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Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58〈Original Contribution〉―――――――――――――――――――――――――――――――――――

Attitudes toward Dietary Management Actions among
Hemodialysis Patients in Japan
Hiromi Onbe
Graduate School of Health Science, Gunma University
日本の透析患者の食事管理行動に対する態度
恩幣宏美
群馬大学大学院保健学研究科＜ Abstract ＞
Background: For behavioral modification to occur, patients must acquire necessary information andunderstand it, and form a desirable attitude or improve their attitude. Attitude is composed of affect andcognition, which influence propensity of behavior. Detailed information is not available, however, on the
structure of affect and cognition as they influence dietary management actions in hemodialysis patients.
Aim: The aim of this study is to extract the factors of affect and cognition that influence attitude in the
dietary management actions of hemodialysis patients.
Methods: The participants in the study were nine patients undergoing chronic maintenance hemodialysis
who had received guidance related to diet and had good test results. Data was collected throughethnography, by means of participant observation and semi-structured interviews. The data was analysed
according to thematic analysis methods.
Findings and discussion: Regarding affect and cognition as factors of attitude influencing dietary
management actions in hemodialysis patients, three themes came to light, with culture as an additional
theme. Also, through strict dietary management carried out while undergoing dialysis treatment, an affectleading to eustress was extracted.
Conclusion: As the elements that contribute to dietary management of the hemodialysis patients, four
factors became clear out of three components, affect, cognition, and culture. Those factors are: Believing in
information perceived to be good for the health; valuing happy feelings and taking a positive approach to dialysis;
feeling that dialysis creates stress; and valuing cooking with seasonal ingredients and creating special meals forseasonal occasions.
＜要旨＞［目的］行動変容では，必要な知識の習得と理解，並びに望ましい態度の形成や改善が必要である。態度は感情と認知で構成され，
行動傾向に影響するが，血液透析患者の食事管理行動に対する感情と認知の詳細な内容は明らかになっていない。本研究の目的は，血液透析患者の食事管理行動における態度に影響する因子である感情・認知を抽出し，その内容を検討することである。
［方法］対象は今までに食事に関する指導を受けた経験がある，検査データが良好な慢性維持血液透析患者 9 名である。データ収集は，参与観察および半構成的面接によるエスノグラフィーで行った。分析は，thematic analysis の手法に則って実施した。
［結果と考察］血液透析患者の食事管理行動における態度に影響する因子である感情・認知では 3 つのテーマが明らかとなり，
さらに文化として 1 つのテーマが明らかとなった。また，
態度の中で，
透析治療上の厳しい食事管理行動の間で，

Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

50

ユーストレスにつながる感情が抽出された。
［結論］透析患者の食事管理行動における望ましい態度を構成する要因として，感情，認知，文化の 3 つの成分から，4 つの因子が明らかになった。それらの因子は，健康に良いと思った情報を信じている，快の感情を大切にし透析を前向きに考えている，透析には辛い感覚が伴うことを感じている，旬を味わう食事をしているであった。

Keywords
affect				感情

attitude			態度

cognition			認知

dietary management actions

食事管理行動hemodialysis patient		

血液透析患者

Ⅰ．Introduction

but to also review patients' self-management

The number of dialysis patients in Japan

in light of the relationship between feelings

undergoing chronic dialysis treatment at the

toward meals and dietary management actions.

end of 2011 was 304,592, exceeding 300,000
for the first time ever 1). According to data

Ⅱ．Background & literature review

from 19 countries around the world, JapaneseAttitude is an important concept indialysis patients have the longest time on

thinking about feelings and behavior. In

dialysis, at 8.76 years, and their prognosis

social psychology, attitude is composed of2)is good . However, since the top cause of1)

three components—affect, cognition, anddeath in Japan is heart failure , it is vital topropensity of behavior. It is said that cognition

prevent cardiovascular system complications.

components influence affects and affective

For dialysis patients, controlling thecomponents influence propensity of behavior4).

concentration of phosphorus, which affects the

In addition, in patient education it is necessary

3)cardiovascular system , and preventing rises

to make patients acquire necessary informationin blood pressure will influence prognoses, so

toward behavior modification, understand it,

medication management, in addition to dietaryand form a desirable attitude or improve their

management, is critical. Dialysis patients

attitude5).

