Effect of Virtual Education and Follow-up on Health Literacy and Resilience in Family Caregivers of Pediatric Hemodialysis Patients: A Randomized Controlled Trial

Effect of Virtual Education and Follow-up on Health Literacy and Resilience in Family Caregivers of Pediatric Hemodialysis Patients: A Randomized Controlled Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Virtual Education and Follow-up on Health Literacy and Resilience in Family Caregivers of Pediatric Hemodialysis Patients: A Randomized Controlled Trial Masoud Zare, Fariba Abaj, Tayyebeh Pourghaznein, Hamidreza Behnam, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7179580/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose: Family caregivers of pediatric hemodialysis patients face challenges that can reduce their health literacy and resilience. This study aimed to evaluate the effect of virtual education and follow-up on these outcomes. Methods: Sixty caregivers were randomly assigned to intervention (n=30) and control (n=30) groups. The intervention group received routine education plus three weeks of virtual training and follow-up via Telegram, including multimedia content and online sessions. Controls received routine education only. Health literacy and resilience were measured at baseline, immediately post-intervention, and one month later using validated instruments: Health Literacy for Iranian Adults (HELIA) and Connor-Davidson Resilience Scale (CD-RISC). Data were analyzed with significance set at p 0.05). The intervention group showed significant improvements in health literacy and resilience immediately post-intervention and at one-month follow-up compared to controls (p < 0.001). Conclusion: Virtual education combined with follow-up via a culturally adapted platform significantly enhances health literacy and resilience among family caregivers of pediatric hemodialysis patients. Trial registration: IRCT20240914063036N1. Registered on October 11, 2024. virtual education health literacy resilience hemodialysis pediatric caregivers Figures Figure 1 Introduction Acute kidney injury (AKI) and chronic kidney disease (CKD) are major renal disorders whose rising prevalence and progression place an increasing burden on global healthcare systems. In pediatric populations, these conditions are associated with higher mortality rates and can progress to end-stage renal disease (ESRD) [1]. The global prevalence of CKD in children ranges from 11% to 13.4%, often remaining asymptomatic but detectable with appropriate diagnostic tools [2]. By 2040, CKD is projected to become one of the leading causes of death worldwide, with significant increases observed particularly in developed countries [3]. Children with ESRD require renal replacement therapies such as hemodialysis or peritoneal dialysis. While these treatments are life-sustaining, they bring numerous physical and psychological complications that impact not only the child but also their families [4,5]. Hemodialysis, the most commonly used modality in Iran and many other countries, places a significant caregiving burden on family members—particularly primary caregivers, often mothers—who provide continuous care and emotional support for their children [4,6]. Over time, this prolonged caregiving can lead to physical exhaustion, emotional distress, reduced quality of life, and diminished resilience among caregivers [7]. Resilience, defined as the ability to adapt positively to stress and adversity, plays a key role in maintaining the mental health and overall wellbeing of caregivers [8]. In parallel, health literacy—the capacity to access, comprehend, and apply health-related information—enables caregivers to manage their child’s illness more effectively [9]. Low levels of health literacy are associated with poorer caregiving outcomes, higher treatment burdens, and increased healthcare costs [10]. Given the critical role of family caregivers in managing the daily care and medical needs of pediatric hemodialysis patients, improving their resilience and health literacy is essential. Enhancing these capabilities can directly contribute to better health outcomes and quality of life for the children themselves [6,11]. Despite growing recognition of the importance of resilience and health literacy in caregivers, most existing studies have focused on adult patients or employed traditional face-to-face education. There remains a notable gap in the literature regarding the effectiveness of virtual education combined with structured follow-up among family caregivers of pediatric hemodialysis patients, particularly in the Iranian context [12]. Virtual education offers flexibility, cost-effectiveness, and the ability to review content repeatedly, making it a promising approach to empower caregivers. However, robust evidence on its impact on health literacy and resilience in this vulnerable group is limited. This study addresses this gap by evaluating a culturally tailored virtual education and follow-up program for family caregivers of children undergoing hemodialysis. To our knowledge, this is among the first randomized controlled trials in Iran targeting this population. The findings may inform healthcare policies and clinical practices to support family caregivers, enhance their mental and functional wellbeing, and ultimately improve outcomes for pediatric patients with end-stage renal disease. Methods Study Design This randomized controlled trial with a pretest-posttest design was conducted among caregivers of pediatric hemodialysis patients at Dr. Sheikh Hospital, Mashhad. The study adhered to the Declaration of Helsinki and was approved by the university ethics committee (IRCT20240914063036N1). Participants Sixty caregivers were enrolled and randomized by the parity of their clinic visit days. Inclusion criteria included age 18–65, basic literacy, ≥4 hours/day caregiving, and caregiving for ≥3 months. Exclusion criteria included psychiatric illness or formal medical education. After exclusions, 55 participants completed the study. (Figure 1). Sample Size Calculation Sample size was determined based on the mean and standard deviation of resilience and health literacy scores obtained from