Introduction
Chronic kidney disease (CKD) is a progressive and irreversible disorder. In this disease, the kidney’s ability to dispose of metabolic wastes and maintain fluid and electrolytes is impaired, leading to the increase of urea and other toxic substances in the blood [1, 2]. The global prevalence of CKD is 13.4% (11.7-15%), and 4.902-7.083 million people need renal replacement therapy or dialysis [5]. The CKD is more common in women than in men [6]. One of the psychological problems in dialysis patients is body image dissatisfaction [8]. Chronic diseases such as heart problems, diabetes and kidney problems cause changes in the shape and appearance of the body, often resulting in body image dissatisfaction [9]. Body image is defined as a person’s perceptions and attitudes towards her/his body, and is a multidimensional concept that includes behavioral, perceptual, cognitive and emotional aspects [10]. Body image satisfaction is directly related to self-compassion [12]. Studies indicate a low level of self-compassion among patients with CKD [14]. According to Neff, the lack of self-compassion can lead to self-criticism, isolation and over-identification with thoughts and emotions. The ability to have self-compassion, on the other hand, shows self-kindness in difficult situations, recognizing one’s shared humanity, and being mindful when exposed to negative thoughts and emotions [16].
Patients undergoing dialysis suffer from many physical and psychological problems and the type of dialysis has no effect on their problems [4, 18]. Identifying effective psychological interventions to improve body image and self-compassion in dialysis patients is necessary for providing health care services to them. Acceptance and commitment therapy (ACT) tend to increase psychological flexibility and emphasizes six components of acceptance, cognitive diffusion, self as context, contact with the present moment, values, and committed action. This approach focuses on accepting difficult inner and outer experiences, adopting a more compassionate and kind way towards oneself, and having action towards living a valuable life. Evidence shows that ACT is effective in managing the problems of patients with chronic pain [20]. Considering that kidney problems are more common among women than men and dialysis women suffer from body image dissatisfaction and lack of self-compassion more than healthy women, this study aims to determine the effect of group ACT on body image and self-compassion of women undergoing dialysis.

Methods
This is a quasi-experimental study (randomized clinical trial) with a pre-test/post-test/follow-up design. Participants were 30 dialysis women referred to Dialysis Patients Support Association in Khorasan Razavi, Iran, who were selected using a convenience sampling method and randomly assigned to two groups of intervention and control. The research tools included body image concern inventory (BICI) and self-compassion scale (SCS). The intervention group received ten 120-minute sessions of group ACT weekly, but the control group did not receive any intervention until the end of the two-month follow-up phase. Data were analyzed using the repeated measures analysis of variance (ANOVA) in SPSS software, version 25. 

Results
The mean age of participants was 48.32±5.32 years in the intervention group and 48.93±4.34 years in the control group. The mean dialysis duration was 7.2±3.8 months in the intervention group and 5±2.75 months in the control group. The results of the multivariate ANOVA showed that the within-group effects (Wilks’ Lambda=0.342, F=12.019, P=0.001), between-group effects (Wilks’ Lambda=0.71, F=5.508, P=0.01), and interaction effects (Wilks’ Lambda=0.29, F=15.267, P=0.001) were significantly different.
Based on the results in Table 1, there were significant differences in within-group, between-group, and interaction effects on body image (P<0.05).


Regarding self-compassion, the within-group effect were not significant (P>0.05), but the between-group and interaction effects were significant (P<0.05). The effect size of the intervention’s interaction effects on body image and self-compassion were 0.584 and 0.208, respectively, which means that 58% of the changes in body image and 21% of the changes in self-compassion during the test were caused by the intervention. The results of Bonferroni post hoc test demonstrated that the mean difference in both variables of body image and self-compassion was significant in the intervention group from the pre-test to the post-test phase and from the pre-test to the follow-up phase (P<0.05), but no significant difference was found from the post-test to the follow-up phase (P>0.05).