need to have strict dietary management, but

A previous study on attitude in dialysis

the affect of naturally enjoying meals alsopatients focused solely on a scale measuring

comes into play. For patients that continue

adherence to food and liquid intake

implementing dietary management actions,

restrictions6). However, the sample for this scale

it is important to have the affect of naturally

was small and validity was not sufficiently

enjoying meals, not simply managing meals

assured. No studies have been done on theto prevent complications. Having this affect,

relationship between dietary management

patients may be able to sustain proper dietary

actions and affect/cognition in hemodialysis

management actions over the long term. It was

patients. In a study unrelated to dialysis

therefore considered important for medical

patients that examined the relationships

caregivers to think not only of proper dietaryamong dietary management actions, cognition

management actions for medical reasons,

performance, and affect, it was found that

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Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

a low-carbohydrate diet intended for losing

difficult to understand attitudes toward dietary

weight had the intended effect, but the study

management actions that are influenced byshowed that the diet did not have a positive

culture through interviews alone, which is why

influence on cognition performance andthis method was chosen.

7)affect . Those results demonstrate that meals
designed primarily for losing weight and1. Ethical considerations

maintaining good test results, while leading toThis study underwent screening by andimprovements on paper, did not have a positive

received the authorization of the Gunma

influence on cognition performance and affect.

University Research Ethics Review Committee

This study was therefore designed to ascertain(Authorization No. 9-7). Following authorization,

what kind of attitude (affect/cognition) dialysis

the researchers explained the study in writing

patients with good test results have related toand verbally to each research facility's director,

their dietary management actions.

director of nursing, and head nurse, and

It is important to include food culture when

received their consent. After receiving consent

trying to understand the relationship between

from the research facilities, the researchers

eating meals and attitude, so this study waswere introduced to about five patients at eachconducted using the qualitative methods offacility who would be potential informants. The

ethnography. The objective of this study

researchers explained the study in writing

was to extract attitude factors in the dietaryand verbally to these potential informants.

management actions of hemodialysis patients.

Specifically, they explained the aim of theConnecting the extracted attitude factors to

study, along with the policy of protecting

the development of an attitude scale can leadindividual privacy, the strict observance ofto an intervention study aimed at behavioral

confidentiality, the benefits and drawbacks

modification with regard to eating habits thatto the individual arising from the study, thetakes affect and cognition into consideration.

voluntary nature of participation in the study,
and that no detriment would arise from

Ⅲ．Aim

withdrawing consent. Notably, because thisThe aim of this study is to extract affectstudy involved observation in the private

and cognition factors, factors that influencespace of the informant's home, the researchers

hemodialysis patients’ attitude on their daily

explained quite carefully about protecting

dietary management actions, and to evaluate

individual privacy and the strict observance ofthe content of these factors.

confidentiality. After explaining these things,
the researchers received written authorization

Ⅳ．Methodology

for cooperation with the study.

Microethnography was chosen as theresearch method. While the culture that

2. Field Overview and Research Participants

serves as the background to people's daily(Table 1)

actions has become so ingrained that it is

The field was hospitals and the homes,

imperceptible even to the person in question

including the kitchens, of people receiving

in most cases, fieldwork is one method for

outpatient dialysis in Japan.

8)

describing a culture . We believe that it is

The participants were selected accordingOnbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

52

to the study's criteria and introduced byresult selection criteria were mean values

dialysis physicians and head nurse, andof around 6.0mg/dl phosphorus, 5.5mEq/l

the researcher explained the study to eachpotassium, 9.0-10.5mg/dl calcium, and 3.5g/dl

person. There were nine patients in the study,

serum albumin six months prior to the time of

who managed their diet themselves, plus

the survey, and a mean monthly weight gaineight of their family members. (See Table 1)of around 5% with two days between dialysis

The age of the patients, five males and four

treatments. Additional requirements were thatfemales, ranged from 50s to 70s with theirno participants have cognitive impairment

hemodialysis history ranging from seven to 32

or the inability to communicate, or higher

years. The nine patients, undergoing chronic

brain dysfunction with regard to reading andmaintenance hemodialysis for over six months

writing; they also had to be between the ages

as outpatients, had received guidance relatedof 20 and 80.

to diet and had good test results. The test
Table 1 Research participants
GenderAgeYears ondialysis

Original condition

FamilyPerson A

Female60s

30

Chronic nephritis andnephropathy of pregnancy

Lives with husband(has 1 daughter)

