The effect of coping efforts on stress management and sleep quality of hemodialysis patients

The effect of coping efforts on stress management and sleep quality of hemodialysis patients | 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 The effect of coping efforts on stress management and sleep quality of hemodialysis patients Hadis Fath Alipour, Somayeh Alizadeh, Abedin Iranpour, Mohammad Moqaddasi Amiri, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6255562/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 Today, many hemodialysis patients suffer from stress caused by their disease. Therefore, the present study was conducted aimed to investigate the effect of training intervention based on transactional model on stress management and sleep quality of hemodialysis patients in 2022. This study was a quasi-experimental conducted from September to February 2021 for 6 months in Bam city hospitals, Kerman province. A total of 105 people participated in this research. 53 people were placed in the test group and 52 people in the control group by simple random method. The test group received training (teaching coping skills and sleep quality) for 6 weeks. Data collection tools included 4 questionnaires (demographic information, PSQI sleep quality, Balderi stress, and coping efforts). The average age of the participants was 57.12 ± 13.25 years. After the educational intervention, the average score of coping efforts, sleep quality and stress management of the patients showed a significant change in the investigated time periods (P < 0.001). The findings indicate the effectiveness of the design and implementation of the training program based on the Lazarus and Folkman model on the stress management and sleep quality of hemodialysis patients. Therefore, this model can be used to promote health and improve quality of life, especially in relation to stress management in chronic diseases. intervention stress sleep quality transactional model coping efforts Introduction With the change in health in the last two decades in the world and Iran, the country's disease patterns have been changing, with the growing trend of chronic illnesses, including kidney diseases. Chronic kidney disease (CKD) is one of the most important of these diseases, which causes significant stress for patients (Hlaing, Sullivan, & Chaiyawat, 2019 ). The number of individual that are undergoing hemodialysis treatment in country of Iran is increases by about 15% annually, and therefore hemodialysis is the most important dialysis method in the country (Dialysis, 2016 ). A dialysis patient has to spend several hours of his life connected to the machine two to three times a week, being dependent on the dialysis machine for a long time has a great impact on the living conditions of these patients (Calano et al., 2019 ). CKD due to high cost of treatment, increasing prevalence and negative influence on the quality of life’s is one of the most important public health issues in the world. Despite the advances in the field of treatment, stress, fatigue and sleep problems are stress-causing factors in dialysis patients. These complications reduce the feeling of well-being in these patients and have many effects on their physical, emotional and cognitive domains (Francis et al., 2024 ). Unfortunately, the examination and control of sleep quality is often neglected compared to other visible non-mental symptoms(Ghiasi, Sarokhani, Dehkordi, Sayehmiri, & Heidari, 2018 ). Sleep disturbance and fatigue is one of the major complaints reported in people undergoing chronic hemodialysis and its prevalence is reported as 60–97% (Picariello, Norton, Moss-Morris, Macdougall, & Chilcot, 2019 ). On the other hand, according to researchers, the process of adaptation is characterized by permanent changes in behavioral and cognitive efforts made by a person to achieve his desires, especially challenging desires or possibly more than the individual's personal capacity (Nguyen et al., 2018 ). Although adaptation mechanisms have been widely studied, considering the complex nature of the relationship between stressors, adaptation mechanisms and physical and mental health, these researches have not been able to provide consistent findings (Shin et al., 2019 ; J. Zhang et al., 2014 ). In the Lazarus and Folkman model of stress (transactional), name two types of problem management and emotional regulation coping methods (Büsselmann et al., 2019 ). One of them is the problem management method that tries to eliminate or change the cause of stress, such as defining the problem, creating alternative solutions, comparing these solutions in terms of cost and possible benefits, choosing a possible solution, and finally reaching a plan and acting on it. Another method is emotional regulation, which is a way of dealing with a stressor that involves methods such as avoidance and daydreaming (Glanz K, 2008 ). Most of the complications related to sleep disorders and stress caused by the disease and its treatment can be controlled by effective education to the patients (Ogundele & Yemula, 2022 ). In the field of stress management and sleep quality, various studies have been conducted, inclusive of the research of Ghafari et al. (Ghaffari, Morowatisharifabad, Jadgal, Mehrabi, & Alizadeh, 2021 ), Stächele et al (Stächele et al., 2020 ) and Morrowati Sharifabad (Morrowati Sharifabad et al., 2020 ). But the review of various studies shows that in the field of stress management training and sleep quality in CKD with a transactional model approach, there is a lack of research. At the same time, hemodialysis patients suffer from very stressful conditions and experience poor sleep quality as a result. One of the strengths of this study compared to other studies is that we have used a transactional model with an intervention method to manage stress in hemodialysis patients. So, the aimed of this study was investigate the effect of training intervention based on transactional model on stress management and sleep quality of hemodialysis patients in 2022. Material and methods Study design setting This study was a quasi-experimental conducted from September to February 2021 for 6 months in Bam (One of the cities of Kerman in Iran) hospitals. Participants This research included all hemodialysis patients of medical centers affiliated to Bam hospitals. Pasteur and Sepehr hospitals were intervention group, Javad Al-Aimeh hospital, Ayatollah Hashemi Rafsanjani hospital in and dialysis center in city were control group. sample size By using the sample size formula related to the comparison of the average of two groups and the average and standard deviation of the variable scores of the coping of individuals, which were extracted from Ghaffari et al.'s study (Ghaffari et al., 2021 ). The sample size for each of the test and control groups was calculated 52 people. Inclusion criteria include CKD and hemodialysis treatment, over 18 years of age, knowledge of Persian language, hemodialysis history of 6 months or more, ability to communicate verbally, performing 2–3 times of hemodialysis per week, and exclusion criteria including a debilitating disease that makes it difficult for the patient to participate and participating in other research projects at the same time. Data collection Data was collected using Pittsburgh Sleep Quality Index (PSQI), Balderi stress questionnaire, and coping efforts questionnaire. The PSQI it evaluates individuals’ attitude toward sleep quality in the last 4 weeks. In scoring PSQI, you must examine 7 components. Scoring is on a 4-point Likert scale from 0 (normal condition), 1 (mild problem), 2 (moderate problem) and 3 (severe problem). The overall score of the numerical questionnaire is between 0 and 21. In this questionnaire, a higher score indicates poorer sleep quality. If the overall score is 6 or more, it means that the sleep quality is inappropriate. The reliability of this questionnaire in Iran has been confirmed with Cronbach's alpha of 83% (Soleimani, Asgari, Imani, & Tammadon, 2017 ). Balderi's standard hemodialysis stress measurement questionnaire contains 29 questions. This has divided the stressful factors into two main sub-categories: physiological (6 cases) and psychosocial (23 cases). Answers are divided according to five Likert scales, from no tension (0), very low tension (1), low tension (2), medium tension (3) and high tension (4). Based on