’s culture and beliefs (Orzech, Vivian, Huebner
Torres, Armin, & Shaw, 2013). People tend to live with family and depend on family
members (Gordon, Bernadett, Evans, Shapiro, & Dang, 2009; Van, Duangpaeng, Deenan,
& Bonner, 2012). The family may be involved in healthcare decisions for hospitalised

family members, such as accompanying patients to hospital for treatment or regular
check-ups, paying for hospital treatment, providing food, and managing the patient’s
hygiene (Khuu, 1999; Nguyen, 1985; Van et al., 2012). Social activities in Vietnam tend
to revolve around shared meals. On the other hand, the family could be a barrier to
following a recommended diet (Orzech et al., 2013; Ramal, Petersen, Ingram, &
Champlin, 2012), or families might not understand how chronic illnesses and long-term
conditions may affect them (Peñarrieta et al., 2015). For example, a study exploring
barriers related to dietary adherence in people with chronic disease revealed that
Vietnamese participants mentioned their reluctance to offend family members or friends
who made or brought them foods that were not recommended by healthcare providers
(Orzech et al., 2013). In Vietnam, fish sauce is used often during food preparation or
cooking, which results in high sodium levels in food (Gordon et al., 2009; Nguyen, 2009).
People may therefore have difficulties in implementing the recommended dietary changes
because they affect the individual and the family in their daily lives.
As previously discussed in Chapter 2, Ong et al. (2013) indicated four behavioural
components in self-management of CKD, including food management, BP management,
blood result management, and medication management. However, each of these
components for CKD self-management is importantly shaped by culture and context,
particularly when applying it in Vietnam. Thus, this study intervention used culturally
relevant examples and materials, yet it was still grounded in an individual model of self-
management. Self-management intervention would likely be enhanced in the context of
Vietnam with greater attention to the social interdependence prevalent in Vietnamese
culture.

In this study, the emphasis of self-efficacy on improving self-management behaviour
among people with CKD was very successful. However, using SCT in a context such as
Vietnam requires more attention to be placed on cultural issues. This highlights the need
for considering family roles in supporting people with CKD, because individuals and
family are socially linked together in this context.
6.2.2 Mechanisms of Behaviour Change
As previously explained in Chapter 2, knowledge and self-efficacy are important skills
for self-management, including for those with CKD. Research indicates that information
sources including performance accomplishment, vicarious experience, verbal persuasion,
and self-appraisal are specific elements directed toward enhancement of self-efficacy
(Dougherty, Johnson-Crowley, Lewis, & Thompson, 2001; Sol, van der Bijl, Banga, &
Visseren, 2005). Knowledge also plays an important role in increasing self-efficacy in
people with chronic disease, because if people are not taught to understand their condition
they may be unwilling to adopt the necessary changes for better disease self-management.
Thus, the intervention of the current study aimed to improve knowledge and self-efficacy
through providing information sources to support people to better self-manage their
kidney disease. The four information sources were selected to guide the self-management
intervention program, and the combination of using these information sources could
enhance participants’ self-efficacy levels to better perform self-management behaviours.
Based on SCT (Bandura, 1986, 1997), performance accomplishment was used to assist
participants to identify their problems and set realistic personal goals to slow the
progression of CKD. Performance accomplishment was used in the face-to-face session
as participants were asked to identify one major problem or issue and to set up workable
personal self-management behaviour goals. This strategy was also used during the

follow-up phone calls at weeks 4 and 12. Participants used the CKD booklet at home to
record and monitor how well they had succeeded in achieving their goals at each follow-
up appointment. This strategy enabled participants to understand the signs and symptoms
of kidney disease, and promoted disease management to build the necessary skills and
behaviours to achieve their goals. A small realistic achievable goal for each participant
was reached at the first appointment follow-up; then they were asked to move to a second
goal and also maintain the first goal. However, adjusting goals needed to be accompanied
with positive feedback and encouragement if participants were unable to achieve the first
goal. The use of performance accomplishment was also reported in the face-to-face
sessions of the intervention study of Lin et al. (2013) although their intervention design
was based on self-regulation theory.
Vicarious experience was also used in both face-to-face education and phone call follow-
ups of the self-management intervention. This strategy requires participants to observe a
positive role model with similar issues performing a healthy behaviour (Bandura, 1986,
1997). Opportunities to observe others with CKD was limited in the clinic settings used in
this study, as previously explained in Chapter 3. In this study, two written scenarios of
people who managed their kidney problems well, together with images and pictures
provided in a CKD booklet, were used instead of a person. These scenarios involved
changing lifestyle and managing BP, which were used to assist participants to have an
overview of planning their tasks. Although, these scenarios were unable to cover
individual participant’s needs, they could help participants to visualise certain tasks
before making a health behaviour change. Two previous pre-dialysis CKD studies also
reported the use of vicarious experience in their intervention; however, one study used the
Health belief model theory to guide their intervention (Williams et al., 2012) and one
study used Self-regulation theory (Lin et al., 2013). These studies provided a video with

examples of people sharing their experiences and strategies of self-managing kidney
disease, such as taking medication and monitoring BP at home, so that people with CKD
could learn to better manage their disease.
Verbal persuasion was the most commonly used strategy in this study to enhance
participants’ self-efficacy. It was used in both the face-to-face session and two follow-up
phone calls. Verbal suggestions and encouragement were important components of the
self-management intervention. In this study, participants received further support and
encouragement via telephone follow-up, which assisted them to build their knowledge
and confidence to continue undertaking behaviour change. For example, some
participants listed their favourite foods and were then assisted to choose appropriate food
for CKD. Earlier studies also indicated that verbal encouragement and support were
important for telephone coaching to enhance efficacy in people with chronic diseases
(Carroll, Robinson, Buselli, Berry, & Rankin, 2001; Hiltunen et al., 2005). These studies
suggested the effect of using verbal persuasion in providing further support and
encouragement for people with chronic disease (Carroll et al., 2001; Hiltunen et al.,
2005). The use of verbal persuasion was reported in only one pre-dialysis CKD study
from the existing literature (Kazawa & Moriyama, 2013), which was developed based on
the National Standards for Diabetes Self-management Education. Verbal persuasion was
effective in improving participants’ self-efficacy in this study.
In this study’s intervention, self-appraisal was also used in the face-to-face session,
although it was used more frequently in the follow-up phone calls. Based on SCT
(Bandura, 1997; Lenz & Shortridge-Baggett, 2002), this strategy allowed participants to
express their concerns or difficulties in managing CKD, such as struggling with their diet,
barriers to medication adherence, or lack of motivation to exercise. In addition,

participants were encouraged to discuss their issues and list possible solutions to achieve
their goals easily. For example, assisting participants to write all of their medications in
the CKD booklet and put it on the dining table or in their favourite place helped them to
remember to take their medications. Therefore, self-appraisal was an important strategy
for building participants’ self-efficacy because saying and sharing how well they
performed their behaviours could assist to improve their confidence levels to continue
performing that self-management behaviour. Self-appraisal was also clearly used in one
study to encourage people with pre-dialysis CKD to express their emotions (Kazawa &
Moriyama, 2013). The use of self-appraisal encouraged them to express their feelings and
experiences of success, and nurses provided positive feedback, which helped to improve
their self-efficacy.
It should be noted in SCT that the four information sources are crucial to drive the self-
management program to improve self-efficacy levels (Bandura, 1986, 1997; Dougherty et
al., 2001; Sol et al., 2005). A systematic review assessed published findings of self-
management programs based on SCT and examined the effectiveness of applying SCT to
develop self-management programs to improve self-management behaviour of Korean
participants with chronic disease (Jang & Yoo, 2012). That review revealed that none of
the self-management programs in the review aimed to improve participants’ self-efficacy
by using all of the four information sources that are crucial to SCT. Two studies, one in
diabetes in China (Ha et al., 2014) and the other in cardiac disease in the U.S. (Hiltunen et
al., 2005), described the use of all four information sources to enhance the level of self-
efficacy. Similar to these studies, performance accomplishment and verbal persuasion
were the two main strategies used during this current study. The four information sources
were integrated into the CKD self-management program during the face-to-face session
and phone call follow-ups across the 16-week study period. The current study findings

revealed several positive outcomes of using SCT to guide the self-management
intervention to support participants with CKD; therefore, healthcare services should
enable self-management programs in order to help patients to improve their kidney
disease self-management.
The current study intervention was driven by SCT, and instrument developments were
required to measure the core concepts of the theory in the Vietnamese context. Therefore,
the translation and validation of the kidney disease knowledge survey (KiKS) and the
chronic kidney disease self-management (CKD-SM) instrument (Phase 1) was
undertaken. Testing these instruments (Phase 2) allowed the researcher to target the
measurement of the primary outcomes of the self-management intervention (Phase 3).
6.3 Phase One: Translation and Validation of Instruments
Prior to undertaking the main study (Phase 3), a robust process of translation and
validation of the primary outcome measures was completed. Two instruments were
selected to measure the primary outcomes of the main study, including the KiKS to
measure knowledge and the CKD-SM to measure self-management behaviour. First,
forward and back-translation of both instruments was undertaken using four bilingual
Vietnamese nurse academics. The translated instruments were then assessed by 10
experts for content face validity (S-CVI/Ave).
The translation process of the study instruments rigorously adhered to the guidelines from
Sousa and Rojjanasrirat (2011), which involved four steps and was clearly presented in
Chapter 4 (see Figure 4.2). No major problems were identified regarding the process of
forward and back-translation. However, linguistic adaptation was noticed through the
translation process of these instruments. It was mainly about different word choices in
everyday life rather than using more formal words in an academic format; therefore, a

few words were amended and few examples also added. These changes are likely due to
cultural differences having a different way of expressing a concept.
The expert panel evaluated the clarity and assessed the content face validity of the
Vietnamese versions of the KiKS and CKD-SM instruments. Among these members, one
renal medical practitioner (nephrologist) and two renal nurses were invited onto the panel
to validate these instruments because they had experience in caring for people with CKD
and were familiar with the language used in this field of healthcare. Inclusion of other
panel members who had differing experiences could provide a certain level of
understanding about chronic disease. The results of the validation of each instrument are
discussed below.
6.3.1 Vietnamese Kidney Disease Knowledge
A good validity of the V.KiKS was found when assessing the S-CVI/Ave of the expert
panel, which indicated that it had face validity to measure knowledge of participants with
CKD. The forward/back translation process revealed no differentiation between the
English and the Vietnamese versions although some linguistic adaptation was required.
Semantic changes in some items have also been necessary when translating the KiKS
from English into Spanish (Anaya, Wright-Nunes, & Mayta-Tristan, 2016). Similarly,
Abd Elhafeez et al. (2012) translated a kidney disease and quality of life survey from
English into Arabic, and also reported having to alter a few words or phrases to reflect
language used in everyday life. Although, the KiKS has been validated and tested before
in the U.S. (Wright et al., 2011), Peru (Anaya et al., 2016), and Australia (Wembenyui,
2017), it is also important to translate and validate it before using it in different linguistic
populations such as Vietnam. As there was no validated instrument to measure kidney
disease-specific knowledge in Vietnamese-speaking patients with CKD, the KiKS was

translated and validated in Vietnamese for the first time. In conclusion, the findings of
this phase demonstrated good content face validity of the V.KiKS before it underwent
further psychometric property testing in Phase 2 of this study.
6.3.2 Vietnamese Chronic Kidney Disease Self-Management
The CKD-SM was translated from English to Vietnamese and then validated using the
same methods as the KiKS. The forward and back-translation of the CKD-SM revealed a
minor difference in linguistic usage between the Vietnamese version and the original
version. For example, some minor grammatical changes were made, although these did
not change the meaning of the questions in the target version compared to the source
language. In addition, a few words were changed and examples were added to several
items to help explain how the specific activities were performed. Minor linguistic changes
have also been reported by others when translating self-management instruments [see for
example Xu, Savage, Toobert, Pan, and Whitmer (2008); Stacciarini and Pace (2014);
Kato, Ito, Kinugawa, and Kazuma (2008)]. This issue was also mentioned in previous
studies in Vietnam and other countries which involved a translation process of a self-care
instrument for people with heart failure (Ávila et al., 2013; Dinh, 2016; Siabani et al.,
2014) and diabetes (Dao-Tran, Anderson, Chang, Seib, & Hurst, 2016). The findings of
this phase indicated excellent content face validity for the V.CKD-SM which may have
been due to the selection of content experts (nephrologist and renal nurses). The expert
panel found the content could be readily understood; thus increasing likelihood that the
target population would also be able to understand and complete the instrument. The
V.CKD-SM was ready to conduct the test/retest reliability in Phase 2.

6.4 Phase Two: Psychometric Testing of Instruments
Phase 2 was the test/retest in 158 participants with CKD, and, of these, 52 participated in
the retest one to two weeks later. Discussion of the psychometric properties of the
V.KiKS and V.CKD-SM in this study, including internal consistency, test/retest
reliability (stability of the instruments), and feasibility of the instruments, is presented
below.
6.4.1 Vietnamese Kidney Disease Knowledge
The V.KiKS has been shown to be reliable and feasible in measuring knowledge in
participants with CKD in Vietnam. The Kuder-Richardson-20 (KR-20) value of the
V.KiKS was acceptable, even though it was lower than previous studies (Anaya et al.,
2016; Welch et al., 2016; Wembenyui, 2017; Wright et al., 2011). The lower internal
consistency result might have been influenced by the sample size during the testing
period or the variability of knowledge about kidney disease. For instance, some items of
the KiKS measured medical knowledge of kidney disease, which might be difficult for
participants to understand and answer. The intra-class correlation coefficient (ICC) value
of the V.KiKS was good indicating the stability of the instrument, meaning that
regardless of time, the responses from participants in the retest seemed to be reliable and
reproducible.
The mean score of the V.KiKS of this phase was similar to the study in Australia
(Wembenyui, 2017), but lower than the mean score found in the original study of the
KiKS (Wright et al., 2011). In general, this phase’s findings indicated that the majority of
participants did not understand some items well, such as item 4 regarding the selection of
one medication that they should avoid and item 28 relating to the absence of symptoms.
Lack of understanding about kidney disease identified in this phase seems to be consistent

with that of other research conducted in the U.S. (Johnson et al., 2016; Welch et al., 2016;
Wright et al., 2011), Australia (Enworom & Tabi, 2015; Gray, Kapojos, Burke,
Sammartino, & Clark, 2016; Wembenyui, 2017), Peru (Anaya et al., 2016), and Iran
(Qobadi, Besharat, Rostami, & Rahiminezhad, 2015). This phase found that Vietnamese
people had limited knowledge about CKD. This result may be explained by the fact that
in Vietnam healthcare providers (renal medical practitioners and nurses) provide very
little education to patients to help them understand kidney disease. It is also possible and
perhaps more likely that patients did not understand the information given by renal
medical practitioners, as other studies of CKD knowledge have found (Finkelstein et al.,
2008; Wright Nunes et al., 2011). This result is likely to be related to the limited health
materials available for people with CKD. Another possible explanation for this result may
be that participants had inadequate health literacy or the health materials had been written
at a high level of complexity; therefore, participants might have had difficulty in reading
and understanding the information presented.
Overall, the lack of kidney knowledge would not only affect the success of slowing the
progression of CKD, it could also affect the management of the disease. The findings
from this phase have practical implications for healthcare providers. There could be a gap
in communication between healthcare providers and people with CKD to help people
understand about kidney disease. This highlights the need to provide adequate education
support from healthcare providers for people with CKD, to improve people’s
understanding of kidney disease in order to achieve better self-management behaviour.
6.4.2 Vietnamese Chronic Kidney Disease Self-Management
This phase’s findings indicated that the V.CKD-SM was reliable and feasible to measure
self-management behaviour among people with CKD in Vietnam. The results revealed a

good Cronbach’s alpha value (internal consistency reliability), although these values were
slightly lower than the original version of Lin et al. (2012), but higher than the study of
Wembenyui (2017) in Australia. The intra-class correlation coefficient (ICC) of the
V.CKD-SM was higher than the acceptable level, which proved the good test/retest
reliability of this instrument. The Vietnamese version should have an equivalent meaning
with the original version, and some phrases in the V.CKD-SM were not clear or concise.
For this reason, examples demonstrating meaning were added to some items. For
example, the phrase ‘maintaining my overall health’ in item 20 was explained in more
detail, such as controlling weight, eating proper foods, and taking exercise. Another
phrase was ‘take steps’ in item 22, which needed to be explained as actions that a person
should do in order to achieve their goals, such as maintaining a healthy diet, controlling
blood pressure, and taking medication. This finding further highlights the need to
consider the expression of words and phrases used during the translation processes in
order to improve the comprehension of the target population.
The mean score of the V.CKD-SM of this phase was lower than the mean score found in
the original study of the CKD-SM (Lin et al., 2012) and the study in Australia
(Wembenyui, 2017). Overall, the results of this study revealed that some activities were
not well managed by participants. For example, participants rarely asked about reasons
for their worsening kidney function or asked renal medical practitioners or nurses to
clarify kidney treatment plans. Participants also rarely sought support from family,
friends, or significant others to cope with their disease. On the other hand, participants in
this study showed adequate abilities to incorporate treatment regimens and self-
management activities into daily life. For instance, they followed recommendations from
medical practitioners or nurses about smoking cessation, drinking, and diet. This phase’s

findings further highlight the need for providing self-management education programs
tailored to the needs of people with CKD.
In conclusion, this phase provides an acceptable level of psychometric properties of the
V.KiKS and V.CKD-SM instruments that could be used to measure knowledge and self-
management behaviour among people with CKD. In Vietnam, these are the first tools to
assess kidney disease-specific knowledge and self-management behaviour. The results
from this phase indicated that the V.KiKS and V.CKD-SM instruments were suitable for
use in Phase 3.
6.5 Phase Three: Effectiveness of a Chronic Kidney Disease Self-Management
Program
This study was a pRCT designed to address some of the gaps in the literature as
previously reviewed in Chapter 2. Developed using SCT, this self-management
intervention deliberately targeted patients with known CKD who were not yet receiving
dialysis when strategies could slow the progression of the disease. To the best of the
researcher’s knowledge, this study is the first pRCT to examine the effectiveness of a
theory-driven self-management intervention aimed at people with CKD stages 3–5 and
which measures patient-reported outcomes (knowledge, self-management behaviour, self-
efficacy and HRQoL) using valid and reliable instruments, and a clinical outcome (BP
control).
The effectiveness of the self-management intervention on the study outcomes are
consistent with SCT. The intervention group pattern of findings showed increases in
participants’ knowledge and self-efficacy, which translated into improved self-
management and HRQoL. Following this model, the intervention effects are discussed for

knowledge and self-efficacy, then self-management behaviour, HRQoL and finally BP
outcomes.
6.5.1 Knowledge
Knowledge is a precondition for behaviour change in people with CKD. While there have
been five systematic reviews in this area, only nine previous RCTs have been conducted.
Of these, only three measured knowledge (Blakeman et al., 2014; Chen et al., 2011; Teng
et al., 2013). Chen et al. (2011) and Teng et al. (2013) found improvement in participants’
knowledge in the intervention group, while this did not increase in the study of Blakeman
et al. (2014); however, three studies used three different instruments to measure
knowledge which have not been validated and used in people with pre-dialysis stages of
CKD. In this current study a valid and reliable instrument, pre-tested in the study
population, was used to measure knowledge. Therefore, comparison with previous RCTs
is limited.
This study demonstrated that those who received the self-management program had a
significantly better understanding of kidney disease compared to those in the control
group. While there are no established cut-off points in the KiKS, the improvement in
knowledge was assessed at two time points and compared with the baseline. Substantial
improvement in knowledge in the intervention group was seen at both week 8 and 16, but
not in the control group. Second, the effect size of this improvement was large (d = 2.86).
There are several potential reasons for the increase in participants’ knowledge in the
intervention group. First, the use of the Vietnamese language CKD booklet and a handout
that summarised the intervention topics during the face-to-face educational sessions
would provide valuable information about kidney disease, which was necessary to
improve participants’ knowledge. Second, the CKD booklet was translated and adapted

(with permission) from two handbooks, Living with Reduced Kidney Function (Kidney
Health Australia, 2008) and Living Well with Chronic Kidney Disease (American Kidney
Fund, 2010). These two handbooks are used in Australia and the U.S., and both are freely
available on their respective websites. Living Well with Chronic Kidney Disease was
produced by a kidney disease advocacy group and was one of the top five CKD patient
education materials (Tuot, Davis, Velasquez, Banerjee, & Powe, 2013). However, a
Vietnamese language version which had been contextualised for Vietnam was not
available, so this study developed this resource. In addition, almost all of the participants
(95%) in the intervention group of the recent study agreed that the CKD booklet was easy
to read and understand.
Third, the intervention program included reinforcement in education; that is, the
researcher repeated the information in the two follow-up phone calls, and allowed time to
discuss and answer individual questions. Reinforcement assisted participants in applying
their knowledge. Using telephone reinforcement in education has also been reported in
previous studies (Blakeman et al., 2014; Chen et al., 2011). On the other hand, a lack of
reinforcement in education might cause a decrease in disease knowledge (Teng et al.,
2013). It is possible that the telephone follow-ups for the intervention group reminded
participants of the main content of the CKD booklet and to use it, thus contributing to
improved knowledge.
Finally, as face-to-face education was mainly used to provide the self-management
program in this study, participants in the intervention could ask questions. As the
researcher was also a nurse, therefore this type of intervention could be delivered by a
nurse, which does seem to indicate that there is an important role for nurses in patient
education. However, a shift in Vietnamese cultural expectations that only the medical

practitioner is respected and listened to will need to change. What this study does also
seem to indicate is that CKD patients previously had not been educated effectively.
6.5.2 Self-Efficacy
The finding of this study revealed a significant improvement in the level of self-efficacy
in the intervention group compared to the control group. It is interesting to see the
effectiveness of the CKD self-management intervention program in improving self-
efficacy as early as 8 weeks post intervention, as well as at the end of the study period
(week 16). There were no cut-off points in the self-efficacy for managing chronic disease
6-item scale (SECDS); however, higher scores indicated greater levels of self-efficacy.
The intervention group’s self-efficacy increased by more than 10% at the completion of
the study period compared to baseline. The increase in self-efficacy levels in this study
has provided evidence to support the important role of the intervention program to
improve self-management behaviour for people with CKD.
The improvement in self-efficacy found in this study is consistent with a recent RCT
involving people with earlier stages of CKD in Japan (Joboshi & Oka, 2016), which also
found a significant improvement in self-efficacy in the intervention group compared to
the control group. Their findings indicated the effect size of their intervention was small
(r = 0.27), while the effect size of the improvement in self-efficacy of the current study
was large (d = 0.96). However, a direct comparison is not possible with Joboshi and Oka
(2016) because of differences in the use of theory-based techniques for measuring self-
efficacy and different time points from the current study.
There are several possible explanations for the increasing levels of self-efficacy in this
study. First, the four information sources were well integrated into the self-management
program, with the specific goal of assisting participants to develop the necessary skills to

improve their self-efficacy in performing self-management behaviours to manage their
kidney disease. Second, the intervention provided extra knowledge, which in turn
improved participants’ confidence in their capability to self-manage and resulted in them
being more willing to perform that behaviour. For example, previous research in CKD
has shown that those with greater self-efficacy are more likely to practise self-
management behaviours and have a better quality of life than those with lower self-
efficacy (Tsay & Healstead, 2002). Lastly, this study provided positive feedback to
participants in the intervention group through follow-up phone calls, which would have
assisted in increasing the belief in their ability to continue performing certain behaviours.
This finding also lends support to the role a nurse can have by following up patients with
CKD.
It is possible that knowledge is a prerequisite for changing behaviour to improve health
outcomes of people with CKD (Welch et al., 2016; Wu, Hsieh, Lin, & Tsai, 2016).
Participants who have a better understanding of kidney disease are likely to have more
confidence in managing their disease and to adhere to treatment plans. Understanding
kidney disease enables participants to bring that knowledge to practice, for example
participants are confident in reading food labels and selecting good foods with low salt
content when eating out. Enhancement of self-efficacy is necessary to improve self-
management behaviours in people with CKD (Joboshi & Oka, 2016). Therefore,
improving knowledge and confidence is important for engaging in self-management in
everyday life.
6.5.3 Self-Management Behaviour
The findings of this study showed that people who received the intervention had better
self-management behaviour than their counterparts in the control group. As no cut-off