prior studies, using a power of 80% and a confidence level of 95%. Intervention The control group received routine education provided by the hemodialysis unit, including information on diet and medication management. The intervention group received the same routine education, in addition to a structured virtual education and follow-up program via the Telegram messaging application (Telegram Inc., USA). The virtual program consisted of nine educational and motivational messages delivered over three weeks in text, audio, and image formats. Additionally, three weekly 30-minute online group sessions were conducted to provide interactive support. The content was developed based on a prior needs assessment and covered areas such as nutrition, medication adherence, and care of vascular access (catheter and fistula). During the online sessions, caregivers were encouraged to share experiences and discuss challenges under the supervision of the research team. Outcome Measures and Data Collection Data were collected at baseline, immediately post-intervention, and one month later using a demographic form, the Health Literacy for Iranian Adults (HELIA) [13] and the Connor-Davidson Resilience Scale (CD-RISC) [14], both with established reliability (α > 0.80). Statistical Analysis All analyses were conducted using SPSS software version 26 (IBM Corp., Armonk, NY, USA). Normality of the data was assessed using the Kolmogorov-Smirnov test. Depending on data distribution and measurement level, appropriate statistical tests were used, including independent t-tests, paired t-tests, Mann-Whitney U test, Wilcoxon signed-rank test, chi-square test, and two-way ANOVA with repeated measures. A significance level of p < 0.05 was considered statistically significant. Analyses were based on the data of participants who completed all phases of the study. Ethical Considerations Written informed consent was obtained from all participants. To ensure ethical equity, educational materials used in the intervention were provided to participants in the control group as printed pamphlets upon study completion. A total of 60 eligible participants were enrolled, with 30 in each group. The mean age of pediatric patients was 13.1 (SD 3.7) years in the intervention group and 13.3 (SD 4.7) years in the control group (range 2–19 years), with no significant difference (P = 0.518, Mann–Whitney U test). The average number of hemodialysis sessions per week was 2.8 (SD 0.4) in the intervention group and 2.7 (SD 0.5) in the control group (range 1–4), with no significant difference (P = 0.354). Mean duration of hemodialysis was 3.4 (SD 3.2) years in the intervention group and 3.1 (SD 2.4) years in the control group, without a significant difference (P = 0.601). These baseline characteristics were comparable between groups (Table 1). Table 1. Demographic characteristics of patients Variable Group P value a Intervention (n = 30) Control (n = 30) Number (%) Number (%) Child's Gender Female 15 (50.0) 12 (40.0) 0.604 Male 15 (50.0) 18 (60.0) Family Caregiver's Gender Female 25 (83.3) 28 (93.3) 0.424 Male 5 (16.7) 2 (6.7) Family History of Disease Yes 6 (20.0) 12 (40.0) 0.158 No 24 (80.0) 18 (60.0) a Statistical comparisons were performed using the Chi-square test for categorical variables. A p-value less than 0.05 was considered statistically significant. At baseline, health literacy scores did not differ significantly between groups: intervention 36.7 (SD 9.4) vs. control 41.6 (SD 13.2) (P = 0.424). Post-intervention, the intervention group showed a significant increase in health literacy (83.6 [SD 6.0]) compared to the control (43.5 [SD 10.9]) (P < 0.001). This improvement persisted at one-month follow-up: intervention 80.0 (SD 6.8) vs. control 42.0 (SD 10.6) (P < 0.001). Within-group analysis confirmed a significant increase over time only in the intervention group (P < 0.001, Friedman test) (Table 2). Table 2. Overall Health Literacy Scores of the Participants in the Study Variable Group P value a Intervention (n = 28) Control (n = 27) Mean (SD) Mean (SD) Total Health Literacy Score Before intervention 36.7 (9.4) 41.6 (13.2) 0.424 After intervention 83.6 (6.0) 43.5 (10.9) <0.001 One month after intervention 80.0 (6.8) 42.0 (10.6) <0.001 Change score (post – pre) 46.9 (12.4) 1.8 (3.6) <0.001 P value for within-group change <0.001 0.086 a P-values for between-group comparisons were calculated using the Mann–Whitney U test at all time points, except for change scores, which were compared using the independent t-test. Within-group comparisons were performed using the Friedman test. Resilience scores at baseline were similar: intervention 66.6 (SD 11.0) and control 67.0 (SD 20.0) (P = 0.164). After the intervention, resilience significantly increased in the intervention group to 113.7 (SD 5.4) compared to control 73.4 (SD 17.7) (P < 0.001), and remained higher at follow-up: 108.3 (SD 7.1) vs. 69.1 (SD 13.9) (P < 0.001). Both groups showed significant within-group changes over time (P < 0.001), with more pronounced improvement in the intervention group (Table 3). Table 3. Overall Resilience Scores of the Participants in the Study Variable Group P value a Intervention (n = 28) Control (n = 27) Mean (SD) Mean (SD) Total Resilience Score Before intervention 66.6 (11.0) 67.0 (20.0) 0.164 After intervention 113.7 (5.4) 73.4 (17.7) <0.001 One month after intervention 108.3 (7.1) 69.1 (13.9) <0.001 Change score (post – pre) 47.1 (8.7) 6.3 (6.2) <0.001 P value for within-group change <0.001 <0.001 a P-values for between-group comparisons were calculated using the Mann–Whitney U test at all time points. Within-group comparisons were performed using the Friedman test. Discussion This study demonstrated that virtual education combined with structured follow-up significantly improves health literacy among family caregivers of pediatric patients undergoing hemodialysis. Although there was no significant difference between the intervention and control groups at baseline, health literacy scores in the intervention group increased markedly immediately after the intervention and remained high at one-month follow-up. These findings align with previous research supporting the effectiveness