End Stage Renal Disease (ESRD) is a known increasing public health concern globally [
In 2015, Rwanda Demographic Health Survey data showed a projected total population of 11,274,221 people with approximately 84 percent of them living in rural area. It is also evident that there is little or nothing known about the proportion of people living with ESRD or requiring RRT in Rwanda. From the national statistics, the majority of the people live in rural areas and yet the majority hemodialysis services for them are available in urban setting of Rwanda. There are four (4) dialysis units in Rwanda for which three are in the city center of Kigali and one in the rural setting in the southern province. There are approximately twenty working machines in the three dialysis units in the city center of Kigali and six (6) in the southern province [
Nonadherence to hemodialysis on the other hand remains a major obstacle in the management of End Stage Renal Disease (ESRD) population. Documented literature reveals that approximately 50% of individuals with ESRD undergoing hemodialysis (HD) were not adhering to their prescribed treatment regimen [
According to Duong et al. [
Informal observations and clinical experience in Rwandan renal units reveal poor adherence to hemodialysis among ESRD patients. Moreover, there are limited studies in Rwanda about adherence to hemodialysis among ESRD. Yet, the health profile of Rwanda 2014 (WHO update) reveals that renal diseases were the fourteenth leading cause of death among 50 top causes of death in Rwanda [
This study used a quantitative approach to quantify the level of adherence to hemodialysis and the associated factors to adherence among ESRD population.
This was a descriptive cross-sectional design in which the researcher collected and analysed quantitative data to determine the level of adherence to hemodialysis and associated factors among End Stage Renal Disease patients.
The study was conducted in three (3) selected referral dialysis centers in the city center of Kigali, Rwanda. The sites included one public hospital and two private settings, all of which are teaching, service, and research centers.
Population is defined as all elements, such as individuals, events, or objects that meet the sample criteria for inclusion in a study, sometimes referred to as a target population [
The eligible respondents were those who were adult conscious patients who agreed to participate and had been on hemodialysis for more than 2 months as well as available at the time of the study. Respondents who were on Continuous Ambulatory Peritoneal Dialysis (CAPD), with Acute Kidney Injury (AKI) on hemodialysis, not in attendance at the time of the study, and critically ill and admitted were excluded from the study. There were some ESRD participants who were eligible but did not complete the interview schedule nor signed the informed consent form and thus were excluded from the study.
Quantitative researchers should select the largest sample possible so that it is representative of the target population. The number of patients on hemodialysis in Rwanda including those in private hospitals was 70 at the time of the study. The researchers only considered patients from the three referral hospitals who met the eligibility criteria and consented to participate in the study; hence a total sample size of 41 was used.
The researcher used purposive sampling to select a total population of study participants from dialysis units. This is whereby the entire population that meets the criteria is included in the research being conducted. The number of ESRD patients on hemodialysis were limited; hence the researcher used the total population. The researchers sampled all the hemodialysis patients from three selected units that met the inclusion and exclusion criteria.
The research instrument for quantitative was developed using components of ERSD adherence questionnaire [
Face validity was ensured through structuring the instrument into two separate stages. Content validity was ensured through giving the instrument to experts in the nephrology field to assess whether all contents to be measured have been included. Again, inclusion of items from literature also enhanced content validity of the instrument. Construct validity was achieved by checking items in the data collection tools against study objectives and concepts in the research instrument to ascertain whether all construct under study had been measured. Translating the research tool from English to local language ensured collection of reliable data, free from misinterpretation. Use of the structured interview schedule and following the items using the same wording and sequencing during the interview also enhanced the reliability of the data obtained through the instruments. A reliability analysis called Cronbach’s alpha was performed to measure the internal consistency of the instrument. It was found to be 0.70 meaning that the instrument was a reliable measure of adherence to hemodialysis.
The instrument was designed to measure adherence to hemodialysis on a scoring system using a Likert scale. The minimum possible total score for adherence to hemodialysis was ten (10) and the maximum possible score, signifying perfect adherence to hemodialysis was thirty-four (34). Dividing the attained score on this section by the maximum possible attainable score (34) and multiplying by a hundred to come up with a percentage calculated adherence to hemodialysis. Adherence to hemodialysis of 90% to 100% was classified as high, 80% to 89% was classified as moderate, and adherence to hemodialysis below 80% was considered low. The researchers adopted the scale used by Chironda et al. [
In this study, descriptive statistics were used to describe the extent of adherence to hemodialysis among ESRD patients. Inferential statistics of chi-square were used to test if there is any association between demographic variables and level of adherence to hemodialysis among End Stage Renal Disease patients.