point exists for the CKD-SM, the clinical significance of improvement in self-
management behaviour in the intervention group was considered using effect size. The
effect size of the improvement in self-management behaviour was large (d = 1.25).
The findings of the recent study are in agreement with those of previous research showing
that self-management programs and ongoing support are important for effective disease
management among people with chronic illnesses, particularly for those with CKD
(Bonner et al., 2014; Joboshi & Oka, 2016; Lee et al., 2016; Lin et al., 2017; Lopez-
Vargas et al., 2016; Welch et al., 2014). The current study was one of only three RCTs in
CKD stages 3–5 (Campbell et al., 2008; Chen et al., 2011; Joboshi & Oka, 2016),
although only Joboshi and Oka (2016) used models to guide the study intervention. It is
difficult to draw a conclusion that the improvement in self-management in either the
current study or that of Joboshi and Oka (2016) was due to the use of behaviour change
theories.
The significantly improved self-management behaviour observed in the current study was
consistent with the findings of two studies that used a self-management program to
support people with earlier stages of CKD in the U.K. (Blakeman et al., 2014) and in
Japan (Joboshi & Oka, 2016). Other four studies (Flesher et al., 2011; Paes-Barreto et al.,
2013; Teng et al., 2013; Williams et al., 2012) did measure self-management, however,
inconsistency was found in the study findings, as previously discussed in Chapter 2. Four
studies all observed change in self-management activities (Flesher et al., 2011), physical
activity (Teng et al., 2013), low-protein diet adherence (Paes-Barreto et al., 2013), BP
record adherence (Williams et al., 2012) in those who received the intervention program
compared to those who did not. However, these six studies did not use the CKD-SM

instrument to measure self-management behaviour and self-management was assessed at
different time points to the current study; direct comparison is therefore impossible.
There are several possible explanations for the improvement in self-management
behaviour among participants in the intervention group in the current study. First, the
effects of a theory-driven intervention program may contribute to the process of self-
management improvement in the intervention group due to the focus on increasing
knowledge. Second, assisting participants in understanding kidney disease was critically
important to enhance their confidence to successfully self-manage their condition.
Overall, understanding and adhering to SCT was key to demonstrating that self-
management behaviour could change, and this in turn improved HRQoL. The effect on
BP was, however, not demonstrated.
6.5.4 Health Related Quality of Life
Changes in HRQoL reflect how patients are able to self-manage CKD to achieve overall
well-being and it can serve as an important indicator to evaluate the effectiveness of self-
management interventions (Wyld, Chadban, & Morton, 2016). After 16 weeks, the
improvement in both the physical health component summary (PCS) and mental health
component summary (MCS) scores in this study indicates that the intervention group had
better HRQoL compared to the control group. This is an important finding as the
intervention has shown to be effective in improving patients’ confidence in taking dietary
change, exercise, and medication adherence to self-manage CKD and further reduce the
disease’s impact on their HRQoL. While no cut-off points existed for the PCS as well as
MCS, the higher scores in PCS and MCS indicated the participants’ improved HRQoL.
The intervention group showed an increase by 10% in PCS and 12% in MCS at week 16
when the study ended, compared to baseline. The improvement in PCS and MCS overall

scores in this study indicates that those who received the self-management intervention
had better HRQoL compared to those who did not.
The effect of the intervention on HRQoL observed in the current study is consistent with
previous studies that also implemented self-management education programs for people
with CKD stages 3–5 (Blakeman et al., 2014; Campbell et al., 2008). Campbell et al.
(2008) reported three components of HRQoL improved among those who received the
intervention as previously indicated in Chapter 2. Blakeman et al. (2014) only reported
the overall score of HRQoL (EQ-5D) and did not describe which subscales the instrument
covered. However, the current study used SF-36v2, which was not used in Campbell et al.
(2008) as well as Blakeman et al. (2014). Therefore, a direct comparison with these two
studies is not possible.
There are several possible reasons for the increased in HRQoL in those who received the
intervention program. First, it is possible that participants who received the self-
management support, such as changes in diet, exercise, and social activities, may have
changed their perceptions of HRQoL. It could be that during the intervention program,
participants learned and participated in their own self-management. Second, it is likely
that the follow-up phone calls provided more positive feedback and encouragement, so
their physical and mental health could improve as expected at the study completion. In
addition, the researcher encouraged the intervention group to set realistic goals for
lifestyle modifications. Therefore, it may be that these modifications improved
participants’ perceptions of their HRQoL.
Health-related quality of life is subjective and is influenced by a person’s beliefs, which
change over time (Abdel-Kader et al., 2009; Howard, Mattacola, Howell, & Lattermann,
2011; Schwartz, Andresen, Nosek, & Krahn, 2007). This change is termed response shift

(Fayers & Machin, 2016; Howard et al., 2011; Schwartz et al., 2007), and this occurs
when an individual with a chronic disease adapts to their illness and learns to cope with
their altered health state. As a disease such as CKD is often asymptomatic and has a long,
slow decline in renal function, people do adapt to this slow change and the effects on their
life. Response shift (Howard et al., 2011) may mask the treatment impact of self-
management on HRQoL although given that our study was only 16 weeks, the
improvement seen in HRQoL was probably real.
6.5.5 Blood Pressure Control
In this study, BP control was a secondary outcome, and there were no changes in systolic
and diastolic BP in the intervention group by week 16. This finding is inconsistent with
the study in the U.K. (Blakeman et al., 2014) that implemented the education program for
people with CKD stage 3. However, BP was measured at different time points, as the
current study measured BP 16 weeks later, while Blakeman et al. (2014) measured at 6
months and in a larger number of people (intervention group = 193, control group = 210).
The current study finding is consistent with Joboshi and Oka (2016), where
improvements in participants’ self-efficacy and self-management behaviour did not
translate to improved BP in the intervention group.
There are several possible reasons to explain the current study findings. First, it could be
due to the study not being powered to detect a change in BP. Second, larger changes in
BP are likely to take longer than 16 weeks. For example, earlier studies indicated a
significant decrease in BP results in the intervention group among people with CKD in
the Netherlands after 2 years’ follow-up (Peeters et al., 2014; Van Zuilen et al., 2011). In
addition, participants in either group could improve the management of BP by reducing
salt intake, by increasing activity, and through stopping smoking. These specific

outcomes were not measured in this study. Moreover, as the outcome was based on the
most recent BP recorded in participants’ charts, there may have been measurement error.
The issue related to using single readings of BP has been described in other studies
(Evans, Hodgkinson, & Berry, 2001; Garcia, Ang, Ahmad, & Lim, 2012). Using a single
data point has limitations because it could introduce error in the outcome. Standardised
measurement is required to measure BP, using the same equipment and accurate
technique for all participants (Evans et al., 2001; Garcia et al., 2012). Therefore, further
research into the effects of the CKD self-management program on BP is warranted.
There is the question of what are minimal clinically important changes in the context of
CKD. Equivocal findings of clinical outcomes, including BP and eGFR, have been
reported in six studies (Blakeman et al., 2014; Chen et al., 2011; Flesher et al., 2011;
Joboshi & Oka, 2016; Paes-Barreto et al., 2013; Williams et al., 2012) as previously
discussed in Chapter 2 (see section 2.5.2). These studies have shown that the effects of
self-management programs on changing behaviour outcomes are consistent; however,
clinical outcome is not clearly changed. It could be explained that previous research
aimed for statistically significant improvements in BP, and this aim might be not possible
to achieve in people living with CKD for several years. In the context of CKD, people
may need time to practise self-management skills to control BP. Therefore, the realistic
goals for people with CKD would be to first adhere to medication regimens, reduce salt in
their diet, and to increase physical activity to stabilize their BP, and then adjust the goal
toward lower BP towards a clinical target.
In the current study, BP results slightly decreased in the intervention group, although it
was not statistically significant. However, BP at the end of the 16-week study period
obtained from the participants’ charts revealed that both SBP and DBP of participants in

the intervention group were lower than baseline. It might be that participants who
received the self-management intervention started translating their understanding of CKD
to change their health behaviour although the change in BP did not reach statistical
significance.
6.6 Chapter Summary
This chapter discussed the findings from each research phase. The findings from the first
two study phases indicated that the Vietnamese versions of the kidney disease knowledge
(V.KiKS) and CKD self-management (V.CKD-SM) were valid and reliable instruments
to measure knowledge and self-management behaviour, respectively, among people with
CKD. The results from the third phase revealed the effectiveness of the CKD self-
management intervention program in improving knowledge, self-management behaviour,
self-efficacy, and HRQoL among participants who received the program. However, the
BP results were not significantly improved after the study period. Controlling BP may
require a longer study follow-up period, and therefore, further similar studies in this
population with a longer follow-up period are warranted to measure changes in BP
management. In conclusion, the findings of the current study have important implications
for further research. Strengths and limitations together with implications for further
studies are addressed in the following chapter.

Chapter 7: Conclusions
7.1 Introduction
This chapter first addresses the strengths and limitations of the entire study. The
implications of the study for nursing practice, education, research, and healthcare
organisations are also discussed, followed by concluding thesis remarks.
7.2 Strengths of the Study
The research conducted for this PhD has several qualities. First, the RCT study design has
several strengths: (1) the successful randomisation reduces bias (Hoffmann, Bennett, &
Del Mar, 2017); (2) it was undertaken in the clinical setting as a pragmatic trial which
reflects real practice (Alford, 2007); (3) the inclusion of a concurrent comparison group
was also a strength; and (4) the study had low (11%) loss to follow-up of participants,
which helped to enable a fair comparison between groups and improve the internal
validity. Loss to follow-up in other RCTs conducted in Vietnam involving those with
diabetes (Dang et al., 2013) or heart failure (Dinh, 2016) had attrition rates of 16% and
24%, respectively. There are two possible reasons to explain the high retention rate in the
current study. The first reason is that the majority of the participants (about 87% of the
total sample) who participated in this study were in earlier stages of CKD with less acute
exacerbation of illness, which was different to Dinh (2016) although not Dang et al.
(2013). Second, obtaining participants’ mobile phone and home phone numbers to contact
for follow-up education and appointments with renal medical practitioners at the clinics
also helped to maintain participation.
Chapter 7: Conclusions 209

In addition, the use of intention-to-treat analysis and linear mixed models which meant
participants were analysed as part of their originally allocated group and participants who
discontinued were still included in the analysis. Intention-to-treat analysis helps to
preserve the value of randomisation (Del Re, Maisel, Blodgett, & Finney, 2013; Little &
Kang, 2015). Linear mixed models and intention-to-treat also assisted with dealing with
missing data at some of the time points, and also that all available data from participants
contributed to the final analysis as previously justified in Chapter 4 (see section 4.4.12).
The third important strength of this study was the design of the intervention program
itself. Carefully integrating the study concepts into the construct of SCT helped to
contribute to the success of the intervention. According to the study’s theoretical
framework, performing self-management behaviour can be improved by enhancing self-
efficacy through information sources and supporting knowledge. Self-management
education support together with culturally relevant scenarios and materials were
incorporated into the study intervention and delivered to participants according to the
study protocol.
Fourth, the study intervention was found to be a feasible and acceptable intervention
program. Participants in the intervention group reported that follow-up strategies were
useful to help them better self-manage their kidney disease. Telephone support is
recognised to be a useful strategy to reinforce education information and encourage
participants to change their health behaviours (Carroll et al., 2001; Hiltunen et al., 2005).
For instance, several RCTs from the existing CKD literature have used telephone follow-
ups as part of the intervention self-management program (Blakeman et al., 2014;
Campbell et al., 2008; Chen et al., 2011; Paes-Barreto et al., 2013; Teng et al., 2013).
210 Chapter 7: Conclusions

Fifth, the study used valid and reliable instruments to measure the study outcomes. The
V.KiKS and V.CKD-SM instruments measured the study’s primary outcomes and both
were first translated, validated, and psychometrically evaluated in people with CKD in a
Vietnamese sample. The valid and reliable Vietnamese versions of these instruments are
now available for researchers and clinicians to use.
7.3 Limitations of the Study
Despite the strengths mentioned above, the study has some limitations that need to be
taken into consideration for future studies.
The first limitation is possible selection bias. Participants involved in the main study were
in CKD stages 3–5 and attending outpatient clinics. However, the most vulnerable
patients with CKD may be underrepresented in the current study. People who are living in
mountainous areas or remote districts in Vietnam often have low literacy levels and poor
access to renal clinics. The poorest patients who tend to live far from the clinics are
admitted to hospital only when they have acute illness rather than having regular
appointments with medical practitioners. However, these patients may need self-
management support more than others to reduce the impact of their illness. Future
research should involve participants who are admitted to inpatient clinics or in
community clinical settings to examine the effectiveness of the self-management program
to slow kidney disease progression in the broader population of people with CKD in
Vietnam.
Second, although the follow-up period was justified in the methods, it is acknowledged
that for clinical outcomes it may be too short to capture the intervention effects. That is
why this study did not consider eGFR as an outcome and also because participants may
not be required to have a blood test at a follow-up time point. The current study found

that health behaviour changed within 16 weeks; however, further examination is required
to find out whether behaviour change is retained over longer periods. Therefore, longer
follow-up studies are needed to assess the maintenance and sustainability of the results
over time and to also examine whether there are beneficial effects on kidney function,
BP, and other clinical outcomes. In addition, objective outcomes such as change in eGFR
and time to dialysis are also needed in future studies to assess the effects of self-
management support on clinical outcomes. Demonstrating that knowledge and confidence
lead to behaviour change which in turn affects outcomes of slowing deterioration of
kidney function and delaying the need to start KRT would have provided objective
evidence for the value of SCT in this population.
Fourth, there was no patient advisory group to inform the development of the self-
management program. Consumer (patient) groups or representation on hospital
committees does not exist currently in Vietnam. Across the country, the traditional
medical model dominates the care of patients (see also section 7.7.4). However, patients’
views are important for clinicians and researchers to include. Previous research in CKD
does show the emerging use of consumers (Thomas & Bryar, 2013; Thomas, Bryar, &
Makanjuola, 2008). Consumers’ input can be useful for developing self-management
programs as it brings in and includes the patient’s perspectives. In addition, by having
consumers involved in research, it helps with translation of research findings into
practice. Therefore, researchers should consider using co-design research approaches in
future CKD self-management studies.
The final limitation of this study is the lack of blinding and primary outcomes were
measured by using self-reported instrument. This study could blind the outcome
evaluators given the nature of the intervention; however, it was difficult in reality because

some participants disclosed their allocation to the outcome evaluators. This limitation
could contribute to response bias (Hoffmann et al., 2017). Self-reported instruments were
suitable measurements in this study although these are subjective outcomes and prone to
responder-bias such as over or under reporting. Objective measures of tracking exercise
with actigraphy or analysing breath samples to detect smoking could have overcome
reporting biases.
7.4 Implications of the Study
This study has some significant implications which can inform the development and
application of self-management programs in clinical practice, nursing education, nursing
research, and healthcare organisations.
7.4.1 Implications in Clinical Practice
First, findings of previous studies of CKD self-management in Western and non-Western
countries indicate the effectiveness of self-management programs to improve behaviour
and health outcome in those with CKD. This study in Vietnam has also shown that
participants’ knowledge and self-management behaviour can be improved with support.
Thus, CKD self-management programs should be available to inpatients, outpatients, and
primary health care clinics across the country. Providing early post-discharge self-
management education may encourage participants to identify their kidney problems and
undertake realistic personal goal-setting, which will help to achieve better self-
management of their disease at home.
Second, nurses are restricted in providing patient education in many hospitals in Vietnam
due to low-status, high patient-to-nurse ratios, and a culture of being a medical-assistant
as previously discussed in Chapter 1. Clinical nurses also do not have resources to

develop patient education material. The CKD booklet is available from the current study
and has been provided to the medical and nursing staff at the site where this study took
place. The information booklet ought to be given to all patients, and nurses could then
provide some short, simple education to patients just prior to discharge from the ward or
while patients are sitting in the waiting room of the outpatient clinic.
Finally, the findings of the current study indicated that the self-management program was
feasible and useful to enhance levels of self-efficacy of participants with CKD to achieve
the aforementioned outcomes. Successful strategies for delivering this self-management
education included face-to-face and telephone follow-up. This highlights the importance
of providing self-management education via telephone for people who are unable to
partake in a hospital-based program. Thus, providing self-management support over the
telephone to people with CKD in communities could help to delay CKD progression and
prevent overcrowding at the major national hospitals. More importantly, those who have
difficulties in accessing the renal clinics at these hospitals could also receive the benefits
from the self-management programs to help them better self-manage their kidney
problems and reduce the impact of their condition.
7.4.2 Implications in Nursing Education
As self-management education is useful to people with CKD, it is also likely to be useful
for other chronic diseases, such as diabetes, hypertension, and heart failure. In addition, in
order to make a change from traditional model of hospital care to standardised care
requires nurses to have life-long learning and the ability to access evidence-based practice
to inform clinical care for patients. Thus, providing professional training for nurses in
discharge education, especially CKD self-management, is necessary to improve nurses’
skills and knowledge in delivering a self-management program prior to providing self-

management education to patients. In particular, educating nurses how to move from a
traditional model of education that is about giving information to one that supports skill
building to improve patients’ confidence to perform their disease self-management is
crucial. Nurse teachers at universities and colleges need to educate nursing students
during undergraduate nursing degrees about the importance of both discharge education
for all patients as well as specific chronic disease patient education which focuses on self-
management.
7.4.3 Implications for Research
This study has three implications for further research. First, as previously discussed,
additional CKD self-management studies over longer periods and powered to detect
changes in kidney function, BP, and cholesterol are needed.
Second, research that builds on or extends the intervention by including families and
significant others is needed because Vietnamese culture is different from Western
cultures. Families in Vietnam have an important role in supporting and caring for their
sick family member (as explained in Chapter 6). Future interventional studies ought to
involve the family and significant others because they are probably influential in self-
management behaviour.
Third, it is probable that some degree of tailoring the intervention to individual needs
could enhance future studies by creating a more person-centred intervention. Qualitative
research to describe what it is like to live with CKD in Vietnam and to examine the ways
self-management occurs is urgently needed. This current study was unable to do this.
Knowing these perspectives will enable the researcher to design a study that prioritises
the needs of patients.

Research in Vietnam is predominantly conducted by medical practitioners in the
traditional biomedical model of treatment methods. Nurses also do some research, but it
lacks robustness as they often use author-created instruments which have not been
adequately tested. The instruments are also not available in English, nor are these studies
published in the international literature. Future studies could use the Vietnamese versions
of the KiKS and the CKD-SM instrument to measure outcomes that would enable
comparisons between studies. Also, both instruments could be used in countries where
there are Vietnamese-speaking people, enabling further comparisons between studies.
Data from several studies could even be combined to test the structural properties within
the instruments and to test hypotheses about the relationships between knowledge and
self-management. Lastly, future CKD interventional research ought to be theory-driven,
using suitable theories or models such as SCT to explain the links between study concepts
and outcomes.
7.4.4 Implications for Healthcare Organisations
In Vietnam, the traditional healthcare model is an acute care model or a traditional
medical model. Patients may not know that they have CKD until they are admitted to
hospital. The medical model is not designed to improve patients’ health literacy. A lack
of basic health literacy means patients may not understand why they need to take
medications or monitor BP; therefore, health literacy could be a major barrier influencing
self-management. Self-management programs have a major place in delaying disease
progression, particularly in CKD. This study’s intervention deliberately included
individual face-to-face sessions, which allowed an individual to discuss, explain, and ask
disease-related questions. It also provided a CKD booklet and phone call follow-ups.

The intervention was not difficult to implement in the outpatient clinics in Vietnam, and
patients were receptive to the format, content, and methods of delivery. The use of all
information sources in the intervention proved effective; however, applying all of them in
clinical settings in Vietnam may result in some difficulties for nurses. There are several
possible reasons for such challenges. First, it may be impossible to always provide a
positive role model with CKD in daily caring for patients because those who manage
their kidney disease well would be attending the clinics less frequently. Second, nurses
often have to care for many patients in the clinics and it would be challenging for nurses
to provide a complex self-management program. In addition, it is unusual for the nurse to
call participants for follow-up appointments in the traditional healthcare services in
Vietnam. Generally, nurses have insufficient time to discuss kidney knowledge and teach
patients to practise self-management skills, meaning that the other three information
sources are also difficult to carefully implement.
While chronic disease self-management programs could be translated into practice in
Vietnam, changing the traditional medical model of healthcare would require a major
shift in policy direction from the Ministry of Health to enable the culture of practice to
change. Internationally, nurses conduct chronic disease management clinics, and these are
known to improve patient and clinical outcomes (Bonner et al., 2015) and reduce the
number of hospital visits (Bonner et al., 2015; Lowery et al., 2012). The findings of this
study add local evidence that establishing CKD self-management programs conducted by
nurses will assist people to achieve better disease management. Given that over 70% of
all deaths in Vietnam are due to a chronic disease (WHO, 2014), hospitals in Vietnam
should establish chronic care management models. Investing in chronic care management
services can help to reduce the number of patients in need of acute hospital care and,
therefore, reduce the overcrowding of hospital wards.

7.5 Thesis Conclusions
The main purpose of this study was to examine the effectiveness of a CKD self-
management intervention program in Vietnam. Underpinned by SCT, the program was
designed to improve knowledge, self-efficacy, self-management behaviour, and outcomes
(HRQoL and BP). Three phases were undertaken to achieve the study outcomes.
First, the Vietnamese versions of the KiKS and CKD-SM instrument are now available to
assess patients in the hospital and for future research. Second, the self-management
program was found to be an effective and simple approach to engage people with CKD in
developing knowledge, confidence, and skills to manage their illness. The resources from
the program are available for clinicians to provide to patients, and it recommended that
the program be implemented into nephrology departments across the country. Finally, this
study was the first CKD self-management RCT in Vietnam, and it contributes to
extending nursing knowledge in this area internationally so that patient care can be
improved.