of educational interventions in enhancing health literacy across various populations [ 13 , 15 , 16 ]. Health literacy plays a crucial role in health outcomes, as low health literacy can lead to misunderstanding of medical instructions, decreased self-care ability, and higher healthcare costs [ 17 , 18 ]. Virtual education provides flexible, accessible learning opportunities, overcoming barriers related to time and place. Using Telegram, a culturally accepted and widely used messaging platform in Iran, likely facilitated better engagement and contributed to the significant improvements observed, compared to studies employing international platforms [ 19 , 20 ]. In addition to health literacy, this study found a significant increase in caregiver resilience after the intervention. Resilience is essential for caregivers to manage the psychological and physical demands of chronic illness care, enabling adaptation and well-being maintenance [ 21 ]. The family-centered empowerment model delivered virtually addressed motivational, psychological, and informational needs, fostering resilience effectively. However, this study has some limitations. The relatively small sample size and short follow-up period may limit the generalizability of results. The single-center design further constrains external validity. Self-reported measures may introduce bias, and focusing solely on caregivers of pediatric hemodialysis patients limits applicability to other caregiver populations or chronic conditions. Future research should include larger, more diverse samples and longer follow-up to evaluate the sustainability of benefits. Comparative studies on different virtual platforms and educational approaches could optimize intervention effectiveness. Expanding to caregivers of patients with other chronic diseases and combining virtual education with supportive strategies such as counseling or peer groups may enhance outcomes further. Overall, these findings provide important evidence for healthcare policymakers and practitioners to consider virtual education and follow-up as scalable, practical strategies to empower caregivers and improve the quality of pediatric chronic care. Conclusion Virtual education and follow-up effectively improve health literacy and resilience among caregivers of pediatric hemodialysis patients, and their integration into routine care is recommended. Declarations Ethical Responsibilities Statement This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (Approval No. IR.MUMS.NURSE.REC.1403.055). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all participants after they were fully informed about the study objectives, procedures, confidentiality, and their right to withdraw from the study at any time without any consequences. Trial Registration: This randomized controlled trial (RCT) was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20240914063036N1, on October 11, 2024. Ethics approval and consent to participate This study was approved by the Ethics Committee of Mashhad University of Medical Sciences (Approval No. IR.MUMS.NURSE.REC.1403.055). All participants provided written informed consent. Consent for publication Not applicable. Availability of data and materials All data generated or analyzed during this study are included in this published article and its supplementary files. The datasets used and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This research was supported by Mashhad University of Medical Sciences (MUMS) as part of a student thesis project. Funding covered participant recruitment and research-related materials. The funding body had no role in the design of the study, data collection, data analysis, interpretation of results, or writing of the manuscript. Authors’ Contributions Milad Rezaei conceptualized and designed the study, collected the data, performed the analysis, and drafted the initial manuscript. Masoud Zare contributed to the study design and supervised the research process. Fariba Abaj assisted in data collection and contributed to manuscript revision. Hamidreza Behnam provided statistical consultation and reviewed the analyses. Tayyebeh Pourghaznein contributed to interpretation of the findings and critically revised the manuscript. All authors read and approved the final manuscript. Acknowledgements The authors sincerely thank Mashhad University of Medical Sciences for its financial and institutional support. We also extend our gratitude to all the participants who took part in this study for their valuable cooperation and time. References Wang Z, Zhang C. From AKI to CKD: maladaptive repair and the underlying mechanisms. Int J Mol Sci. 2022;23(18):10880. https://doi.org/10.3390/ijms231810880 Zhang Q, et al. The mediating effect of family resilience between coping styles and caregiver burden in maintenance hemodialysis patients: a cross-sectional study. BMC Nephrol. 2024;25(1):83. https://doi.org/10.1186/s12882-024-02800-5 Komaba H. 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Development of health literacy for regular hemodialysis patients in Menoufia Governorate: a cross-sectional study. Open J Nephrol. 2021;11(2):199–216. Sørensen K, et al. Health literacy in Europe: comparative results of the European health literacy survey (HLS-EU). Eur J Public Health. 2015;25(6):1053–8. https://doi.org/10.1093/eurpub/ckv043 Rahimi S, et al. Investigating the relationship between health literacy with resilience and mental health of Kermanshah public librarians. Health Inf Manag. 2022;19(1):35–42. Fleishman TT, Dreiher J, Shvartzman P. Patient-reported outcomes in maintenance hemodialysis: a cross-sectional, multicenter study. Qual Life Res. 2020;29(9):2345–54. https://doi.org/10.1007/s11136-020-02520-z Rohwer E, Mojtahedzadeh N, Neumann FA, et al. The role of health literacy among outpatient caregivers during the COVID-19 pandemic. Int J Environ Res Public Health. 2021;18(22):11743. https://doi.org/10.3390/ijerph182211743 Murali KM, et al. Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: a systematic review and meta-analysis of randomized intervention trials. PLoS One. 2019;14(1): e0211479. https://doi.org/10.1371/journal.pone.0211479 Lotfi M, Sedghi S, Panahi S. Evaluation of the Effect of Training on the Health Literacy, Self-Care, and HbA1c of Type 2 Diabetic Patients. J Med Libr Inf Sci [Internet]. 