Conclusion
The results indicated that ACT had a significant effect on increasing self-compassion and reducing body image dissatisfaction in women undergoing dialysis. Due to the application of techniques derived from ACT such as mindfulness and cognitive diffusion, the women were able to communicate with their experiences in the present moment and be kind and compassionate towards themselves, instead of ruminating and blaming themselves for their difficult situation in the present moment and accept their unpleasant feelings, thoughts and bodily sensations without judgment and not to define themselves according to their sufferings. According to the results, in addition to conventional medical treatments, it is recommended to use ACT to reduce body image dissatisfaction and enhance self-compassion in women undergoing dialysis

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Mashhad Medical Sciences Branch of Islamic Azad University (Code: IR.IAU.MSHD.REC.1401.118) and was registered by Iranian Registry of Clinical Trials (ID: IRCT20101130005280N60). Written informed consent was obtained from all participants, and their information was kept confidential.

Funding
This article was extracted from the PhD dissertation of Monire Pourfarahani, approved by Department of Educational Sciences, Mashhad Medical Sciences Branch of Islamic Azad University. 

Authors contributions
Conceptualization: Monire Pourfarahani, Hossein Shareh and Fateme Haji Arbabi; Investigation: Monire Pourfarahani and Hossein Shareh; Review & editing: Monire Pourfarahani and Hossein Shareh; Supervision: Hossein Share and Fateme Haji Arbabi.

Conflicts of interest
The authors declared no conflicts of interest.

Acknowledgements
The authors would like to thank all the women participated in the study for their cooperation.

References

1. Lameire NH, Levin A, Kellum JA, Cheung M, Jadoul M, Winkelmayer WC, et al. Harmonizing acute and chronic kidney disease definition and classification: Report of a Kidney Disease: Improving Global Outcomes (KDIGO) Consensus Conference. Kidney International. 2021; 100(3):516-26. [DOI:10.1016/j.kint.2021.06.028] [PMID]
2. Aguiar R, Pei M, Qureshi AR, Lindholm B. Health-related quality of life in peritoneal dialysis patients: A narrative review. Seminars in Dialysis. 2019; 32(5):452-62. [DOI:10.1111/sdi.12770] [PMID]
3. Vaidya SR, Aeddula NR. Chronic renal failure. 2022. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023  [PMID]
4. Güçer BK, Kantarci G. Body image perception of chronic kidney disease patients and its impact on their personal relationships. Turkish Journal of Nephrology. 2020; 29(2):122-8. [DOI:10.5152/turkjnephrol.2020.3601]
5. Lv JC, Zhang LX. Prevalence and disease burden of chronic kidney disease. Advances in Experimental Medicine and Biology. 2019; 1165:3-15. [PMID] 
6. James SL, Lucchesi LR, Bisignano C, Castle CD, Dingels ZV, Fox JT, et al. The global burden of falls: Global, regional and national estimates of morbidity and mortality from the Global Burden of Disease Study 2017. Injury Prevention. 2020; 26(Suppl 2):i3-11. [DOI:10.1136/injuryprev-2019-043286] [PMID] [PMCID]
7. Tannor EK, Archer E, Kapembwa K, van Schalkwyk SC, Davids MR. Quality of life in patients on chronic dialysis in South Africa: A comparative mixed methods study. BMC Nephrology. 2017; 18(1):4. [DOI:10.1186/s12882-016-0425-1] [PMID] [PMCID]
8. Dąbrowska-Bender M, Dykowska G, Żuk W, Milewska M, Staniszewska A. The impact on quality of life of dialysis patients with renal insufficiency. Patient Preference and Adherence. 2018; 12:577-83. [DOI:10.2147/PPA.S156356] [PMID] [PMCID]
9. Partridge KA, Robertson N. Body-image disturbance in adult dialysis patients. Disability and Rehabilitation. 2011; 33(6):504-10. [DOI:10.3109/09638288.2010.498556] [PMID]
10. Grogan S. Body image: Understanding body dissatisfaction in men, women and children. London: Routledge; 2021. [DOI:10.4324/9781003100041]
11. Griffiths C, Williamson H, Zucchelli F, Paraskeva N, Moss T. A systematic review of the effectiveness of acceptance and commitment therapy (ACT) for body image dissatisfaction and weight self-stigma in adults. Journal of Contemporary Psychotherapy. 2018; 48(4):189-204. [DOI:10.1007/s10879-018-9384-0] [PMID] [PMCID]
12. Turk F, Waller G. Is self-compassion relevant to the pathology and treatment of eating and body image concerns? A systematic review and meta-analysis. Clinical Psychology Review. 2020; 79:101856. [DOI:10.1016/j.cpr.2020.101856] [PMID]
13. Seekis V, Bradley GL, Duffy AL. Does a Facebook-enhanced Mindful Self-Compassion intervention improve body image? An evaluation study. Body Image. 2020; 34:259-69. [DOI:10.1016/j.bodyim.2020.07.006] [PMID]