their feeling of the severity of each of the items mentioned in the tool, patients indicate their desired answer by putting a mark. The total scores of the questions range from 0 to 116, and according to the answers of the patients, the intensity of stress was considered severe (116 − 81), moderate (80 − 41) and mild (0–40) (Baldree, Murphy, & Powers, 1982 ). The validity and reliability of this questionnaire has been confirmed with Cronbach's alpha 81.2% in internal studies (elali, mahdavi, jannati, Yazdani, & Setareh, 2012 ). The questionnaire of coping efforts includes 21 options to measure coping efforts, including problem management and emotional regulation sub-structures. In this questionnaire, a 3-point Likert scale is used to measure coping efforts: agree (1), no opinion (2) and disagree (3). The total score of the questionnaire is between zero and 100. A higher score in problem management and emotional regulation indicates weakness in problem management and emotional regulation, respectively. This questionnaire was used for the first time by Ghafari et al (Ghaffari et al., 2021 ) and its validity was 0.86 and Cronbach's alpha was obtained for the reliability of problem management (0.75), emotional regulation (0.77), social support (0.86) and dispositional coping style (0.71). Information from patients was collected in morning, evening and night, after the patient's hemodynamic status was stable and the patient's condition was favorable. In order to achieve the goals of the research, the mentioned questionnaires were completed by the patients and enough time was given to them to complete the questionnaires. If necessary and desired by the patient, the questionnaires were completed with the researcher. A total of people in each group were selected randomly from the clients to the centers, taking into account the entry and exit criteria. After identifying the eligible people, the researcher referred to each person to fully explain the study and its objectives and obtain their consent to participate in the research, informed consent was also obtained from them, and the questionnaires were given to the test group before the educational intervention. The control group was placed and the objectives of the training course were presented to the participants and they were asked to answer the questions and they were assured that the principle of confidentiality of information will be maintained and that not participating in the research will not affect the continuation of the treatment process. Intervention The test group received training sessions (teaching coping skills and methods to improve sleep) in the number of 6 sessions, one session every week in groups of 5 to 6 people and for an hour and a half. Educational methods included lectures and group discussions, questions and answers, and educational clips. The trainings were carried out at the patients' bedside after the hemodynamic status stabilized and the patient's condition was favorable. The educational content included the topics of defining stress and types of stressful situations and coping strategies, coping skills, the concept of problem solving and the benefits of planning for problems, relaxation techniques, sleep disorders and sleep hygiene and the technique of positive thoughts. In all stages of the research, the training of the groups was the responsibility of the researcher. Data were collected one month and three months after the intervention through the mentioned questionnaires. The time of the training sessions was during the hemodialysis of the patients, and in order to respect the well-being of the patients, the training session was not held at a time other than the time of the patients' dialysis (before the dialysis). If needed, the number of sessions increased. In order to ensure that the educational content is the same for all people, the researcher recorded the audio in each session and asked the patients to raise their possible questions at the end of the session so that the educational content of each session is not affected by the questions of the patients. People in the control group received only routine hemodialysis care. The contact information of all the participants was obtained if they wanted to follow up on completing the questionnaires and possible information. Study analysis In this research, response variables were: coping efforts score, stress management score and sleep quality score. The paired t-test was used to compare each of the response variables before and after the intervention, in each of the test and control groups (separately). Two independent sample t-test was used to compare the response variables in the test and control groups before and after the intervention (separately). In this study significance level was set at P < 0.05 for all statistical tests. Results The average age of the participants was 57.12 ± 13.25 years. The minimum age was 20 and the maximum was 86 years. The average years of dialysis was 4.47 ± 2.78 years. The results of the independent t-test showed that there is a significant difference between the average age of patients in the two groups (P = 0.014, t = 2.50). The results of the Chi-square test showed that there was a statistically significant difference between the two groups in terms of the demographic characteristics of the education level (P = 0.007). However, no significant difference was observed between the two groups in terms of other demographic variables (P < 0.05). Table 1 shows the distribution of demographic variables in the intervention and control groups. Table 1 Demographic characteristics of patients in Test and control groups (n = 104) Variable Total population Control Test p-value* N (%) N (%) N (%) Gender 51 (48.6) 25 (48.1) 26 (49.1) Female 0.920 Man 54 (51.4) 27 (51.9) 27 (50.9) Marital status Single 11 (10.5) 8 (15.4) 3 (5.7) 0.104 Married 94 (89.5) 44 (84.6) 50 (94.3) Income Weak 49 (46.7) 23 (44.2) 26 (49.1) Medium 52 (49.5) 28 (53.8) 24 (45.3) 0.477 Good 4 (3.8) 1 (1.9) 3 (5.7) Education Illiterate 13 (12.4) 11 (21.2) 2 (3.8) High school 58 (55.2) 21 (40.4) 37 (69.8) Diploma or postgraduate diploma 20 (19.0) 11 (21.2) 9 (17.0) 0.007 Bachelor or higher 14 (13.3) 9 (17.3) 5 (9.4) Sickness HTN 42 (40.0) 21 (40.4) 21 (39.6) DM 18 (17.1) 8 (15.4) 10 (18.9) 0.889 Renal 45 (42.9) 23 (44.2) 22 (41.5) * Chi-square test Comparing the mean scores of coping efforts and its subscales (Emotional regulation and Problem management) the changes within the group showed that in the intervention group, after the implementation of training based on transactional model, 2.79 units of the problem management substructure score decreased; And based on the paired t-test, this difference was significant (P < 0.001). Also, the changes within the group showed that in the intervention group, after intervention 1.34 units of the emotional regulation sub-structure score decreased; And based on the paired t-test, this difference was significant (P = 0.003). Also, the changes within the group showed that in the intervention group, after intervention, 9.79 units of the score of people's coping efforts from stressful situations have decreased; and based on the paired t-test, this difference was significant (P < 0.001). As shown in Table 2 , the average score of coping efforts has increased significantly in the control group (P < 0.001). While in relation to emotional regulation and problem management in the control group, no statistically significant difference was observed before and after the educational intervention. Table 2 Comparison of Emotional regulation, Problem management and Coping effort scores between test and control groups before, one month and three months after the intervention Variable group Before intervention One month after the intervention P** Three months after the intervention P*** mean (SD) mean (SD) mean (SD) Problem management intervention 27.72 (5.02) 26.38 (4.05) < 0.001 26.64 (4.26) < 0.001 Control 28.31 (4.04) 28.71 (4.14) 0.522 28.71 (4.89) 0.110 P* 0.094 Emotional regulation intervention 27.72 (5.02) 28.71 (4.14) 0.003 26.64 (4.26) 0.030 Control 28.31 (4.04) 26.38 (4.05) 0.075 28.71 (4.89) 0.497 P* 0.507 Coping effort intervention 51.06(25.09) 41.27(20.83) < 0.001 51.72(18.69) < 0.001 Control 56.61(21.15) 61.24(21.08) < 0.001 67.01(20.36) < 0.001 P* 0.224 * Two independent sample t-test ** Paired t-test *** Repeated measures analysis of variance