The permission was requested from ethical boards and research committee to carry out the study. Patient’s rights were respected which include right to refuse or to withdraw from the study at any time without any consequences and they were prevented from discomfort and harm. Privacy and confidentiality were also observed. The purpose of the study was explained to the participants. Informed consent and participant’s authorization were sought.
Table
Demographic characteristics of ESRD participants (N = 41).
Variable | Frequency (%) |
---|---|
| |
18-30 years | 5 (12%) |
31-40 years | 9 (22%) |
41-50 years | 6 (15%) |
51-60 years | 11 (27%) |
Greater than 60 years | 10 (24%) |
| |
Male | 24 (58%) |
Female | 17 (42%) |
| |
Married | 28 (68%) |
Single | 7 (17%) |
Separated | 1 (2%) |
Widowed | 5 (12%) |
| |
Not educated | 4 (10%) |
Primary | 13 (32%) |
Secondary | 16 (39%) |
College/university | 8 (20%) |
| |
Self-employed | 6 (15%) |
Public servant | 4 (10%) |
Unemployed | 31 (75%) |
| |
Less than 50000 (< 58USD) | 31 (75%) |
50000-100000 (58USD – 116 USD) | 3 (7%) |
More than 100000 to 200000 (>116USD – 232 USD) | 3 (7%) |
More than 200000 (> 232USD) | 4 (10%) |
| |
Christian | 39 (95%) |
Muslim | 2 (5%) |
| |
3 months to 1 year | 11 (26%) |
More than a year to 2 years | 4 (10%) |
More than 2 years to 3 years | 6 (15%) |
More than 3 years to 5 years | 8 (20%) |
More than 5 years | 12 (29%) |
| |
Self-sponsored | 8 (19%) |
Government assisted | 7 (7%) |
FARG | 20 (49%) |
Private medical insurances | 6 (15%) |
Community based Health Insurance | 4 (10%) |
Regarding the number of dialysis sessions received per week in ESRD participants, 14 (34%) were receiving two dialysis sessions, 26 (64%) were receiving three sessions, and 1 (2%) was receiving four dialysis sessions per week (Table
Adherence to hemodialysis among ESRD participants (N = 41).
Variable | Frequency | Percentage (%) |
---|---|---|
| ||
2 days or less | 14 | 34 |
3 days | 26 | 64 |
4 days | 1 | 2 |
| ||
4 hours | 41 | 100 |
| ||
No | 2 | 5 |
Yes | 39 | 95 |
| ||
Never | 1 | 2 |
More than a month ago | 1 | 2 |
One month ago | 1 | 2 |
Last week | 2 | 5 |
This week | 36 | 89 |
| ||
Moderate important | 1 | 2 |
Very important | 6 | 15 |
Highly important | 34 | 83 |
| ||
A lot of difficulty | 6 | 15 |
Moderate difficulty | 3 | 7 |
Little difficulty | 11 | 27 |
No difficulty | 21 | 51 |
| ||
Missed three | 2 | 5 |
Missed two | 5 | 12 |
Missed one | 9 | 22 |
None | 25 | 61 |
| ||
Once | 2 | 5 |
None | 39 | 95 |
About the importance of following a dialysis schedule, 1 (2%) participant reported that it was moderately important to follow dialysis schedule, 6 (15%) reported that it was very important, and 34 (84%) agreed that it was highly important to follow a dialysis schedule. Six (14%) ESRD participants reported having a lot of difficulty in staying for the entire dialysis session, 3 (7%) complained of having moderate difficulty, and 11 (27%) experienced little difficulty, while 21 (51%) reported having no difficulty in staying for the entire dialysis session. The difficulties experienced were mainly treatment related complications which include hypotension, muscle spasm, and pain at the insertion catheter site as well as headaches. On the number of dialysis sessions missed in the past month which was assessed using both self-report and hospital records, the study results showed that 2 (5%) ESRD participants missed 3 dialysis sessions, 5 (12%) missed 2 dialysis sessions, 9 (22%) missed one session, and 25 (61%) did not miss any dialysis session in the last month. Two (5%) ESRD participants shortened dialysis session once, while 39 (95%) did not shorten dialysis session in the last month.
