The effect of empowerment education on depression level and laboratory indicators of patients treated with hemodialysis: a meta-analysis

We used computer to search some databases such as Cochrane Library, Web of Science, PubMed, Chinese Biomedical Literature Database (CBM), Chinese Academic Journals Full-text Database (CNKI), VIP Database (VIP) and Wanfang Data Knowledge Service Platform. The retrieval time was from the establishment of the database to November, 2017. English search terms were empower*, empowerment theory, empowerment education, renal dialysis, renal dialyses, hemodialysis, hemodialyses, haemodialysis, haemodialyses, extracorporeal dialyses, extracorporeal dialysis, and hemodiafiltrat*; Chinese search terms were empowerment theory, empowerment education; hemodialysis hemodialysis, hemodiafiltration, hemofiltration, plasma exchange, and blood perfusion. MeSH subject terms, free words, and Boolean operators were used to combine word combinations; corresponding search-based search literatures were formulated based on different databases; and references included in original documents and related reviews were referred to determine other relevant literature.

Two researchers independently selected the literature according to the inclusion and exclusion criteria, crosschecked after extracting the literature data, and if there were any objections, they were resolved through arbitration by the third researcher. According to the content of the literature, a data extraction form was prepared. The extracted contents included the included literature, publication time, sample size, interventions, intervention time, and data extraction time and outcome indicators.

Two investigators evaluated the quality of the included literature according to the Cochrane Handbook Quality Standards 2011. The evaluation items included random sequence generation, allocation concealment, blinding of study subjects and implementers, blinding of outcome measurers, completeness of result data, selective reporting of study results, and other sources of bias. According to the above criteria, each article included was evaluated one by one using “low risk of bias”, “high risk of bias”, or “unclear”. Literature quality was divided into three levels: A, B, and C. The characteristics of “Grade A” were low biased and fully satisfying the above quality standards, “Grade B” were moderately biased and partially satisfying the above quality standards, and “Grade C” were highly biased and completely dissatisfied with the abovementioned quality standards; such documents were excluded. After independently evaluating the quality of the literature, two researchers discussed the quality of each study based on the above evaluation criteria and reached a consensus to form the final evaluation of the quality of the literature. If there were differences, the third researcher arbitrated.

RevMan 5.3 software was used for meta-analysis. Measured data were expressed as the weighted mean difference (MD) or standardized mean difference (SMD) and its 95% confidence interval (CI). Count data used relative risk (RR) or odds ratio (OR) and 95% CI. The heterogeneity between the results of the included studies was determined using the Q test, and the effectivity values were analyzed for heterogeneity. If there was no statistically significant heterogeneity between studies (P > 0.1, I² < 50%), a fixed-effects model was used. If there was statistical heterogeneity (P < 0.1, I² ≥ 50%), these factors, which may lead to heterogeneity, were analyzed in subgroups. If there was a statistical difference and no clinical heterogeneity between the two groups, or difference was not statistically significant, a random effects model was used to combine the effect sizes. If the heterogeneity was too obvious and the source could not be judged, a descriptive analysis was performed.

A total of 530 reports in literature were retrieved, including 106 Chinese studies and 424 English studies. After removing duplicate literature with NoteExpress, there were 292 studies, including 41 in Chinese and 251 in English; after reading the title, abstract, and full text, the studies that did not meet the inclusion criteria were deleted, and finally, 10 studies were identified. See Figure 1 for details.

Figure 1

For the 10 studies included, the total sample size was 817; the basic characteristics of the included studies are given in Table 1. The quality of the 10 studies included was evaluated by the Cochrane Systematic Review Manual 5.1.0. Some of the studies were lost to follow-up, but all were explained. Among the 10 studies included in the results, one had a quality rating of A and the others had a quality rating of B. See Table 2 for details.

A total of 10 studies were included in this study. One study had a quality rating of A. The rest had a quality rating of B. The overall quality was moderate and may be related to the stringency of the randomized interventions included in the literature. The included studies used a randomization method, but most studies did not describe the specific randomization method, and the included studies did not specifically describe the allocation concealment and blinding methods, so there may be a certain offset, and therefore, we should pay attention to the concealment and endgame blindness when we make some related researches.

Empowerment education is an education model in which patients are the whole body and they can participate in decision-making. In fact, educators and patients become friends and cooperate with each other to formulate nursing plans together.19 Its intervention is mainly carried out through five steps,20 namely, clarifying problems, expressing emotions, setting goals, setting plans, and evaluating results. Each step is crucial. In addition, attention should be paid to clarifying the issues and expressing emotions, always insisting on people centeredness, and paying attention to the patient’s own wishes, emotions, and needs.21 In this study, metaanalysis was used to evaluate the impact of empowerment education intervention on hemodialysis patients’ self-efficacy, depression, and serum, creatinine, Alb, and other biochemical indicators. The results showed that empowerment education can improve self-efficacy, relieve depression, and improve related indicators. The reason may be that hemodialysis patients can vent their bad feelings, face their own health problems correctly, and make correct choices and positive changes.

In assessing the role of empowerment education interventions in the self-efficacy of hemodialysis patients, subgroup analyses were performed considering the heterogeneity. In the 6-week intervention self-efficacy subgroup, self-efficacy was evaluated using the self-efficacy (SUPPH) scale and the remaining subgroups were all managed using the Chronic Disease Management Self-Efficacy Scale. In addition, the study10 on empowerment education interventions for depression indicators in hemodialysis patients, using the Hospital Anxiety and Depression Scale. Blood biochemical indicators are important indicators for evaluating the nutritional status of hemodialysis patients. Attention should be paid to the conversion of each unit when data are extracted, and data analysis can only be performed when the units are consistent. In this study, serum creatinine, Alb, Hb, BUN, and other biochemical indicators are commonly used in domestic units, which are μmol/L, g/L, g/L, and mmol/L, respectively. The meta-analysis showed that empowerment education had a certain improvement on serum creatinine, urea nitrogen, and Alb, probably because empowerment education was based on the individualized implementation plan of the patients. The patients’ own problems were clearer. However, there was no statistically significant difference in Hb between the empowerment education group and the control group. The analysis of the causes may be related to the treatment with erythropoietin, and it also may be different investigator or intervention program.