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Appendices
Appendix 1. Author’s Permission for Using Original version of the KiKS
254 Appendices
Appendix 2. Author’s Permission for Using Original version of the CKD-SM
Appendices 255
Appendix 3. Original English Kidney Disease Knowledge Survey (E.KiKS)
256 Appendices
Appendix 4. English Version of the Chronic Kidney Disease Self-Management
Appendices 257
Appendix 5. Phase 1 and 2 − QUT Ethics Approval
258 Appendices
Appendix 6. Phase 1 and 2 − Bach Mai Hospital Approval
Appendices 259
Appendix 7. Phase 2 − Participant Demographic Information Questionnaire
A. English
The following questions related to your personal information. Please tick (√) or fill in blanks
in the following questions:
1. Age: ………………………………….. years old (current age in Western calendar)
2. Gender: ☐ Male ☐ Female
3. Marital status:
☐ Married ☐ Single
☐ Separated ☐Divorced ☐ Widowed
4. What is your highest education level?
☐ Primary school (level 1 to 5)
☐ Secondary school (level 6 to 9)
☐ High school (level 10 to 12) ☐ Two years certificate
☐ College (3 years) ☐ Bachelor (University)
☐ Others (please specify) ……………………………………
5. What is your occupation?
☐ Professional ☐ Farmer
☐ Industrial worker ☐ Salesperson
☐ Home worker ☐ Retired
☐ Other jobs (please specify)………………………………………
6. How much of your income and your family income per month?
a. Your income per month: ……………………………………………VND
b. Your family income per month: ……………………………………..VND
7. How many people are living with you? ☐☐
260 Appendices
B. Vietnamese
Thông tin cá nhân
Xin Ông/Bà vui lòng cho biết một số thông tin về bản thân. Ông/Bà có thể đánh dấu √ hoặc
điền vào chỗ trống những thông tin cần thiết trong những câu hỏi sau đây:
1. Tuổi: ………………………………….. (tuổi hiện tại tính theo năm dương lịch)
2. Giới tính: ☐ Nam ☐ Nữ
3. Tình trạng hôn nhân:
☐ Lập gia đình ☐ Độc thân
☐ Ly thân ☐ Ly dị ☐ Góa bụa
4. Trình độ học vấn cao nhất của Ông/Bà là gì?
☐ Tiểu học (Cấp 1) ☐ Trung học cơ sở (Cấp 2)
☐ Trung học phổ thông (Cấp 3) ☐ Trung cấp
☐ Cao đẳng ☐ Đại học
☐ Trình độ khác (vui lòng ghi rõ) ……………………………………
5. Nghề nghiệp hiện tại của Ông/Bà là gì?
☐ Cán bộ và nhân viên văn phòng ☐ Nông dân
☐ Công nhân ☐ Buôn bán
☐ Nội trợ ☐ Hưu trí
☐ Nghề khác (xin vui lòng ghi rõ)………………………………………
6. Thu nhập cá nhân/của gia đình Ông/Bà mỗi tháng là bao nhiêu?
a. Thu nhập cá nhân/tháng: …………………………………………Việt Nam Đồng
b. Thu nhập của gia đình/tháng: ……………………………………..Việt Nam Đồng
7. Có bao nhiêu người sống cùng với Ông/Bà? ☐☐
Appendices 261
Appendix 8. Phase 2 − Kidney Disease Knowledge Survey
A. English
Below is a list of 28 questions related to your knowledge about chronic kidney disease,
please tick (√) in the choice if you think it is true.
1. On average, your blood pressure should be maintained:

□ 160/90
□ 150/100
□ 170/80
□ Lower than 130/80
2. Are there certain medications your doctor can prescribe which is useful for your
kidneys?
□ Correct □ Incorrect
3. Why it is not good for kidneys when there is too much protein in the urine?
□ It may cause scar the kidney
□ It is a sign of kidney damage
□ It is a sign of kidney damage AND can scar the kidney
□ It may cause urine infection
□ All of the above answers
4. Select the ONE MEDICATION from the list below that a person with CHRONIC
kidney disease should AVOID:
□ Lisinopril
□ Tylenol
□ Motrin / Ibuprofen
□ Vitamin E
□ Fe supplement tablets
5. If the kidney(s) fail, treatment might include (FOR THIS QUESTION you can
CHOOSE up to TWO ANSWERS):
□ Lung biopsy
□ Haemodialysis
□ Bronchoscopy
□ Colonoscopy
□ Kidney transplant
6. What does “GFR” stand for?

□ Glomerular Filtration Rate – gives us information about kidney function
□ Good Flow Renal – gives us information about urine flow from the kidney
□ Gain For Renal – gives us information if kidney function is improved
□ Glucose Function Rate – gives us information about your blood glucose level
7. Does CHRONIC kidney disease have different stages?

262 Appendices
8. Does CHRONIC kidney disease increase risks of heart attack for people?
9. Does CHRONIC kidney disease increase risks of mortality for people?

This section is about WHAT THE KIDNEY DOES. Please select one answer to each
question below.
Correct Incorrect
10. Does the kidney make urine? □ □
11. Does the kidney clean blood? □ □
12. Does the kidney keep bones healthy □ □
13. Does the kidney keep a person from losing hair? □ □
14. Does the kidney help keep red blood cell counts normal? □ □
15. Does the kidney help keep blood pressure normal? □ □
16. Does the kidney help keep blood glucose normal? □ □
17. Does the kidney help keep potassium levels in the blood normal? □ □
18. Does the kidney help keep phosphorus levels in the blood normal? □ □
Correct Incorrect
19. Increased fatigue? □ □
20. Shortness of breath? □ □
21. Metallic taste / bad taste in the mouth? □ □
22. Abnormal itching? □ □
23. Nausea and / or vomiting? □ □
24. Hair loss? □ □
25. Increased difficulty in sleeping? □ □
26. Weight loss? □ □
27. Confused? □ □
28. No symptoms at all? □ □
Thank you for completing this survey.
Appendices 263
B. Vietnamese
Khảo sát kiến thức về bệnh thận (KiKS)

Dưới đây là 28 câu hỏi liên quan đến những hiểu biết của Ông/Bà về bệnh thận mãn tính. Xin
Ông/Bà vui lòng đánh dấu √ vào câu trả lời mà Ông/Bà cho là đúng.
1. Tính trung bình, huyết áp của Ông/Bà nên duy trì ở mức:
□ 160/90 mmHg
□ 150/100 mmHg
□ 170/80 mmHg
□ Thấp hơn 130/80 mmHg
2. Có một số loại thuốc nhất định mà bác sỹ có thể chỉ định dùng để tốt cho thận của
Ông/Bà đúng không?
□ Đúng □ Không đúng
3. Tại sao quá nhiều đạm (protein) trong nước tiểu thì không tốt cho thận?
□ Nó có thể gây sẹo ở thận
□ Nó là dấu hiệu của tổn thương thận
□ Nó là dấu hiệu của tổn thương thận VÀ có thể gây sẹo ở thận
□ Nó có thể gây nhiễm trùng nước tiểu
□ Tất cả các ý kiến trên
4. Chọn MỘT THUỐC trong danh sách dưới đây mà một người mắc bệnh thận MÃN
TÍNH nên TRÁNH:
□ Lisinopril
□ Tylenol
□ Vitamin E
□ Viên sắt
5. Nếu thận bị suy, điều trị bệnh có thể bao gồm (ĐỐI VỚI CÂU HỎI NÀY Ông/Bà có
thể chọn HAI ĐÁP ÁN):
□ Sinh thiết phổi
□ Chạy thận nhân tạo
□ Nội soi phế quản
□ Nội soi đại tràng
□ Ghép thận
6. “MLCT” có nghĩa là gì?

□ Tốc độ lọc cầu thận – cho chúng ta biết mức độ chức năng thận.
□ Lưu lượng tưới máu thận tốt – cho chúng ta biết dòng chảy của nước tiểu từ thận
□ Thận cải thiện – cho chúng ta biết chức năng thận đang được cải thiện
□ Tỷ lệ đường huyết – cho chúng ta biết về mức độ đường huyết
7. Bệnh thận MÃN TÍNH có các giai đoạn khác nhau đúng không?
8. Bệnh thận MÃN TÍNH làm tăng nguy cơ đau tim cho người bệnh đúng không?
264 Appendices
9. Bệnh thận MÃN TÍNH sẽ làm tăng nguy cơ tử vong cho con người đúng không?
Phần này sẽ hỏi về THẬN LÀM NHỮNG GÌ. Xin Ông/Bà vui lòng chọn một câu trả lời
bằng cách đánh dấu √ vào ô trống cho mỗi câu hỏi sau đây.
TT Câu hỏi Đúng Không đúng
10. Thận tạo ra nước tiểu đúng không? □ □
11. Thận làm sạch máu đúng không? □ □
12. Thận giữ cho xương khoẻ mạnh đúng không? □ □
13. Thận giữ cho không bị rụng tóc đúng không? □ □
14. Thận giúp giữ cho số lượng hồng cầu bình thường đúng □ □
không?
15. Thận giúp giữ cho huyết áp bình thường đúng không? □ □
16. Thận giúp cho việc giữ đường huyết bình thường đúng □ □
không?
17. Thận giúp cho việc giữ nồng độ Kali trong máu bình □ □
thường đúng không?
18. Thận giúp cho việc giữ nồng độ phốt-pho trong máu bình □ □
Phần này hỏi về TRIỆU CHỨNG. Ông/Bà vui lòng chọn từ danh sách dưới đây những
triệu chứng mà một người mắc bệnh thận mãn tính hoặc suy thận có thể có bằng cách
đánh dấu √ vào ô trống cho mỗi câu hỏi?
19. Mệt mỏi tăng? □ □
20. Thở nông? □ □
21. Miệng có vị kim loại/có vị khó chịu trong miệng? □ □
22. Ngứa bất thường? □ □
23. Buồn nôn và/hoặc nôn mửa? □ □
24. Rụng tóc? □ □
25. Khó ngủ tăng lên? □ □
26. Gầy sút cân (Giảm cân)? □ □
27. Nhầm lẫn (Giảm trí nhớ)? □ □
28. Không có bất kỳ triệu chứng nào cả? □ □
Cảm ơn Ông/Bà đã hoàn thành bộ câu hỏi này.
Appendices 265
Appendix 9. Phase 2 − Chronic Kidney Disease Self-Management Instrument
A. English
The following questions are about how you feel and deal with chronic kidney disease. Please select one of four responses that best reflects
your real situation in the last three months. 1: Never 2: Sometimes 3: Usually 4: Always
No Questions Never Sometimes Usually Always
1 When I have questions of my kidney disease, I discuss what I have to do with my
family and friends
2 I will ask about the reasons which might cause the decrease of my kidney function
3 I inform my family and friends about my kidney treatment plan (such as, medications
changes, lifestyle changes).
4 I share my personal experience about kidney disease with other kidney disease patients
5 I understand results of laboratory tests which were used to evaluate my kidney’s
function (For example: creatinine, eGFR)
6 When my blood pressure increases (more than 140/90), I try to find out any possible
cause for this.
7 To prevent the increased workload on my kidneys, I am able to control what I eat
8 I follow the diet which was recommended by my doctors or nurses.
9 I solve problem related to my kidney disease by using different sources of information
(For example: calling my doctors or nurses, using internet, Google, group of supporting
patients with kidney diseases)
10 When I feel uncomfortable or disappointed, I discussed with someone about my
emotion
11 I integrate closely my treatment of kidney disease into my daily life
12 I quit habits which worsen my kidney function (for example smoking, drinking alcohol,
salty diet)
13 I follow doctors and nurses’ recommendations of doing exercises
14 I monitor my early warning signs and symptoms (for example: blood glucose, weight,
266 Appendices
shortness of breath, foot swelling)
15 I follow doctors and nurses’ recommendations about eating a balanced diet.
16 I asked doctors or nurses questions to understand clearly the plan of treating my kidney
disease
17 I follow doctors and nurses’ recommendations about not smoking
18 I have changed my lifestyle to prevent my kidney disease from getting worse
19 I seek help from others when I am feeling upset or frustrated.
20 I keep my kidney healthy by keeping my general health condition
21 I stop bad habits which might harm my kidneys (For example: smoking, eating salty
food, drinking)
22 I take steps to understand the risk factors associated with chronic kidney disease (such
as high blood pressure, diabetes, smoking, obesity).
23 I control my weight based on doctors or nurses advice
24 I make good choices about the type and amount of food I eat when I am not at home
(for example: in restaurant, party, eating out)
25 I can adjust my daily activities based on my kidney disease treatment plan when I am
not at home (for example: on travel, retreat)
26 When my body has new or worsen symptoms (for example: foot swelling, severe
headache, urinate frequently at night), I tried to find reasons
27 I still take all of my medications even when I am not at home
28 I feel I am able to attend social activities (wedding, party), even though I have kidney
disease.
29 I search for information about chronic kidney disease from different sources (for
example internet, leaflet, manual, kidney disease patient peer group)
30 I take my medications as prescribed by my doctors.
31 I take action when my early warning signs and symptoms get worse
32 When I have questions about my kidney disease, I discuss what to do with my doctors
or nurses.
Thank you for completing this questionnaire.
Appendices 267
B. Vietnamese
TỰ QUẢN LÝ BỆNH THẬN MÃN TÍNH (CKD - SM)

Dưới đây là 32 câu hỏi liên quan đến cảm giác và cách làm của Ông/Bà trong việc chống đỡ lại bệnh thận mãn tính. Ông/Bà vui lòng đánh
dấu √ vào một trong bốn lựa chọn (1: Không bao giờ, 2: Thỉnh thoảng, 3: Thường xuyên, 4: Luôn luôn) mà phản ánh tốt nhất tình trạng thực
tại của Ông/Bà trong ba tháng vừa qua.
Câu hỏi Không Thỉnh Thường Luôn
bao giờ thoảng xuyên luôn
1. Khi tôi có thắc mắc về tình trạng bệnh thận của mình, tôi thảo luận những gì cần làm với gia đình và bạn
bè của tôi.
2. Tôi sẽ hỏi bác sĩ hoặc điều dưỡng về các nguyên nhân có thể gây ra việc suy giảm chức năng thận của tôi.
3. Tôi thông báo với gia đình và bạn bè mình về kế hoạch điều trị bệnh thận của tôi (ví dụ như thay đổi
thuốc sử dụng, thay đổi lối sống).
4. Tôi chia sẻ kinh nghiệm của cá nhân mình về bệnh thận với những người khác cũng mắc bệnh thận.
5. Tôi hiểu ý nghĩa các chỉ số đánh giá chức năng thận của các xét nghiệm máu của tôi (ví dụ như
creatinine, eGFR).
6. Khi huyết áp của tôi tăng cao (lớn hơn 140/ 90), tôi cố gắng tìm ra các nguyên nhân có thể dẫn đến việc
này.
7. Để tránh gây hại cho thận, tôi nên kiểm soát chế độ ăn.
8. Tôi thực hiện chế độ ăn kiêng theo lời khuyên của bác sĩ hoặc điều dưỡng.
9. Tôi giải quyết các vấn đề liên quan đến bệnh thận của mình bằng cách sử dụng các nguồn thông tin khác
nhau (ví dụ như gọi cho bác sĩ hoặc điều dưỡng, sử dụng internet, Google, nhóm hỗ trợ người mắc bệnh
thận).
10. Khi tôi cảm thấy khó chịu hoặc thất vọng, tôi thảo luận với người khác về cảm xúc đó.
11. Tôi kết hợp chặt chẽ việc điều trị bệnh thận với mọi sinh hoạt hằng ngày của mình.
12. Tôi từ bỏ những thói quen làm xấu đi chức năng thận của tôi (ví dụ: hút thuốc lá, uống các loại đồ uống
có cồn, ăn mặn).
13. Tôi tập thể dục hàng ngày theo lời khuyên của bác sĩ và điều dưỡng.
14. Tôi theo dõi sát các triệu chứng và những dấu hiệu cảnh báo sớm về bệnh thận mãn tính và suy thận của
268 Appendices
mình (ví dụ như mức đường huyết, cân nặng, thở nông, phù chân).
15. Tôi thực hiện theo lời khuyên của bác sĩ và điều dưỡng về một chế độ ăn uống hợp lý.
16. Tôi hỏi bác sĩ hoặc điều dưỡng những câu hỏi để hiểu rõ kế hoạch điều trị bệnh thận của mình.
17. Tôi thực hiện theo lời khuyên của bác sĩ và điều dưỡng về việc không hút thuốc lá.
18. Tôi đã thay đổi lối sống của mình để bệnh thận không trở nên nặng hơn.
19. Tôi tìm kiếm sự giúp đỡ từ người khác khi cảm thấy khó chịu hoặc thất vọng.
20. Tôi giữ cho thận của mình khoẻ mạnh bằng cách giữ gìn sức khoẻ chung.
21. Tôi dừng những thói quen gây hại cho thận của mình (ví dụ: hút thuốc lá, sử dụng thức ăn nhiều muối,
uống rượu bia).
22. Tôi thực hiện các bước để hiểu về các yếu tố nguy cơ liên quan đến bệnh thận mãn tính (ví dụ: tăng
huyết áp, đái tháo đường, hút thuốc lá, béo phì).
23. Tôi kiểm soát cân nặng của mình theo lời khuyên của bác sĩ và điều dưỡng.
24. Tôi đưa ra những lựa chọn hợp lý về số lượng và loại thức ăn của mình khi tôi không ăn ở nhà (ví dụ: tại
các nhà hàng, tiệc tùng, ăn ở ngoài).
25. Tôi có thể điều chỉnh thói quen hàng ngày theo kế hoạch điều trị bệnh thận của mình khi không ở nhà
(ví dụ: đi du lịch, đi nghỉ dưỡng).
26. Khi cơ thể của tôi có những triệu chứng thực thể mới hoặc xấu đi (ví dụ như là phù nề chân, đau đầu
trầm trọng, đi tiểu nhiều vào ban đêm), tôi cố gắng tìm ra nguyên nhân của nó.
27. Tôi vẫn uống thuốc đầy đủ kể cả khi tôi không ở nhà.
28. Tôi cảm thấy mình có thể tham gia các sự kiện xã hội (ví dụ như đám cưới, tiệc tùng), mặc dù tôi mắc
bệnh thận.
29. Tôi tìm kiếm các thông tin về bệnh thận mãn tính từ nhiều nguồn khác nhau (ví dụ như là internet, tờ
rơi, sách hướng dẫn bỏ túi, nhóm hỗ trợ người mắc bệnh thận).
30. Tôi uống thuốc theo chỉ định của bác sĩ.
31. Tôi sẽ thực hiện hành động khi các dấu hiệu cảnh báo sớm và các triệu chứng về bệnh thận của mình trở
nên tồi tệ hơn.
32. Khi tôi có thắc mắc về bệnh thận của mình, tôi thảo luận những gì cần làm với bác sĩ hoặc điều dưỡng.
Appendices 269
Appendix 10. Phase 2 – Clinical Characteristics (from patients’ medical records)
A. English
1. eGFR:............... 2. Serum creatinine: ...............

3. Cholesterol: ............... 4. HbA1C: ...............
5. Blood pressure: ............... 6. Potassium: ...............
7. Calcium: ............... 8. Phosphate: ...............
9. Haemoglobin (Hb): ............... 10. Weight: ...............
11. Height: ............... 12. BMI: ...............
Current medications used:

Patient’s Medical Records
270 Appendices
B. Vietnamese
Xét nghiệm cận lâm sàng (từ hồ sơ người bệnh)
1. Chỉ số lọc cầu thận: ............... 2. Serum creatinine: ...............
3. Cholesterol: ............... 4. HbA1C: ...............
5. Huyết áp: ............... 6. K+: ...............
7. Ca+: ............... 8. Phospho: ...............
9. Huyết sắc tố (Hb): ............... 10. Cân nặng: ...............
11. Chiều cao: ............... 12. BMI: ...............
Thuốc về bệnh Thận mà Ông/Bà đang dùng:

Hồ sơ người bệnh
Appendices 271
Appendix 11. Permission to use the ‘Living with Reduced Kidney Function’
272 Appendices
Appendix 12. Permission to use the ‘Living Well with Chronic Kidney Disease’
Appendices 273
Appendix 13. Chronic Kidney Disease Booklet
A. English: Looking After My Kidney and Health
274 Appendices
Appendices 275
276 Appendices
Appendices 277
278 Appendices
Appendices 279
280 Appendices
Appendices 281
282 Appendices
Appendices 283
284 Appendices
Appendices 285
286 Appendices
Appendices 287
288 Appendices
Appendices 289
290 Appendices
Appendices 291
292 Appendices
Appendices 293
294 Appendices
Appendices 295
296 Appendices
Appendices 297
298 Appendices
Appendices 299
300 Appendices
Appendices 301
B. Vietnamese: Cẩm nang chăm sóc Thận và sức khỏe của tôi
302 Appendices
Appendices 303
304 Appendices
Appendices 305
306 Appendices
Appendices 307
308 Appendices
Appendices 309
310 Appendices
Appendices 311
312 Appendices
Appendices 313
314 Appendices
Appendices 315
316 Appendices
Appendices 317
318 Appendices
Appendices 319
320 Appendices
Appendices 321
322 Appendices
Appendices 323
324 Appendices
Appendices 325
326 Appendices
Appendices 327
328 Appendices
Appendices 329
Appendix 14. Agreement to use SF-36v2
330 Appendices
Appendix 15. Phase 3 − QUT Ethics Approval
Appendices 331
Appendix 16. Phase 3 − Bach Mai Hospital Approval
332 Appendices
Appendix 17. Registration ANZCTR Number
Appendices 333
Appendix 18. Phase 3 − Kidney Disease Knowledge Survey
A. English Baseline ☐
Week 8 ☐
Week 16 ☐
Below is a list of 28 questions related to your knowledge about chronic kidney disease,
please tick (√) in the choice if you think it is true.
1. On average, your blood pressure should be maintained:

□ 160/90
□ 150/100
□ 170/80
□ Lower than 130/80
2. Are there certain medications your doctor can prescribe which is useful for your
kidneys?
3. Why it is not good for kidneys when there is too much protein in the urine?
□ It may cause scar the kidney
□ It is a sign of kidney damage
□ It is a sign of kidney damage AND it may cause scar the kidney
□ It may cause urine infection
□ All of the above answers
4. Choose ONE MEDICATION from the list below that people with CHRONIC kidney
disease should AVOID:
□ Lisinopril (type of hypertension medication)
□ Tylenol (type of pain reliever)
□ Motrin / Ibuprofen (a nonsteroidal anti-inflammatory drug)
□ Vitamin E
□ Fe supplement tablets
5. If the kidney(s) fail, treatment might include (FOR THIS QUESTION you can
CHOOSE up to TWO ANSWERS):
□ Lung biopsy
□ Haemodialysis
□ Bronchoscopy
□ Colonoscopy
□ Kidney transplant
6. What does “GFR” stand for?

□ Glomerular Filtration Rate – gives us information about kidney function
□ Good Flow Renal – gives us information about urine flow from the kidney
□ Gain For Renal – gives us information if your kidney function is improved
□ Glucose Function Rate – gives us information about your blood glucose level
7. Does CHRONIC kidney disease have different stages?
334 Appendices
8. Does CHRONIC kidney disease increase risks of heart attack for people?
9. Does CHRONIC kidney disease increase risks of mortality for people?

This section is about WHAT THE KIDNEY DOES. Please select one answer to each
question below.
Correct Incorrect
10. Does the kidney make urine? □ □
11. Does the kidney clean blood? □ □
12. Does the kidney keep bones healthy □ □
13. Does the kidney keep a person from losing hair? □ □
14. Does the kidney help keep red blood cell counts normal? □ □
15. Does the kidney help keep blood pressure normal? □ □
16. Does the kidney help keep blood glucose normal? □ □
17. Does the kidney help keep potassium levels in the blood normal? □ □
18. Does the kidney help keep phosphorus levels in the blood normal? □ □
Correct Incorrect
19. Increased fatigue? □ □
20. Shortness of breath? □ □
21. Metallic taste / bad taste in the mouth? □ □
22. Abnormal itching? □ □
23. Nausea and / or vomiting? □ □
24. Hair loss? □ □
25. Increased difficulty in sleeping? □ □
26. Weight loss? □ □
27. Confused? □ □
28. No symptoms at all? □ □
Appendices 335
B. Vietnamese
Khảo sát kiến thức về bệnh thận Bắt đầu ☐

Tuần 8 ☐
Tuần 16 ☐
Dưới đây là 28 câu hỏi liên quan đến những hiểu biết của Ông/Bà về bệnh thận mãn tính.
Xin Ông/Bà vui lòng đánh dấu √ vào câu trả lời mà Ông/Bà cho là đúng.
1. Tính trung bình, huyết áp của Ông/Bà nên duy trì ở mức:
□ 160/90 mmHg
□ 150/100 mmHg
□ 170/80 mmHg
□ Thấp hơn 130/80 mmHg
2. Có một số loại thuốc nhất định mà bác sỹ có thể chỉ định dùng để tốt cho thận của
Ông/Bà đúng không?
3. Tại sao quá nhiều đạm (protein) trong nước tiểu thì không tốt cho thận?
□ Nó là dấu hiệu của tổn thương thận
□ Nó là dấu hiệu của tổn thương thận VÀ có thể gây sẹo ở thận
□ Nó có thể gây nhiễm trùng nước tiểu
4. Chọn MỘT THUỐC trong danh sách dưới đây mà một người mắc bệnh thận
MÃN TÍNH nên TRÁNH:
□ Lisinopril (thuốc để kiểm soát huyết áp)
□ Tylenol (thuốc giảm đau)
□ Motrin / Ibuprofen (thuốc giảm đau, chống dị ứng)
□ Vitamin E
□ Viên sắt
5. Nếu thận bị suy, điều trị bệnh có thể bao gồm (ĐỐI VỚI CÂU HỎI NÀY Ông/Bà
có thể chọn HAI ĐÁP ÁN):
□ Ghép thận
6. “MLCT” có nghĩa là gì?

