https://orcid.org/0000-0003-4039-5118
Figures
Abstract
Background
Chronic Kidney Failure is a significant global public health concern requiring kidney replacement therapy such as dialysis. Perception of the importance of adhering to dialysis helps to determine how patients interpret and interact with the influencing attitude, thoughts and behaviours towards adhering to dialysis. This study aimed to assess the perception of the importance of adherence to haemodialysis and its associated factors among end-stage Kidney failure patients in tertiary care centres in Nepal.
Methods
This was a cross-sectional study conducted from May to August 2025 in two tertiary care centres in Nepal that included patients undergoing hemodialysis aged 18 years and above. The outcome variable was perception of the importance of adherence to dialysis and was measured using The End Stage Renal Disease Adherence Questionnaire (ESRD-AQ). The independent variables were socio-demographics, dialysis-related characteristics and accessibility factors.
Results
Among 283 hemodialysis patients in the study, their mean age was 50.6 years with higher prevalence of good perception (91%) among single [APR (adjusted prevalence ratio):1.12; 95% CI (confidence interval): 1.03–1.21)] and parents accompanying patients (APR:1.14; 95% CI:1.01–1.28) compared to married, and non-parent accompanying patients respectively.
Citation: Shrestha P, Koirala A, Satyal P, Bhurtel AM, Karmacharya BM (2026) Factors influencing perceived importance of haemodialysis adherence among end stage kidney failure patients in tertiary care centres in Nepal. PLoS One 21(6): e0351702. https://doi.org/10.1371/journal.pone.0351702
Editor: Nik Hisamuddin Nik Ab. Rahman, Universiti Sains Malaysia, MALAYSIA
Received: February 13, 2026; Accepted: May 29, 2026; Published: June 17, 2026
Copyright: © 2026 Shrestha et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data are available upon reasonable request from the Kathmandu University Institutional Review Committee (KUIRC), at irc@kusms.edu.np (or website to contact: https://kusms.edu.np/irc/), for researchers who meet the criteria for access to confidential data. Data are stored on secure institutional servers with regular backups and will be maintained in accordance with institutional data retention policies to ensure long-term availability.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Chronic Kidney Failure (CKF) is a significant global public health concern, leading to chronic kidney failure requiring costly treatments like dialysis or kidney transplantation for survival. It also significantly affects health care expenses, productivity and growth [1]. Worldwide, an estimated 4.9 to 9.7 million chronic kidney failure patients’ needs kidney replacement therapy with the majority residing in low-to-middle income countries [2,3]. In Nepal, CKF accounted for approximately two per cent of total deaths and one per cent of total DALYs, placing a significant financial burden on patients, the health care system and society [4,5]. Kidney transplantation requires substantial resources such as donor availability and long-term financial support. Therefore, dialysis is used as primary treatment option for patients with chronic kidney failure [6,7]. The effectiveness of treatment depends on adherence to treatment regimen as prescribed by the physician [8,9].
More than half of the patients undergoing dialysis from a study in Northern Indian showed good treatment adherence, which was influenced by patients’ perceptions of treatment and counselling frequency [10]. Perception of the patients on the importance of adhering to the CKF treatment affects the treatment adherence in haemodialysis patients [10,11]. Non adherence to treatment regimen increases risks of morbidity and mortality [12,13]. Perception of the importance of adhering to dialysis helps to determine how patients interpret and interact with the influencing attitude, thoughts and behaviours towards adhering to dialysis [14,15]. Good perception encourages patients to receive effective dialysis treatment [16]. Perception of dialysis adherence can be modified with interventions such as awareness sessions, counselling, peer support and revisiting health systems [14,15]. Despite growing evidence on treatment adherence among hemodialysis patients, most studies have focused on clinical and socio-demographic factors, with limited exploration of patients’ perceptions regarding the importance of adherence in Nepal. Patients’ perceptions play a important role in shaping their adherence behavior, as they influence attitudes, motivation, and engagement with treatment. Understanding these perceptions is essential for developing targeted interventions to improve adherence outcomes. Therefore, this study aims to assess the factors influencing the perceived importance of adherence to hemodialysis among patients with chronic kidney failure. The findings contribute evidence on patient’s perception regarding the importance of dialysis and may inform policies and health systems to plan and implement effective interventions that improve adherence.