14. Narimani M, Ghasemkhanlo A, Sabri V. [The comparison of self-compassion, anxiety and depression in patients with chronic pain and normal people (Persian)]. Journal of Anesthesiology and Pain. 2020; 11(3):57-65. [Link]
15. Ferrari M, Ciarrochi J, Yap K, Sahdra B, Hayes SC. Embracing the complexity of our inner worlds: Understanding the dynamics of self-compassion and self-criticism. Mindfulness. 2022; 13(7):1652-61. [DOI:10.1007/s12671-022-01897-5]
16. Neff KD. The development and validation of a scale to measure self-compassion. Self and Identity. 2003; 2(3):223-50. [DOI:10.1080/15298860309027]
17. Grodin J, Clark JL, Kolts R, Lovejoy TI. Compassion focused therapy for anger: A pilot study of a group intervention for veterans with PTSD. Journal of Contextual Behavioral Science. 2019; 13:27-33. [DOI:10.1016/j.jcbs.2019.06.004]
18. Nataatmadja M, Evangelidis N, Manera KE, Cho Y, Johnson DW, Craig JC, et al. Perspectives on mental health among patients receiving dialysis. Nephrology, Dialysis, Transplantation. 2020; 36(7):1317-25. [PMID]
19. White RG, Bethell A, Charnock L, Leckey S, Penpraze V. Acceptance and commitment approaches for athletes’ wellbeing and performance. Cham: Palgrave Macmillan; 2021. [DOI:10.1007/978-3-030-64942-5]
20. Farokhi S, Rezaei F, Gholamrezaei S. [The effectiveness of self-compassion cognitive training on experiential avoidance & cognitive fusion in patients with chronic pain (Persian)]. Positive Psychology Research. 2018; 3(4):29-40. [DOI:10.22108/PPLS.2018.111042.1420]
21. Mehryar M. [The effectiveness of acceptance and commitment therapy (ACT) on promoting mental health and quality of life in elderly women (Persian)]. Journal of Gerontology. 2020; 4(4):21-9. [DOI:10.29252/joge.4.3.21]
22. Carvalho SA, Gillanders D, Forte T, Trindade IA, Pinto-Gouveia J, Lapa T, et al. Self-compassion in Acceptance and Commitment Therapy for chronic pain: A pilot study. Scandinavian Journal of Pain. 2022; 22(3):631-8. [DOI:10.1515/sjpain-2021-0214] [PMID]
23. Gustafson C. Reclaim your life: Acceptance & commitment therapy in 7 weeks. California: Callisto Media; 2020. [Link]
24. Sasani K, Seirafi M, Meschi F, Sarami G, Peymani J. [Modeling of health-related quality of life based on self-approach to body image by mediating of self-compassion and shame in overweight and obese people (Persian)]. Iranian Journal of Nursing Research. 2020; 14(6):78-87. [Link]
25. Amini P, Karami Nejad R. [The effectiveness of acceptance and commitment therapy on marital burnout and self-compassion in unsupervised women under the cover of NGOs of Tehran (Persian)]. The Journal of Tolooebehdasht. 2021; 20(1):25-37. [DOI:10.18502/tbj.v20i1.6186]
26. Rostami M, Fatollahzadeh N, Saadati N. [The effectiveness of acceptance and commitment training on improving the quality of life and self-compassion of the mothers of educable disabled children (Persian)]. Journal of Psychological Studies. 2016; 12(3):103-22. [Link]