2024 Aug 12 [cited 2025 Jul 21]; 5:1-12. Available from: https://journals.sbmu.ac.ir/jmlis/article/view/44712 Neyestani A, Ghanbari H, Ebrahimi Sales N. The effectiveness of dialogic skills training on resilience and adjustment in mothers with physically challenged children. J Principles Ment Health. 2023;25(5):339–45. Khandan M, Amjadi SH. Effect of educational intervention based on Orem’s self-care theory on health literacy in patients with prostate cancer under chemotherapy: a quasi-experimental study. Avicenna J Nurs Midwifery Care. 2023;31(3):155–64. Peyman N, et al. Assessment of the effect of a health literacy educational program for health personnel on promoting self-efficacy among patients with chronic diseases. J Health Syst Res. 2016;12(3):350–57. Vozikis A, Drivas K, Milioris K. Health literacy among university students in Greece: determinants and association with self-perceived health, health behaviours and health risks. Arch Public Health. 2014;72(1):15. https://doi.org/10.1186/2049-3258-72-15 Cash-Gibson L, Guerra G, Salgado-de-Snyder VN. SDH-NET: a South-North-South collaboration to build sustainable research capacities on social determinants of health in low- and middle-income countries. Health Res Policy Syst. 2015; 13:45. https://doi.org/10.1186/s12961-015-0031-4 Dung DTH. The advantages and disadvantages of virtual learning. IOSR J Res Method Educ. 2020;10(3):45–8. Safari Shali R, Eslami M. Benefits and barriers of the e-learning experience for students during the COVID-19 pandemic. J Soc Continuity Change. 2024;2(2):395–414. Ang SY, et al. Differing pathways to resiliency: a grounded theory study of enactment of resilience among acute care nurses. Nurs Health Sci. 2019;21(1):132–8. https://doi.org/10.1111/nhs.12535 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7179580","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":489142143,"identity":"6a44a615-b83c-4467-9d78-d16bb1e3076d","order_by":0,"name":"Masoud Zare","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Masoud","middleName":"","lastName":"Zare","suffix":""},{"id":489142147,"identity":"fbbab3ab-39cb-4cf8-bd49-41d6740f56ba","order_by":1,"name":"Fariba Abaj","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Fariba","middleName":"","lastName":"Abaj","suffix":""},{"id":489142148,"identity":"88a019c8-d643-4975-a685-d2e5e6facf80","order_by":2,"name":"Tayyebeh Pourghaznein","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Tayyebeh","middleName":"","lastName":"Pourghaznein","suffix":""},{"id":489142149,"identity":"98ac4d09-b7eb-497c-86e1-5655527697a6","order_by":3,"name":"Hamidreza Behnam","email":"","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hamidreza","middleName":"","lastName":"Behnam","suffix":""},{"id":489142151,"identity":"dd2c8796-830b-4952-9893-cb641b880e46","order_by":4,"name":"Milad Rezaei","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYBACg8PMDQw8DAw8/Oz9Hx98AIqwsRPQYnmYEaxFRrLngLHhDJAWZgJa7A9AtNgY3EgwE+YBCRHSYnacsfHD2z11PEBb0phtfm2T52NmYPzwMQePlsOMzZJznrEB/dJw7HFu323DNmYGZsmZ2/BqaZDmOcADtOVgu3Fuz21GoBY2Zl48WgyAtvzmOSDBY3AjmU3asue2PTFa2oC2GAC1pLFJM/y4nUiUFss5BxKADjvDbNjbcDu5jRnoO3x+MTh/+PCNNwfq7PnZexgf/Phz23Z+e/PBDx/xaEEFjG1gsoFY9SDwhxTFo2AUjIJRMFIAAKrdU6tUTtTnAAAAAElFTkSuQmCC","orcid":"","institution":"Mashhad University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Milad","middleName":"","lastName":"Rezaei","suffix":""}],"badges":[],"createdAt":"2025-07-21 16:38:18","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7179580/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7179580/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87552573,"identity":"68215a9e-b811-4171-bb99-cb41a39598bf","added_by":"auto","created_at":"2025-07-25 06:29:05","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":243601,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCONSORT flow diagram of participant recruitment, allocation, follow-up, and analysis Results\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7179580/v1/9408567eede0b5a8142e88a4.png"},{"id":94988440,"identity":"bd65ce0d-849c-4617-97df-0dca07c09107","added_by":"auto","created_at":"2025-11-03 07:09:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":802312,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7179580/v1/052258c4-00f7-450f-aa32-1e55c26a55b0.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effect of Virtual Education and Follow-up on Health Literacy and Resilience in Family Caregivers of Pediatric Hemodialysis Patients: A Randomized Controlled Trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAcute kidney injury (AKI) and chronic kidney disease (CKD) are major renal disorders whose rising prevalence and progression place an increasing burden on global healthcare systems. In pediatric populations, these conditions are associated with higher mortality rates and can progress to end-stage renal disease (ESRD) [1]. The global prevalence of CKD in children ranges from 11% to 13.4%, often remaining asymptomatic but detectable with appropriate diagnostic tools [2]. By 2040, CKD is projected to become one of the leading causes of death worldwide, with significant increases observed particularly in developed countries [3].\u003c/p\u003e\n\u003cp\u003eChildren with ESRD require renal replacement therapies such as hemodialysis or peritoneal dialysis. While these treatments are life-sustaining, they bring numerous physical and psychological complications that impact not only the child but also their families [4,5]. Hemodialysis, the most commonly used modality in Iran and many other countries, places a significant caregiving burden on family members\u0026mdash;particularly primary caregivers, often mothers\u0026mdash;who provide continuous care and emotional support for their children [4,6]. Over time, this prolonged caregiving can lead to physical exhaustion, emotional distress, reduced quality of life, and diminished resilience among caregivers [7].