test As shown in Table 3 , the changes within the group showed that in the test group, after intervention, the mean score of sleep quality decreased by 0.5 units, and based on the paired t-test, this difference was significant (P = 0.010). In fact, with a decrease in the mean score, sleep quality increases, but in the control group, intra-group changes indicate an increase in the sleep quality score and as a result, a decrease in sleep quality, and based on the paired t-test, this difference was significant (P < 0.001). The results of the independent t-test showed that before the intervention, there was a significant difference between the mean stress management in the intervention and control groups (P < 0.001). Also, the changes within the group showed that in the intervention group, intervention, 10.51 units of the stress management score decreased; and based on the paired t-test, this difference was significant (P < 0.001). However, the results of the paired t-test showed that there was no significant difference between the change in stress scores one month after the intervention and before the intervention in the control group (P = 0.093). Table 3 Comparison of Sleep quality and stress management scores between test and control groups before, one month and three months after the intervention Variable group Before intervention One month after the intervention P** Three months after the intervention P*** mean (SD) mean (SD) mean (SD) Sleep quality intervention 6.55 (3.60) 6.05 (3.45) 0.010 5.60 (3.02) 0.011 Control 6.25 (2.12) 7.86 (2.48) < 0.001 7.16 (2.01) < 0.001 P* 0.978 stress management intervention 47.02(36.67) 36.51(28.62) < 0.001 35.96(28.09) < 0.001 Control 88.79(22.37) 89.60(21.73) 0.093 92.46(20.86) < 0.001 P* < 0.001 The changes of research variables over time are given in Table 4 . according to the significance of the interaction effect between time and group, it can be stated that the difference in the average score of coping efforts of people from stressful situations, emotional regulation, problem management and stress management at different times is different according to the levels of the group (P < 0.001). The results of repeated measurement analysis of variance in Table 4 show that the effect of measurement time on sleep quality score in hemodialysis patients is significant (P = 0.006). Therefore, it can be said that regardless of the two groups, there was a significant difference between the mean score of sleep quality before, one month and three months after the intervention. Also, according to the significance of the interaction effect between time and group, it can be stated that the mean score of sleep quality at different times is different according to the group levels. As can be seen in Table 4 , the effect of the group on the sleep quality score is not significant (P = 0.063). In relation to emotional regulation, considering the significance of Mauchly's test (P < 0.001), Greenhouse-Geisser adjustment was used to check the significance of time variables and the interaction effect of time with treatment group. The results of repeated measurement analysis of variance in Table 4 show that the effect of measurement time on the emotional regulation substructure score in hemodialysis patients is not significant (P = 0.332), so it can be said that regardless of the two groups, between There was no significant difference in the mean of emotional regulation substructure before, one month and three months after the intervention. Also, according to the significance of the interaction effect between time and group, it can be said that the difference in the mean score of the emotional regulation substructure is different at different times according to the group levels. As can be seen in Table 4 , the effect of the group on the emotional regulation substructure score is significant (P = 0.034). Table 4 Repeated measures analysis of variance by investigating the interaction effect of test group and time Variable Time Group × time Group Emotional regulation 0.332 0.029 0.034 Problem management < 0.001 < 0.001 < 0.001 Coping effort < 0.001 < 0.001 < 0.001 Sleep quality 0.006 < 0.001 0.063 stress management < 0.001 < 0.001 < 0.001 Discussion In this research, there is a significant difference between the mean scores of people's coping efforts from stressful situations before the intervention, one month, and three months after the intervention. However, the number of changes in the scores of people's coping efforts from stressful situations in the test group was much higher than in the control group. The results indicate the improvement of coping efforts after the implementation of the transactional model. Based on the results, the score of the substructure of problem management and emotional regulation of people from stressful situations is significant one month and three months after the intervention. The number of changes in mean scores of problem management and emotional regulation was decreasing in the test group and increasing in the control group. Therefore, the findings of the study show that education based on transactional model is effective on problem management and emotional regulation in hemodialysis patients. Appropriate emotional regulation is considered a necessary prerequisite and an important feature of mental health, while difficulty in emotional regulation is a high-risk factor for people's mental health (Monzani et al., 2015 ). In Zamanian et al.'s research, after the educational intervention, the average emotional regulation score in the test group showed a significant change, which indicated the effectiveness of the educational intervention (Zamanian, Poorolajal, & Taheri-Kharameh, 2018 ). The results of Zhang et al.'s study also indicated that hemodialysis patients use emotional regulation coping styles more than other coping styles to deal with stress (L. Zhang, Zou, & Zhou, 2024 ). The use of educational interventions to improve the use of coping styles in different diseases and groups has been investigated and their effectiveness has been confirmed, which are in line with our study. (Alhawatmeh, Alshammari, & Rababah, 2022 ; Amone-P'Olak, Boitumelo, & Mberengwa, 2019 ; Shavaki, Harandi, Pourabbasi, & Rahimzadeh, 2018 ) . Probably, one of the reasons for these studies to be in line with the present study is the similarity of educational content, type of study, teaching method and duration of education. The stress management in the test group improved in comparison with the control group after the intervention, indicating the effectiveness of educational intervention in improving the use of stress management in the hemodialysis patients. This was despite the fact that the stress management score in the control group had increased significantly, and this indicated the worsening of the stress situation in hemodialysis patients over time. In line with this study, the effectiveness of educational interventions to stress management in hemodialysis patients has been shown in different studies (Ghaffari et al., 2021 ; Ghasemi Bahraseman, Mangolian Shahrbabaki, & Nouhi, 2021 ; Haririan, Aghajanlo, & Ghafurifard, 2013 ; Morrowati Sharifabad et al., 2020 ; Rahale, 2018 ). In this study, the number of changes in sleep quality scores decreased in the test group and increased in the control group. Additionally, the results showed that the effect of measurement time on sleep quality score in hemodialysis patients is significant. Therefore, it can be said that regardless of the two groups, there was a significant difference between the average score of sleep quality before, one month and three months after the intervention. Finally, it can be said that transactional model has been effective in improving the sleep quality of hemodialysis patients. Sleep is necessary for staying healthy and reviving the nervous, immune and skeletal muscle systems. Approximately 25–36% of adults suffer from a sleep disorder. While 40 to 85% of patients with chronic kidney failure suffer from these disorders, which is much higher than the prevalence in the general population (Liaveri et al., 2017 ). In Omidi et al. study, the results demonstrated the transactional effect of the group over time on perceived stress, self-efficacy and sleep quality of the elderly and the implementation of the independent variable have led to a reduction in perceived stress, an increase in self-efficacy and sleep