27. Pearson AN, Follette VM, Hayes SC. A pilot study of acceptance and commitment therapy as a workshop intervention for body dissatisfaction and disordered eating attitudes. Cognitive and Behavioral Practice. 2012; 19(1):181-97. [DOI:10.1016/j.cbpra.2011.03.001]
28. Fogelkvist M, Gustafsson SA, Kjellin L, Parling T. Acceptance and commitment therapy to reduce eating disorder symptoms and body image problems in patients with residual eating disorder symptoms: A randomized controlled trial. Body Image. 2020; 32:155-66. [DOI:10.1016/j.bodyim.2020.01.002] [PMID]
29. Givehki R, Afshar H, Goli F, Scheidt CE, Omidi A, Davoudi M. Effect of acceptance and commitment therapy on body image flexibility and body awareness in patients with psychosomatic disorders: A randomized clinical trial. Electron Physician. 2018; 10(7):7008-16. [DOI:10.19082/7008] [PMID]
30. Moradi F, Ghadiri-Anari A, Dehghani A, Vaziri SR, Enjezab B. The effectiveness of counseling based on acceptance and commitment therapy on body image and self-esteem in polycystic ovary syndrome: An RCT [Int J Reprod BioMed 2020; 18: 243-252]. International Journal of Reproductive Biomedicine. 2020; 18(12):1087. [DOI:10.18502/ijrm.v18i12.8143] [PMID] [PMCID]
31. Khamoshi Ghalenoei S, Mansouri A. [The effectiveness of acceptance and commitment therapy on self-compassion and self-criticism in individuals with opioid use disorder (Persian)]. Scientific Quarterly Research on Addiction. 2020; 14(57):237-54. [DOI:10.29252/etiadpajohi.14.57.237]
32. Roohi R, Soltani AA, Zinedine Meimand Z, Razavi Nematollahi V. [The effect of acceptance and commitment therapy (ACT) on increasing the self-compassion, distress tolerance, and emotion regulation in students with social anxiety disorder (Persian)]. Quarterly Journal of Child Mental Health. 2019; 6(3):173-87. [DOI:10.29252/jcmh.6.3.16]
33. Pourfarahani M, Barabadi HA, Heydarnia A. [The effectiveness of acceptance and commitment group therapy in the social anxiety of adolescent orphan girls (Persian)]. Quarterly Journal of Social Work. 2019, 8(4):5-13.‏ [Link]
34. Moran DJ, Ming S. The mindful action plan: Using the MAP to apply acceptance and commitment therapy to productivity and self-compassion for behavior analysts. Behavior Analysis in Practice. 2020; 15(1):330-8. [DOI:10.1007/s40617-020-00441-y] [PMID] [PMCID]
35. Roy J, Gurjar NR, Bhattacharjee T. Effectiveness of structured teaching programme on knowledge and practice of home based self-care among patients undergoing haemodialysis. Innovational Journal of Nursing and Healthcare. 2017; 3(3):155-9. [Link]
36. Ebrahimi Z, Azizi Z. Investigating the effectiveness of Transcranial Direct Current Stimulation (tDCS) on the treatment of anxiety disorder in chronic renal dialysis patients. Journal of Research in Psychopathology. 2022; 3(8):19-25. [Link]
37. Sarizadeh MS, Rafienia P, Sabahi P, Tamaddon M. [The effectiveness of acceptance and commitment therapy on hemodialysis patients’ quality of life: A randomized educational trial study (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2018; 17(3):241-52. [Link]
38. Littleton HL, Axsom D, Pury CL. Development of the body image concern inventory. Behaviour Research and Therapy. 2005; 43(2):229-41. [DOI:10.1016/j.brat.2003.12.006] [PMID]
39. Basaknejad S, Ghafari M. The relationship between fear of body dysmorphia and psychological disorders of university students. Journal of Behavioral Sciences. 2007; 2:179-87. [Link]
40. Mohammadi N, Sajadinejad MS. [The evaluation of psychometric properties of Body Image Concern Inventory and examination of a model about the relationship between body mass index, body image dissatisfaction and self-esteem in adolescent girls (Persian)]. Journal of Psychological Studies. 2007; 3(1):85-101. [DOI:10.22051/PSY.2007.1650]
