Effects of psycho-educational intervention on health-related quality of life (QOL) of patients with chronic liver disease referring to Shiraz University of Medical Sciences
© Sharif et al; licensee BioMed Central Ltd. 2005
Received: 03 October 2005
Accepted: 16 December 2005
Published: 16 December 2005
Chronic liver diseases (CLDs) are progressive disorder which has a significant impact on the well-being of patients and leads to significant morbidity. CLDs are characterized by disturbances in physical, psychological and social aspects of well-being. It causes significant health-related quality of life (QOL) impairment. Psycho-educational interventions targeting to functional factors could be beneficial for patients with CLDs.
An interventional study was conducted on 110 patients with CLDs in Shiraz Liver Transplantation Center (SLTC). Subjects with the required CLDs criteria were selected and randomly divided into experimental (55) and control (55) groups. A two part questionnaire with 25 items concerning demographic and general information and 29 items regarding QOL was used. The psycho-educational needs of the experimental group were assessed in a session before the intervention, then the experimental group took part in 3 sessions individually and one session in groups. The questionnaires were filled in again for both groups but the control group did not receive the intervention program. The questionnaires were filled in again for both groups one day and three months after the intervention.
Findings revealed no significant differences between the two groups from the view point of demographic characteristics such as marital status, gender, etc... (p > 0.05) and from the point of clinical variables no statistically significant differences were found (p > 0.05).
Findings revealed statistically significant differences in all domain of QOL in the experimental group three months after the intervention (p = 0.001), while there was no statistically significant differences in the control group.
The results of this study revealed that psycho-educational intervention had a significant effect on QOL of patients with CLDs.
Chronic liver diseases (CLDs) are an extensive disorder affecting 5 million people in the United States and are one of the leading causes of death . People with chronic HBV infection are at a lifetime risk of developing hepatocellular carcinoma (HCC) or cirrhosis, or both. Many people with HBV are unaware that they are bearer the infection, while of those who are chronically infected, only a minority receive routine, scheduled follow-up to monitor their disease status. [2–4]. Chronic hepatitis C virus (CHCV) infection is a prevalent and extensive condition leading to cirrhosis in up to 20% of those chronically affected [1, 2]. Patient with CLDs suffer from debilitating fatigue, pruritus, loss of esteem, depression, and complications of cirrhosis [1, 5]. CLDs lead to reduction of health-related quality of life (QOL) as reflected in the disturbances of cognitive, behavioral, physical and social aspects of well-being and therefore lead to physical and psychological problems . The impact of chronic hepatitis on QOL and creating complications such as encephalopathy, variceal hemorrhage and ascitis is well recognized .
A large number of studies have been performed regarding QOL of patients with CLDs in terms of assessing the impact of treatment intervention however, there is little information concerning QOL for such patients and there is relatively little published evidence concerning the effectiveness of psycho-educational intervention. According to our knowledge, the only published related article regarding QOL of patients suffering from CLDs in Iran has been conducted on the effect s of self-care program on QOL of 44 patients referring to Tehran Hepatitis Center. The self care questionnaire and CLDQ for measuring the QOL was used. Then self-care educational program was conducted and the patients were followed for 3 months. The results confirmed the positive effects of the educational and self care program on the QOL of cirrhotic patients. The QOL significantly improved in the experimental group after the intervention(p= 0.001), while the QOL decreased in the control group . The objective of this study was to investigate the effect of psycho-educational intervention on QOL of patients with CLDs referring to the SLTC.
In this study a randomized controlled clinical trial was used. The study was consisted two groups of subjects. One hundred and ten patients with CLDs out of 1585 patients who were registered by the Shiraz University of Medical Sciences Liver Transplantation Center were selected according to inclusion criteria. They were randomly assigned into experimental (55) and control (55) groups. The diagnosis of both groups and blood tests was approved by gastroenterologist. Patients were 18 years and older, not having other chronic illness such as malignancy, diabetes, mental illness, preferably living in Shiraz and close cities and patients with chronic hepatitis c were in the expected list of liver transplantation. The patients were registered at the liver transplantation center or liver clinic. The SLTC is covering all the chronic liver disease patients in Fars province. At the time of study from 1585 registered cases, 1128 of them had been chronic hepatitis B and 457 of cases chronic hepatitis C which 191 of them liver transplanted and 337 child score of C in transplant waiting list.