□ Tốc độ lọc cầu thận – cho chúng ta biết mức độ chức năng thận.
□ Lưu lượng tưới máu thận tốt– cho chúng ta biết dòng chảy của nước tiểu từ thận
□ Thận cải thiện– cho chúng ta biết chức năng thận đang được cải thiện
□ Tỷ lệ chức năng đường máu – cho chúng ta biết về mức độ đường huyết
7. Bệnh thận MÃN TÍNH có các giai đoạn khác nhau đúng không?
336 Appendices
8. Bệnh thận MÃN TÍNH làm tăng nguy cơ đau tim cho người bệnh đúng không?
9. Bệnh thận MÃN TÍNH sẽ làm tăng nguy cơ tử vong cho con người đúng không?
Phần này sẽ hỏi về THẬN LÀM NHỮNG GÌ. Xin Ông/Bà vui lòng chọn một câu trả
lời bằng cách đánh dấu √ vào ô trống cho mỗi câu hỏi sau đây.
10. Thận tạo ra nước tiểu đúng không? □ □
11. Thận làm sạch máu đúng không? □ □
12. Thận giữ cho xương khoẻ mạnh đúng không? □ □
13. Thận giữ cho không bị rụng tóc đúng không? □ □
14. Thận giúp giữ cho số lượng hồng cầu bình thường đúng □ □
không?
15. Thận giúp giữ cho huyết áp bình thường đúng không? □ □
16. Thận giúp cho việc giữ đường huyết bình thường đúng □ □
không?
17. Thận giúp cho việc giữ nồng độ Kali trong máu bình □ □
18. Thận giúp cho việc giữ nồng độ phốt-pho trong máu bình □ □
Phần này hỏi về TRIỆU CHỨNG. Ông/Bà vui lòng chọn từ danh sách dưới đây
những triệu chứng mà một người mắc bệnh thận mãn tính hoặc suy thận có thể có
bằng cách đánh dấu √ vào ô trống cho mỗi câu hỏi?
19. Mệt mỏi tăng? □ □
20. Thở nông? □ □
21. Miệng có vị kim loại/có vị khó chịu trong miệng? □ □
22. Ngứa bất thường? □ □
23. Buồn nôn và/hoặc nôn mửa? □ □
24. Rụng tóc? □ □
25. Khó ngủ tăng lên? □ □
26. Gầy sút cân (Giảm cân)? □ □
27. Nhầm lẫn (Giảm trí nhớ)? □ □
28. Không có bất kỳ triệu chứng nào? □ □
Cảm ơn ông/Bà đã hoàn thành bộ câu hỏi này.
Appendices 337
Appendix 19. Phase 3 − Chronic Kidney Disease Self-Management Instrument
Week 8 ☐
Week 16 ☐
The following questions are about how you feel and deal with chronic kidney disease. Please select one of four responses that best reflects
your real situation in the last three months. 1: Never 2: Sometimes 3: Usually 4: Always
No Questions Never Sometimes Usually Always

1 When I have questions of my kidney disease, I discuss what I have to do with my family and
friends.
2 I will ask about the reasons which might cause the decrease of my kidney function.
3 I inform my family and friends about my kidney treatment plan (such as, medications changes,
lifestyle changes).
4 I share my personal experience about kidney disease with other kidney disease patients.
5 I understand results of laboratory tests which were used to evaluate my kidney’s function (For
example: creatinine, eGFR).
6 When my blood pressure increases (more than 140/90), I try to find out any possible cause for
this.
7 To prevent the increased workload on my kidneys, I am able to control what I eat.
8 I follow the diet which was recommended by my doctors or nurses.
9 I solve problem related to my kidney disease by using different sources of information (For
example: calling my doctors or nurses, using internet, Google, group of supporting patients with
kidney diseases).
10 When I feel uncomfortable or disappointed, I discussed with someone about my emotion.
11 I integrate closely my treatment of kidney disease into my daily life.
12 I quit habits which worsen my kidney function (for example smoking, drinking alcohol, salty
diet).
13 I follow doctors and nurses’ recommendations of doing exercises.
338 Appendices
14 I monitor my early warning signs and symptoms (for example: blood glucose, weight, shortness
of breath, foot swelling).
15 I follow doctors and nurses’ recommendations about eating a balanced diet.
16 I asked doctors or nurses questions to understand clearly the plan of treating my kidney disease.
17 I follow doctors and nurses’ recommendations about not smoking.
18 I have changed my lifestyle to prevent my kidney disease from getting worse.
19 I seek help from others when I am feeling upset or frustrated.
20 I keep my kidney healthy by maintaining my overall health, such as controlling weight, eating
proper foods, and taking exercise activities.
21 I stop bad habits which might harm my kidneys (for example: smoking, eating salty food,
drinking).
22 I take steps to understand the risk factors associated with chronic kidney disease (such as
maintaining a healthy diet, controlling blood pressure, and taking medication).
23 I control my weight based on doctors or nurses advice.
24 I make good choices about the type and amount of food I eat when I am not at home (for
example: in restaurant, party, eating out).
25 I can adjust my daily activities based on my kidney disease treatment plan when I am not at
home (for example: on travel, retreat).
26 When my body has new or worsen symptoms (for example: foot swelling, severe headache,
urinate frequently at night), I tried to find reasons.
27 I still take all of my medications even when I am not at home.
28 I feel I am able to attend social activities (wedding, party), even though I have kidney disease.
29 I search for information about chronic kidney disease from different sources (for example
internet, leaflet, manual, kidney disease patient peer group).
30 I take my medications as prescribed by my doctors.
31 I take action when my early warning signs and symptoms get worse.
32 When I have questions about my kidney disease, I discuss what to do with my doctors or nurses.
Appendices 339
B. Vietnamese
TỰ QUẢN LÝ BỆNH THẬN MÃN TÍNH Bắt đầu ☐

Tuần 8 ☐
Tuần 16 ☐
Dưới đây là 32 câu hỏi liên quan đến cảm giác và cách làm của Ông/Bà trong việc chống đỡ lại bệnh thận mãn tính. Ông/Bà vui lòng đánh
dấu √ vào một trong bốn lựa chọn (1: Không bao giờ, 2: Thỉnh thoảng, 3: Thường xuyên, 4: Luôn luôn) mà phản ánh tốt nhất tình trạng thực
tại của Ông/Bà trong ba tháng vừa qua.
1. Khi tôi có thắc mắc về tình trạng bệnh thận của mình, tôi thảo luận những gì cần làm với gia
đình và bạn bè của tôi.
2. Tôi sẽ hỏi bác sĩ hoặc điều dưỡng về các nguyên nhân có thể gây ra việc suy giảm chức năng
thận của tôi.
3. Tôi thông báo với gia đình và bạn bè mình về kế hoạch điều trị bệnh thận của tôi (ví dụ như thay
đổi thuốc sử dụng, thay đổi lối sống).
4. Tôi chia sẻ kinh nghiệm của cá nhân mình về bệnh thận với những người khác cũng mắc bệnh
thận.
5. Tôi biết được các chỉ số đánh giá chức năng thận của các xét nghiệm máu của tôi (ví dụ như
creatinine, eGFR).
6. Khi huyết áp của tôi tăng cao (lớn hơn 140/ 90), tôi cố gắng tìm ra các nguyên nhân có thể dẫn
đến việc này.
7. Để tránh gây hại cho thận, tôi nên kiểm soát chế độ ăn.
8. Tôi thực hiện chế độ ăn kiêng theo lời khuyên của bác sĩ hoặc điều dưỡng.
9. Tôi giải quyết các vấn đề liên quan đến bệnh thận của mình bằng cách sử dụng các nguồn thông
tin khác nhau (ví dụ như gọi cho bác sĩ hoặc điều dưỡng, sử dụng internet, Google, nhóm hỗ trợ
người mắc bệnh thận).
10. Khi tôi cảm thấy khó chịu hoặc thất vọng, tôi thảo luận với người khác về cảm xúc đó.
11. Tôi kết hợp chặt chẽ việc điều trị bệnh thận với mọi sinh hoạt hằng ngày của mình.
12. Tôi từ bỏ những thói quen làm xấu đi chức năng thận của tôi (ví dụ: hút thuốc lá, uống các loại
340 Appendices
đồ uống có cồn, ăn mặn).
13. Tôi tập thể dục hàng ngày theo lời khuyên của bác sĩ và điều dưỡng.
14. Tôi theo dõi sát các triệu chứng và những dấu hiệu cảnh báo sớm về bệnh thận mãn tính và suy
thận của mình (ví dụ như mức đường huyết, cân nặng, thở nông, phù chân).
15. Tôi thực hiện theo lời khuyên của bác sĩ và điều dưỡng về một chế độ ăn uống hợp lý.
16. Tôi hỏi bác sĩ hoặc điều dưỡng những câu hỏi để hiểu rõ kế hoạch điều trị bệnh thận của mình.
17. Tôi thực hiện theo lời khuyên của bác sĩ và điều dưỡng về việc không hút thuốc lá.
18. Tôi đã thay đổi lối sống của mình để bệnh thận không trở nên nặng hơn.
19. Tôi tìm kiếm sự giúp đỡ từ người khác khi cảm thấy khó chịu hoặc thất vọng.
20. Tôi giữ cho thận của mình khoẻ mạnh bằng cách giữ gìn sức khoẻ chung (ví dụ: kiểm soát cân
nặng, kiểm soát việc ăn uống, thực hiện việc tập thể dục.
21. Tôi dừng những thói quen gây hại cho thận của mình (ví dụ: hút thuốc lá, sử dụng thức ăn
nhiều muối, uống rượu bia).
22. Tôi thực hiện các bước để hiểu về các yếu tố nguy cơ liên quan đến bệnh thận mãn tính (ví dụ:
thực hiện chế độ ăn kiêng, kiểm soát huyết áp, uống thuốc).
23. Tôi kiểm soát cân nặng của mình theo lời khuyên của bác sĩ và điều dưỡng.
24. Tôi đưa ra những lựa chọn hợp lý về số lượng và loại thức ăn của mình khi tôi không ăn ở nhà
(ví dụ: tại các nhà hàng, tiệc tùng, ăn ở ngoài).
25. Tôi có thể điều chỉnh thói quen hàng ngày theo kế hoạch điều trị bệnh thận của mình khi không
ở nhà (ví dụ: đi du lịch, đi nghỉ dưỡng).
26. Khi cơ thể của tôi có những triệu chứng thực thể mới hoặc xấu đi (ví dụ như là phù nề chân,
đau đầu trầm trọng, đi tiểu nhiều vào ban đêm), tôi cố gắng tìm ra nguyên nhân của nó.
27. Tôi vẫn uống thuốc đầy đủ kể cả khi tôi không ở nhà.
28. Tôi cảm thấy mình có thể tham gia các sự kiện xã hội (ví dụ như đám cưới, tiệc tùng), mặc dù
tôi mắc bệnh thận.
29. Tôi tìm kiếm các thông tin về bệnh thận mãn tính từ nhiều nguồn khác nhau (ví dụ như là
internet, tờ rơi, sách hướng dẫn bỏ túi, nhóm hỗ trợ người mắc bệnh thận).
30. Tôi uống thuốc theo chỉ định của bác sĩ.
31. Tôi sẽ thực hiện hành động khi các dấu hiệu cảnh báo sớm và các triệu chứng về bệnh thận của
Appendices 341
mình trở nên tồi tệ hơn.
32. Khi tôi có thắc mắc về bệnh thận của mình, tôi thảo luận những gì cần làm với bác sĩ hoặc điều
dưỡng.
342 Appendices
Appendix 20. Phase 3 − Self-Efficacy for Managing Chronic Disease Instrument
Week 8 ☐
Week 16 ☐
We would like to know how confident you are in doing certain activities. For each of the following questions, please choose the number that
corresponds to your confidence that you can do the tasks regularly at the present time. The numbers in the columns stand for:
1 = not at all confident 10 = totally confident
How CONFIDENT are you that you can Level of confidence

1 keep the fatigue caused by your disease from interfering with the 1 2 3 4 5 6 7 8 9 10
things you want to do?
2 keep the physical discomfort or pain of your disease from interfering 1 2 3 4 5 6 7 8 9 10
with the things you want to do?
3 keep the emotional distress caused by your disease from interfering 1 2 3 4 5 6 7 8 9 10
4 keep any other symptoms or health problems you have from interfering 1 2 3 4 5 6 7 8 9 10
5 do the different tasks and activities needed to manage your health 1 2 3 4 5 6 7 8 9 10
condition so as to reduce you need to see as doctor?
6 do things other than just taking medication to reduce how much you 1 2 3 4 5 6 7 8 9 10
illness affects your everyday life?
Appendices 343
B. Vietnamese
Sự tự tin trong quản lý bệnh mãn tính Bắt đầu ☐

Tuần 8 ☐
Tuần 16 ☐
Chúng tôi muốn biết Ông/Bà tự tin như thế nào khi thực hiện những việc cụ thể sau. Đối với mỗi câu hỏi dưới đây, xin Ông/Bà hãy chọn con
số tương ứng với mức độ tự tin đối với những hoạt động được đề cập mà Ông/Bà có thể thực hiện một cách thường xuyên tại thời điểm hiện
tại. Các con số trong bảng dưới đây tương ứng thể hiên cho:
1 = không tự tin chút nào 10 = hoàn toàn tự tin
Ông/Bà tự tin như thế nào về việc Ông/bà có thể Mức độ tự tin
1 Giữ cho sự mệt mỏi do bệnh tật gây ra không gây ảnh hưởng đến những việc Ông/Bà 1 2 3 4 5 6 7 8 9 10
muốn làm?
2 Giữ cho những khó chịu về thể chất và cơn đau do bệnh tật gây ra không gây ảnh 1 2 3 4 5 6 7 8 9 10
hưởng đến những việc Ông/Bà muốn làm?
3 Giữ cho căng thẳng vì bệnh tật ảnh hưởng đến những việc Ông/Bà muốn làm? 1 2 3 4 5 6 7 8 9 10
4 Giữ cho những triệu chứng hoặc các vấn đề sức khỏe khác ảnh hưởng đến những việc 1 2 3 4 5 6 7 8 9 10
Ông/Bà muốn làm?
5 Làm những việc và những hoạt động cần thiết khác để kiểm soát tình trạng sức khỏe 1 2 3 4 5 6 7 8 9 10
của mình nhằm làm giảm việc phải đi khám bác sĩ của Ông/Bà?
6 Làm những việc khác hơn là chỉ uống thuốc để làm giảm ảnh hưởng của bệnh tật lên 1 2 3 4 5 6 7 8 9 10
cuộc sống hàng ngày?
344 Appendices
Appendix 21. Phase 3 − Health Related Quality of Life (SF-36v2)
Week 16 ☐
These first questions are about your health now.

Please try to answer as accurately as you can.
1. In general, would you say your health is…

[READ RESPONSE CHOICES] (Circle one number)
Excellent ..............................................................................................................................1
Very good.............................................................................................................................2
Good.....................................................................................................................................3
Fair .......................................................................................................................................4
or Poor .................................................................................................................................5
2. Compared to one year ago, how would you rate your health in general now?
Would you say it is…
Much better now than one year ago .....................................................................................1
Somewhat better now than one year ago .............................................................................2
About the same as one year ago ...........................................................................................3
Somewhat worse now than one year ago .............................................................................4
or Much worse now than one year ago ................................................................................5
Now I'm going to read a list of activities that you might do during a typical day.
As I read each item, please tell me if your health now limits you a lot, limits you a little,
or does not limit you at all in these activities.
3a. First, vigorous activities, such as running, lifting heavy objects, participating
in strenuous sports. Does your health now limit you a lot, limit you a little, or
not limit you at all? [READ RESPONSE CHOICES ONLY IF NECESSARY]
[IF RESPONDENT SAYS S/HE DOES NOT DO ACTIVITY, PROBE: Is that

because of your health?]
(Circle one number)
Appendices 345
Yes, limited a lot ..................................................................................................................1
Yes, limited a little ...............................................................................................................2
No, not limited at all ............................................................................................................3
3b. . . . moderate activities, such as moving a table, pushing a vacuum cleaner,

bowling, or playing golf. Does your health now limit you a lot, limit you a
little, or not limit you at all? [READ RESPONSE CHOICES ONLY IF
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
3c. . . . lifting or carrying groceries. Does your health now limit you a lot, limit
you a little, or not limit you at all? [READ RESPONSE CHOICES ONLY IF
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
3d. . . . climbing several flights of stairs. Does your health now limit you a lot,
limit you a little, or not limit you at all? [READ RESPONSE CHOICES ONLY
IF NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
346 Appendices
3e. . . . climbing one flight of stairs. Does your health now limit you a lot, limit
NECESSARY]

(Circle one number)
Yes, limited a lot .................................................................................................................1
3f. . . . bending, kneeling, or stooping. Does your health now limit you a lot, limit
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
3g. . . . walking more than a mile. Does your health now limit you a lot, limit you
a little, or not limit you at all? [READ RESPONSE CHOICES ONLY IF
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
3h. . . . walking several hundred yards. Does your health now limit you a lot,
limit you a little, or not limit you at all? [READ RESPONSE CHOICES ONLY
IF NECESSARY]
(Circle one number)
Appendices 347
Yes, limited a lot ..................................................................................................................1
3i. . . . walking one hundred yards. Does your health now limit you a lot, limit
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
3j. . . . bathing or dressing yourself. Does your health now limit you a lot, limit
NECESSARY]

(Circle one number)
Yes, limited a lot ..................................................................................................................1
The following four questions ask you about your physical health and your daily
activities.
4a. During the past four weeks, how much of the time have you had to cut down
on the amount of time you spent on work or other daily activities as a result
of your physical health?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
A little of the time ................................................................................................................4
348 Appendices
or None of the time ..............................................................................................................5
4b. During the past four weeks, how much of the time have you accomplished
less than you would like as a result of your physical health?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
4c. During the past four weeks, how much of the time were you limited in the
kind of work or other regular daily activities you do as a result of your
physical health?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
4d. During the past four weeks, how much of the time have you had difficulty
performing work or other regular daily activities as a result of your physical
health, for example, it took extra effort?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
The following three questions ask about your emotions and your daily activities.
Appendices 349
5a. During the past four weeks, how much of the time have you had to cut down
the amount of time you spent on work or regular daily activities as a result of
any emotional problems, such as feeling depressed or anxious?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
5b. During the past four weeks, how much of the time have you accomplished
less than you would like as a result of any emotional problems, such as feeling
depressed or anxious?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
5c. During the past four weeks, how much of the time did you do work or other
regular daily activities less carefully than usual as a result of any emotional
problems, such as feeling depressed or anxious?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
6. During the past four weeks, to what extent has your physical health or
emotional problems interfered with your normal social activities with family,
friends, neighbors, or groups? Has it interfered . . .
350 Appendices
Not at all ...............................................................................................................................1
Slightly .................................................................................................................................2
Moderately ...........................................................................................................................3
Quite a bit .............................................................................................................................4
or Extremely ........................................................................................................................5
7. During the past four weeks, how much did pain interfere with your normal
work, including both work outside the home and housework? Did it interfere
...
Not at all ...............................................................................................................................1
A little bit .............................................................................................................................2
Moderately ...........................................................................................................................3
Quite a bit .............................................................................................................................4
or Extremely ........................................................................................................................5
8. How much bodily pain have you had during the past four weeks? Have you
had . . .
None .....................................................................................................................................1
Very mild .............................................................................................................................2
Mild ......................................................................................................................................3
Moderate ..............................................................................................................................4
Severe ...................................................................................................................................5
or Very severe ......................................................................................................................6
The next questions are about how you feel and how things have been with you during
the past four weeks.
As I read each statement, please give me the one answer that comes closest to the way
you have been feeling; is it all of the time, most of the time, some of the time, a little of
the time, or none of the time?
9a. How much of the time during the past four weeks . . . did you feel full of life?
Appendices 351
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9b. How much of the time during the past four weeks . . . have you been very
nervous?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9c. How much of the time during the past four weeks . . . have you felt so down
in the dumps that nothing could cheer you up?
[READ RESPONSE CHOICES ONLY IF NECESSARY] (Circle one number)
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9d. How much of the time during the past four weeks . . . have you felt calm and
peaceful?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
352 Appendices
9e. How much of the time during the past four weeks . . . did you have a lot of
energy?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9f. How much of the time during the past four weeks . . . have you felt
downhearted and depressed?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9g. How much of the time during the past four weeks . . . did you feel worn out?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9h. How much of the time during the past four weeks . . . have you been happy?
All of the time ......................................................................................................................1
Appendices 353
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
9i. How much of the time during the past four weeks . . . did you feel tired?
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
10. During the past four weeks, how much of the time has your physical health
or emotional problems interfered with your social activities like visiting with
friends or relatives? Has it interfered . . .
All of the time ......................................................................................................................1
Most of the time ...................................................................................................................2
Some of the time ..................................................................................................................3
These next questions are about your health and health-related matters.
Now, I'm going to read a list of statements. After each one, please tell me if it is
definitely true, mostly true, mostly false, or definitely false. If you don't know, just tell
me.
11a. I seem to get sick a little easier than other people. Would you say that's . . .
Definitely true ......................................................................................................................1
Mostly true ...........................................................................................................................2
354 Appendices
Don't know ...........................................................................................................................3
Mostly false ..........................................................................................................................4
or Definitely false ................................................................................................................5
11b. I am as healthy as anybody I know. Would you say that's . . .

Definitely true ......................................................................................................................1
Mostly true ...........................................................................................................................2
Don't know ...........................................................................................................................3
Mostly false ..........................................................................................................................4
11c. I expect my health to get worse. Would you say that's . . .

Definitely true ......................................................................................................................1
Mostly true ...........................................................................................................................2
Don't know ...........................................................................................................................3
Mostly false ..........................................................................................................................4
11d. My health is excellent. Would you say that's . . .