quality in the experimental group. Based on the findings of this research, emotional regulation training can be used to reduce perceived stress and improve self-efficacy and sleep quality of the elderly with type 2 diabetes (Omidi, Sabet, Ahadi, & Nejat, 2022 ). In Moradi et al. study, the results showed that the sleep health education based on the continuous care model improves the sleep quality of the elderly, so this method it is recommended to improve the sleep quality of the elderly (Moradi, Ebrahimi, Goli, & Khajeh, 2022 ). Conclusion This research recommends that to improving coping efforts, stress management and sleep quality in hemodialysis patients, apply transactional model is helpful. Also, it seems that the treatment system should pay more attention to the psychological needs of people, including counseling services to improve stress in areas such as dialysis centers. In health education and health promotion, one of the main components of health care is education. In this regard, it is necessary to pay attention to educational plans based on educational theories and models for various health-related issues. One of the comprehensive models in the field of stress management is transactional model, so it can play an important role in health promotion planning and improving the quality of life. Declarations Ethical considerations Before starting the study, Ethics Committee of Faculty of Medical Sciences of Kerman provided the permission with ethics code of IR.KMU.REC.1401.408, related references were provided by Kerman University of Medical Sciences for dialysis centers in Kerman and the study was registered at clinical trials registration center with the code of IRCT20221220056882N1 Acknowledgements This study is part of the results of a MSc thesis on health education and health promotion. We acknowledge all the officials of Kerman University of Medical Sciences, the hemodialysis centers and all the patients who participated in this study. Funding This work was supported by Kerman University of Medical Sciences. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the article. Author Contributions Statement H. FA. has designed the study, analyzed and interpreted the data and drafted the manuscript. S. 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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-6255562","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":436072151,"identity":"d34ac933-78b1-4266-a5bc-a7abddaf60d1","order_by":0,"name":"Hadis Fath Alipour","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hadis","middleName":"Fath","lastName":"Alipour","suffix":""},{"id":436072152,"identity":"f261323a-abc8-4995-a4a8-4f5065b408f2","order_by":1,"name":"Somayeh Alizadeh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABBElEQVRIie3QMUvDQBTA8Xc8uCxNuzZU2q9wIZNQ9aukBDK1a1YjB9fldLaTX8Epc0sEF+kcuNHV4UKXIBV7URAcetFN8H7DDY/7c7wDcJy/yCM5AIUxRVyDNgPqdSX4mUQDT8Tktk2wM2kPCrOVfGLY+5pYDDhy3WRTcl/No930tZj0EYiu58eTYUnyUG5TZFWajRY3KhQIGKwKyzMmiX1RUlYlBS6kIiah6FuSiUk2b+K9x6o42p1KddGZsJJccV+sh4F8YCNo1KwzCUvC8WSbMPPJaXCdq0Qg4dZdxo/L5/olO78UiKVu9ursbsk3urat/w0RH2f+0/ut/W8uO47j/BcHFvBR044oWPQAAAAASUVORK5CYII=","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Somayeh","middleName":"","lastName":"Alizadeh","suffix":""},{"id":436072153,"identity":"e1905836-3753-4923-b1c8-2c7d503dc67c","order_by":2,"name":"Abedin Iranpour","email":"","orcid":"","institution":"Kerman University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Abedin","middleName":"","lastName":"Iranpour","suffix":""},{"id":436072154,"identity":"159655d5-647d-4802-b19a-9670dfcdd83a","order_by":3,"name":"Mohammad Moqaddasi Amiri","email":"","orcid":"","institution":"Sirjan University of Technology","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Moqaddasi","lastName":"Amiri","suffix":""},{"id":436072155,"identity":"cc78a738-1842-49df-898b-24b8716929e2","order_by":4,"name":"Hadi Khoshab","email":"","orcid":"","institution":"Bam University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Hadi","middleName":"","lastName":"Khoshab","suffix":""}],"badges":[],"createdAt":"2025-03-18 18:08:05","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6255562/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6255562/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":80233522,"identity":"efd2e148-f6b5-4f29-b14c-17fa54e32753","added_by":"auto","created_at":"2025-04-09 13:17:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":593093,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6255562/v1/73c2bcee-8193-4083-ac17-79f2965419c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The effect of coping efforts on stress management and sleep quality of hemodialysis patients","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWith the change in health in the last two decades in the world and Iran, the country's disease patterns have been changing, with the growing trend of chronic illnesses, including kidney diseases. Chronic kidney disease (CKD) is one of the most important of these diseases, which causes significant stress for patients (Hlaing, Sullivan, \u0026amp; Chaiyawat, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe number of individual that are undergoing hemodialysis treatment in country of Iran is increases by about 15% annually, and therefore hemodialysis is the most important dialysis method in the country (Dialysis, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). A dialysis patient has to spend several hours of his life connected to the machine two to three times a week, being dependent on the dialysis machine for a long time has a great impact on the living conditions of these patients (Calano et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCKD due to high cost of treatment, increasing prevalence and negative influence on the quality of life\u0026rsquo;s is one of the most important public health issues in the world. Despite the advances in the field of treatment, stress, fatigue and sleep problems are stress-causing factors in dialysis patients. These complications reduce the feeling of well-being in these patients and have many effects on their physical, emotional and cognitive domains (Francis et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUnfortunately, the examination and control of sleep quality is often neglected compared to other visible non-mental symptoms(Ghiasi, Sarokhani, Dehkordi, Sayehmiri, \u0026amp; Heidari, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Sleep disturbance and fatigue is one of the major complaints reported in people undergoing chronic hemodialysis and its prevalence is reported as 60\u0026ndash;97% (Picariello, Norton, Moss-Morris, Macdougall, \u0026amp; Chilcot, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). On the other hand, according to researchers, the process of adaptation is characterized by permanent changes in behavioral and cognitive efforts made by a person to achieve his desires, especially challenging desires or possibly more than the individual's personal capacity (Nguyen et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). Although adaptation mechanisms have been widely studied, considering the complex nature of the relationship between stressors, adaptation mechanisms and physical and mental health, these researches have not been able to provide consistent findings (Shin et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; J. Zhang et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2014\u003c/span\u003e). In the Lazarus and Folkman model of stress (transactional), name two types of problem management and emotional regulation coping methods (B\u0026uuml;sselmann et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). One of them is the problem management method that tries to eliminate or change the cause of stress, such as defining the problem, creating alternative solutions, comparing these solutions in terms of cost and possible benefits, choosing a possible solution, and finally reaching a plan and acting on it. Another method is emotional regulation, which is a way of dealing with a stressor that involves methods such as avoidance and daydreaming (Glanz K, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2008\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost of the complications related to sleep disorders and stress caused by the disease and its treatment can be controlled by effective education to the patients (Ogundele \u0026amp; Yemula, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In the field of stress management and sleep quality, various studies have been conducted, inclusive of the research of Ghafari et al. (Ghaffari, Morowatisharifabad, Jadgal, Mehrabi, \u0026amp; Alizadeh, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), St\u0026auml;chele et al (St\u0026auml;chele et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and Morrowati Sharifabad (Morrowati Sharifabad et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). But the review of various studies shows that in the field of stress management training and sleep quality in CKD with a transactional model approach, there is a lack of research. At the same time, hemodialysis patients suffer from very stressful conditions and experience poor sleep quality as a result. One of the strengths of this study compared to other studies is that we have used a transactional model with an intervention method to manage stress in hemodialysis patients. So, the aimed of this study was investigate the effect of training intervention based on transactional model on stress management and sleep quality of hemodialysis patients in 2022.