Data collection tools
In this study two part questionnaire and one "needs assessment" session were used. The first part of questionnaire was consisted of 23 items demographic and general information questions. It included age, gender, education level, marital status, number of admission, number of children, the duration of illness, financial status, number of admission in hospital, the cause of disease, kind of medication that they were taking and complication. The second part of questionnaire was about CLDs QOL which is the first liver specific instrument for measuring QOL in chronic liver disease developed by Younossi et al.. It includes 29 items in the 6 domains which are abdominal symptoms, fatigue, activity, worry, emotional functions and systemic symptoms. It is 7 point likert scale type of answers ranging from "all of the time" to "none of the time". The main advantage of CLDs QOL scale is its wide application in hematologic studies. The construct validity of the scale has been supported with a strong correlation with patients' global rating scores (r = 0.84; p = 0.02). The fatigue domain of CLDQ, both correlated highly with GRC (r = 0.83 and r = 0.90, respectively; p = 0.006) [7, 8].
Also the content validity of translated CLDs QOL was approved by all faculty members of Gastroenterology Department. Reliability was determined from test-retest on 30 patients with the interval period of 10 days for test-retest. Spearman's rank correlation coefficient was r = 0.98 (p < 0.001).
At the beginning in the experimental group patients were asked to attend one discussion session to assess their needs. Their needs were knowledge about the nature of disease, sign and symptoms of disease, physical limitation, nutrition, adaptation and adjustment to chronic illness, social function, anxiety and drug therapy.
Both groups filled out the questionnaires, then the experimental group was divided into 5 subgroup, according to their disease stage, level of education and their free time. Each group consisting of 11 patients, and four interventional program sessions (three sessions individually in 3 weeks and one session in group) were conducted only for the experimental group. Each session lasted for 90 minutes and one of the close patients' relative was attended in individual session.. When family members have enough information, they play a supportive and helpful role to maintain clients' need... The psycho-educational intervention program consisted information relating to CLDs and its effect on QOL, adjustment to chronic disease (coping strategies), relaxation, exercise, diet and nutrition, drugs used and possible side effects. Posters and handouts were used as training aids in each session based on the subjects' educational level... Educational booklet was given to all patients. The questionnaires were filled in again by both groups one day and three months after the intervention... After data collection, the educational booklet was given to the control group to provide equity too. Data were controlled, encoded and analyzed after data collection.
The study was conducted after approval had been obtained from Vice-Chancellor for research of Shiraz University of Medical Sciences.. All participants were informed of the objective and design of the study and written consents were received from the participants for interview.
Frequency distribution of demographic and clinical characteristics of patients in the control and experimental group
Diploma and higher
Duration of disease
6 month to one year
More than 1 to 2 year
More than 2 year
No of Admission
Triple and more
Comparison of Mean score of CLDQ domains in the experimental group (pre and post test no 1 and 2
Post test 1
Post test 2
Comparison of Mean score of CLDQ domains in the control group (pre and post test no 1 and 2)
Post test 1
Post test 2
Comparison of mean differences score of CLDQ domains in the control and experimental groups
Differences of pre-test score and first follow-up
Differences of pre-test score and second follow-up
Findings revealed that, intervention was effective on all aspects of QOL after 3 months in the experimental group. The inability of the intervention program to provide evidence of significant changes on all aspects of QOL from pre to one day after the intervention may be due to the various reasons. One may be that, four sessions may not have provided sufficient time for patients to effectively learn and develop the necessary skills regarding QOL. Besides receiving knowledge and information about disease to keep their good QOL and relief their anxiety, long term behavioral and attitude changes need to take place which can occur only over a longer period of time.
Structured format of psycho-educational intervention
Topic of discussion
Introduction to liver and its function, sign and symptoms of chronic liver diseases
Treatment and Medication and possible side effects, adjustment to chronic disease, coping strategy
Exercise, relaxation exercise, anxiety reduction, diet and nutrition
Open group and open discussion
The result of this study showed that the majority of patients in experimental (76.4%) and control group (74.5%) were male. These findings are supported by the previous studies conducted by Gledhill, et al. and Alavian, et al. and Zandi et al. [12, 13, 9].
The finding of this study revealed that none of the patient in both group had any other diseases and no significant differences between two groups were found (P = 0.69). This findings is in contrast to the finding of Khozema, et al.  who found out that 71% of their patients had history of other diseases and it was statistically significant (p < 0.001).
The findings of this study showed that most of the patients in the experimental group 54.5% and in the control group 58.2% had hepatitis B but not statistically significant differences were showed (P = 0.47). This finding is similar to the study conducted by Burke et al. . The higher rate of Hepatitis B may be due to many reasons. The findings revealed that the majority of patients in experimental (76.4%) and control group (74.5%) were male. Male are more susceptible to high risk behavior, using harmful drugs, alcohol and engaging in sexual activity without protection.
The result of the present study have added support to an earlier study by Hauser, et al.(2004) who found out that health related QOL in chronic hepatitis C is not determined by severity of liver diseases but psychiatric and medical co-morbidities and disease-related worries .
The results of need assessment of patients with CLDs supported a need for an intervention program to increase their QOL.