Definitely true ......................................................................................................................1
Mostly true ...........................................................................................................................2
Don't know ...........................................................................................................................3
Mostly false ..........................................................................................................................4
Appendices 355
B. Vietnamese
Chất lượng cuộc sống liên quan tới sức khỏe Bắt đầu ☐
Tuần 16 ☐
Bảng câu hỏi này liên quan đến quan điểm của bạn về sức khỏe của chính mình.
Thông tin này sẽ giúp bạn theo dõi bạn cảm thấy ra sao và khả năng thực hiện các
sinh hoạt thông thường của bạn tốt như thế nào. Cảm ơn bạn đã tham gia cuộc
khảo sát này!
Đối với mỗi câu hỏi sau đây, xin vui lòng đánh dấu chéo vào một ô trả lời mô tả
chính xác nhất câu trả lời của bạn.
1. Nhìn chung, bạn cảm thấy sức khỏe của mình là:
Tuyệt vời Rất tốt Tốt Hơi kém Kém
1 2 3 4 5
2. Nhìn chung, so với thời điểm cách đây một năm, bạn đánh giá sức khỏe hiện
nay của mình như thế nào?
Bây giờ tốt Bây giờ tốt Gần giống Bây giờ kém Bây giờ kém
hơn nhiều so hơn một chút như thời điểm hơn một chút hơn nhiều so
với thời điểm so với thời cách đây một so với thời với thời điểm
cách đây một điểm cách năm điểm cách cách đây một
năm đây một năm đây một năm năm
1 2 3 4 5
3. Sau đây là những câu hỏi về các sinh hoạt mà có thể bạn sẽ thực hiện trong
một ngày bình thường. Sức khỏe hiện tại của bạn có làm hạn chế bạn trong
những sinh hoạt này không? Nếu có, mức độ hạn chế là như thế nào?
Có, hạn chế Có, hạn chế Không, chẳng

nhiều một ít hạn chế gì cả
a Các hoạt động dùng nhiều sức như chạy,

nâng vật nặng, tham gia các môn thể
thao mạnh .................................................................... 1 .................. 2 ................. 3
b Các hoạt động đòi hỏi sức lực vừa phải
như di chuyển một cái bàn, quét nhà,
bơi lội, hoặc chạy xe đạp ............................................. 1 .................. 2 ................. 3
c Nâng hoặc mang vác đồ thực phẩm linh tinh .............. 1 .................. 2 ................. 3
d Leo lên vài tầng lầu...................................................... 1 .................. 2 ................. 3
e Leo lên một tầng lầu .................................................... 1 .................. 2 ................. 3
f Uốn người, quỳ gối hoặc khom lưng
và gập gối ..................................................................... 1 .................. 2 ................. 3
g Đi bộ hơn một kílômét ................................................ 1 .................. 2 ................. 3
356 Appendices
h Đi bộ vài trăm mét ...................................................... 1 .................. 2 ................. 3
i Đi bộ một trăm mét ..................................................... 1 .................. 2 ................. 3
j Tắm rửa hoặc thay quần áo cho chính bạn .................. 1 .................. 2 ................. 3
4. Trong suốt 4 tuần vừa qua, do ảnh hưởng của sức khỏe thể chất, bạn có thường
gặp phải bất kỳ khó khăn nào sau đây trong công việc hoặc các sinh hoạt
thường ngày khác của bạn?
Luôn Rất thường Thỉnh Ít khi Không bao
luôn xuyên thoảng giờ
a Làm giảm thời lượng bạn tiến

hành công việc hoặc
sinh hoạt khác ................................. 1 ............. 2 ............. 3 ............. 4 ........... 5
b Hoàn thành công việc ít hơn
bạn muốn ......................................... 1 ............. 2 ............. 3 ............. 4 ........... 5
c Bị giới hạn trong một loại

công việc nào đó hoặc
sinh hoạt .......................................... 1 ............. 2 ............. 3 ............. 4 ........... 5
d Gặp khó khăn trong việc
thực hiện công việc hoặc
các sinh hoạt khác
(chẳng hạn như phải mất
nhiều công sức hơn) ........................ 1 ............. 2 ............. 3 ............. 4 ........... 5
5. Trong suốt 4 tuần vừa qua, do ảnh hưởng của yếu tố cảm xúc (chẳng hạn như
cảm thấy buồn phiền hoặc lo lắng), bạn có thường gặp phải bất kỳ khó khăn
nào sau đây trong công việc hoặc các sinh hoạt thường ngày khác của bạn?
a Làm giảm thời lượng bạn tiến

hành công việc hoặc
sinh hoạt khác ................................. 1 ............. 2 ............. 3 ............. 4 ........... 5
b Hoàn thành công việc ít hơn
bạn muốn ......................................... 1 ............. 2 ............. 3 ............. 4 ........... 5
c Làm việc hoặc tiến hành các

sinh hoạt khác kém
cẩn thận hơn bình thường ............... 1 ............. 2 ............. 3 ............. 4 ........... 5
6. Trong suốt 4 tuần vừa qua, sức khỏe thể chất hoặc các yếu tố cảm xúc có gây
trở ngại cho bạn trong các hoạt động xã hội thông thường mà bạn tham gia với
gia đình, bạn bè, hàng xóm hoặc các nhóm hội không, và ở mức độ nào?
Không hề Một chút Vừa phải Hơi nhiều Rất nhiều
1 2 3 4 5
Appendices 357
7. Trong suốt 4 tuần vừa qua, bạn cảm thấy cơ thể đau nhức ở mức độ nào?
Không Đau rất Đau nhẹ Đau vừa Đau trầm Đau rất
cảm thấy nhẹ phải trọng trầm trọng
đau
1 2 3 4 5 6
8. Trong suốt 4 tuần vừa qua, cảm giác đau đớn đã gây trở ngại cho công việc bình
thường của bạn ở mức độ nào (bao gồm cả công việc bên ngoài cũng như việc
nội trợ)?
Không hề Một chút Vừa phải Hơi nhiều Rất nhiều
1 2 3 4 5
9. Những câu hỏi này liên quan đến việc bạn cảm thấy ra sao và mọi việc như thế
nào với bạn trong suốt 4 tuần vừa qua. Đối với mỗi câu hỏi, xin vui lòng chọn
một câu trả lời đúng với cảm nhận của bạn nhất. Trong suốt 4 tuần vừa qua
bạn có thường cảm thấy...

a Bạn đã từng cảm thấy tràn đầy

sinh lực? .......................................... 1 ............. 2 ............. 3 ............. 4 ............. 5
b Bạn có cảm thấy rất lo lắng? ........... 1 ............. 2 ............. 3 ............. 4 ............. 5
c Bạn có cảm thấy quá đau

buồn và thất vọng đến độ
không có gì có thể làm bạn
vui lên được? ................................... 1 ............. 2 ............. 3 ............. 4 ............. 5
d Bạn có cảm thấy bình tĩnh và
thanh thản? ...................................... 1 ............. 2 ............. 3 ............. 4 ............. 5
e Bạn đã từng cảm thấy dồi dào
năng lượng?..................................... 1 ............. 2 ............. 3 ............. 4 ............. 5
f Bạn có cảm thấy buồn và
nản lòng? ......................................... 1 ............. 2 ............. 3 ............. 4 ............. 5
g Bạn đã từng cảm thấy kiệt sức? ...... 1 ............. 2 ............. 3 ............. 4 ............. 5
h Bạn có cảm thấy hạnh phúc? .......... 1 ............. 2 ............. 3 ............. 4 ............. 5
i Bạn đã từng cảm thấy mệt mỏi? ..... 1 ............. 2 ............. 3 ............. 4 ............. 5
358 Appendices
10. Trong suốt 4 tuần vừa qua, bạn có thường vì sức khỏe thể chất hoặc các yếu tố
cảm xúc của bạn cản trở đến các hoạt động xã hội mà bạn thực hiện (chẳng hạn
như đi thăm bạn bè, họ hàng, vv.)?
Luôn luôn Rất thường Thỉnh thoảng Ít khi Không bao
xuyên giờ
1 2 3 4 5
11. Mỗi nhận xét sau đây có mức độ ĐÚNG hay SAI như thế nào đối với bạn?
Hoàn toàn Hầu như Không biết Hầu như Hoàn toàn
đúng đúng sai sai
a Dường như tôi hơi dễ bị bệnh

hơn những người khác .................... 1 ............. 2 ............ 3.............. 4 ............. 5
b Tôi khỏe mạnh như bất kì
người nào mà tôi biết. ..................... 1 ............. 2 ............ 3.............. 4 ............. 5
c Tôi nghĩ rằng sức khỏe của
tôi sẽ trở nên tệ hơn ......................... 1 ............. 2 ............ 3.............. 4 ............. 5
d Sức khỏe của tôi tuyệt vời............... 1 ............. 2 ............ 3.............. 4 ............. 5
Appendices 359
Appendix 22. Phase 3 − Participant Demographic Information Questionnaire
The following questions related to your personal information. Please tick (√) or fill in
blanks in the following questions:
1. Age: ………………………………….. years old (current age in Western calendar)
2. Gender: ☐ Male ☐ Female
3. Marital status:
☐ Married ☐ Single
☐ Separated ☐ Divorced ☐ Widowed
4. What is your highest education level?

☐ Primary school (level 1 to 5) ☐ Secondary school (level 6 to 9)
☐ High school (level 10 to 12) ☐ Two years certificate
☐ College (3 years) ☐ Bachelor (University)
☐ Others (please specify) ……………………………………………………
5. What is your occupation?

☐ Professional ☐ Farmer
☐ Industrial worker ☐ Salesperson
☐ Home worker ☐ Retired
☐ Other jobs (please specify)……………………………………….……
6. How much of your income and your family income per month?
a. Your income per month: ………………………..……….…………VND
b. Your family income per month: …………………..…….…………..VND
7. Do you have your health insurance? Yes ☐ No ☐

If yes, please indicate how much it covers for your treatment? ....................... (percent)
8. How many people are living with you at home? …………………… (in number)
9. How long you have been diagnosed with kidney problem? ……..… (in years)
10. Did you or your family members look at the meaning of the blood results or
medications on the internet [eg. google search] to get a better understanding about
your kidney problems?
Yes ☐ No ☐
360 Appendices
B. Vietnamese
Thông tin cá nhân Baseline ☐
Xin Ông/Bà vui lòng cho biết một số thông tin về bản thân. Ông/Bà có thể đánh dấu √
hoặc điền vào chỗ trống những thông tin cần thiết trong những câu hỏi sau đây:
1. Tuổi: ………………………………….. (tuổi hiện tại tính theo năm dương lịch)
2. Giới tính: ☐ Nam ☐ Nữ
3. Tình trạng hôn nhân:

☐ Lập gia đình ☐ Độc thân
☐ Ly thân ☐ Ly dị ☐ Góa bụa
4. Trình độ học vấn cao nhất của Ông/Bà là gì?

☐ Tiểu học (lớp 1-5) ☐ Trung học cơ sở (lớp 6-9)
☐ Trung học phổ thông (lớp 10-12) ☐ Trung cấp (2 năm)
☐ Cao đẳng (3 năm) ☐ Đại học (≥4 năm)
☐ Trình độ khác (vui lòng ghi rõ) ……………………………………
5. Nghề nghiệp hiện tại của Ông/Bà là gì?

☐ Cán bộ và nhân viên văn phòng ☐ Nông dân
☐ Công nhân ☐ Buôn bán
☐ Nội trợ ☐ Hưu trí
☐ Nghề khác (xin vui lòng ghi rõ)………………………………………
6. Thu nhập cá nhân/của gia đình Ông/Bà mỗi tháng là bao nhiêu?
a. Thu nhập cá nhân/tháng: ………………………………………Việt Nam Đồng
b. Thu nhập của gia đình/tháng: …………………………………..Việt Nam Đồng
7. Ông/Bà có bảo hiểm y tế không? Có ☐ Không ☐

Nếu có thì bảo hiểm y tế chi trả bao nhiêu phần trăm cho ông/bà?..…....% (phần trăm)
8. Có bao nhiêu người sống cùng với Ông/Bà? …………………………………….
9. Ông/Bà được chẩn đoán bệnh thận bao lâu? …………………… (tính theo năm)
10. Ông/Bà hoặc người thân của ông/bà có tìm kiếm thêm thông tin về kết quả xét
nghiệm máu hoặc thuốc được bác sĩ kê đơn trên mạng [ví dụ như tìm kiếm trên
google] để hiểu hơn về bệnh thận của ông/bà? Có ☐ Không ☐
Appendices 361
Appendix 23. Phase 3 – Renal Clinical Characteristics (Patients’ Medical Records)
Week 16 ☐
1. What was the main cause of your kidney problem?
……………………………………
2. Your renal clinical results
1. eGFR: ……………………… 2. Creatinine: ………………
3. Urea: ……………………… 4. Albumin: …………………
5. Cholesterol: ………………… 6. HDL: ……………………
7. LDL: ………………………… 8. HbA1c: ……………………
9. Blood glucose level: …………………… 10. Blood pressure: ………………..
11. Calcium: ………………………… 12. Sodium: ……………………
13. Potassium: ……………………… 14. Phosphate: ……………………
15. Bicarbonate (HCO3): …………………… 16. Iron (Fe): ………………………
17. Haemoglobin (Hb): …………………….. 18. Urine protein: ………………………
19. Height: ……………………………... 20. Weight: …………………………
21. BMI: …………………………………
3. Current medications used

Patient’s Medical Records
362 Appendices
B. Vietnamese
Kết quả cận lâm sàng từ sổ khám của người bệnh
Bắt đầu ☐
Tuần 16 ☐
1. Nguyên nhân dẫn đến bệnh thận? ………………………………………….
2. Kết quả cận lâm sàng:
1. Chỉ số lọc cầu thận: ............... 2. Serum creatinine: ...............
3. Urê: ............... 4. Albumin: ...............
5. Cholesterol: ............... 6. HDL: ...............
7. LDL: ............... 8. HbA1C: ...............
9. Mức đường máu: ............... 10. Huyết áp: ...............
11. Canxi toàn phần: ............... 12. Na+: ...............
13. K+: ............... 14. Phospho: ...............
15. HCO3: ............... 16. Sắt (Fe): ...............
17. Huyết sắc tố (Hb): ............... 18. Protein niệu: ...............
19. Chiều cao: ............... 20. Cân nặng: ...............
21. BMI: ...............
3. Thuốc về bệnh Thận mà Ông/Bà đang dùng:

Hồ sơ người bệnh
Appendices 363
Appendix 24. Phase 3 − Patients’ Comorbidity
Week 16 ☐
Comorbidities collected from patient with CKD (stages 3–5)
Comorbidity Comments/Notes
Comorbidities identified in Patient’s Medical Chart

Comorbidity Comments/Notes
364 Appendices
B. Vietnamese
Bệnh đi kèm Bắt đầu ☐
Tuần 16 ☐
Bệnh đi kèm thu thập từ người bệnh thận mãn tính (giai đoạn 3–5)
Bệnh đi kèm Ghi chú
Bệnh đi kèm được ghi chép trong hồ sơ người bệnh

Bệnh đi kèm Ghi chú
Appendices 365
Appendix 25. Phase 3 − Scoring of Patients’ Comorbidities
Charlson Comorbidity Index (Charlson et al., 1994; Charlson et al., 1987; You-qun et al.,
2014)
1. Indication: assess whether a patient will live long enough to benefit from a specific
screening measure or medical intervention
2. Scoring: Comorbidity Component (apply 1 point to each unless otherwise noted)
2.1. Myocardial infarction
2.2. Congestive Heart Failure
2.3. Peripheral Vascular Disease
2.4. Cerebrovascular Disease
2.5. Dementia
2.6. COPD
2.7. Connective Tissue Disease
2.8. Peptic Ulcer Disease
2.9. Diabetes Mellitus (1 point uncomplicated, 2 points if end-organ damage)
2.10. Moderate to Severe Chronic Kidney Disease (2 points)
2.11. Hemiplegia (2 points)
2.12. Leukaemia (2 points)
2.13. Malignant Lymphoma (2 points)
2.14. Solid Tumor (2 points, 6 points if metastatic)
2.15. Liver Disease (1 point mild, 3 points if moderate to severe)
2.16. AIDS (6 points)
3. Scoring: Age
3.1. Age <40 years: 0 points
3.2. Age 41‐50 years: 1 point
3.3. Age 51‐60 years: 2 points
Interpretation
1. Calculate Charlson Score or Index (i)
1. Add Comorbidity score to age score
2. Total denoted as 'i' below
2. Calculate Charlson Probability (10 year mortality)
1. Calculate Y = e^(i * 0.9)
2. Calculate Z = 0.983^Y
3. where Z is the 10 year survival
366 Appendices
Appendix 26. Phase 3 − Evaluation of the Intervention Program
A. English Intervention group ☐

Week 16 ☐
We would like to know how you feel about the kidney disease self-management program. For each of the following items, please tick (√) in the
columns which reflect your feeling about this program.
Items Strongly Agree Neutral Disagree Strongly
Agree Disagree
1. Did you find the self-management program (booklet, teaching, phone calls) helped
you to look after yourself better?
2. Was the CKD booklet easy to read and understand?
3. Are you more motivated to look after yourself?
4. Was the length of the education session appropriate?
5. Was the length of the telephone calls appropriate?
6. Would you recommend the kidney disease self-management program to other patients? Yes ☐ No ☐
7. Did you or anyone in your family look up on the internet to get information about your
kidney problems or its treatment (e.g., medications)? Yes ☐ No ☐
Doctor Yes ☐ No ☐
8. Who should provide the kidney disease self-management program? Nurse Yes ☐ No ☐
9. Do you have suggestions to improve the kidney disease self-management program?

…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
Thank you for completing this evaluation.
Appendices 367
B. Vietnamese−Đánh giá về chương trình can thiệp Nhóm can thiệp ☐
Tuần 16 ☐
Chúng tôi muốn biết Ông/Bà cảm thấy như thế nào về chương trình hướng dẫn tự quản lý bệnh thận. Đối với mỗi câu hỏi dưới đây, xin Ông/Bà
vui lòng đánh dấu (√) vào cột mà phản ánh đúng nhất cảm giác của Ông/Bà về chương trình này.
Items Hoàn toàn Đồng ý Có thể Không Hoàn toàn
đồng ý đồng ý không đồng ý
1. Ông/Bà có thấy chương trình tự quản lý bệnh thận (cẩm nang hướng dẫn,
giảng dạy, gọi điện thoại) giúp Ông/Bà trong việc tự chăm sóc mình tốt hơn?
2. Ông/Bà có thấy quyển sách hướng dẫn quản lý bệnh thận là dễ đọc và dễ hiểu?
3. Ông/Bà có thêm động lực để tự chăm sóc bản thân?
4. Thời gian dành cho phần giảng dạy là phù hợp?
5. Thời gian dành cho phần gọi điện thoại là phù hợp?
6. Ông/Bà có muốn giới thiệu chương trình hướng dẫn tự quản lý bệnh thận này tới Có ☐ Không ☐
những người bệnh khác?
7. Ông/Bà hoặc người thân có tìm kiếm trên mạng để có them thông tin về bệnh thận
hoặc phương pháp điều trị (ví dụ: thuốc) Có ☐ Không ☐
8. Theo Ông/Bà ai là người nên cung cấp chương trình hướng dẫn tự quản lý bệnh thận Bác sĩ Đồng ý ☐ Không đồng ý ☐
này? Điều dưỡng Đồng ý ☐ Không đồng ý ☐
9. Ông/Bà có những góp ý gì không để góp phần nâng cao chương trình hướng dẫn tự quản lý bệnh thận này?
…………………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………………
Cảm ơn Ông/Bà đã hoàn thành đánh giá này.
368 Appendices
Appendix 27. Problematic words and phrases from Forward Translation of KiKS
Original Forward translator 1 Forward translator 2 Reviewer’s comments and agreements made
statement
Kidney Khảo sát kiến thức về bệnh thận Khảo sát kiến thức về thận (KiKS) Khảo sát kiến thức về bệnh thận (KiKS)
Knowledge (KiKS)
Survey
(KiKS)
Item 1 Nhìn chung, chỉ số huyết áp của bạn Tính trung bình, huyết áp của Ông/Bà “Tính trung bình [one average], huyết áp [blood
nên là: nên là: pressure], and Thấp hơn [Lower than]” were
□ 160/90 □ 160/90 accepted for close meaning to the original.
□ 150/100 □ 150/100
□ 170/80 □ 170/80
□ Thấp hơn 130/80 □ Dưới 130/80
Item 2 Có những loại thuốc nhất định mà Có một số thuốc mà bác sỹ của The phrases “nhất định, chỉ định [certain,
bác sĩ của bạn có thể kê đơn để giúp Ông/Bà có thể chỉ định để giúp giữ prescribe]” were accepted for close meaning
thận của bạn khoẻ mạnh có đúng cho thận của Ông/Bà càng khoẻ mạnh with the original.
không? càng tốt có phải không? The answer of the original is “yes or no”
□ Có □ Không có □ Đúng □ Không đúng translated into Vietnamese is (có/đúng or không
có/không đúng), therefore, the choice “đúng or
không đúng [correct or incorrect]” were used to
appropriate with the normal answer of yes/no
questions.
Item 3 Tại sao quá nhiều đạm (protein) Tại sao quá nhiều protein trong nước The word “đạm [protein]” was accepted as it is a
trong nước tiểu lại không tốt cho tiểu thì không tốt cho thận? plain word.
thận
Item 4 Chọn 1 THUỐC trong danh sách Chọn MỘT LOẠI THUỐC trong danh Phrase “Chọn MỘT THUỐC [choose one
dưới đây mà một người mắc bệnh sách dưới dây mà một người bị mắc medication]” was accepted because “Chọn MỘT
thận MÃN TÍNH nên tránh: bệnh thận MÃN TÍNH nên TRÁNH: LOẠI THUỐC [choose one type of medication]”
□ Lisinopril □ Lisinopril the original is select the one medication not one
Appendices 369
statement
□ Tylenol □ Tylenol type of medication.
□ Motrin / Ibuprofen □ Motrin / Ibuprofen
□ Vitamin E □ Vitamin E
□ Viên sắt □ Viên sắt
Item 5 Nếu thận bị suy, điều trị có thể bao Nếu thận bị suy, điều trị bệnh có thể The phrase “Chạy thận nhân tạo
gồm (ĐỐI VỚI CÂU HỎI NÀY bạn bao gồm (ĐỐI VỚI CÂU HỎI NÀY [haemodialysis]” were used instead of “Lọc máu
có thể CHỌN 1 CHO ĐẾN 2 CÂU Ông/Bà có thể chọn HAI ĐÁP ÁN): and Lọc thận nhân tạo [kidney dialysis]” for
TRẢ LỜI): □ Sinh thiết phổi more appropriate.
□ Sinh thiết phổi □ Lọc thận nhân tạo □ Sinh thiết phổi
□ Lọc máu □ Nội soi phế quản □ Chạy thận nhân tạo
□ Soi phế quản □ Nội soi đại tràng □ Nội soi phế quản
□ Soi đại tràng □ Ghép thận □ Nội soi đại tràng
□ Ghép thận □ Ghép thận
Item 6 “GFR” là viết tắt của từ gì? “GFR” có nghĩa là gì? The phrases “có nghĩa là gì [mean], mức độ
□ Tốc Độ Lọc Cầu Thận □ Glomerular Filtration Rate – cho [level], and dòng chảy [flow]” were accepted.
(Glomerular Filtration Rate) – cho chúng ta biết mức độ chức năng thận “GFR” có nghĩa là gì?
chúng ta biết cấp độ của chức năng □ Good Flow Renal – cho chúng ta □ Glomerular Filtration Rate – cho chúng ta biết
thận biết dòng chảy của nước tiểu từ thận mức độ chức năng thận
□ Lưu Lượng Tuới Máu Thận Tốt □ Gain For Renal – cho chúng ta viết □ Good Flow Renal – cho chúng ta biết dòng
(Good Flow Renal) – cho chúng ta nếu chức năng thận đang được cải chảy của nước tiểu từ thận
biết về lưu lượng của nước tiểu từ thiện □ Gain For Renal – cho chúng ta biết chức năng
thận □ Glucose Function Rate – cho chúng thận đang được cải thiện
□ Thận Cải Thiện (Gain For Renal) ta biết về mức độ đường huyết của □ Glucose Function Rate – cho chúng ta biết về
– cho chúng ta biết nếu chức năng Ông/Bà mức độ đường huyết
thận của bạn đang cải thiện
□ Glucose Function Rate – cho
chúng ta biết về mức đường huyết
của bạn
Item 7 Bệnh thận MÃN TÍNH có các giai Bệnh thận MÃN TÍNH có các giai “Đúng không” was used to appropriate with the
370 Appendices
statement
đoạn không? đoạn khác nhau có phải không? answer scale. The answer “đúng or không đúng”
was used for yes/no questions of the
questionnaire.
Item 8 Bệnh thận MÃN TÍNH có làm tăng Bệnh thận MÃN TÍNH làm tăng nguy “nguy cơ đau tim cho người bệnh đúng không”
khả năng gặp cơn đau tim (nhồi máu cơ đau tim cho người bệnh có phải was used to appropriate with the answer scale
cơ tim) của một người không? không? and close to normal speaking language in
Vietnam.
Item 9 Bệnh thận MÃN TÍNH có làm tăng Bệnh thận MÃN TÍNH làm tăng nguy “làm tăng nguy cơ tử vong cho con người đúng
khả năng tử vong của một người do cơ tử vong cho một người vì bất cứ không” was used for easy understanding.
bất kỳ lý do nào không? nguyên nhân gì có phải không?
Phần này sẽ hỏi về THẬN LÀM Phần này sẽ hỏi về THẬN LÀM Phần này sẽ hỏi về THẬN LÀM NHỮNG GÌ.
NHỮNG GÌ. Xin Ông/Bà vui lòng NHỮNG GÌ. Xin Ông/Bà vui lòng Xin Ông/Bà vui lòng chọn một câu trả lời
chọn một câu trả lời bằng cách chọn một câu trả lời bằng cách đánh bằng cách đánh dấu √ vào ô trống cho mỗi
đánh dấu √ vào ô trống cho mỗi dấu √ vào ô trống cho mỗi câu hỏi câu hỏi sau đây.
câu hỏi sau đây. sau đây.
Item 10 Thận tạo nước tiểu phải không? Thận tạo ra nước tiểu? Thận tạo ra nước tiểu đúng không?
Item 11 Thận làm sạch máu phải không? Thận làm sạch máu? Thận làm sạch máu đúng không?
Item 12 Thận giữ cho xương khoẻ mạnh Thận giữ cho xương khoẻ mạnh? Thận giữ cho xương khoẻ mạnh đúng không?
đúng không?
Item 13 Thận giữ cho ta không bị rụng tóc Thận giữ cho không bị rụng tóc? Thận giữ cho không bị rụng tóc đúng không?
đúng không?
Item 14 Thận giúp giữ cho số lượng hồng Thận giữ cho số lượng hồng cầu bình Thận giúp giữ cho số lượng hồng cầu bình
cầu bình thường đúng không? thường? thường đúng không?
Item 15 Thận giúp giữ cho huyết áp bình Thận giữ cho huyết áp bình thường? Thận giúp giữ cho huyết áp bình thường đúng
thường đúng không? không?
item 16 Thận giúp giữ cho đường máu bình Thận giúp cho việc giữ đường huyết “Đường huyết [blood glucose]” was accepted for
thường đúng không? bình thường? easy understanding.
Item 17 Thận giúp giữ cho mức Kali trong Thận giúp cho việc giữ nồng độ Kali “Giữ nồng độ Kali [potassium level]” was used
Appendices 371
statement
máu bình thường đúng không? trong máu bình thường? for easy understanding.
Item 18 Thận giúp giữ cho mức phốt pho Thận giúp cho việc giữ nồng độ phốt- “Giữ nồng độ phốt-pho [phosphorus level]” was
trong máu bình thường đúng không? pho trong máu bình thường? used for easy understanding.
Phần này hỏi về TRIỆU CHỨNG. Phần này hỏi về TRIỆU CHỨNG. Phần này hỏi về TRIỆU CHỨNG. Ông/Bà vui
Ông/Bà vui lòng chọn từ danh Ông/Bà vui lòng chọn từ danh sách lòng chọn từ danh sách dưới đây những triệu
sách dưới đây những triệu chứng dưới đây những triệu chứng mà một chứng mà một người mắc bệnh thận mãn tính
mà một người mắc bệnh thận mãn người mắc bệnh thận mãn tính hoặc hoặc suy thận có thể có bằng cách đánh dấu √
tính hoặc suy thận có thể có bằng suy thận có thể có bằng cách đánh vào ô trống cho mỗi câu hỏi?
cách đánh dấu √ vào ô trống cho dấu √ vào ô trống cho mỗi câu hỏi?
mỗi câu hỏi?
Item 19 Tăng mệt mỏi? Mệt mỏi tăng? “Mệt mỏi tăng” was used as normal spoken
language in Vietnam.
Item 20 Khó thở (thở hụt hơi)? Thở nông? “Thở nông [shortness of breath]” was accepted
to close meaning with the original.
Item 21 Có vị kim loại/vị khó chịu trong Miệng có vị kim loại/có vị khó chịu “Miệng có vị kim loại/có vị khó chịu trong
miệng? trong miệng? miệng?” was used.
Item 22 Ngứa bất thường? Ngứa bất thường? Ngứa bất thường?
Item 23 Buồn nôn và/hoặc nôn? Buồn nôn và/hoặc nôn mửa? Buồn nôn và/hoặc nôn mửa?
Item 24 Rụng tóc? Rụng tóc? Rụng tóc?
Item 25 Khó ngủ tăng? Khó ngủ tăng lên? Khó ngủ tăng lên?
Item 26 Sụt cân? Giảm cân? “Giảm cân [weight loss])?” was used instead of
“Sụt cân” for more appropriate.
Item 27 Lẫn lộn? Nhầm lẫn? “Nhầm lẫn (Giảm trí nhớ) [confusion]” was used
for easy understanding.
Item 28 Không có bất kỳ triệu chứng nào? Không có triệu chứng nào cả? “Không có bất kỳ triệu chứng nào cả” was used
as normal spoken language in Vietnam.
Note: Problematic words and phrases were highlighted in yellow colour.
372 Appendices
Appendix 28. Problematic words and phrases from Forward Translation of CKD-SM
Original Forward translator 1 Forward translator 2 Reviewer’s comments and agreements