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design setting\u003c/h2\u003e \u003cp\u003eThis study was a quasi-experimental conducted from September to February 2021 for 6 months in Bam (One of the cities of Kerman in Iran) hospitals.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThis research included all hemodialysis patients of medical centers affiliated to Bam hospitals. Pasteur and Sepehr hospitals were intervention group, Javad Al-Aimeh hospital, Ayatollah Hashemi Rafsanjani hospital in and dialysis center in city were control group.\u003c/p\u003e\n\u003ch3\u003esample size\u003c/h3\u003e\n\u003cp\u003eBy using the sample size formula related to the comparison of the average of two groups and the average and standard deviation of the variable scores of the coping of individuals, which were extracted from Ghaffari et al.'s study (Ghaffari et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The sample size for each of the test and control groups was calculated 52 people.\u003c/p\u003e \u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\u003cp\u003eInclusion criteria include CKD and hemodialysis treatment, over 18 years of age, knowledge of Persian language, hemodialysis history of 6 months or more, ability to communicate verbally, performing 2\u0026ndash;3 times of hemodialysis per week, and exclusion criteria including a debilitating disease that makes it difficult for the patient to participate and participating in other research projects at the same time.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eData was collected using Pittsburgh Sleep Quality Index (PSQI), Balderi stress questionnaire, and coping efforts questionnaire. The PSQI it evaluates individuals\u0026rsquo; attitude toward sleep quality in the last 4 weeks. In scoring PSQI, you must examine 7 components. Scoring is on a 4-point Likert scale from 0 (normal condition), 1 (mild problem), 2 (moderate problem) and 3 (severe problem). The overall score of the numerical questionnaire is between 0 and 21. In this questionnaire, a higher score indicates poorer sleep quality. If the overall score is 6 or more, it means that the sleep quality is inappropriate. The reliability of this questionnaire in Iran has been confirmed with Cronbach's alpha of 83% (Soleimani, Asgari, Imani, \u0026amp; Tammadon, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Balderi's standard hemodialysis stress measurement questionnaire contains 29 questions. This has divided the stressful factors into two main sub-categories: physiological (6 cases) and psychosocial (23 cases). Answers are divided according to five Likert scales, from no tension (0), very low tension (1), low tension (2), medium tension (3) and high tension (4). Based on their feeling of the severity of each of the items mentioned in the tool, patients indicate their desired answer by putting a mark. The total scores of the questions range from 0 to 116, and according to the answers of the patients, the intensity of stress was considered severe (116\u0026thinsp;\u0026minus;\u0026thinsp;81), moderate (80\u0026thinsp;\u0026minus;\u0026thinsp;41) and mild (0\u0026ndash;40) (Baldree, Murphy, \u0026amp; Powers, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e1982\u003c/span\u003e). The validity and reliability of this questionnaire has been confirmed with Cronbach's alpha 81.2% in internal studies (elali, mahdavi, jannati, Yazdani, \u0026amp; Setareh, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). The questionnaire of coping efforts includes 21 options to measure coping efforts, including problem management and emotional regulation sub-structures. In this questionnaire, a 3-point Likert scale is used to measure coping efforts: agree (1), no opinion (2) and disagree (3). The total score of the questionnaire is between zero and 100. A higher score in problem management and emotional regulation indicates weakness in problem management and emotional regulation, respectively. This questionnaire was used for the first time by Ghafari et al (Ghaffari et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) and its validity was 0.86 and Cronbach's alpha was obtained for the reliability of problem management (0.75), emotional regulation (0.77), social support (0.86) and dispositional coping style (0.71).\u003c/p\u003e \u003cp\u003eInformation from patients was collected in morning, evening and night, after the patient's hemodynamic status was stable and the patient's condition was favorable. In order to achieve the goals of the research, the mentioned questionnaires were completed by the patients and enough time was given to them to complete the questionnaires. If necessary and desired by the patient, the questionnaires were completed with the researcher. A total of people in each group were selected randomly from the clients to the centers, taking into account the entry and exit criteria. After identifying the eligible people, the researcher referred to each person to fully explain the study and its objectives and obtain their consent to participate in the research, informed consent was also obtained from them, and the questionnaires were given to the test group before the educational intervention. The control group was placed and the objectives of the training course were presented to the participants and they were asked to answer the questions and they were assured that the principle of confidentiality of information will be maintained and that not participating in the research will not affect the continuation of the treatment process.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe test group received training sessions (teaching coping skills and methods to improve sleep) in the number of 6 sessions, one session every week in groups of 5 to 6 people and for an hour and a half. Educational methods included lectures and group discussions, questions and answers, and educational clips. The trainings were carried out at the patients' bedside after the hemodynamic status stabilized and the patient's condition was favorable.\u003c/p\u003e \u003cp\u003eThe educational content included the topics of defining stress and types of stressful situations and coping strategies, coping skills, the concept of problem solving and the benefits of planning for problems, relaxation techniques, sleep disorders and sleep hygiene and the technique of positive thoughts. In all stages of the research, the training of the groups was the responsibility of the researcher. Data were collected one month and three months after the intervention through the mentioned questionnaires. The time of the training sessions was during the hemodialysis of the patients, and in order to respect the well-being of the patients, the training session was not held at a time other than the time of the patients' dialysis (before the dialysis). If needed, the number of sessions increased. In order to ensure that the educational content is the same for all people, the researcher recorded the audio in each session and asked the patients to raise their possible questions at the end of the session so that the educational content of each session is not affected by the questions of the patients. People in the control group received only routine hemodialysis care. The contact information of all the participants was obtained if they wanted to follow up on completing the questionnaires and possible information.