\u003c/p\u003e\n\u003cp\u003eResilience, defined as the ability to adapt positively to stress and adversity, plays a key role in maintaining the mental health and overall wellbeing of caregivers [8]. In parallel, health literacy\u0026mdash;the capacity to access, comprehend, and apply health-related information\u0026mdash;enables caregivers to manage their child\u0026rsquo;s illness more effectively [9]. Low levels of health literacy are associated with poorer caregiving outcomes, higher treatment burdens, and increased healthcare costs [10]. Given the critical role of family caregivers in managing the daily care and medical needs of pediatric hemodialysis patients, improving their resilience and health literacy is essential. Enhancing these capabilities can directly contribute to better health outcomes and quality of life for the children themselves [6,11].\u003c/p\u003e\n\u003cp\u003eDespite growing recognition of the importance of resilience and health literacy in caregivers, most existing studies have focused on adult patients or employed traditional face-to-face education. There remains a notable gap in the literature regarding the effectiveness of virtual education combined with structured follow-up among family caregivers of pediatric hemodialysis patients, particularly in the Iranian context [12].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eVirtual education offers flexibility, cost-effectiveness, and the ability to review content repeatedly, making it a promising approach to empower caregivers. However, robust evidence on its impact on health literacy and resilience in this vulnerable group is limited.\u003cbr\u003e\u0026nbsp;This study addresses this gap by evaluating a culturally tailored virtual education and follow-up program for family caregivers of children undergoing hemodialysis. To our knowledge, this is among the first randomized controlled trials in Iran targeting this population.\u003cbr\u003e\u0026nbsp;The findings may inform healthcare policies and clinical practices to support family caregivers, enhance their mental and functional wellbeing, and ultimately improve outcomes for pediatric patients with end-stage renal disease.\u003c/p\u003e"},{"header":"Methods ","content":"\u003cp\u003eStudy Design\u003c/p\u003e\n\u003cp\u003eThis randomized controlled trial with a pretest-posttest design was conducted among caregivers of pediatric hemodialysis patients at Dr. Sheikh Hospital, Mashhad. The study adhered to the Declaration of Helsinki and was approved by the university ethics committee (IRCT20240914063036N1).\u003c/p\u003e\n\u003cp\u003eParticipants\u003c/p\u003e\n\u003cp\u003eSixty caregivers were enrolled and randomized by the parity of their clinic visit days. Inclusion criteria included age 18\u0026ndash;65, basic literacy, \u0026ge;4 hours/day caregiving, and caregiving for \u0026ge;3 months. Exclusion criteria included psychiatric illness or formal medical education. After exclusions, 55 participants completed the study.\u003c/p\u003e\n\u003cp\u003e(Figure 1).\u003c/p\u003e\n\u003cp\u003eSample Size Calculation\u003c/p\u003e\n\u003cp\u003eSample size was determined based on the mean and standard deviation of resilience and health literacy scores obtained from prior studies, using a power of 80% and a confidence level of 95%.\u003c/p\u003e\n\u003cp\u003eIntervention\u003c/p\u003e\n\u003cp\u003eThe control group received routine education provided by the hemodialysis unit, including information on diet and medication management. The intervention group received the same routine education, in addition to a structured virtual education and follow-up program via the Telegram messaging application (Telegram Inc., USA). The virtual program consisted of nine educational and motivational messages delivered over three weeks in text, audio, and image formats. Additionally, three weekly 30-minute online group sessions were conducted to provide interactive support. The content was developed based on a prior needs assessment and covered areas such as nutrition, medication adherence, and care of vascular access (catheter and fistula). During the online sessions, caregivers were encouraged to share experiences and discuss challenges under the supervision of the research team.\u003c/p\u003e\n\u003cp\u003eOutcome Measures and Data Collection\u003c/p\u003e\n\u003cp\u003eData were collected at baseline, immediately post-intervention, and one month later using a demographic form, the Health Literacy for Iranian Adults (HELIA) [13] and the Connor-Davidson Resilience Scale (CD-RISC) [14], both with established reliability (\u0026alpha; \u0026gt; 0.80).\u003c/p\u003e\n\u003cp\u003eStatistical Analysis\u003c/p\u003e\n\u003cp\u003eAll analyses were conducted using SPSS software version 26 (IBM Corp., Armonk, NY, USA). Normality of the data was assessed using the Kolmogorov-Smirnov test. Depending on data distribution and measurement level, appropriate statistical tests were used, including independent t-tests, paired t-tests, Mann-Whitney U test, Wilcoxon signed-rank test, chi-square test, and two-way ANOVA with repeated measures. A significance level of p \u0026lt; 0.05 was considered statistically significant. Analyses were based on the data of participants who completed all phases of the study.\u003c/p\u003e\n\u003cp\u003eEthical Considerations\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from all participants. To ensure ethical equity, educational materials used in the intervention were provided to participants in the control group as printed pamphlets upon study completion.\u003c/p\u003e\n\u003cdiv dir=\"RTL\"\u003e\n \u003cp dir=\"LTR\"\u003eA total of 60 eligible participants were enrolled, with 30 in each group. The mean age of pediatric patients was 13.1 (SD 3.7) years in the intervention group and 13.3 (SD 4.7) years in the control group (range 2\u0026ndash;19 years), with no significant difference (P = 0.518, Mann\u0026ndash;Whitney U test). The average number of hemodialysis sessions per week was 2.8 (SD 0.4) in the intervention group and 2.7 (SD 0.5) in the control group (range 1\u0026ndash;4), with no significant difference (P = 0.354). Mean duration of hemodialysis was 3.4 (SD 3.2) years in the intervention group and 3.1 (SD 2.4) years in the control group, without a significant difference (P = 0.601). These baseline characteristics were comparable between groups (Table 1).