Methods
Study design
This was a cross-sectional hospital-based study conducted to assess the perception of the importance of adherence to dialysis and its associated factors among chronic kidney failure disease patients from two tertiary care centres in Nepal. The study was conducted from May to August 2025.
Study site and justification
The study was conducted at two different tertiary care centres in Nepal: Dhulikhel Hospital-Kathmandu University Hospital (DHKUH), located in Dhulikhel, Kavrepalanchowk district and Sahid Dharmabhakta National Transplant Centre (SDNTC) situated in Bhaktapur district of Bagmati province. Each patient had a different schedule of dialysis sessions: once, twice, or three times a week. These tertiary hospitals were selected because they provide specialized care for patients with chronic kidney failure undergoing haemodialysis and have patient flow from diverse geographical and socioeconomic backgrounds that enhance representativeness.
Study population
The study included patients with chronic kidney failure disease who had been receiving hemodialysis at DHKUH and SDNTC for at least 3 months. The study selected all eligible patients attending dialysis sessions on the day of data collection who provided written informed consent to participate. The study selected adults aged 18 years and above, diagnosed with stage five CKF, undergoing haemodialysis and willing to participate voluntarily in the study. Moreover, the participants were excluded if the patients were critically ill or were under peritoneal dialysis.
Sampling technique
In each hospital, the list of patients receiving hemodialysis was obtained from their medical records. The study approached patients attending dialysis sessions on the day of data collection. Hemodialysis patients were selected consecutively at DHKUH and SDNTC until the planned sample size was reached.
Sample size
The population parameter in the study was a proportion, so the sample size was calculated using the standard formula for a single proportion: n = z²pq/d² [17]. Assuming 63% hemodialysis adherence from a study conducted in Nepal [8], at a 95% level of significance and 5.6% error, the total calculated sample size was 283. Out of these, 50 participants belonged to DHKUH, and 233 participants were included from SDNTC. The following is the computation of how this number was obtained.
Study variables
Dependent variables.
The study included “perception of the importance of adherence to dialysis” as the dependent variable and was measured by the End Stage Renal Disease Adherence Questionnaire (ESRD-AQ), which consisted of 46 questions divided into five sections [18]. The fourth part of the questionnaire included questions on information for perception on each treatment regimen. The answers to the perception questions about the dialysis schedule were categorised on a 5-point Likert scale: very important, important, moderately important [3], slightly important, and not important. Perception of the importance of adherence to dialysis was then recategorized into good perception (responses of very important and important; scores 5 and 4) and poor perception (responses of moderately important, little important, and not important; scores 3−1).
Independent variables.
The independent variables used in the study were grouped into three domains: sociodemographic variables, dialysis-related characteristics and accessibility factors.
Socio-demographic characteristics. This included age (in completed years), sex, place of residence (urban/rural), religion, education status, family sources of income and marital status. Agriculture referred to subsistence or commercial farming and livestock rearing, which is distinct from service (formal salaried employment in government or private institutions) and daily wage labor (informal, short-term, wage-based work without a fixed salary). Business was retained as a separate category for self-employed, income-generating activities. Overlapping and ambiguous categories were merged where appropriate to improve interpretability.
Dialysis-related characteristics. This comprised the length of dialysis treatment (hours), frequency of dialysis sessions per week and presence of comorbidities.
Accessibility factors. The accessibility factors in the study included mode of transportation (private transport, bus, taxi, ambulance, others), distance from the dialysis center (in kilometers), accompany to dialysis center (myself, parents, spouse, child, friend, others), hemodialysis access history was defined as any previous vascular access used prior to the current access, while current dialysis access site was categorized as arteriovenous fistula, temporary catheter, or permanent catheter).
Data collection tools
The study collected quantitative data employing face-to-face interviews utilizing a structured questionnaire. The End Stage Renal Disease Adherence Questionnaire [18] was employed to determine perception and adherence levels, and a structured survey from NCD Steps Survey 2019 [19] was utilized to gather socio-demographic characteristics of the patients. Furthermore, a structured questionnaire was prepared to capture accessibility factors. The study also reviewed clinical records to capture dialysis-related characteristics.