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStudy analysis\u003c/h2\u003e \u003cp\u003eIn this research, response variables were: coping efforts score, stress management score and sleep quality score. The paired t-test was used to compare each of the response variables before and after the intervention, in each of the test and control groups (separately). Two independent sample t-test was used to compare the response variables in the test and control groups before and after the intervention (separately).\u003c/p\u003e \u003cp\u003eIn this study significance level was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all statistical tests.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe average age of the participants was 57.12\u0026thinsp;\u0026plusmn;\u0026thinsp;13.25 years. The minimum age was 20 and the maximum was 86 years. The average years of dialysis was 4.47\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78 years. The results of the independent t-test showed that there is a significant difference between the average age of patients in the two groups (P\u0026thinsp;=\u0026thinsp;0.014, t\u0026thinsp;=\u0026thinsp;2.50). The results of the Chi-square test showed that there was a statistically significant difference between the two groups in terms of the demographic characteristics of the education level (P\u0026thinsp;=\u0026thinsp;0.007). However, no significant difference was observed between the two groups in terms of other demographic variables (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the distribution of demographic variables in the intervention and control groups.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics of patients in Test and control groups (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ep-value*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eN (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e51 (48.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e25 (48.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e26 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (51.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27 (51.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e27 (50.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (10.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94 (89.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e44 (84.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e50 (94.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (46.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26 (49.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedium\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (49.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e28 (53.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24 (45.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1 (1.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3 (5.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (12.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2 (3.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (55.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e37 (69.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiploma or postgraduate diploma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20 (19.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11 (21.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e9 (17.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBachelor or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (13.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9 (17.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e5 (9.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSickness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42 (40.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (40.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e21 (39.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDM\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18 (17.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8 (15.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10 (18.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.889\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRenal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e23 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22 (41.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* Chi-square test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eComparing the mean scores of coping efforts and its subscales (Emotional regulation and Problem management) the changes within the group showed that in the intervention group, after the implementation of training based on transactional model, 2.79 units of the problem management substructure score decreased; And based on the paired t-test, this difference was significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Also, the changes within the group showed that in the intervention group, after intervention 1.34 units of the emotional regulation sub-structure score decreased; And based on the paired t-test, this difference was significant (P\u0026thinsp;=\u0026thinsp;0.003). Also, the changes within the group showed that in the intervention group, after intervention, 9.79 units of the score of people's coping efforts from stressful situations have decreased; and based on the paired t-test, this difference was significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). As shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, the average score of coping efforts has increased significantly in the control group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). While in relation to emotional regulation and problem management in the control group, no statistically significant difference was observed before and after the educational intervention.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Emotional regulation, Problem management and Coping effort scores between test and control groups before, one month and three months after the intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne month after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThree months after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eProblem management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.72 (5.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.38 (4.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.64 (4.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.31 (4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.71 (4.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.522\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.71 (4.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eEmotional regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27.72 (5.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.71 (4.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e26.64 (4.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.030\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.31 (4.04)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.38 (4.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.075\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e28.71 (4.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.497\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eCoping effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.06(25.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.27(20.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e51.72(18.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e56.61(21.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.24(21.