Person B

Male

70s

16

Chronic nephritis

Lives with wife and eldest
son's family including 1
daughter and 1 son

Person C

Male

50s

18

Polycystic Kidney Disease

Lives with wife and son

Person D

Male

60s

16

Chronic nephritis

Lives with wife

Person E

Female50s

32

Chronic nephritis

Lives with mother, brotherand brother's wife

Person F

Male

70s

15

Polycystic Kidney Disease

Lives with wife

Person G

Male

60s

7

Chronic glomerulonephritis Lives with wife and daughter

Person H

Female60s

18

Polycystic Kidney Disease

Lives with husband,
son's family(3 people)

Person I

Female60s

22Unknown

Lives with husband

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Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

followed thematic analysis methodolog11,12). All

3. Data collection
Data collection was carried out from 2010

fieldwork and data transcripts were carried

to 2011. Consistent with an ethnographicout by the first author while checking with thea p pr o a c h, da t a w e r e c o lle c t e d t hr o ugh

co-researchers. The data set consisted of theinterviews, field notes, and documents.

verbatim transcripts and field notes. The data

Participant observation was carried out at theset was read numerous times until familiarity

scenes of cooking and eating for 45 hours inwith the data was established. Then, items

total, all of which was recorded in the fieldof interest in the data, especially items that

notes. An interview was conducted after apertained to the concept of attitude, wereparticipant observation for about one to one

extracted and codified. Latent themes andand a half hours per session, 77 hours in total.

the codes were compared. Then, to make the

The interviews were structured according

relationships between the themes and codes

9)classic approach of using open-

visible, a thematic map was created and theended general to more specific questions.

themes revisited in the process of studying the

Although an interview guide was used tooverall stories. The themes extracted in theassure a systematic approach to data collection,

end were named and definitions were created.

it still provided flexibility in the sequencing of

The initial analysis was conducted by the firstinterview questions. Questions were broadly

author, then the relationships between therelated to participants' perceptions of thecodes and themes and the map were discussed

attitude components. After the informant

with the other researchers. The agreement

signed an informed consent form, the dataof the other researchers was obtained on thecollector turned on the audio recorder.

naming and definitions of the themes extracted

to Spradley's

Four roles of the field worker have beenin the end.

identified (the complete participant, theparticipant-as-observer, the observer-as-

5. Trustworthiness

10)

participant, and the complete observer) .

Trustworthiness was addressed using

For this study the field worker's role was theLincoln & Guba's 13) criteria of credibility,

participant as observer. The researchers spenttransferability, dependability andas much time as possible with participants,

confirmability. To ensure credibility andsuch as during cooking or eating meals,

transferability, both researchers independently

while trying to keep any disturbance to thecoded the text for relevant themes during

flow of their daily lives to a minimum. The

meetings. Following agreement on the key

observations were documented in field notes

themes, the researchers reviewed ideas,

written as soon as feasible and transformed

assumption and ensuring consistency.

into a short report and later into a more

Dependability and confirmability weredetailed report.

achieved by maintaining an audit trail
throughout the work.

4. Data analysis
All field work and individual interviews wereⅤ．Findings

recorded and transcribed by the first author

The results of analysis revealed four themes

prior to thematic analysis. The data analysis

of desirable attitudes in dietary management

Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

54

actions among hemodialysis patients. Key

express the feeling of being stressed, itthemes are hereafter indicated by boldface

represents the affective component of attitude.

type.

Although the participants undergoing dialysis
do not necessarily feel restricted and stressed

Theme 1: Believing in information perceived

constantly, when their desire for food was not

to be good for the healthfulfilled, they inevitably felt that undergoing

Because this factor indicates believing, or an

dialysis brought stress. This stress became aevaluation of truth or falsehood, it represents

deterrent, however, keeping the participants

the cognitive component of attitude. The

from overeating.

researchers learned that when participants"I love fruits. Just a little. Yeah, just a few

get information not only from a health care

nibbles. But I have to hold myself back and ..."

practitioner such as a doctor, nurse, or a

(Person I)

dietician, but from family members, neighbours,
the mass media, or other source, which if they

Theme 4: Valuing cooking with seasonal

deem to be useful for leading a healthy life

ingredients and creating special meals forin light of their disease or physical condition,seasonal occasions

they believe in that information. However,As shown by the term 'seasonal', this factor

there were patients who believed that shrimps

does not involve any of the three components

are good for their kidney, and accordinglyof attitude, so it is considered a finding related

took shrimps. As it is known, this was a false

to culture. Analysis revealed that participants

information. Thus, it became clear that someoften prepare such seasonal foods withinformation, such as this one, was not correct.