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv dir=\"RTL\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTable 1. Demographic characteristics of patients\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" rowspan=\"3\" style=\"width: 264px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 264px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eGroup\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eP value \u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eIntervention (n = 30)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eControl (n = 30)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eNumber (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eNumber (%)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eChild\u0026apos;s Gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e15 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e12 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.604\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e15 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e18 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFamily Caregiver\u0026apos;s Gender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e25 (83.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e28 (93.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e5 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e2 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eFamily History of Disease\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e6 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e12 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.158\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e24 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 132px;\"\u003e\n \u003cp dir=\"LTR\"\u003e18 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp dir=\"LTR\"\u003e\u003csup\u003ea\u003c/sup\u003e \u003cem\u003eStatistical comparisons were performed using the Chi-square test for categorical variables. A p-value less than 0.05 was considered statistically significant.\u003c/em\u003e\u003cstrong\u003e\u003cbr\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv dir=\"RTL\"\u003e\n \u003cp dir=\"LTR\"\u003eAt baseline, health literacy scores did not differ significantly between groups: intervention 36.7 (SD 9.4) vs. control 41.6 (SD 13.2) (P = 0.424). Post-intervention, the intervention group showed a significant increase in health literacy (83.6 [SD 6.0]) compared to the control (43.5 [SD 10.9]) (P \u0026lt; 0.001). This improvement persisted at one-month follow-up: intervention 80.0 (SD 6.8) vs. control 42.0 (SD 10.6) (P \u0026lt; 0.001). Within-group analysis confirmed a significant increase over time only in the intervention group (P \u0026lt; 0.001, Friedman test) (Table 2).\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTable 2. Overall Health Literacy Scores of the Participants in the Study\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 321px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eGroup\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eP value \u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eIntervention (n = 28)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eControl (n = 27)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTotal Health Literacy Score\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eBefore intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e36.7\u0026nbsp;(9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e41.6\u0026nbsp;(13.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.424\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAfter intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e83.6\u0026nbsp;(6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e43.5\u0026nbsp;(10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eOne month after intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e80.0 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e42.0\u0026nbsp;(10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eChange score (post \u0026ndash; pre)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e46.9 (12.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e1.8 (3.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eP value for within-group change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.086\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003cem\u003e\u0026nbsp;P-values for between-group comparisons were calculated using the Mann\u0026ndash;Whitney U test at all time points, except for change scores, which were compared using the independent t-test. Within-group comparisons were performed using the Friedman test.\u003c/em\u003e\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003eResilience scores at baseline were similar: intervention 66.6 (SD 11.0) and control 67.0 (SD 20.0) (P = 0.164). After the intervention, resilience significantly increased in the intervention group to 113.7 (SD 5.4) compared to control 73.4 (SD 17.7) (P \u0026lt; 0.001), and remained higher at follow-up: 108.3 (SD 7.1) vs. 69.1 (SD 13.9) (P \u0026lt; 0.001). Both groups showed significant within-group changes over time (P \u0026lt; 0.001), with more pronounced improvement in the intervention group (Table 3).\u003c/p\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTable 3. Overall Resilience Scores of the Participants in the Study\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv align=\"left\" dir=\"ltr\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eVariable\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 321px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eGroup\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eP value \u003csup\u003ea\u003c/sup\u003e\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eIntervention (n = 28)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eControl (n = 27)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cem\u003eMean (SD)\u003c/em\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u003cstrong\u003eTotal\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eResilience\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eScore\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eBefore intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e66.6\u0026nbsp;(11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e67.0\u0026nbsp;(20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e0.164\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eAfter intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e113.7\u0026nbsp;(5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e73.4\u0026nbsp;(17.