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e67.01(20.36)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.224\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* Two independent sample t-test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e** Paired t-test\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e*** Repeated measures analysis of variance test\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, the changes within the group showed that in the test group, after intervention, the mean score of sleep quality decreased by 0.5 units, and based on the paired t-test, this difference was significant (P\u0026thinsp;=\u0026thinsp;0.010). In fact, with a decrease in the mean score, sleep quality increases, but in the control group, intra-group changes indicate an increase in the sleep quality score and as a result, a decrease in sleep quality, and based on the paired t-test, this difference was significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe results of the independent t-test showed that before the intervention, there was a significant difference between the mean stress management in the intervention and control groups (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAlso, the changes within the group showed that in the intervention group, intervention, 10.51 units of the stress management score decreased; and based on the paired t-test, this difference was significant (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). However, the results of the paired t-test showed that there was no significant difference between the change in stress scores one month after the intervention and before the intervention in the control group (P\u0026thinsp;=\u0026thinsp;0.093).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Sleep quality and stress management scores between test and control groups before, one month and three months after the intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBefore intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOne month after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eThree months after the intervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eP***\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003emean (SD)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eSleep quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.55 (3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6.05 (3.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.60 (3.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.25 (2.12)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7.86 (2.48)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.16 (2.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.978\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003estress management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e47.02(36.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e36.51(28.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e35.96(28.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.79(22.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e89.60(21.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e92.46(20.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eP*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe changes of research variables over time are given in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. according to the significance of the interaction effect between time and group, it can be stated that the difference in the average score of coping efforts of people from stressful situations, emotional regulation, problem management and stress management at different times is different according to the levels of the group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eThe results of repeated measurement analysis of variance in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e show that the effect of measurement time on sleep quality score in hemodialysis patients is significant (P\u0026thinsp;=\u0026thinsp;0.006). Therefore, it can be said that regardless of the two groups, there was a significant difference between the mean score of sleep quality before, one month and three months after the intervention.\u003c/p\u003e \u003cp\u003eAlso, according to the significance of the interaction effect between time and group, it can be stated that the mean score of sleep quality at different times is different according to the group levels. As can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the effect of the group on the sleep quality score is not significant (P\u0026thinsp;=\u0026thinsp;0.063).\u003c/p\u003e \u003cp\u003eIn relation to emotional regulation, considering the significance of Mauchly's test (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), Greenhouse-Geisser adjustment was used to check the significance of time variables and the interaction effect of time with treatment group. The results of repeated measurement analysis of variance in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e show that the effect of measurement time on the emotional regulation substructure score in hemodialysis patients is not significant (P\u0026thinsp;=\u0026thinsp;0.332), so it can be said that regardless of the two groups, between There was no significant difference in the mean of emotional regulation substructure before, one month and three months after the intervention.\u003c/p\u003e \u003cp\u003eAlso, according to the significance of the interaction effect between time and group, it can be said that the difference in the mean score of the emotional regulation substructure is different at different times according to the group levels. As can be seen in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the effect of the group on the emotional regulation substructure score is significant (P\u0026thinsp;=\u0026thinsp;0.034).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRepeated measures analysis of variance by investigating the interaction effect of test group and time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGroup \u0026times; time\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional regulation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.332\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.029\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.034\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProblem management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoping effort\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSleep quality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.063\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estress management\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this research, there is a significant difference between the mean scores of people's coping efforts from stressful situations before the intervention, one month, and three months after the intervention. However, the number of changes in the scores of people's coping efforts from stressful situations in the test group was much higher than in the control group. The results indicate the improvement of coping efforts after the implementation of the transactional model.\u003c/p\u003e \u003cp\u003eBased on the results, the score of the substructure of problem management and emotional regulation of people from stressful situations is significant one month and three months after the intervention. The number of changes in mean scores of problem management and emotional regulation was decreasing in the test group and increasing in the control group. Therefore, the findings of the study show that education based on transactional model is effective on problem management and emotional regulation in hemodialysis patients.\u003c/p\u003e \u003cp\u003eAppropriate emotional regulation is considered a necessary prerequisite and an important feature of mental health, while difficulty in emotional regulation is a high-risk factor for people's mental health (Monzani et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). In Zamanian et al.'s research, after the educational intervention, the average emotional regulation score in the test group showed a significant change, which indicated the effectiveness of the educational intervention (Zamanian, Poorolajal, \u0026amp; Taheri-Kharameh, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2018\u003c/span\u003e). The results of Zhang et al.'s study also indicated that hemodialysis patients use emotional regulation coping styles more than other coping styles to deal with stress (L. Zhang, Zou, \u0026amp; Zhou, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The use of educational interventions to improve the use of coping styles in different diseases and groups has been investigated and their effectiveness has been confirmed, which are in line with our study. (Alhawatmeh, Alshammari, \u0026amp; Rababah, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Amone-P'Olak, Boitumelo, \u0026amp; Mberengwa, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Shavaki, Harandi, Pourabbasi, \u0026amp; Rahimzadeh, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) .