special care. As it is known, eating seasonal
vegetables raise the hemodialysis patients'

Theme 2: Valuing happy feelings and taking

serum potassium.

a positive approach to dialysis

boiled vegetables, following their culture based

Because this factor includes the word
'feelings' and words that indicate cognition

However, the patients

cooking ideas, and successfully avoided raisingserum potassium.

in 'taking a positive approach', it represents

The vegetable drawer of Person A's

both the behavioral and cognitive components

refrigerator is stocked full with vegetables. Sheof attitude. Dialysis brings with it various

chooses some vegetables from the vegetable

restrictions and distress, but the participants

drawer to prepare a meal. "A neighbour brings

valued the good feelings they had in daily life.

me eggplant and scallions, which is a big help.

While dialysis has a tendency to be viewed

In the summer vegetables are the best", she

negatively, they did not think of it in that light,

says as she chooses vegetables and begins toinstead taking a positive approach.

prepare them.

"(Ice cube after dialysis is over) One cube.
Just one. It's good. That is what I look forward
to". (Person B)

Ⅵ．Discussion
This discussion covers two things—thefactors of affect and cognition that influence

Theme 3: Feeling that dialysis creates stressattitude, which is the objective of the study,

Because this factor involves words thatplus the factor of culture, which does not55

Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,2014

belong to the three components of attitude

49 - 58

Regarding emotions, participants generally
had the positive emotion of valuing happy feelings

found in the analysis.

and taking a positive approach to dialysis and the

1. Affect and cognition in dietary management

negative emotion of feeling that dialysis creates

actionsstress. Although the ratio of positive to negative

The participants in this study, who have goodemotions—and which was greater—was nottest results, have the cognition of believing inapparent, it is important that the participants

information perceived to be good for the health. Some

felt positive emotions despite living withof that information, however, was incorrect withthe severe dietary restrictions demanded

regard to health. Because no drop in cognitiveby dialysis. Also, participants had negative

functions such as higher brain dysfunction

thinking, but from interviews it was learned

was observed, it is considered that a low levelthat this became a deterrent in practicing

of information literacy played more of a part

dietary management. For this reason, it isthan a reduced ability to interpret information.

considered to be eustress. Eustress encourages

It remains unclear as to how holding thebetter behavior, so it is necessary for doctors

cognition of a belief in incorrect informationin talking with patients to give them eustresscan lead to good test results. Depending on

rather than distress with regard to dietary

the type of food, one would anticipate thatmanagement actions.

following such information would lead to a risein potassium levels, for example, in the dialysis

2. Food culture in dietary management

patient, which would be a significant threat

actions

to their health. Through interviews with the

In the participants who had good test results,

participants in this study it became clear that

their affect/cognition of v aluing cooking withcognitively they believed what doctors andseasonal ingredients and creating special meals fornutritionists told them, and also informationseasonal occasions was found to be the factor ofthat they got from the media, and used all of

culture.

that information in their dietary management

Participants ate meals primarily based on

actions. One study shows that a low level ofseasonal Japanese foods. Japanese cuisine isinformation literacy is related to an insufficientconsidered healthy in general, but for seasoning

understanding of the information received

it calls for the use of soy sauce, which is high. Japanese patients place thein salt, and employs fresh vegetables, whichhighest degree of trust in information when

are high in potassium. Because Japanese foodreceived from doctors, but it has been pointed

is high in salt and potassium17), both of which

out that the information from doctors alone

need to be controlled in hemodialysis patients,

does not fulfil their needs and so they makeit is by no means the basis for a healthy

from doctors

14,15)

use of multiple sources of information . For

diet for them. The participants of this study,

that reason, raising the information literacy

however, had good test results. In addition theyof patients is vital, but it is also important for

did not take in a large amount of fluids. This is

doctors to accurately communicate the kindlikely due to the fact that the participants didof information that will properly satisfy the

not have excessive intakes of potassium andpatient's informational needs.

salt. Participant observation revealed a meal

16)

Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

56

style of a soup and three side dishes. Their

effective, highly personalized patient education

desirable condition may also be influenced

as they carry out their regular duties.

by the 'soup and three side dishes' approach

After going through many books on

to cuisine that has been part of Japanese

dialysis nursing, nowhere was the necessity

food culture since olden times, an approachof incorporating the concept of attitude into