statement made
CKD-SM
Chronic kidney TỰ QUẢN LÝ BỆNH THẬN TỰ CHĂM SÓC BỆNH THẬN MÃN “TỰ QUẢN LÝ [self-management]” was
disese self- MÃN TÍNH TÍNH used as a plain phrase.
management
CHRONIC TỰ QUẢN LÝ BỆNH THẬN TỰ CHĂM SÓC BỆNH THẬN MÃN TỰ QUẢN LÝ BỆNH THẬN MÃN
KIDNEY MÃN TÍNH TÍNH TÍNH (CKD - SM)
DISEASE SELF- Dưới đây là 32 câu hỏi liên quan đến cảm
MANAGEMENT Dưới đây là một số những câu hỏi Dưới đây là một số những câu hỏi liên giác và cách làm của Ông/Bà trong việc
liên quan đến việc bạn cảm thấy quan đến việc Ông/Bà cảm thấy như chống đỡ lại bệnh thận mãn tính. Ông/Bà
There are a như thế nào và bạn làm thế nào để thế nào và làm như thế nào để chống vui lòng đánh dấu √ vào một trong bốn lựa
number of giải quyết với bệnh thận mãn tính, đỡ bệnh thận mãn tính, xin Ông/Bà chọn (1: Không bao giờ; 2: Thỉnh thoảng;
questions in xin hãy chọn 1 trong 4 đáp án trên hãy chọn một trong bốn đáp án mà 3: Thường xuyên; 4: Luôn luôn) mà phản
relation to how mà phản ánh tốt nhất tình trạng phản ánh tốt nhất tình trạng thực tại ánh tốt nhất tình trạng thực tại của Ông/Bà
you feel and deal thực tế của bạn trong 3 tháng gần của Ông/Bà trong ba tháng vừa qua. trong ba tháng vừa qua.
with chronic đây. 1: Không bao giờ;
kidney disease, 1: Không bao giờ; 2: Thỉnh thoảng;
please select one 2: Thỉnh thoảng 3: Thường xuyên;
of four response 3: Thường xuyên; 4: Luôn luôn
that best reflects 4: Luôn luôn
your real
situation in the
Appendices 373
statement made
last three months.
1: Never; 2:
Sometimes; 3:
Often; 4: Always
Item 1 Khi tôi có câu hỏi về bệnh thận của Khi tôi có thắc mắc về tình trạng bệnh “Thắc mắc [questions]” was accepted for
tôi, tôi thảo luận những điều sẽ làm thận của tôi, tôi thảo luận những gì cần normal spoken way.
với gia đình và bạn bè làm với gia đình và bạn bè của tôi.
Item 2 Tôi sẽ hỏi về những nguyên nhân Tôi sẽ hỏi về các nguyên nhân có thể The phrase “các nguyên nhân có thể gây ra
có thể dẫn đến việc suy giảm chức gây ra việc suy giảm chức năng thận [the reasons which might cause]” was
năng thận của tôi. của tôi accepted as normal spoken way.
Item 3 Tôi thông báo với gia đình và bạn Tôi thông báo với gia đình và bạn bè Tôi thông báo với gia đình và bạn bè của
bè tôi về kế hoạch điều trị thận của của tôi về kế hoạch điều trị bệnh thận tôi về kế hoạch điều trị bệnh thận của tôi
tôi (ví dụ như sự thay đổi thuốc, của tôi (ví dụ như thay đổi thuốc sử (ví dụ như thay đổi thuốc sử dụng, thay
thay đổi lối sống). dụng, thay đổi lối sống). đổi lối sống).
Item 4 Tôi chia sẻ kinh nghiệm cá nhân tôi Tôi chia sẻ kinh nghiệm/sự từng trải Tôi chia sẻ kinh nghiệm của cá nhân mình
về bệnh thận với những người khác của cá nhân tôi về bệnh thận với về bệnh thận với những người cũng mắc
mắc bệnh thận. những người cũng mắc bệnh thận. bệnh thận.
Item 5 Tôi hiểu ý nghĩa của những xét Tôi hiểu ý nghĩa của các xét nghiệm This item was modified as “Tôi hiểu ý
nghiệm máu về chức năng thận của máu dùng để đánh giá chức năng thận nghĩa các chỉ số đánh giá chức năng thận
tôi (ví dụ như creatinine, eGFR). của tôi (ví dụ như creatinine, eGFR). của các xét nghiệm máu của tôi (ví dụ như
creatinine, eGFR) [I understand results of
laboratory tests which were used to
evaluate my kidney’s function]” for easy
374 Appendices
statement made
understanding.
Item 6 Khi huyết áp của tôi tăng cao (hơn Khi huyết áp của tôi cao (lớn hơn This item was modified as “Khi huyết áp
140/90), tôi cố gắng tìm ra lý do có 140/90), tôi cố gắng tìm ra các nguyên của tôi tăng cao (lớn hơn 140/ 90), tôi cố
thể. nhân có thể dẫn đến việc này. gắng tìm ra các nguyên375nhân có thể dẫn
đến việc này [when my blood pressure
increased (more than 140/90), I try to find
out any possible cause for this]” for easy
understanding.
Item 7 Để phòng tránh sự gia tăng hoạt Để phòng tránh sự làm việc quá tải “Để tránh gây hại cho thận, tôi nên kiểm
động đối với thận của mình, tôi có cho thận, tôi có khả năng kiểm soát soát chế độ ăn [to prevent an overwork for
thể kiểm soát những gì mà tôi ăn. những gì tôi ăn. my kidney, I am able to control what I
eat]” was used as normal spoken language.
Item 8 Tôi tuân theo những chế độ ăn Tôi thực hiện theo chế độ ăn kiêng This item was modified as “Tôi thực hiện
được khuyến cáo bởi bác sĩ hoặc được khuyến nghị bởi bác sĩ hoặc điều chế độ ăn kiêng theo lời khuyên của bác sĩ
điều dưỡng hoặc nhà dinh dưỡng dưỡng hoăc chuyên gia dinh dưỡng hoặc điều dưỡng.” [I follow the diet which
của tôi. của tôi. was recommended by my doctors or
nurses].
Item 9 Tôi giải quyết các vấn để liên quan Tôi giải quyết các vấn đề liên quan “Nguồn thông tin khác nhau [different
đến bệnh thận của tôi bằng cách sử đến bệnh thận của tôi bằng cách sử sources]” was accepted.
dụng các nguồn lực đa dạng (ví dụ dụng các nguồn thông tin khác nhau
gọi cho điều dưỡng hoặc bác sĩ của (ví dụ như gọi cho bác sĩ hoặc điều
tôi, sử dụng internet, Google, nhóm dưỡng của tôi, sử dụng internet,
hỗ trợ bệnh thận). Google, nhóm hỗ trợ người mắc bệnh
Appendices 375
statement made
thận).
Item 10 Khi tôi cảm thấy bối rối hoặc nản Khi tôi cảm thấy khó chịu hoặc thất “Khó chịu hoặc thất vọng [feeling upset or
lòng, tôi thảo luận cảm giác của tôi vọng, tôi thảo luận với người khác về frustrated]” and “cảm xúc [emotion]” were
với những người khác cảm xúc của tôi. accepted.
Item 11 Tôi kết hợp chặt chẽ việc điều trị Tôi kết hợp việc điều trị bệnh thận của The item was modified as “Tôi kết hợp
bệnh thận của tôi vào cuộc sống tôi vào trong cuộc sống thường nhật chặt chẽ việc điều trị bệnh thận với mọi
của tôi. của tôi. sinh hoạt hằng ngày của mình [I integrate
closely my treatment of kidney disease
into my daily life]” for easy
understanding.
Item 12 Tôi tránh những thói quen mà làm Tôi từ bỏ những thói quen mà làm xấu Tôi từ bỏ những thói quen làm xấu đi chức
tồi đi chức năng thận của tôi (ví dụ đi chức năng thận của tôi (ví dụ như năng thận của tôi (ví dụ như hút thuốc lá,
như hút thuốc, tiêu thụ đồ uống có hút thuốc, uống các loại đồ uống có uống các loại đồ uống có cồn, ăn mặn).
cồn, thức ăn nhiều muối) cồn, ăn mặn).
Item 13 Tôi tuân theo những khuyến cáo Tôi thực hiện theo những khuyến nghị This item was modified as “Tôi tập thể dục
của các chuyên gia sức khoẻ về của các chuyên gia y tế về việc tập thể hàng ngày theo lời khuyên của bác sĩ và
việc luyện tập. dục. điều dưỡng [I follow doctors and nurses’
recommendations of doing exercise]”.
Item 14 Tôi theo dõi những triệu chứng của Tôi theo dõi sát các triệu chứng và các Tôi theo dõi sát các triệu chứng và những
mình và những dấu hiệu cảnh báo dấu hiệu cảnh báo sớm của tôi (ví dụ dấu hiệu cảnh báo sớm về bệnh thận mãn
sớm (mức đường huyết, cân nặng, như đường máu, cân nặng, thở nông, tính và suy thận của tôi (ví dụ như mức
khó thở, phù chân). phù chân) đường huyết, cân nặng, thở nông, phù
chân).
376 Appendices
statement made
Item 15 Tôi tuân theo những khuyến cáo Tôi thực hiện theo các khuyến nghị Tôi thực hiện theo lời khuyên của bác sĩ và
của các chuyên gia sức khoẻ về một của các chuyên gia y tế về một chế độ điều dưỡng về một chế độ ăn uống hợp lý.
chế độ ăn cân bằng. ăn uống cân bằng.
Item 16 Tôi hỏi bác sĩ hoặc điều dưỡng Tôi hỏi bác sĩ hoặc điều dưỡng để hiểu Tôi hỏi bác sĩ hoặc điều dưỡng để hiểu rõ
những câu hỏi để làm rõ kế hoạch rõ kế hoạch điều trị bệnh thận của tôi. kế hoạch điều trị bệnh thận của tôi.
điều tri thận của tôi.
Item 17 Tôi tuân theo những khuyến cáo Tôi thực hiện theo những khuyến nghị Tôi thực hiện theo lời khuyên của bác sĩ và
của các chuyên gia sức khoẻ về của các chuyên gia y tế về việc không điều dưỡng về việc không hút thuốc lá.
việc không hút thuốc. hút thuốc.
Item 18 Tôi thay đổi lối sống của tôi để Tôi đã thay đổi nếp sống của mình để This item was modified as “Tôi đã thay
tránh làm bệnh thận của tôi bị tồi phòng ngừa bệnh thận của tôi trở nên đổi lối sống của mình để bệnh thận không
đi. nặng hơn. trở nên nặng hơn [I have changed my
lifestyle to prevent my kidney disease
from getting worse]”.
Item 19 Tôi tìm kiếm sự giúp đỡ từ người Tôi tìm kiếm sự giúp đỡ từ người khác “Khó chịu hoặc thất vọng [upset or
khác khi tôi cảm thấy bối rối hoặc khi tôi cảm thấy khó chịu hoặc thất frustrated]” was accepted.
nản lòng. vọng.
Item 20 Tôi giữ cho thận của tôi khoẻ mạnh Tôi giữ cho thận của tôi khoẻ mạnh “Giữ gìn sức khoẻ chung [keeping my
bằng cách duy trì sức khoẻ chung bằng cách giữ gìn sức khoẻ tổng thể general health condition]” was accepted.
của tôi. của tôi.
Item 21 Tôi dừng những thói quen xấu mà Tôi dừng những thói quen mà gây hại Tôi dừng những thói quen gây hại cho
có hại đối với thận của tôi (như hút cho thận của tôi (ví dụ như hút thuốc, thận của mình (ví dụ như hút thuốc lá, sử
thuốc, sử dụng thức ăn nhiều muối ăn mặn, uống rượu). dụng thức ăn nhiều muối, uống rượu bia).
Appendices 377
statement made
và đồ uống có cồn).
Item 22 Tôi áp dụng các biện pháp để hiểu Tôi thực hiện các bước để hiểu về các “Thực hiện các bước [take steps]” was
được những yếu tố nguy cơ liên yếu tố nguy cơ liên quan đến bệnh accepted because “áp dụng các biện pháp
quan đến bệnh thận mạn tính (ví dụ thận mãn tính (ví dụ như tăng huyết [using several methods]” means use
cao huyết áp, đái tháo đường, hút áp, đái tháo đường, hút thuốc, béo difference methods and do not have close
thuốc, béo phì). phì). meaning with the original.
Item 23 Tôi kiểm soát cân nặng của tôi theo Tôi kiểm soát cân nặng của mình dựa Tôi kiểm soát cân nặng của mình theo
những lời khuyên từ bác sĩ hay điều theo lời khuyên của bác sĩ và điều những lời khuyên từ bác sĩ và điều dưỡng.
dưỡng. dưỡng.
Item 24 Tôi đưa ra những lựa chọn tốt về Tôi đưa ra những lựa chọn tốt về số Tôi đưa ra những lựa chọn hợp lý về số
loại và lượng thức ăn tôi ăn khi tôi lượng và loại thức ăn mà tôi ăn khi tôi lượng và loại thức ăn của mình khi tôi
không ở nhà (ví dụ như ở cửa hàng, không ăn ở nhà (ví dụ như tại các cửa không ăn ở nhà (ví dụ như tại các nhà
nhà thờ, tiệc, ăn ở ngoài). hàng, nhà thờ, tiệc tùng, ra ngoài ăn). hàng, nhà thờ, tiệc tùng, ra ngoài ăn).
Item 25 Tôi có thể điều chỉnh thói quen Tôi có thể điều chỉnh thói quen hàng Tôi có thể điều chỉnh thói quen hàng ngày
hàng ngày của tôi để tuân theo kế ngày của tôi theo kế hoach điều trị theo kế hoach điều trị bệnh thận của mình
hoạch điều trị thận khi tôi không ở bệnh thận của tôi khi tôi không ở nhà khi không ở nhà (ví dụ như đi du lịch, đi
nhà (ví dụ như, du lịch, kỳ nghỉ). (ví dụ như đi du lịch, đi nghỉ dưỡng). nghỉ dưỡng).
Item 26 Khi cơ thể tôi có những triệu chứng Khi cơ thể của tôi có các dấu hiệu thể “Triệu chứng thực thể [physical
thực thể mới hoặc tồi đi (ví dụ như: chất mới hoặc xấu đi (ví dụ như là phù symptoms]” was accepted.
dịch ở chân (sưng), đau đầu trầm nề chân [sưng], nhức đầu nặng, đi tiểu
trọng, đi tiểu nhiều vào ban đêm), nhiều vào ban đêm), tôi cố gắng tìm ra
tôi cố gắng tìm ra nguyên nhân. nguyên nhân của nó.
Item 27 Tôi vẫn uống tất cả thuốc của tôi kể Tôi vẫn uống thuốc đầy đủ khi tôi “Thuốc đầy đủ [take all medication]” was
378 Appendices
statement made
cả khi tôi không ở nhà. không ở nhà. accepted.
Item 28 Tôi cảm thấy có thể đến các sự kiện Tôi cảm thấy tôi có khả năng tham gia “Có thể tham gia [able to attend]” was
xã hội (ví dụ như đám cưới, tiệc, đi các sự kiện xã hội (ví dụ như đám used instead of “có thể đến [able to go]
nhà thờ) mặc dù tôi mắc bệnh thận. cưới, tiệc tùng, đi lễ nhà thờ), mặc dù and có khả năng tham gia [could
tôi mắc bệnh thận. participate]”
Item 29 Tôi tìm kiếm những thông tin về Tôi tìm kiếm các thông tin về bệnh Tôi tìm kiếm các thông tin về bệnh thận
bệnh thận mạn tính từ nhiều nguồn thận mãn tính từ các nguồn khác nhau mãn tính từ các nguồn khác nhau (ví dụ
(ví dụ như internet, tờ rơi, sách (ví dụ như là internet, tờ phơi, sách, như là internet, tờ phơi, sách hướng dẫn bỏ
hướng dẫn bỏ túi, sách, nhóm hỗ nhóm hỗ trợ người mắc bệnh thận. túi, nhóm hỗ trợ người mắc bệnh thận.
trợ bệnh thận).
Item 30 Tôi uống thuốc của tôi đúng theo Tôi dùng thuốc theo chỉ định của bác This item was modified as “Tôi uống
đơn được kê bởi bác sĩ hoặc điều sĩ hoặc điều dưỡng hoặc dược sĩ. thuốc theo chỉ định của bác sĩ [I take my
dưỡng hoặc dược sĩ của tôi. medications as prescribed by my
doctors]”. The phrases “hoặc điều dưỡng
hoặc dược sĩ [nurses or pharmacists]” had
been deleted because only physicians can
prescribe medications for patients who
admitted in hospital in Vietnam.
Item 31 Tôi hành động khi những dấu hiệu Tôi có hành động khi các dấu hiệu Tôi có thực hiện hành động khi các dấu
cảnh báo sớm và những triệu chứng cảnh báo sớm và các triệu chứng của hiệu cảnh báo sớm và các triệu chứng của
của tôi trở nên tồi tệ. tôi trở nên tồi tệ hơn. mình trở nên tồi tệ hơn.
Item 32 Khi tôi có câu hỏi về bệnh thận của Khi tôi có thắc mắc bề bệnh thận của Khi tôi có thắc mắc bề bệnh thận của
tôi, tôi thảo luận những điều sẽ làm tôi, tôi thảo luận những gì cần làm với mình, tôi thảo luận những gì cần làm với
Appendices 379
statement made
với bác sĩ, điều dưỡng hoặc dược sĩ bác sĩ hoặc điều dưỡng hoặc dược sĩ. bác sĩ hoặc điều dưỡng.
của tôi.
380 Appendices
Appendix 29. Comparison of English and Back-Translated of Vietnamese KiKS
No Original version Translator 1 Translator 2 Finalise the English