\u003c/p\u003e \u003cp\u003eProbably, one of the reasons for these studies to be in line with the present study is the similarity of educational content, type of study, teaching method and duration of education.\u003c/p\u003e \u003cp\u003eThe stress management in the test group improved in comparison with the control group after the intervention, indicating the effectiveness of educational intervention in improving the use of stress management in the hemodialysis patients. This was despite the fact that the stress management score in the control group had increased significantly, and this indicated the worsening of the stress situation in hemodialysis patients over time.\u003c/p\u003e \u003cp\u003eIn line with this study, the effectiveness of educational interventions to stress management in hemodialysis patients has been shown in different studies (Ghaffari et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Ghasemi Bahraseman, Mangolian Shahrbabaki, \u0026amp; Nouhi, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Haririan, Aghajanlo, \u0026amp; Ghafurifard, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Morrowati Sharifabad et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Rahale, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2018\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn this study, the number of changes in sleep quality scores decreased in the test group and increased in the control group. Additionally, the results showed that the effect of measurement time on sleep quality score in hemodialysis patients is significant. Therefore, it can be said that regardless of the two groups, there was a significant difference between the average score of sleep quality before, one month and three months after the intervention. Finally, it can be said that transactional model has been effective in improving the sleep quality of hemodialysis patients. Sleep is necessary for staying healthy and reviving the nervous, immune and skeletal muscle systems. Approximately 25\u0026ndash;36% of adults suffer from a sleep disorder. While 40 to 85% of patients with chronic kidney failure suffer from these disorders, which is much higher than the prevalence in the general population (Liaveri et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn Omidi et al. study, the results demonstrated the transactional effect of the group over time on perceived stress, self-efficacy and sleep quality of the elderly and the implementation of the independent variable have led to a reduction in perceived stress, an increase in self-efficacy and sleep quality in the experimental group. Based on the findings of this research, emotional regulation training can be used to reduce perceived stress and improve self-efficacy and sleep quality of the elderly with type 2 diabetes (Omidi, Sabet, Ahadi, \u0026amp; Nejat, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In Moradi et al. study, the results showed that the sleep health education based on the continuous care model improves the sleep quality of the elderly, so this method it is recommended to improve the sleep quality of the elderly (Moradi, Ebrahimi, Goli, \u0026amp; Khajeh, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis research recommends that to improving coping efforts, stress management and sleep quality in hemodialysis patients, apply transactional model is helpful.\u003c/p\u003e \u003cp\u003eAlso, it seems that the treatment system should pay more attention to the psychological needs of people, including counseling services to improve stress in areas such as dialysis centers. In health education and health promotion, one of the main components of health care is education. In this regard, it is necessary to pay attention to educational plans based on educational theories and models for various health-related issues. One of the comprehensive models in the field of stress management is transactional model, so it can play an important role in health promotion planning and improving the quality of life.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore starting the study, Ethics Committee of Faculty of Medical Sciences of Kerman provided the permission with ethics code of IR.KMU.REC.1401.408, related references were provided by Kerman University of Medical Sciences for dialysis centers in Kerman and the study was registered at clinical trials registration center with the code of IRCT20221220056882N1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is part of the results of a MSc thesis on health education and health promotion. We acknowledge all the officials of Kerman University of Medical Sciences, the hemodialysis centers and all the patients who participated in this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Kerman University of Medical Sciences. The funders of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eH. FA. has designed the study, analyzed and interpreted the data and drafted the manuscript. S. A. supervised the study and helped with data analysis and manuscript preparation. M. MA. helped with data analysis and manuscript preparation. A. I. ,literature search, and drafting the manuscript and interpretation of results. H. KH. helped with data analysis, drafted the manuscript and manuscript preparation. All the authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlhawatmeh H, Alshammari S, Rababah JA. Effects of mindfulness meditation on trait mindfulness, perceived stress, emotion regulation, and quality of life in hemodialysis patients: A randomized controlled trial. 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Ren Fail. 2024;46(1):2331613. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/0886022X.2024.2331613\u003c/span\u003e\u003cspan address=\"10.1080/0886022X.2024.2331613\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\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":"intervention, stress, sleep quality, transactional model, coping efforts","lastPublishedDoi":"10.21203/rs.3.rs-6255562/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6255562/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eToday, many hemodialysis patients suffer from stress caused by their disease. Therefore, the present study was conducted aimed to investigate the effect of training intervention based on transactional model on stress management and sleep quality of hemodialysis patients in 2022. This study was a quasi-experimental conducted from September to February 2021 for 6 months in Bam city hospitals, Kerman province. A total of 105 people participated in this research. 53 people were placed in the test group and 52 people in the control group by simple random method. The test group received training (teaching coping skills and sleep quality) for 6 weeks. Data collection tools included 4 questionnaires (demographic information, PSQI sleep quality, Balderi stress, and coping efforts). The average age of the participants was 57.12\u0026thinsp;\u0026plusmn;\u0026thinsp;13.25 years. After the educational intervention, the average score of coping efforts, sleep quality and stress management of the patients showed a significant change in the investigated time periods (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The findings indicate the effectiveness of the design and implementation of the training program based on the Lazarus and Folkman model on the stress management and sleep quality of hemodialysis patients. Therefore, this model can be used to promote health and improve quality of life, especially in relation to stress management in chronic diseases.\u003c/p\u003e","manuscriptTitle":"The effect of coping efforts on stress management and sleep quality of hemodialysis patients","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-02 19:58:13","doi":"10.21203/rs.3.rs-6255562/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":"4a5da81a-39ee-4135-8208-7ba14c0baffc","owner":[],"postedDate":"April 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-09T13:08:48+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-02 19:58:13","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6255562","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6255562","identity":"rs-6255562","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}