18)

that is nutritionally well-balanced . Also,patient education found. From the perspective

an intervention study conducted in Greeceof the findings of attitude expressed inreported that the use of olive oil, essential forbehavior and based in cognition and emotion,

preparing local Greek cuisine, significantly

it is important for nurses to first look at the19)

improved cognitive functions . This result cancognition, emotion and culture in a patient,

be understood to mean that being able to eat

instead of looking exclusively at the dietary

meals based on the food culture of a person's

management actions being taken or thecountry may contribute to a better attitude.

patient's test results. If the nurse looks at

Also, participants limited the amount of their

cognition and emotion and culture, and isintake. Eating a variety of different foods, evenable to draw them from the patient to makein small amounts, provided satisfaction to thean assessment, it then becomes possible toparticipants. In patient education, nurses canprovide support directed toward attitudeintroduce the idea of increasing the number

change and behavior change that is moreof dishes and eating smaller amounts, rather

specific and individually tailored. Moreover,than simply promoting conventional eating

this study may reveal more than cultural

restrictions. This approach should give people

discoveries of the attitudes of Japanese people.

a sense of satisfaction—a positive emotion that

It may offer concepts that can be applied inwill lead to forming a good attitude toward

other countries, as well. From this point on,

good dietary management actions.

the researchers would like to verify desirable
attitudes in dietary management that arise

3. Implications for Practicethrough national and cultural differences.

People tend to think that most dietary
guidance is provided by nationally certified

4. Limitations of the Study and Futuresenior dieticians and doctors, but because theChallenges

nurses who provide guidance think of the

In this study, in order to understand attitude

patient as a person leading everyday life, theyin the dietary management of hemodialysis

are in the best position to give that guidance

patients in Japan as much as possible, datausing the attitude elements learned from thewas collected in three regions of the country.

informants and obtained in this study. Also,

But because of the diversity of regional

most hemodialysis patients receive dialysis atcharacteristics that affect diet even withinclinics that do not have a resident nationallyJapan there are limits to the applicability of thecertified senior dietician, and often nurses also

results of the study to hemodialysis patients

serve as dieticians. For that reason, if nurses

nationwide in terms of attitudes in dietary

are able to understand the element of attitude

management. Also, because environmental

in the dietary management of hemodialysis

factors have such a strong influence on thepatients they will likely be able to carry out

food habits of informants from their birth

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Onbe ／ Journal of The Japan Academy for Health Behavioral Science 28（2）,201449 - 58

to the present day, it will also be important

Hemodialysis Patients, American Journal of

to investigate correlations that include theKidney Diseases, 46: 68-77, 2005

informants' life history.

4) Rosenberg MJ, Hovland CI: Attitude
Organization and Change, Yale University

Ⅶ．Conclusion

Press, NY, 1960

As the elements that contribute to dietary5) Kim K, Reicks M, Sjoberg S: Applying

management of the hemodialysis patients, four

the theory of planned behavior to predictfactors became clear out of three components,

dairy product consumption by older

affect, cognition, and culture. Those factors are:adults, Journal of Nutrition Education andBelieving in information perceived to be good for the

Behavior, 35: 294-301, 2003

health; valuing happy feelings and taking a positive6) R u s h e H , M c b e e M H : A s s e s s i n gapproach to dialysis; feeling that dialysis creates

adherence to dietary recommendations forstress; and valuing cooking with seasonal ingredients

hemodialysis patients: The renal adherence

and creating special meals for seasonal occasions.

In cognition, belief in information without
confirming its veracity suggested a low levelof information literacy. In attitude, affects
leading to eustress were extracted from thestrict dietary management actions demandedby dialysis treatment. Plus, a factor related
to culture was extracted and it was foundthat this might constitute a factor making up
attitude.

Journal of Psychosomatic Research, 45: 149157, 1998
7) Cheathama AR, Robertsa BS, Dasa SK,
Gilhoolya HC, Goldena KJ, Hyattb R, Debra
L Saltzmana E, Liebermand RH: Longterm effects of provided low & highglycemic load low energy diets on mood
374–379, 2009

The author wishes to thank the dialysis
patients who participated in the study.

8) Spradley JP: Participant observation, Holt
Rinehart and Winston Inc, NY, 1980
9) Spradley JP: The Ethnographic Interview,
Holt Rinehart and Winston Inc, NY, 1979

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