Reliability and validity of the tool
The standard tools were used after obtaining the authors’ permission. The questionnaire was translated into Nepali and back translated into English to ensure linguistic appropriateness. Translation was done by expert. The translated Nepali version was then retranslated into English by another translator not involved in initial translation. Differences observed were reviewed and solved by research team. The questionnaires were also reviewed by Nephrologist from DHKUH and filled out by the research team and trained research assistants. The training for data collection was provided to the enumerators before starting data collection. Training was given on study objectives, inclusion and exclusion criteria of the patients, informed consent process, confidentiality and interview techniques to ensure consistency and minimize interviewer bias. Pretesting of the quantitative questionnaire was conducted among 17 hemodialysis patients of Methinkot Hospital, Kavrepalanchok, and patients from the surgery outpatient department of DHKUH visited for their fistula treatment. After pretesting, the tools were modified and the questions were restructured to simplify and make the participants understand and use them correctly. Content validity was ensured through expert review by nephrologists.
Data management and analysis
The study collected data using Kobo Toolbox and then exported it to STATA 14.2 for statistical analysis and further cleaning. The perception on importance of adherence to dialysis was presented into frequency and percentage. The sociodemographic factors, dialysis-related factors and accessibility related factors were presented in frequency and percentage for categorical variables and mean and standard deviation for numeric variables. Poisson regression was used to assess the association between perception on the importance of adherence to dialysis and sociodemographic, dialysis-related factors and accessibility related factors, adjusting for sex, residence, marital status, religion, educational status, occupation and family source of income. Prior to multivariate analysis, multicollinearity was assessed using the variation inflation factor. High multicollinearity with VIF > 10 was seen in the variable frequency of dialysis sessions per week. Pairwise correlation was examined but did not show correlation of variable frequency of dialysis session per week with other exposure variables and therefore predicted this was due to combination of other independent variables. Therefore, frequency of dialysis session per week was excluded in final multivariate model.Crude and adjusted prevalence ratios were reported within95% confidence interval, and statistical significance was decided if the p-value was < 0.0. Data completeness was checked at the time of collection to minimize missing information so we did not have any missing data.
Bias
The study might have introduced selection bias, as it was not possible to adapt probability sampling. The self-reported information might have generated social desirability bias and/or recall bias in answering the questions that they were asked. Also, the study could not include all the possible confounders, resulting in inclusion of residual bias leading to underestimated or overestimated effect measures.
Ethical approval
The protocol was approved by the Kathmandu University Institutional Review Committee (KU-IRC) on 6 April 2025, with approval number 72/25. Permissions were taken from Shahid Dharma Bhakta National Transplant Center and Dhulikhel Hospital. Verbal and written consent was obtained from each of the participants prior to data collection, and they were informed about their rights to participate in the study or not. Participant privacy and confidentiality were maintained throughout the study, ensuring their voluntary participation.
Results
Sociodemographic and dialysis related characteristics
Tables 1 and 2 summarise the sociodemographic and dialysis-related characteristics of the participants, respectively. A total of 283 hemodialysis patients were included with a mean age of 50.6 ± 14.6 years. Most of the participants were male, married, mostly residing in urban settings, belonged to the Hindu religion, attended secondary or higher education, and their main source of family income was business. The majority did not have any companions to the dialysis centre, lived within 5 kilometres, and used private transportation to reach it.
Most of the participants received dialysis for the standard duration of 4 hours, were on dialysis sessions twice a week and used AV fistula for dialysis currently, while having both arteriovenous fistula and catheter as hemodialysis access history. Around two-fifths of the participants had the presence of one comorbidity, and the majority of them adhered to dialysis and had a good perception of its importance.
Factors associated with the perception of importance of adherence to dialysis schedule
In the study, about 91% of the patients under hemodialysis had a good perception of the importance of adherence to the dialysis schedule. Table 3 summarises the association of sociodemographic factors, dialysis-related characteristics and access-related characteristics with perception of the importance of adherence to the dialysis schedule. In the multivariate model, the participant with single status had 9% higher prevalence of good perception towards the importance of adherence to dialysis compared to the married (APR:1.09; 95% CI: 1.01–1.21; P = 0.005). Participants who reached the dialysis centre with their parents had 14% higher prevalence of good perception compared to those accompanied by others (APR: 1.14; 95% CI: 1.01–1.28; p = 0.02).