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eOne month after intervention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e108.3\u0026nbsp;(7.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e69.1\u0026nbsp;(13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eChange score (post \u0026ndash; pre)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e47.1\u0026nbsp;(8.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e6.3\u0026nbsp;(6.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 198px;\"\u003e\n \u003cp dir=\"LTR\"\u003eP value for within-group change\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 161px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 85px;\"\u003e\n \u003cp dir=\"LTR\"\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp dir=\"LTR\"\u003e\u003csup\u003ea\u003c/sup\u003e \u003cem\u003eP-values for between-group comparisons were calculated using the Mann\u0026ndash;Whitney U test at all time points. Within-group comparisons were performed using the Friedman test.\u003c/em\u003e\u003cem\u003e\u003cspan dir=\"RTL\"\u003e\u003cbr\u003e \u003c/span\u003e\u003c/em\u003e\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated that virtual education combined with structured follow-up significantly improves health literacy among family caregivers of pediatric patients undergoing hemodialysis. Although there was no significant difference between the intervention and control groups at baseline, health literacy scores in the intervention group increased markedly immediately after the intervention and remained high at one-month follow-up. These findings align with previous research supporting the effectiveness of educational interventions in enhancing health literacy across various populations [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eHealth literacy plays a crucial role in health outcomes, as low health literacy can lead to misunderstanding of medical instructions, decreased self-care ability, and higher healthcare costs [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Virtual education provides flexible, accessible learning opportunities, overcoming barriers related to time and place. Using Telegram, a culturally accepted and widely used messaging platform in Iran, likely facilitated better engagement and contributed to the significant improvements observed, compared to studies employing international platforms [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn addition to health literacy, this study found a significant increase in caregiver resilience after the intervention. Resilience is essential for caregivers to manage the psychological and physical demands of chronic illness care, enabling adaptation and well-being maintenance [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The family-centered empowerment model delivered virtually addressed motivational, psychological, and informational needs, fostering resilience effectively.\u003c/p\u003e\u003cp\u003eHowever, this study has some limitations. The relatively small sample size and short follow-up period may limit the generalizability of results. The single-center design further constrains external validity. Self-reported measures may introduce bias, and focusing solely on caregivers of pediatric hemodialysis patients limits applicability to other caregiver populations or chronic conditions.\u003c/p\u003e\u003cp\u003eFuture research should include larger, more diverse samples and longer follow-up to evaluate the sustainability of benefits. Comparative studies on different virtual platforms and educational approaches could optimize intervention effectiveness. Expanding to caregivers of patients with other chronic diseases and combining virtual education with supportive strategies such as counseling or peer groups may enhance outcomes further.\u003c/p\u003e\u003cp\u003e Overall, these findings provide important evidence for healthcare policymakers and practitioners to consider virtual education and follow-up as scalable, practical strategies to empower caregivers and improve the quality of pediatric chronic care.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVirtual education and follow-up effectively improve health literacy and resilience among caregivers of pediatric hemodialysis patients, and their integration into routine care is recommended.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Responsibilities Statement\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Mashhad University of Medical Sciences (Approval No. IR.MUMS.NURSE.REC.1403.055). All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Written informed consent was obtained from all participants after they were fully informed about the study objectives, procedures, confidentiality, and their right to withdraw from the study at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial Registration:\u0026nbsp;\u003c/strong\u003eThis randomized controlled trial (RCT) was prospectively registered in the Iranian Registry of Clinical Trials (IRCT) under the registration number IRCT20240914063036N1, on October 11, 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Mashhad University of Medical Sciences (Approval No. IR.MUMS.NURSE.REC.1403.055). All participants provided written informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are included in this published article and its supplementary files. The datasets used and/or analyzed during the current study are not publicly available due to privacy restrictions but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was supported by Mashhad University of Medical Sciences (MUMS) as part of a student thesis