Table
Adherence to hemodialysis scores among ESRD participants (N = 41).
| | | | |
---|---|---|---|---|
| 56 | Low | 1 | 2 |
| 65 | Low | 1 | 2 |
| 68 | Low | 1 | 2 |
| 71 | Moderate | 3 | 7 |
| 74 | Moderate | 5 | 12 |
| 77 | Moderate | 6 | 15 |
| 79 | Moderate | 3 | 8 |
| 82 | High | 14 | 35 |
| 85 | High | 7 | 17 |
| 41 | 100 |
Table
Associated factors of adherence to hemodialysis among ESRD participants.
| | | | |
---|---|---|---|---|
| ||||
18 -30 years | 5 | 26.11 | 26.76 – 28.84 | |
41 – 50 years | 9 | 26.17 | 25.06 – 27.16 | |
51 – 60 years | 11 | 25.91 | 23.24 – 29.09 | |
Greater than 60 years | 10 | 27.70 | 26.23 – 29.17 | |
| ||||
Christianity | 39 | 26.90 | 26.29 – 27.50 | |
Muslim | 2 | 22.00 | 16,12 – 60.12 | |
| ||||
Every dialysis session | 36 | 27.22 | 26.71 – 27.73 | |
Once a week | 2 | 23.50 | 4.44 – 42.56 | |
| ||||
Very Important | 6 | 23.67 | 20.44 – 26.90 | |
Highly important | 34 | 27.21 | 26.65 – 27.76 | |
| ||||
A lot of difficulty | 6 | 23.67 | 20.80 – 26.53 | |
Moderate difficulty | 3 | 24.67 | 21.80 – 27.54 | |
Little difficulty | 11 | 27.00 | 26.14 – 27.85 | |
No difficulty | 21 | 27.62 | 26.88 – 28.36 |
The findings from this study revealed low adherence in 49% of ESRD participants. The findings are consistent with findings from other studies that estimated 50% of patients on hemodialysis not adhering to at least part of their dialysis regimen [
Additionally, the findings of the study showed that age was statistically significantly associated with adherence to hemodialysis. However, it is noted that the effect of age is clinically quite small despite a statistically significant association that exists. The only difference seems to be in the mean ages between the age groups under 60s and over 60s. In this regard, participants of the ages of 41-50 years were observed to be the majority. The results are consistent with findings of Gerard et al. [
Again, the study results revealed that religion was significantly associated with adherence to hemodialysis. This is in line with a prospective study conducted by Freire de Medeiros et al. [
Varying levels of education were not significantly associated with the level of adherence to hemodialysis among ESRD population. This shows that ESRD affects both educated and noneducated people meaning that knowledge alone is not a predictor of adherence to hemodialysis [
Three-quarters of the participants were unemployed meaning that they did not have any monthly income. Moreover, there was no significant association between occupation, income, and adherence to hemodialysis among ESRD patients. However, dialysis in low income countries is an expensive procedure [
This situation is different from that of Europe, where the majority of ESRD patients on renal replacement therapy were covered at 100% [
Firstly, our study presents a smaller sample size that is related to the fact that patient number keeps dwindling depending on the financial capacity of the patients to maintain all hemodialysis sessions. Also, the number of patients that report at the hemodialysis centers is small, therefore, making data collection procedures quite challenging.
Our results also face a limitation of bias as we used face to face interview method for data collection. This might have introduced interviewer and information recall biases. Interviewer bias was mitigated by using three trained research assistants. Meanwhile, information bias was mitigated by the investigators sticking to the research instrument/protocol.
Thirdly, the fact that the study involved respondents on hemodialysis, asking them questions related to their adherence at the time of the interview may not necessarily mean they will adhere throughout the treatment regimen. Interviewers further tried to elicit questions to ascertain the willingness and ability of the patients to stay on hemodialysis.
Altered adherence to hemodialysis is still a big concern in Rwanda affecting negatively ESRD patients’ treatment outcomes thus causing a huge burden on health care institutions. Age and religion were implicated to be significantly associated with adherence to hemodialysis. Health care providers and particularly nurses who care for patients and stay with them for longer hours need to advocate for patients with ESRD in view of completing their sessions for compliance and adherence to hemodialysis. Further research is required to identify barriers and promoters of adherence to HD among patients with ESRD in Rwanda.
The data used to support the findings of this study are available from the corresponding author upon request.
The manuscript was developed from the thesis done as a fulfilment of the M.S. degree in nursing science at University of Rwanda. The citation of the thesis is as follows: Mukakarangwa MC, Adherence to Haemodialysis among End Stage Renal Disease Patients (ESRD) in selected nephrology units in Rwanda, masters dissertation, University of Rwanda, 2017.
The support from College of Medicine and Health Sciences does not lead to any conflicts of interest regarding the publication of this manuscript. Again, the authors declare no conflicts of interest.
The authors acknowledge the support from the College of Medicine and Health Sciences, University of Rwanda, and the Human Resources for Health (HRH), Rwanda.