41. KHosravi S, Sadeghi M, Yabandeh MR. [Psychometric properties of self-compassion scale (SCS) (Persian)]. Journal of Psychological Methods and Models. 2013; 4(13):47-59. [Link]
42. Shahbazi M, Rajabi G, Maghami E, Jeloudari A. [Confirmatory factor structure of the Persian version of the Revised Compassion Rating Scale in a group of Prisoners (Persian)]. Sychological Methods and Models. 2014; 6(19):31-46. [Link]  
43. Mohammadalipour Z, Rasoli M, Asadpour E, Zahrakar K. [The effectiveness of group counseling based on acceptance and commitment therapy on body image and self-esteem of female university students (Persian)]. Journal of Applied Psychology. 2020; 14(2):51-75. [Link]
44. Zucchelli F, Donnelly O, Williamson H, Hooper N. Acceptance and commitment therapy for people experiencing appearance-related distress associated with a visible difference: A rationale and review of relevant research. Journal of Cognitive Psychotherapy. 2018; 32(3):171-83. [DOI:10.1891/0889-8391.32.3.171] [PMID]
45. Mohammadi Z, Atashpour SH, Golparvar M. [Differential effects of existentialism acceptance and commitment therapy and compassion-focused therapy on psychological capital and self-compassion (Persian)]. Positive Psychology Research. 2022; 8(3):99-120. [DOI:10.22108/PPLS.2022.132212.2255]
46. Mohammadizadeh S, Khalatbari J, Ahadi H, Hatami HR. [Effectiveness of acceptance and commitment therapy on perceived stress, body image and quality of life in women with breast cancer (Persian)]. Journal of Social Psychology. 2021; 8(57):87-100. [Link]
47. Rahmanian M, Nejatali R, Oraki M. [The effectiveness of Acceptance and Commitment Therapy in cognitive emotion regulation and concerns of body image in females with Bulimia Nervosa (Persian)]. Journal of Health Promotion Management. 2018; 7(4):33-40. [Link]
48. Ghafari Jahed Z, Amini N, Deyreh E, Mirzaei K. [The effectiveness of commitment and admission approach on irrational belief and physical image in patients suffering from irritable bowel syndrom (Persian)]. Scientific Journal of Social Psychology. 2021; 9(59):1-3. [Link]
49. Goel V, Sil A, Das A. Cutaneous manifestations of chronic kidney disease, dialysis and post-renal transplant: A review. Indian Journal of Dermatology. 2021; 66(1):3-11. [DOI:10.4103/ijd.IJD_502_20] [PMID] [PMCID]
50. Azari S, Kiani G, Hejazi M. [The effect of acceptance and commitment based group therapy on increasing the quality of life in kidney transplant and hemodialysis patients in Zanjan city: A randomized clinical trial study (Persian)]. Journal of Rafsanjan University of Medical Sciences. 2020; 19(6):555-68. [DOI:10.29252/jrums.19.6.555]
51. Ghafari-Jam M, Mahmoodfakheh H, Mostafaee A. [Effectiveness of acceptance and commitment-based therapy on self-compassion and self-worth in the children of self-reported drug addicts (Persian)]. Navid No, 2021; 24(77):84-97. [Link]
52. Roohi R, Soltani A, Zeinodini Z, Nematollah VS. [Effectiveness of acceptance and commitment therapy on self-compassion and distress tolerance in students with social anxiety disorder (Persian)]. Middle Eastern Journal of Disability Studies. 2019;  8:63. [Link]
53. Ong CW, Barney JL, Barrett TS, Lee EB, Levin ME, Twohig MP. The role of psychological inflexibility and self-compassion in acceptance and commitment therapy for clinical perfectionism. Journal of Contextual Behavioral Science. 2019; 13:7-16. [DOI:10.1016/j.jcbs.2019.06.005]
54. Karimi S, Moradi Manesh F, Asgari P, Bakhtiarpour S. [Effectiveness of treatment based on commitment and acceptance on self-care behaviors and follow-up of treatment in hemodialysis patients (Persian)]. Medical Journal of Mashhad University of Medical Sciences. 2020; 63(3):2324-33. [DOI: 10.22038/MJMS.2020.16892]