The findings revealed that there was a significant difference in three domain of QOL, such as fatigue, emotional function, worry and systemic symptoms for patients in the experimental group one day after the intervention, whereas, A statistically significant difference in all domains of QOL was shown in three months after the intervention. A statistically significant difference in three domains of QOL, such as abdominal symptoms, emotional function and worry was observed in control group one day and three months after intervention, but in two domains of QOL, such as fatigue and activity, no statistically significant difference was seen after one day and three months after intervention.
Generally, the result of this study revealed that psycho-educational intervention had an improving effect on QOL of patients with chronic liver diseases. It seems that the combination of psychological and educational intervention leads to improvement of QOL.
The authors would like to acknowledge all patients for their active contribution and participation in this research and Mr Shenasa for final editing of the paper.
- Younossi ZM, Guyatt G: : Quality of life assessment and chronic liver disease. Am J Gastroenterol 1998, 93: 1037–1041. 10.1111/j.1572-0241.1998.00325.xPubMedView ArticleGoogle Scholar
- Everhart J: Digestive disease in the United States: Epidemiology and impact. NIH publication No. 94:1447 1994.Google Scholar
- Kim WR, Brown RS Jr, Terrault NA, El-Serag H: Burden of liver disease in the United States. Hepatology 2002, 36: 227–242. 10.1053/jhep.2002.34734PubMedView ArticleGoogle Scholar
- Poynard T, Bedossa P, Opolon P: Natural history of fibrosis progression in patients with chronic hepatitis C. Lancet 1997, 349: 825–832. 10.1016/S0140-6736(96)07642-8PubMedView ArticleGoogle Scholar
- Brian J, McMahon MD: Epidemiology and Natural History of Hepatitis. Semin Liver Dis 2005, 25: 3–8. 10.1055/s-2005-915644View ArticleGoogle Scholar
- Spiker B: Quality of life assessment in clinical trials. Raven press, New York; 1990.Google Scholar
- Ware JE, Bayliss MS, Mannocchia M, Davis GL, The International Hepatitis Interventional Therapy Group: Health – related quality of life in chronic hepatitis C: Impact of disease and treatment response. Hepatology 1999, 30: 550–555. 10.1002/hep.510300203PubMedView ArticleGoogle Scholar
- Younossi ZM, Guyatt G, Kiwi M, Boparai N, King D: Development of disease specific questionnaire to measure health related quality of life in patient with chronic liver disease. Gut 1999, 45: 295–300.PubMed CentralPubMedView ArticleGoogle Scholar
- Zandi M, Adib-Hajbagheri M, Memarian R, Kazem Nejhad A, Alavian SM: Effects of a self-care program on quality of life of cirrhotic patients referring to Tehran Hepatitis Center. Health Qual Life Outcomes 2005, 3: 35. 10.1186/1477-7525-3-35PubMed CentralPubMedView ArticleGoogle Scholar
- Van der plas SM, Hansen BE, de Boer JB, Stijnen T, Passchier J, de Man RA, Schalm SW: Generic and disease- specific health related quality of life in non-cirrhotic, cirrhotic and transplanted liver patients: a cross-sectional study. BMC Gastroenterol 2003, 3: 33. 10.1186/1471-230X-3-33PubMed CentralPubMedView ArticleGoogle Scholar
- Kato S, Ishii H: Lifestyle guidance for patients with chronic liver disease; information provision via educational classes on liver diseases. Hepatol Res 2004, 30S: 81–85. 10.1016/j.hepres.2004.08.014PubMedView ArticleGoogle Scholar
- Gledhill LJ, Burroughs A, Rolles K: Psychiatric outcome, quality of life and alcohol consumption. In Department of psychiatry, liver transplantation and Hepatobiliary medicine and surgery. The royal free Hospital, London; 1998:359–367.Google Scholar
- Alavian SM, Azimi K, Sarafi M, Alavi M, Malek Zadeh R: To determine ethiologic factors of liver cirrhosis in hospitalized patients in Shariaty Hospital. Iranian Journal of Gastroenteria 2002, 38: 19–26.Google Scholar
- Hussain KB, Fontana RJ, Moyer CA, Su GL, Sneed-Pee N, Lok AS: Comorbid illness an important determinant of health-related quality of life in patients with chronic hepatitis C. Am J Gastroenterol 2001, 9: 2737–2744. 10.1111/j.1572-0241.2001.04133.xView ArticleGoogle Scholar
- Burke NJ, Jackson JC, Thai HC: : Horning traditional, accepting new ways development of a hepatitis B control intervention for Vietnamese immigrant. Ethl-Health 2004, 2: 153–169.View ArticleGoogle Scholar
- Hauser W, Holtmann G, Grandt D: Determinants of health-related quality of life in patients with chronic liver diseases. Clin Gastroenterol Hepatol 2004, 2: 157–163. 10.1016/S1542-3565(03)00315-XPubMedView ArticleGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.