version according to the
final Vietnamese version
Kidney Knowledge Survey Knowledge survey about kidney Investigating knowledge of Kidney Disease
(KiKS) disease kidney diseases (KiKS) Knowledge Survey
(KiKS)
1 On average, your blood In average, your blood pressure On average, your blood pressure On average, your blood
pressure should be: should be: should be: pressure should be:
□ 160/90 □ 160/90 □ 160/90 □ 160/90
□ 150/100 □ 150/100 □ 150/100 □ 150/100
□ 170/80 □ 170/80 □ 170/80 □ 170/80
□ Lower than 130/80 □ Less than 130/80 □ Below 130/80 □ Lower than 130/80
2 Are there certain There are certain medicines There are some medications which There are some
medications your doctor can which your doctor prescribes for your doctors can prescribe to keep medications which your
prescribe to help keep your you to keep your kidney healthy, your kidneys as good as possible? doctors can prescribe to
kidney(s) as healthy as isn’t it? □ Correct □ Not keep your kidneys as
possible? □ Correct □ Not correct correct good as possible?
□ Yes □ No □ Correct
□ Incorrect
3 Why is too much protein in Why is it not good for kidney Why it is not good for kidneys Why it is not good for
the urine not good for the when there is too much protein in when there is so much protein in kidneys when there is too
kidney? urine? urine? much protein in urine?
□ It can scar the kidney □ It can cause scar in kidney □ It may cause scar in kidneys □ It may cause scar the
□ It is a sign of kidney □ It is a sign of kidney injury □ It is the sign of kidney damage kidney
damage □ It is a sign of kidney injury □ It is the sign of kidney damage □ It is a sign of kidney
□ It is a sign of kidney AND it can cause scar in kidney AND it may cause scar in kidneys damage
damage AND can scar the □ It can cause urine infection □ It may cause urine infection □ It is a sign of kidney
Appendices 381
kidney □ All of above options □ All the above answers damage AND it may
□ It can cause an infection in cause scar the kidney
the urine □ It may cause urine
□ All of the above infection
□ All the above answers
4 Select the ONE Choose ONE KIND OF Choose ONE MEDICATION in Choose ONE
MEDICATION from the list MEDICINE in following list that the below list which people with MEDICATION from the
below that a person with CHRONIC kidney disease CHRONIC kidney diseases should list below that people
CHRONIC kidney disease patients should AVOID: AVOID: with CHRONIC kidney
should AVOID: □ Lisinopril □ Lisinopril diseases should AVOID:
□ Lisinopril □ Tylenol □ Tylenol □ Lisinopril
□ Tylenol □ Motrin / Ibuprofen □ Motrin / Ibuprofen □ Tylenol
□ Motrin / Ibuprofen □ Vitamin E □ Vitamin E □ Motrin / Ibuprofen
□ Vitamin E □ Iron tablet □ Fe supplement tablets □ Vitamin E
□ Iron Pills □ Fe supplement tablets
5 If the kidney(s) fail, When there is kidney failure, If kidneys are failure, treatment If the kidney(s) fail,
treatment might include treatment can include (FOR THIS may include (ACCORDING TO treatment might include
(FOR THIS QUESTION QUESTION, you can choose THIS QUESTION you can choose (FOR THIS QUESTION
you can PICK up to TWO TWO ANSWERS): TWO ANSWERS): you can CHOOSE up to
ANSWERS): □ Lung biopsy □ Lung biopsy TWO ANSWERS):
□ Lung biopsy □ Kidney dialysis □ Haemodialysis □ Lung biopsy
□ Haemodialysis □ Bronchoscopy □ Bronchoscopy □ Haemodialysis
□ Bronchoscopy □ Colonoscopy □ Colonoscopy □ Bronchoscopy
□ Colonoscopy □ Kidney implant □ Kidney replacement □ Colonoscopy
□ Kidney transplant □ Kidney transplant
6 What does “GFR” stand for? What does “GFR” mean? What does “GFR” mean? What does “GFR” mean?
□ Glomerular Filtration Rate □ Glomerular Filtration Rate – □ Glomerular Filtration Rate – □ Glomerular Filtration
– tells us level of kidney give us information about kidney indicates level of kidney function Rate – gives us
function function □ Good Flow Renal – indicates the information about kidney
□ Good Flow Renal – tell us □ Good Flow Renal – give us flow of urine from kidneys function
about flow of urine from information about urine flow □ Gain For Renal – indicates the □ Good Flow Renal –
382 Appendices
kidney from the kidney improvement of kidney function gives us information
□ Gain For Renal – tells us □ Gain For Renal – give us □ Glucose Function Rate – about urine flow from the
if your kidney function is information if kidney function is indicates your level of blood kidney
improving improved glucose □ Gain For Renal – gives
□ Glucose Function Rate – □ Glucose Function Rate – give us information if kidney
tells us about your blood us information about your blood function is improved
sugar level glucose □ Glucose Function Rate
– gives us information
about your blood glucose
level
7 Are there stages of Does CHRONIC kidney disease Do CHRONIC kidney diseases Does CHRONIC kidney
CHRONIC kidney disease? have different stages? have different stages? disease have different
□ Yes □ No □ Correct □ Not □ Yes □ No stages?
correct □ Correct
□ Incorrect
8 Does CHRONIC kidney Does CHRONIC kidney disease Do CHRONIC kidney diseases Does CHRONIC kidney
disease increase a person’s increase risk for heart attack for increase risks of heart diseases? disease increase risks of
chances for a heart attack? patients? □ Yes □ No heart attack for people?
□ Yes □ No □ Correct □ Not correct □ Correct
□ Incorrect
9 Does CHRONIC kidney Does CHRONIC kidney disease Do CHRONIC kidney diseases Does CHRONIC kidney
disease increase a person’s increase risk for death because of increase risks of death for people disease increase risk for
chance for death from any any cause? caused by any reasons? death because of any
cause? □ Correct □ Not correct □ Yes □ No cause?
□ Incorrect
This section is about This part will ask about WHAT This part will ask for WHAT This part will ask about
WHAT THE KIDNEY KIDNEY DOES. Please choose KIDNEYS DO. Please choose one WHAT KIDNEY
DOES. Please select one one answer for each following answer for each below question. DOES. Please choose
answer to each question questions. one answer for each
below. following questions.
Appendices 383
10 Does the kidney make Kidney creates urine, doesn’t it? Do kidneys create urine? Does kidney create urine?
urine? □ Correct □ Not correct □ Yes □ No □ Correct
□ Yes □ No □ Incorrect
11 Does the kidney clean Kidney cleans blood, doesn’t it? Do kidneys clean blood? Does kidney clean blood?
blood? □ Correct □ Not correct □ Yes □ No □ Correct
□ Yes □ No □ Incorrect
12 Does the kidney keep bones Kidney keeps bone healthy, Do kidneys keep bone strong? Does kidney keep bone
healthy? doesn’t it? □ Correct □ Not □ Yes □ No strong?
□ Yes □ No correct □ Correct
□ Incorrect
13 Does the kidney keep a Kidney keeps hair not loss, Do kidneys keep hair from Does kidney keep hair
person from losing hair? doesn’t it? loosing? from loosing?
□ Yes □ No □ Correct □ Not correct □ Yes □ No □ Correct
□ Incorrect
14 Does the kidney help keep Kidney keeps number of Do kidneys keep the number of Does kidney keep the red
red blood cell counts erythrocyte in normal range, hemoglobins normal? blood cell normal?
normal? doesn’t it? □ Yes □ No □ Correct
□ Yes □ No □ Correct □ Not correct □ Incorrect
15 Does the kidney help keep Kidney keeps blood pressure Do kidneys keep blood pressure Does kidney keep blood
blood pressure normal? normal, doesn’t it? normal? pressure normal?
□ Incorrect
16 Does the kidney help keep Kidney helps in keeping blood Do kidneys keep blood glucose Does kidney keep blood
blood sugar normal? glucose normal, doesn’t it? normal? glucose normal?
□ Incorrect
17 Does the kidney help keep Kidney helps in keeping Do kidneys keep level of potassium Does kidney keep level of
potassium levels in the potassium in blood normal, in blood normal? potassium in blood
blood normal? doesn’t it? □ Yes □ No normal?
□ Incorrect
384 Appendices
18 Does the kidney help keep Kidney helps in keeping Do kidneys keep level of Does kidney keep level of
phosphorus levels in the phosphorus in blood normal, phosphorus in blood normal? phosphorus in blood
blood normal? doesn’t it? □ Yes □ No normal?
□ Incorrect
This section is about This part asks about This part asks about This section is about
SYMPTOMS. Please select SYMPTOMS. Please choose SYMPTOMS. Please select all SYMPTOMS. Please
from the list, all of the from the following list all symptoms which one people may select from the list, all of
symptoms a person might symptoms saying that a person have when they have chronic the symptoms a person
have if they have chronic may have chronic kidney kidney disease or kidney failure. might have if they have
kidney disease or kidney disease or kidney failure. chronic kidney disease
failure. or kidney failure.
19 Increased fatigue? Increase fatigue? Increasing fatigue? Increased fatigue?
□ Incorrect
20 Shortness of breath? Shortness of breath? Narrow breathing? Shortness of breath?
□ Incorrect
21 Metal taste / bad taste in the Discomfort taste? Metallic taste/ bad taste in mouth? Metallic taste/ bad taste in
mouth? □ Correct □ Not correct □ Yes □ No mouth?
□ Incorrect
22 Unusual itching? Abnormal itching? Abnormal ichy? Abnormal itching?
□ Incorrect
23 Nausea and / or vomiting? Nausea and/ or vomit? Vomit and/or nausea? Nausea and/ or vomit?
□ Incorrect
24 Hair loss? Hair loss? Hair loss? Hair loss?
□ Incorrect
Appendices 385
25 Increased trouble sleeping? Increase difficulty in sleeping? Increasing difficulty in sleeping? Increased difficulty in
□ Yes □ No □ Correct □ Not correct □ Yes □ No sleeping?
□ Correct
□ Incorrect
26 Weight loss? Weight loss? Weight loss? Weight loss?
□ Incorrect
27 Confusion? Confuse? Confused? Confused?
□ Incorrect
28 No symptoms at all? No symptoms? No symptoms at all? No symptoms at all?
□ Incorrect
386 Appendices
Appendix 30. Comparison of English and Back-Translated of Vietnamese CKD-SM
No Original version Back-translator 1 Back-translator 2 Finalise the English version