Discussion
The findings showed that the majority of the participants (91.17%) had a good perception of the importance of adherence to dialysis. This finding was consistent with the study conducted in North India, Pakistan, Palestine and Yemen, showing good perception of following dialysis schedule [10,15,20,21]. The patients under dialysis are in continuous interaction with the health personnel, receiving counselling and instructions from them, enhancing positive perception [22].
This study showed that participants who were single and accompanied by parents to the dialysis centre had a positive perception, and the findings were consistent with other studies from Malaysia and other settings [23–25]. In the Nepalese context, although marital status and parents’ accompaniment are related, they correspond to distinct dimensions of social support. Being married does not necessarily imply active involvement of parents in dialysis care, whereas accompaniment during dialysis sessions reflects functional support. Hence, higher adherence among single participants of the study might have occurred due to more self-management practices and independence. Moreover, parental accompaniment might have improved adherence through their emotional and logistical support.
This study found no significant association between perception of the importance of adherence to dialysis and factors including gender, residence, religion, education, current dialysis access site, comorbid condition, complications during dialysis, number of medications taken as prescribed, and intradialytic weight gain. A systematic review revealed that illness perception was associated with domains of adherence especially to diet and fluid restriction but not to dialysis sessions [26]. A study from Palestine and Rawanda revealed age, gender and residence were positively associated with dialysis adherence score [15,27]. Even though, the Nepal Government has been offering free dialysis services since 2016, not all hemodialysis patients consistently follow their treatment plans. More than one fourth of the people have faced catastrophic health expenditure for dialysis [28,29]. Studies suggest that a large proportion of chronic kidney failure patients struggle with adherence to treatment regimen due to financial constraints, lack of awareness, and limited access to treatment facilities [30].The lack of association between these variables in the study could be due to a relatively small sample size and other possible residual confounders.
The study team did not provide any additional counselling or explicit warnings regarding the consequences of missing hemodialysis sessions prior to or during the data collection period. Due to the observational, cross-sectional nature of the study, the perception was based on the regular care they have been receiving from their health professionals. However, the absence of structured counselling about the probable outcomes of missed dialysis sessions may have prompted patients’ adherence and perception. Future studies should explore whether targeted patient education and counselling interventions can improve adherence to haemodialysis schedules.
The study was conducted under a few limitations. Firstly, the study was conducted in only two tertiary care centres in Nepal, which may not have adequately represented all the hospitals throughout Nepal, which could affect the generalizability of results. Secondly, the cross-sectional design might have been limited in generating causal inference, as we were not able to know if the perception towards dialysis adherence was already improved, or it was improved only after getting exposed to the dialysis treatment-related exposures. The majority of the questions were self-reported by the participants, establishing social desirability or recall bias as a fourth limitation of the study. Also, the study might have residual confounders that might have distorted the effect measures. Moreover, the study primarily measured perception of patients on adherence and self-reported practices related to adherence, which may not completely reflect their actual treatment adherence behaviour. This can be applied to qualitative studies; future studies may consider doing so for in-depth information on perceptions. The categorization of the perception score may have introduced loss of data granularity reducing variability and statistical power. Future studies may use alternative ordinal or continuous modelling methods for more nuanced insights. Some variables were collected as multiple-response items, which might have limited the ability to model them as mutually exclusive categories. The use of convenient consecutive sampling might have introduced selection bias, limiting the generalizability of the findings. Despite limitations, the study had strengths as well. The study was the first of its kind in Nepal, conducted at two tertiary care centres, where patients undergoing dialysis were interviewed to learn about their perceptions of the significance of dialysis. This will provide insightful evidence and inform programs or studies to focus on enhancing their perceptions as well as to minimise the psychosocial burden of the patients who are already under stress to attend continuous dialysis sessions.
Conclusion
Patients under hemodialysis had a good perception of the importance of adherence to dialysis, particularly for those who were still single and those accompanied by their parents. The findings highlighted that personal independence and social support play a significant role in adherence to the dialysis schedule. The study recommends incorporating interventions such as counselling, peer support, awareness sessions and health education that can enhance the positive perception of the significance of adherence to dialysis, leading to increased adherence to dialysis, which can help prolong the patient’s life. Also, future research should encompass the qualitative perspective on the perception of the importance of adherence to the dialysis schedule to gain deeper insights.
Acknowledgments
We would like to acknowledge the support from the teams DHKUH and SDNTC and all the participants in the study.
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