project. Funding covered participant recruitment and research-related materials. The funding body had no role in the design of the study, data collection, data analysis, interpretation of results, or writing of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMilad Rezaei conceptualized and designed the study, collected the data, performed the analysis, and drafted the initial manuscript. Masoud Zare contributed to the study design and supervised the research process. Fariba Abaj assisted in data collection and contributed to manuscript revision. Hamidreza Behnam provided statistical consultation and reviewed the analyses. Tayyebeh Pourghaznein contributed to interpretation of the findings and critically revised the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors sincerely thank Mashhad University of Medical Sciences for its financial and institutional support. We also extend our gratitude to all the participants who took part in this study for their valuable cooperation and time.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eWang Z, Zhang C. From AKI to CKD: maladaptive repair and the underlying mechanisms. \u003cem\u003eInt J Mol Sci.\u003c/em\u003e 2022;23(18):10880. https://doi.org/10.3390/ijms231810880\u003c/li\u003e\n \u003cli\u003eZhang Q, et al. The mediating effect of family resilience between coping styles and caregiver burden in maintenance hemodialysis patients: a cross-sectional study. \u003cem\u003eBMC Nephrol.\u003c/em\u003e 2024;25(1):83. https://doi.org/10.1186/s12882-024-02800-5\u003c/li\u003e\n \u003cli\u003eKomaba H. 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Strategies to improve dietary, fluid, dialysis or medication adherence in patients with end stage kidney disease on dialysis: a systematic review and meta-analysis of randomized intervention trials. \u003cem\u003ePLoS One.\u003c/em\u003e 2019;14(1): e0211479. https://doi.org/10.1371/journal.pone.0211479\u003c/li\u003e\n \u003cli\u003eLotfi M, Sedghi S, Panahi S. Evaluation of the Effect of Training on the Health Literacy, Self-Care, and HbA1c of Type 2 Diabetic Patients. \u003cem\u003eJ Med Libr Inf Sci\u003c/em\u003e [Internet]. 2024 Aug 12 [cited 2025 Jul 21]; 5:1-12. Available from: https://journals.sbmu.ac.ir/jmlis/article/view/44712\u003c/li\u003e\n \u003cli\u003eNeyestani A, Ghanbari H, Ebrahimi Sales N. The effectiveness of dialogic skills training on resilience and adjustment in mothers with physically challenged children. \u003cem\u003eJ Principles Ment Health.\u003c/em\u003e 2023;25(5):339\u0026ndash;45.\u003c/li\u003e\n \u003cli\u003eKhandan M, Amjadi SH. 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SDH-NET: a South-North-South collaboration to build sustainable research capacities on social determinants of health in low- and middle-income countries. \u003cem\u003eHealth Res Policy Syst.\u003c/em\u003e 2015; 13:45. https://doi.org/10.1186/s12961-015-0031-4\u003c/li\u003e\n \u003cli\u003eDung DTH. The advantages and disadvantages of virtual learning. \u003cem\u003eIOSR J Res Method Educ.\u003c/em\u003e 2020;10(3):45\u0026ndash;8.\u003c/li\u003e\n \u003cli\u003eSafari Shali R, Eslami M. Benefits and barriers of the e-learning experience for students during the COVID-19 pandemic. \u003cem\u003eJ Soc Continuity Change.\u003c/em\u003e 2024;2(2):395\u0026ndash;414.\u003c/li\u003e\n \u003cli\u003eAng SY, et al. Differing pathways to resiliency: a grounded theory study of enactment of resilience among acute care nurses. \u003cem\u003eNurs Health Sci.\u003c/em\u003e 2019;21(1):132\u0026ndash;8. https://doi.org/10.1111/nhs.12535\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"virtual education, health literacy, resilience, hemodialysis, pediatric caregivers","lastPublishedDoi":"10.21203/rs.3.rs-7179580/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7179580/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eFamily caregivers of pediatric hemodialysis patients face challenges that can reduce their health literacy and resilience. This study aimed to evaluate the effect of virtual education and follow-up on these outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eSixty caregivers were randomly assigned to intervention (n=30) and control (n=30) groups. The intervention group received routine education plus three weeks of virtual training and follow-up via Telegram, including multimedia content and online sessions. Controls received routine education only. Health literacy and resilience were measured at baseline, immediately post-intervention, and one month later using validated instruments: Health Literacy for Iranian Adults (HELIA) and Connor-Davidson Resilience Scale (CD-RISC). Data were analyzed with significance set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFifty-five participants completed the study after five exclusions. Baseline characteristics were comparable between groups (p \u0026gt; 0.05). The intervention group showed significant improvements in health literacy and resilience immediately post-intervention and at one-month follow-up compared to controls (p \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Virtual education combined with follow-up via a culturally adapted platform significantly enhances health literacy and resilience among family caregivers of pediatric hemodialysis patients.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration: \u003c/strong\u003eIRCT20240914063036N1. Registered on October 11, 2024.\u003c/p\u003e","manuscriptTitle":"Effect of Virtual Education and Follow-up on Health Literacy and Resilience in Family Caregivers of Pediatric Hemodialysis Patients: A Randomized Controlled Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-25 06:29:01","doi":"10.21203/rs.3.rs-7179580/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"941b951f-286c-4111-9699-ccecc1e5c0f5","owner":[],"postedDate":"July 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-01T16:08:31+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-25 06:29:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7179580","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7179580","identity":"rs-7179580","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}