according to the final
Vietnamese version
Chronic Kidney Disease Self- CHRONIC KIDNEY DISEASE CHRONIC KIDNEY DISEASE CHRONIC KIDNEY
Management (CKD-SM) SELF- MANAGEMENT SELF-CARE DISEASE SELF-
MANAGEMENT
There are a number of The following questions are about These questions below are related The following questions are
questions in relation to how how you feel and do to deal with to how do you feel and how do about how you feel and deal
you feel and deal with chronic chronic kidney disease you do to face with your chronic with chronic kidney disease.
kidney disease, please select Please choose one in four options kidney diseases, please choose Please select one of four
one of four response that best which best describes your current one option of answering which responses that best reflects
reflects your real situation in state during the last three months best reflect your condition in the your real situation in the last
the last three months. 1: Never 2: Sometime past three months. three months.
1: Never 2: Sometimes 3: Usually 4: Always 1: Never 2: Sometimes 1: Never 2: Sometimes
3: Often 4: Always 3: Often 4: Always 3: Usually 4: Always
1 When I have questions about When I have any questions about When I have questions of my When I have questions of my
my kidney disease, I discuss my kidney disease, I discuss what kidney disease, I discussed what I kidney disease, I discuss what
what to do with my family and need to be done with my family and have to do with my family and I have to do with my family
friends friends friends and friends
2 I would ask about the possible I will ask about cause for any I will ask about the reasons which I will ask about the reasons
reasons for my decline in decrease in my kidney function might cause the decrease of my which might cause the
kidney function kidney function decrease of my kidney
function
3 I inform my family and friends I inform my family and friends I told my family and friends about I inform my family and
about my kidney treatment about my kidney disease treatment treating plan of my kidney disease friends about my kidney
plan (such as, medications plan (For example: change in (For example: change of treatment plan (such as,
changes, lifestyle changes). medication, change in lifestyle) medications, change of living medications changes, lifestyle
style) changes).
Appendices 387
4 I share my personal experience I share my personal experience I shared my personal experiences I share my personal
of kidney disease with other about kidney disease with other of kidney diseases with other experience about kidney
patients who have kidney kidney disease patients patients who also have thesedisease with other kidney
disease diseases disease patients
5 I understand the meaning of I understand laboratory test using to I understand results of laboratory
I understand results of
my kidney function blood tests assess my kidney function (for tests which were used to evaluate laboratory tests which were
(such as creatinine, eGFR.) example: Creatine, eGFR). my kidney’s function (For used to evaluate my kidney’s
example: creatine, eGFR) function (For example:
creatinine, eGFR)
6 When my blood pressure is When my blood pressure increases When my blood pressure increase When my blood pressure
high (more than 140/90), I try (more than 140/90), I try to find out (above 140/90), I tried to find increases (more than 140/90),
to find out the possible reasons. any possible cause for this. reasons which might cause this I try to find out any possible
cause for this.
7 To prevent the increased To prevent an overwork for my In order to avoid the overworking
To prevent the increased
workload on my kidneys, I am kidney, I am able to control what I of the kidneys, I have ability of
workload on my kidneys, I
able to control what I eat eat controlling what to eat am able to control what I eat
8 I follow the kidney diet I follow diet recommended by my I follow the diet which was I follow the diet which was
suggested by my doctor or doctors or nurses or my dietitian recommended by my doctors or recommended by my doctors
nurse or dietitian nurses or nutritional specialists
or nurses.
9 I solve problems related to my I solve problems related to my I solved problem related to my I solve problem related to my
kidney disease using various kidney disease by using different kidney disease by using different
kidney disease by using
sources (such as calling my information sources (for example sources of information (For different sources of
nurse or doctor, using the phone my doctor or nurse, internet, example: calling my doctors or information (For example:
internet, Google, kidney Google, peer group) nurses, using internet, Google,calling my doctors or nurses,
support group). group of supporting patients with
using internet, Google, group
kidney diseases) of supporting patients with
kidney diseases)
10 When I am feeling upset or When I feel uncomforted or upset, I When I feel uncomfortable or When I feel uncomfortable or
frustrated, I discuss my discuss with others about my disappointed, I discussed with disappointed, I discussed with
feelings with others. emotion. someone about my emotion someone about my emotion
388 Appendices
11 I incorporate my kidney I combine kidney disease treatment I integrated closely my treatment I integrate closely my
disease treatment into my life. with my daily life. of kidney disease into my daily treatment of kidney disease
life into my daily life
12 I avoid habits that worsen my I quit habits which worsen my I quit my bad habits which made I quit habits which worsen
kidney function (such as kidney function (for example my kidney’s function worsen (For my kidney function (for
smoking, consuming alcoholic smoking, drinking alcohol, salty example: smoking, drinking example smoking, drinking
drinks, overly salty food) diet) alcohol, eating salty food) alcohol, salty diet)
13 I follow health professionals’ I follow health experts’ I followed healthcare I follow doctors and nurses’
recommendations about recommendations about exercise professionals’ recommendations recommendations of doing
exercise. of doing exercises exercises
14 I keep track of my symptoms I monitor my early warning signs I monitored closely symptoms and I monitor my early warning
and early warning signs (blood and symptoms and (for example: early detective signs (For signs and symptoms (for
sugar levels, weight, shortness blood glucose, weight, shortness of example: glucose blood, weight, example: blood glucose,
of breath, swelling in feet) breath, leg edema) narrow breathing, foot swelling) weight, shortness of breath,
foot swelling)
recommendations about eating recommendations about balance professionals’ recommendations recommendations about
a balanced diet. diet. of balance eating eating a balanced diet.
16 I ask doctors or nurses I ask doctor or nurse to clarify my I asked doctors or nurses I asked doctors or nurses
questions to clarify my kidney kidney disease treatment plan. questions to understand clearly questions to understand
treatment plan. the plan of treating my kidney clearly the plan of treating my
disease kidney disease
recommendations about not recommendations about no professionals’ recommendations recommendations about not
smoking smoking of NOT smoking smoking
18 I have changed my lifestyle to I change my lifestyle to prevent my I changed my life style to prevent I have changed my lifestyle to
prevent my kidney disease kidney disease to become worse worsen my kidney disease prevent my kidney disease
from getting worse from getting worse
19 I seek help from others when I I find help from others when I feel I found help from other people I seek help from others when
am feeling upset or frustrated. discomforted or upset. when I was uncomfortable and I am feeling upset or
disappointed frustrated.
Appendices 389
20 I keep my kidneys healthy by I keep my kidney healthy by I kept my kidney healthy by I keep my kidney healthy by
maintaining my overall health. keeping my general health. keeping my general health keeping my general health
condition condition
21 I stop bad habits which are I stop my harmful for kidney habit I stopped bad habbits which might I stop bad habits which might
harmful to my kidneys (such as (for example: smoking, eating salty harm my kidneys (For example: harm my kidneys (For
smoking, consuming overly food, drinking alcohol) smoking, eating salty food, example: smoking, eating
salty food and alcohol). drinking) salty food, drinking)
22 I take steps to understand the I perform steps to understand risk I did steps of studying risk factors I take steps to understand the
risk factors associated with for kidney disease (for example: related to chronic kidney diseases risk factors associated with
chronic kidney disease (such as increase blood pressure, diabetes, (For example: hypertension, chronic kidney disease (such
high blood pressure, diabetes, smoking, obesity) diabetes, smoking, obesity) as high blood pressure,
smoking, obesity). diabetes, smoking, obesity).
23 I control my body weight I control my weight based on I controlled my weight based on I control my weight based on
according to the advice from advices of my doctors and nurses doctors or nurses’ advices doctors or nurses advice
doctors or nurses.
24 I make good choices about the I have good choice about amount I showed up good choice of I make good choices about
type and amount of food I eat and kind of food I eat when I am number and types of eating food the type and amount of food I
when I am not at home (such not eating at home (for example: in when I did not eat at home (For eat when I am not at home
as at the shops, church, parties, restaurant, church, party, eating example: restaurants, church, (for example: in restaurant,
eating out). out) parties, eating outside) church, party, eating out)
25 I can adjust my daily routine to I can adjust my daily activities I could adjust daily habits based I can adjust my daily
follow my kidney treatment based on my kidney disease on the treating plan of my kidney activities based on my kidney
plan when I am not at home treatment plan when I am not at disease when I was not at home disease treatment plan when I
(such as, traveling, holidays). home (for example: on travel, (For example: travelling, go to am not at home (for example:
retreat) resort) on travel, retreat)
26 When my body has new or When my body has new symptoms When my body had new or When my body has new or
worsening physical symptoms or become worse (leg edema, worsen symptoms (For example: worsen symptoms (For
(such as: fluid in my legs serious headache, urinate many foot swelling, severe headache, example: foot swelling,
[swelling], severe headaches, time at night), I try to find out the urinate frequently at night), I tried severe headache, urinate
passing extra urine at night), I causes. to find reasons frequently at night), I tried to
try to find out the cause. find reasons
390 Appendices
27 I still take all of my I still have my medicine even I had medications frequently even I still take all of my
medications even when I am though I am not at home when I was not at home medications even when I am
not at home not at home
28 I feel able to go to social I feel I am able to attend social I felt that I could participate social I feel I am able to attend
events (such as weddings, activities (wedding, party, church events (For example: wedding, social activities (wedding,
parties, church) even though I events), even though I have kidney parties, going to church), although party, church), even though I
have kidney disease. disease. I have kidney disease have kidney disease.
29 I seek out information about I search information about chronic I found information of chronic I search for information about
chronic kidney disease from a kidney disease from different kidney diseases form many chronic kidney disease from
range of sources (such as, sources (for example internet, different resources (For example: different sources (for example
internet, flyers, brochures, leaflet, manual, kidney disease internet, brochures, leaflets, group internet, leaflet, manual,
books, kidney support group). patient peer group) of supporting patients with kidney kidney disease patient peer
diseases) group)
30 I take my medications as I have medication as prescribed by I used medications based on I take my medications as
prescribed by my doctors or my doctor, nurse or pharmacist prescriptions of doctors or prescribed by my doctors.
nurses or pharmacist pharmacists
31 I take action when my early I have action when early warning I had actions when my early I take action when my early
warning signs and symptoms sign and symptom become worse detective signs and symptoms warning signs and symptoms
get worse worsen get worse
32 When I have questions about When I have any concern about my When I had questions of my When I have questions about
my kidney disease, I discuss kidney disease, I discuss what need kidney disease, I discussed about my kidney disease, I discuss
what to do with my doctors, to be done with my doctor, nurse or what to do with doctors, or nurses what to do with my doctors or
nurses or pharmacist. pharmacist. or pharmacists. nurses.
Appendices 391
Appendix 31. Assessment Tool for Panel
KHẢO SÁT TỪ NHỮNG THÀNH VIÊN PHẢN BIỆN - Giai đoạn 1
Sử dụng những nhận định của Ông/Bà, đánh giá từng phần nội dung lớn và những nội dung nhỏ trong bảng dưới đây bằng cách cho điểm 1, 2, 3
hoặc 4 cho những nội dung dưới đây:
Xin Ông/Bà vui lòng đánh dấu √ vào chỗ thích hợp
Liên quan (Relevance) Rõ ràng (Clarity) Hoàn thiện Phù hợp và hợp lý về
1. Không có liên quan 1. Không rõ ràng (not (Comprehensivenes thang đánh giá cho từng
(not relevant) clear) s) câu (Appropriateness and
2. Khá phù hợp nhưng 2. Cần thay đổi lớn để 1. Nên bỏ đi (should Adequacy)
cần thay đổi lớn được rõ ràng (major be deleted) 1. Đánh giá không phù
(major change to be change to be clear) 2. Nên giữ lại hợp (not appropriate)
relevant) 3. Cần thay đổi nhỏ để (should be retained) 2. Cần thay đổi lớn để
3. Có liên quan và cần rõ ràng hơn (minor phù hợp với việc đánh giá
Nội dung
thay đổi nhỏ (minor change to be clear) (major change to be
change to be relevant) 4. Rất rõ ràng (very appropriate)
4. Rất có liên quan clear) 3. Cần thay đổi nhỏ để
(very relevant) phù hợp với việc đánh giá
(minor change to be
appropriate)
4. Đánh giá rất phù hợp
(very appropriate)
Đánh giá 1 2 3 4 1 2 3 4 1 2 1 2 3 4
Khảo sát kiến thức về bệnh thận (KiKS)
Dưới đây là 28 câu hỏi liên quan
đến những hiểu biết của Ông/Bà
về bệnh thận mãn tính. Xin
Ông/Bà vui lòng đánh dấu √ vào
392 Appendices
Nội dung
(minor change to be
appropriate)
(very appropriate)
câu trả lời mà Ông/Bà cho là
đúng.
1. Tính trung bình, huyết áp của
Ông/Bà nên là:
□ 160/90
□ 150/100
□ 170/80
□ Thấp hơn 130/80
2. Có một số loại thuốc nhất định
mà bác sĩ của Ông/Bà có thể chỉ
định để giúp giữ cho thận của
Ông/Bà càng khoẻ mạnh càng tốt
có phải không?
3. Tại sao quá nhiều đạm
Appendices 393
Nội dung
(minor change to be
appropriate)
(very appropriate)
(protein) trong nước tiểu thì
không tốt cho thận?
□ Nó là dấu hiệu của tổn thương
thận
□ Nó là dấu hiệu của tổn thương
thận VÀ có thể gây sẹo ở thận
□ Nó có thể gây nhiễm trùng
nước tiểu
4. Chọn MỘT THUỐC trong
danh sách dưới dây mà một người
mắc bệnh thận MÃN TÍNH nên
TRÁNH:
□ Lisinopril
394 Appendices
Nội dung
(minor change to be
appropriate)
(very appropriate)
□ Tylenol
□ Vitamin E
□ Viên sắt
5. Nếu thận bị suy, điều trị bệnh
có thể bao gồm (ĐỐI VỚI CÂU
HỎI NÀY Ông/Bà có thể chọn
HAI ĐÁP ÁN):
□ Ghép thận
6. “GFR” có nghĩa là gì?
□ Tốc độ lọc cầu thận
Appendices 395
Nội dung
(minor change to be
appropriate)
(very appropriate)
(Glomerular Filtration Rate) –
cho chúng ta biết mức độ chức
năng thận
□ Lưu lượng tưới máu thận tốt
(Good Flow Renal) – cho chúng
ta biết dòng chảy của nước tiểu từ
thận
□ Thận cải thiện (Gain For Renal)
– cho chúng ta biết nếu chức năng
thận đang được cải thiện
□ Glucose Function Rate – cho
chúng ta biết về mức độ đường
huyết
7. Bệnh thận MÃN TÍNH có các
giai đoạn khác nhau có phải
396 Appendices
Nội dung
(minor change to be
appropriate)
(very appropriate)
không?
8. Bệnh thận MÃN TÍNH làm
tăng nguy cơ đau tim cho người
bệnh có phải không?
9. Bệnh thận MÃN TÍNH làm
tăng nguy cơ tử vong cho một
người vì bất cứ nguyên nhân gì có
phải không?
Phần này sẽ hỏi về THẬN LÀM NHỮNG GÌ. Xin Ông/Bà hãy chọn một câu trả lời cho mỗi câu hỏi sau đây (Câu 10 -18).
10. Thận tạo ra nước tiểu phải
không?
Appendices 397
Nội dung
(minor change to be
appropriate)
(very appropriate)
11. Thận làm sạch máu phải
không?
12. Thận giữ cho xương khoẻ
mạnh đúng không?
13. Thận giữ cho không bị rụng
tóc đúng không?
14. Thận giữ cho số lượng hồng
cầu bình thường đúng không?
15. Thận giữ cho huyết áp bình
398 Appendices
Nội dung
(minor change to be
appropriate)
(very appropriate)
16. Thận giúp cho việc giữ
đường huyết bình thường đúng
không?
17. Thận giúp cho việc giữ nồng
độ Kali trong máu bình thường
đúng không?
18. Thận giúp cho việc giữ nồng
độ phốt-pho trong máu bình
Phần này hỏi về TRIỆU CHỨNG. Xin Ông/Bà chọn từ danh sách dưới đây tất cả những triệu chứng mà một người có thể có nếu
người đó mắc bệnh thận mãn tính hoặc suy thận (Câu 19 - 28).
19. Mệt mỏi tăng?
Appendices 399
Nội dung
(minor change to be
appropriate)
(very appropriate)
20. Thở nông?
21. Miệng có vị kim loại/có vị
khó chịu trong miệng?
22. Ngứa bất thường?
23. Buồn nôn và/hoặc nôn mửa?
24. Rụng tóc?
25. Khó ngủ tăng lên?
26. Giảm cân?
400 Appendices
Nội dung
(minor change to be
appropriate)
(very appropriate)
27. Nhầm lẫn?
28. Không có bất kỳ triệu chứng
nào cả?
Appendices 401
TỰ QUẢN LÝ BỆNH THẬN MÃN TÍNH (CKD-SM)
Dưới đây là 32 câu hỏi liên quan
đến việc Ông/Bà cảm thấy như
thế nào và làm như thế nào để
chống đỡ bệnh thận mãn tính, xin
Ông/Bà hãy chọn một trong bốn
đáp án mà phản ánh tốt nhất tình
trạng thực tại của Ông/Bà trong
ba tháng vừa qua. (Câu trả lời là:
Không bao giờ, Thỉnh thoảng,
Thường xuyên, Luôn luôn)
1. Khi tôi có thắc mắc về tình
trạng bệnh thận của tôi, tôi thảo
luận những gì cần làm với gia
đình và bạn bè của tôi.
2. Tôi sẽ hỏi về các nguyên nhân
có thể gây ra việc suy giảm chức
năng thận của tôi.
3. Tôi thông báo với gia đình và
bạn bè của tôi về kế hoạch điều trị
bệnh thận của tôi (ví dụ như thay
đổi thuốc sử dụng, thay đổi lối
sống).
4. Tôi chia sẻ kinh nghiệm của cá
nhân tôi về bệnh thận với những
người khác cũng mắc bệnh thận.
5. Tôi hiểu kết quả của các xét
nghiệm máu dùng để đánh giá
chức năng thận của tôi (ví dụ như
creatinine, eGFR).
6. Khi huyết áp của tôi tăng cao
402 Appendices
(lớn hơn 140/90), tôi cố gắng tìm
ra các nguyên nhân có thể dẫn
đến việc này.
7. Để phòng tránh sự làm việc
quá tải cho thận, tôi có khả năng
kiểm soát những gì tôi ăn.
8. Tôi thực hiện theo chế độ ăn
kiêng được khuyến nghị bởi các
bác sĩ hoặc điều dưỡng.
9. Tôi giải quyết các vấn đề liên
quan đến bệnh thận của tôi bằng
cách sử dụng các nguồn thông tin
khác nhau (ví dụ như gọi cho bác
sĩ hoặc điều dưỡng của tôi, sử
dụng internet, Google, nhóm hỗ
trợ người mắc bệnh thận).
10. Khi tôi cảm thấy khó chịu
hoặc thất vọng, tôi thảo luận với
người khác về cảm xúc của tôi.
11. Tôi kết hợp chặt chẽ việc điều
trị bệnh thận của tôi vào cuộc
sống thường nhật của tôi.
12. Tôi từ bỏ những thói quen mà
làm xấu đi chức năng thận của tôi
(ví dụ như hút thuốc, uống các
loại đồ uống có cồn, ăn mặn).
13. Tôi thực hiện theo những
khuyến nghị của các chuyên gia y
tế về việc tập thể dục.
14. Tôi theo dõi sát các triệu
chứng và những dấu hiệu cảnh
Appendices 403
báo sớm của tôi (ví dụ như đường
máu, cân nặng, thở nông, phù
chân).
15. Tôi thực hiện theo các khuyến
nghị của các chuyên gia y tế về
một chế độ ăn uống hợp lý.
16. Tôi hỏi bác sĩ hoặc điều
dưỡng những câu hỏi để hiểu rõ
kế hoạch điều trị bệnh thận của
tôi.
17. Tôi thực hiện theo những
khuyến nghị của các chuyên gia y
tế về việc không hút thuốc lá.
18. Tôi đã thay đổi lối sống của
mình để phòng ngừa bệnh thận
của tôi trở nên nặng hơn.
19. Tôi tìm kiếm sự giúp đỡ từ
người khác khi tôi cảm thấy khó
chịu hoặc thất vọng.
20. Tôi giữ cho thận của tôi khoẻ
mạnh bằng cách giữ gìn sức khoẻ
chung của tôi.
21. Tôi dừng những thói quen mà
gây hại cho thận của tôi (ví dụ
như hút thuốc lá, sử dụng thức ăn
nhiều muối, uống rượu bia).
22. Tôi thực hiện các bước để
hiểu về các yếu tố nguy cơ liên
quan đến bệnh thận mãn tính (ví
dụ như tăng huyết áp, đái tháo
đường, hút thuốc lá, béo phì).
404 Appendices
23. Tôi kiểm soát cân nặng của
mình dựa theo lời khuyên của bác
sĩ và điều dưỡng.
24. Tôi đưa ra những lựa chọn
hợp lý về số lượng và loại thức ăn
mà tôi ăn khi tôi không ăn ở nhà
(ví dụ như tại các nhà hàng, nhà
thờ, tiệc tùng, ăn ở ngoài).
25. Tôi có thể điều chỉnh thói
quen hàng ngày của tôi theo kế
hoạch điều trị bệnh thận của tôi
khi tôi không ở nhà (ví dụ như đi
du lịch, đi nghỉ dưỡng).
26. Khi cơ thể của tôi có những
triệu chứng thực thể mới hoặc xấu
đi (ví dụ như là phù nề chân, đau
đầu trầm trọng, đi tiểu nhiều vào
ban đêm), tôi cố gắng tìm ra
nguyên nhân của nó.
27. Tôi vẫn uống thuốc đầy đủ kể
cả khi tôi không ở nhà.
28. Tôi cảm thấy tôi có thể tham
gia các sự kiện xã hội (ví dụ như
đám cưới, tiệc tùng, đi nhà thờ),
mặc dù tôi mắc bệnh thận.
29. Tôi tìm kiếm các thông tin về
bệnh thận mãn tính từ nhiều
nguồn khác nhau (ví dụ như là
internet, tờ rơi, sách hướng dẫn
bỏ túi, nhóm hỗ trợ người mắc
bệnh thận).
Appendices 405
30. Tôi uống thuốc theo chỉ định
của bác sĩ hoặc điều dưỡng hoặc
dược sĩ.
31. Tôi có hành động khi các dấu
hiệu cảnh báo sớm và các triệu
chứng của tôi trở nên tồi tệ hơn.
32. Khi tôi có thắc mắc về bệnh
thận của tôi, tôi thảo luận những
gì cần làm với bác sĩ hoặc điều
dưỡng hoặc dược sĩ.
Cảm ơn Ông/Bà đã hoàn thành đánh giá này.
406 Appendices
Appendix 32. Revision made for items that the Suggested by Panellists
Original version Draft Vietnamese version Panellists’ suggestions Final revision by supervisor team
Kidney Disease Knowledge Survey
Item 1: Tính trung bình, huyết áp của The phrase word “nên duy trì ở mức” This suggestion was accepted and
On average, your blood Ông/Bà nên là: (should be maintained) instead of the question was finalised as “tính
pressure should be: “nên là”. trung bình, huyết áp của Ông/Bà
nên duy trì ở mức”.
Item 2: Có một số loại thuốc nhất định mà Panellists suggested this item should This suggestion was accepted and
Are there certain medications bác sĩ có thể chỉ định dùng để tốt be revised as “Are there certain the question was finalised as “Có
your doctor can prescribe to cho thận của Ông/Bà đúng không? medications your doctor can một số loại thuốc nhất định mà bác
help keep your kidney(s) as prescribe which is useful for your sỹ có thể chỉ định dùng để tốt cho
healthy as possible? kidneys?” thận của Ông/Bà đúng không?”
Item 4: Chọn MỘT THUỐC trong danh Two panels suggested adding the This suggestion was rejected
Select the ONE sách dưới đây mà một người mắc effects of these medications and because it has not happen in the
MEDICATION from the list bệnh thận MÃN TÍNH nên tránh: images of these medications so original version.
below that a person with □ Lisinopril patients can easily recognise.
CHRONIC kidney disease □ Tylenol
should AVOID: □ Motrin / Ibuprofen
□ Lisinopril □ Vitamin E
□ Tylenol □ Viên sắt
□ Vitamin E
□ Iron Pills
Item 5: Nếu thận bị suy, điều trị có thể Two panels requested to add one This suggestion also was rejected
If the kidney(s) fail, treatment bao gồm (ĐỐI VỚI CÂU HỎI more choice such as peritoneal because it has not happen in the
might include (FOR THIS NÀY bạn có thể CHỌN 1 CHO dialysis. original version.
QUESTION you can PICK ĐẾN 2 CÂU TRẢ LỜI):
up to TWO ANSWERS):
Item 6: “GFR” có nghĩa là gì? One panel member commented that This item was kept as the original
Appendices 407
What does “GFR” stand for? this question was too professional. version. This item is to test
One panel suggested this item should knowledge of kidney disease.
be deleted.
Item 8: Bệnh thận MÃN TÍNH làm tăng Two panels suggested changing the The word “heart attack” was kept to
Does CHRONIC kidney nguy cơ đau tim cho người bệnh word “heart attack” to “heart be similar with the original version.
disease increase a person’s đúng không? disease” or “cardiovascular
chances for a heart attack? diseases”.
Item 9: Bệnh thận MÃN TÍNH làm tăng Panellists suggested to use the phrase This suggestion was accepted for
Does CHRONIC kidney nguy cơ tử vong cho con người “increase risks of mortality for easily understanding.
disease increase a person’s đúng không? people”
chance for death from any
cause?
Item 13: Thận giữ cho không bị rụng tóc One panel suggested this item should This suggestion was not accepted as
Does the kidney keep a đúng không? be deleted because it is not the this item was kept as the original.
person from losing hair? kidney function. This item is to test knowledge of
kidney disease.
Item 14: Thận giúp giữ cho số lượng hồng One panel suggested to use the word This suggestion was not accepted
Does the kidney help keep cầu bình thường đúng không? “thận tạo máu” (kidney produce because the kidneys to NOT
red blood cell counts normal? blood) instead of “thận giúp giữ cho produce blood cells. The phrase
số lượng hồng cầu bình thường” “thận giúp giữ cho số lượng hồng
(kidneys help keep red blood cell cầu bình thường” was kept.
count normal).
Item 16: Thận giúp cho việc giữ đường One panel suggested this item should This suggestion was not accepted as
Does the kidney help keep huyết bình thường đúng không? be deleted because it is not the this item was kept as the original.
blood sugar normal? kidney function. This item is to test knowledge of
kidney disease.
Item 18: Thận giúp cho việc giữ nồng độ One panel suggested this item should This suggestion was not accepted as
Does the kidney help keep phốt-pho trong máu bình thường be deleted because it is not the this item was kept as the original.
phosphorus levels in the đúng không? kidney function. This item is to test knowledge of
blood normal? kidney disease.
408 Appendices
Item 21: Miệng có vị kim loại/có vị khó One panel suggested this item should This suggestion was not accepted as
Metal taste / bad taste in the chịu trong miệng? be deleted because it is not the this item was kept as the original.
mouth? kidney function. This item is to test knowledge of
kidney disease.
Item 24: Rụng tóc One panel suggested this item should This suggestion was not accepted as
Hair loss? be deleted because it is not the this item was kept as the original.
kidney function. This item is to test knowledge of
kidney disease.
Item 26: Giảm cân? Panellists suggested using the phrase This suggestion was accepted for
Weight loss? “Gầy sút cân (Giảm cân) [weight easily understanding.
loss/reduce weight]”.
Item 27: Nhầm lẫn One panel suggested this item should This suggestion was not accepted as
Confusion? be deleted because it is not the this item was kept as the original.
kidney function. This item is to test knowledge of
kidney disease.
Other items included 3, 7, 10, Panellists agreed with these items. No change was made.
11, 12, 15, 17, 19, 20, 22, 23,
25, 28.
Chronic Kidney Disease Self-Management
Item 21: Tôi dừng những thói quen gây hại Panellists suggested this item was This suggestion was acknowledged
I stop bad habits which are cho thận của mình (ví dụ: hút similar to item 12. but the item 12 and 21 still be kept.
harmful to my kidneys (such thuốc lá, sử dụng thức ăn nhiều
as smoking, consuming muối, uống rượu bia).
overly salty food and
alcohol).
Item 24: Tôi đưa ra những lựa chọn hợp lý Panellists agreed with this item; This suggestion was accepted and
I make good choices about về số lượng và loại thức ăn của however, they suggested to delete the the word “church” was deleted.
the type and amount of food I mình khi tôi không ăn ở nhà (ví word “church” as not many people
eat when I am not at home dụ như tại các nhà hàng, nhà thờ, have religion.
(such as at the shops, church, tiệc tùng, ra ngoài ăn).
Appendices 409
parties, eating out).
Item 28: Tôi cảm thấy tôi có thể tham gia Panellists agreed with this item; This suggestion was accepted and
I feel able to go to social các sự kiện xã hội (ví dụ như đám however, they suggested to delete the the word “church” was deleted.
events (such as weddings, cưới, tiệc tùng, đi lễ nhà thờ), mặc word “church” as not many people
parties, church) even though I dù tôi mắc bệnh thận. have religion.
have kidney disease.
Item 29: Tôi tìm kiếm các thông tin về Panellists suggested this item was This suggestion was acknowledged
I seek out information about bệnh thận mãn tính từ nhiều similar to item 9. but the item 9 and 29 still be kept.
chronic kidney disease from a nguồn khác nhau (ví dụ như là
range of sources (such as, internet, tờ rơi, sách hướng dẫn bỏ
internet, flyers, brochures, túi, nhóm hỗ trợ người mắc bệnh
books, kidney support group). thận).
Other items included 1, 2, 3, Panellists agreed with these items as This suggestion was accepted. The
4, 5, 6, 7, 8, 10, 11, 13, 14, these items are related to the topic. term health care professional was
15, 16, 17, 18, 19, 20, 22, 23, However, the panellists suggested changed to doctors or nurses in
25, 26, 27, 30, 31, 32. using the term doctors or nurses some items.
instead of health care professional in
some items.
410 Appendices
Appendix 33. Histograms, Normal Q-Q plots, and Box plots of Variables
Appendices 411
412 Appendices
Appendices 413
414 Appendices
Appendices 415
416 Appendices
Appendices 417
418 Appendices
Appendices 419
420 Appendices
Appendix 34. Normality testing of Outcome Variables at each time point
Variables M Mdn SD Skewness Kurtosis

Total V.KiKS T0 18.01 18.0 3.06 -0.70 0.52
Total V.CKDSM T0 84.61 85.00 15.17 -0.31 -0.29
Total V.SECD T0 38.03 38.0 10.13 0.17 -0.45
Physical Functioning T0 72.11 75.0 19.83 -0.60 -0.67
Role Physical T0 54.91 50.0 26.67 0.55 -0.98
Bodily Pain T0 71.31 77.5 26.66 -0.44 -1.13
General Health T0 38.70 35.00 20.89 0.47 -0.53
Vitality T0 48.66 50.00 20.59 0.39 -0.27
Social Functioning T0 75.30 75.00 25.76 -0.58 -0.92
Role Emotional T0 64.44 58.33 23.55 0.30 -0.96
Mental Health T0 66.44 70.00 21.77 -0.29 -0.88
Systolic blood pressure T0 128.87 130.0 18.56 0.69 0.60
Diastolic blood pressure T0 81.52 80.0 11.0 0.24 -0.63
Total V.KiKS T1 21.07 21.0 3.79 -0.32 -0.59
Total V.CKDSM T1 90.76 92.00 16.02 -0.24 -0.46
Total V.SECD T1 39.83 41.0 9.70 -0.03 -0.47
Total V.KiKS T2 21.98 22.0 4.23 -0.44 -0.79
Total V.CKDSM T2 94.13 97.00 15.80 -0.48 -0.16
Total V.SECD T2 41.83 42.0 9.43 -0.02 -0.75
Physical Functioning T2 76.88 80.00 16.32 -0.94 0.83
Role Physical T2 63.66 56.25 24.03 0.24 -1.10
Bodily Pain T2 82.60 90.00 20.55 -1.02 0.36
General Health T2 37.83 37.00 20.80 0.46 -0.43
Vitality T2 52.44 50.00 15.32 -0.09 0.19
Social Functioning T2 84.33 93.75 19.77 -1.17 0.66
Role Emotional T2 71.40 75.00 26.38 -0.25 -1.39
Mental Health T2 71.04 70.00 15.08 -0.39 0.02
Systolic blood pressure T2 129.48 130.0 14.86 0.18 -0.27
Diastolic blood pressure T2 80.58 80.0 10.02 0.14 -0.42
Abbreviation: M, Mean; SD, Standard deviation; Mdn, Median; T0, Baseline; T1, Week 8; T2, Week 16;
V.KiKS, Vietnamese Kidney disease knowledge; V.CKD-SM, Vietnamese Chronic kidney disease self-
management; V.SECD, Vietnamese Self-efficacy for managing chronic disease; SD, Standard deviation
Appendices 421
Appendix 35. Participant Evaluation of Self-Management Program
No Items Percent (%)

Neutral Agree Strongly Agree
1 Did you find the self-management program 0 42.60 57.40
(booklet, teaching, phone calls) helped you
to look after yourself better?
2 Was the CKD booklet easy to read and 4.90 49.20 45.90
understand?
3 Are you more motivated to look after 16.40 41.00 42.60
yourself?
4 Was the length of the education session 1.60 55.70 42.60
appropriate?
5 Was the length of the telephone calls 1.60 55.70 42.60
appropriate?
Percent (%)
No Yes
6 Would you recommend the kidney disease 0 100
self-management program to other patients?
7 Did you or anyone in your family look up on 57.40 42.60
the internet to get information about your
kidney problems or its treatment (e.g.,
medications)?
8 Should doctors provide the kidney disease 0 100
self-management program?
9 Should nurses provide the kidney disease 0 100
self-management program?
10 Do you have suggestions to improve the 78.70 21.30
kidney disease self-management program?
422 Appendices

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Queensland University of Technology

SELF-MANAGEMENT PROGRAM FOR PEOPLE WITH CHRONIC KIDNEY

DISEASE IN VIETNAM: A PRAGMATIC RANDOMISED CONTROLLED TRIAL

Nguyet Thi Nguyen

RN, BN, MSN

Submitted in fulfilment of the requirements for the degree of

Institute of Health and Biomedical Innovation

Queensland University of Technology

Background: Globally, chronic kidney disease (CKD) is a major problem, and in

Vietnam it is increasing rapidly. Active involvement in self-management can prevent

efficacy have been shown to improve self-management behaviours and health-related

very little education is provided by healthcare providers to patients with a chronic

country. This thesis reports on a three-phase study.

the effectiveness of a self-management intervention designed for pre-dialysis CKD

patients attending renal clinics in Vietnam.

validity by an expert panel (n = 10). Phase 2 used a test/retest design to psychometrically

Self-management program for people with chronic kidney disease i

Vietnamese, and able to be contacted by phone. Exclusion criteria consisted of

group received face-to-face education and telephone support provided by a nurse

Primary outcomes were knowledge and self-management behaviour measured by the

(SF-36v2) instruments were used to measure self-efficacy and health-related quality of

with time and group.

management instruments (V.KiKS and V.CKD-SM, respectively) demonstrated good

ii Self-management program for people with chronic kidney disease

the validity and reliability of these instruments.

intervention and 67 receiving usual care. There were no significant differences in

both groups (60%). There were no significant differences in knowledge, self-management

knowledge, self-management behaviour, and self-efficacy were significant, with p values

Self-management program for people with chronic kidney disease iii

measures suitable for clinical practice and research in Vietnamese-speaking populations.

effective in improving patients’ knowledge, self-management, and self-efficacy.

health promotion activities. Finally, this study contributes to nursing knowledge to

improve patient care in the earlier stages of CKD.

Keywords: blood pressure, chronic kidney disease, health-related quality of life,

knowledge, pragmatic randomised controlled trial, self-efficacy, self-management, social

iv Self-management program for people with chronic kidney disease

List of Figures ........................................................................................................... xii

List of Tables ........................................................................................................... xiii

List of Abbreviations ................................................................................................xv

Statement of Original Authorship ......................................................................... xvi

Acknowledgements ................................................................................................ xvii

Chapter 1: Introduction .......................................................................................1

1.1 Introduction .........................................................................................................1

1.2 Chronic Kidney Disease ......................................................................................2

1.2.1 Definition ...................................................................................................2

1.2.2 Prevalence ..................................................................................................3

1.2.3 Risk Factors and Causes ............................................................................5

1.2.4 Management and Treatment.......................................................................8

1.2.5 Healthcare in Vietnam .............................................................................10

1.3 Significance of the Research .............................................................................13

1.4 Research Aims ...................................................................................................13

1.5 Research Questions ...........................................................................................14

1.6 Thesis Overview ................................................................................................14

Chapter 2: Literature Review ............................................................................17

2.1 Introduction .......................................................................................................17

2.2 Impact of Chronic Kidney Disease....................................................................17

2.2.1 Physical Impact ........................................................................................17

2.2.2 Psychological Impact ...............................................................................19

2.2.3 Social Impact............................................................................................19

Self-management program for people with chronic kidney disease v

2.3 Self-Management and Self-Care in Chronic Disease ........................................22

2.3.1 Self-Care ..................................................................................................22

2.3.2 Self-Management .....................................................................................23