Volume 21, Issue 4 (12-2024)
J Res Dev Nurs Midw 2024, 21(4): 2-8 |
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Rafiee-Vardanjani L, Mohammadi-Shahboulaghi F, Khankeh H, Norouzi-Tabrizi K. Concept analysis of adherence to treatment in hemodialysis patients: Using a hybrid model. J Res Dev Nurs Midw 2024; 21 (4) :2-8
URL: http://nmj.goums.ac.ir/article-1-1847-en.html
URL: http://nmj.goums.ac.ir/article-1-1847-en.html
Leila Rafiee-Vardanjani1 
, Farahnaz Mohammadi-Shahboulaghi2 , HamidReza Khankeh3 , Kain Norouzi-Tabrizi4
, Farahnaz Mohammadi-Shahboulaghi2 , HamidReza Khankeh3 , Kain Norouzi-Tabrizi4
1- Student Research Committee, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran; School of Nursing and Midwifery, Shahrekord University of Medical Sciences, Shahrekord, Iran
2- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran ,mohammdifarahnaz@gmail.com
3- Health in Emergency and Disaster Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Science, Tehran, Iran ; QUEST Center for Responsible Research, Berlin Institute of Health at Charité, Berlin, Germany
4- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
2- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran ,
3- Health in Emergency and Disaster Research Center, Social Health Research Institute, University of Social Welfare and Rehabilitation Science, Tehran, Iran ; QUEST Center for Responsible Research, Berlin Institute of Health at Charité, Berlin, Germany
4- Iranian Research Center on Aging, Nursing Department, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
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Discussion
This study identified five characteristics of AT in HD patients: "Process-oriented, active participation in care, patient-centered, accepting responsibility for the treatment, and commitment to the care process."
"Process-oriented" refers to individuals transitioning from accepting dialysis to adhering wholeheartedly, emphasizing the unique dimensions of adherence in HD patients (48,49). "A patient-centered approach" emphasizes the importance of individualized approaches within HD units, tailoring treatment decisions daily based on the patient's needs and enhancing AT (44).
"Active participation in care" is essential for achieving AT. By participating in treatment decisions, HD patients are empowered by routine ward visits to assist them in achieving their unique level of engagement (10,30).
"Commitment to the care process" refers to an attitude characterized by a sense of personal responsibility for maintaining health, which can lead to improved adherence, quality of life, and positive health outcomes (51,57).
AT, "accepting responsibility for treatment," entails acknowledging the consequences of individual actions, motivating patients to lead healthier lives, and increasing their commitment to the treatment process. Higher levels of responsibility are correlated with increased acceptance and adherence among HD patients (19,31,47).
This study employed a hybrid concept analysis method to better understand adherence to treatment (AT) in Iranian hemodialysis (HD) patients. It aimed to identify the factors influencing AT behavior among Iranian patients by combining theoretical and empirical approaches. The findings of this study can provide a foundation for future research to explore the determinants of AT in this population further. However, the study was limited by the restricted access to all relevant literature and the exclusion of non-Persian and non-English language studies, which may have impacted the comprehensiveness of the analysis.
Conclusion
This research defined characteristics of AT in HD patients, providing a foundation for healthcare assessment and application in this population. The antecedents identified can give insight into the development of AT strategies. Based on these findings, future research should focus on developing effective health interventions, enhancing the quality of care, and improving quality of life, thereby mitigating the financial burdens associated with non-AT treatments. The authors wish to extend their sincere gratitude to the patients who participated in this study and freely shared their experiences and opinions. Additionally, we want to acknowledge the cooperation of the hospital officials at Hajar Hospital.
Acknowledgement
The authors would like to express their sincere gratitude to the patients who took part in this study and generously shared their experiences and opinions. We would also like to recognize the collaboration of the hospital officials at Hajar Hospital.
Funding sources
None.
Ethical statement
The present study was approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health (Project number 2988 and ethical code: IR.USWR.REC.1403.007). In this study, the researcher adhered to ethical considerations such as maintaining the confidentiality of participants' names, recording interviews, obtaining informed written consent, and allowing participants to withdraw from the study at any time.
Conflicts of interest
The authors declare that they have no competing interests.
Author contributions
FMS and LRV made significant contributions to the design of the review protocol. LRV and HKh developed the search strategy and drafted the initial protocol. KNT conducted the searches and was responsible for data selection and extraction. LRV and FMS were involved in data analysis and the interpretation of the results. LRV, FMS, and KNT collaborated on drafting, revising, and approving the final manuscript.
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Introduction
The rise in chronic illnesses and aging populations has prompted healthcare organizations to focus on these patients (1). The key to successful chronic disease management is adherence to treatment (AT) (2), which is associated with reduced complications, an increased life expectancy, an improved quality of life, and lower healthcare costs (3). A critical component of AT is developing and refining methods for assessing and intervening across various chronic patient groups (2).
In the medical literature, AT is often confused with terms such as "concordance" and "compliance"(3-5), causing confusion and a lack of consensus as to its definition and characteristics. AT is a context-based concept emphasizing the importance of understanding and measuring specific settings (2,6). Cohen et al. (2009) define AT as "persistence in practice and maintenance of desired health behaviors" influenced by social, cultural, and economic factors (7).
There is evidence that AT for chronic illnesses is variable depending on several factors, including the nature of the condition, the complexity of the treatment, the health consequences, lifestyle implications, and long-term consequences (8,9). For example, post-stroke patients are recommended to undergo rehabilitation programs followed by monthly outpatient follow-ups (9,10), while diabetic patients are advised to change their lifestyles and take medications at regular intervals to control their disease (8).
There is a distinct trajectory regarding adherence to treatment (AT) in cases of comorbidity or chronic conditions resulting from underlying health conditions (11,12). Patients with chronic kidney disease (CKD), often caused by non-adherence to treatment regimens, have difficulty adapting to a new lifestyle, coping with renal replacement therapy (RRT), and managing additional health issues, such as anemia and cardiac problems (13,14).
In CKD, adherence is commonly associated with treating the underlying causes, but this oversimplifies the intricate nature of AT (15). As part of their CKD management, hemodialysis (HD) patients must adhere to dietary restrictions, fluid management, medication plans, and regular facility visits, sometimes thrice weekly (16,17). In HD, adherence is monitored, and underlying diseases and complications associated with the procedure are addressed comprehensively (11). Ignoring these dimensions can lead to severe consequences such as mortality and hospital readmissions (17,18).
Despite interventions for improving adherence to treatment (AT) among hemodialysis patients (19), challenges remain due to a lack of understanding of this concept among nurses (20). A lack of straightforward assessment methods contributes to uncertainty in nursing care strategies (19,21). Furthermore, clinical practice gaps related to AT in HD patients, including medication adherence, dietary restrictions, and fluid intake management, further complicate the situation. In this study, we analyzed "AT in HD patients," utilizing Schwartz-Barkot and Kim's integrated framework to identify defining characteristics of the condition and clarify its meaning. The hybrid model was divided into three phases: theoretical, fieldwork, and integration.
Methods
Study design
Hybrid models are powerful tools for concept analysis because they combine empirical observation with theoretical exploration. Incorporating real-world experiences into definitions and identifying key attributes helps researchers better understand concepts' multifaceted nature. According to Schwartz-Barcott and Kim, the hybrid model consists of three phases: theory, fieldwork, and integration. This concept analysis was conducted between May and August 2024 utilizing Schwartz-Barkot and Kim's hybrid model (22). There were three phases in this model, namely the theoretical, the fieldwork, and the final analysis.
Theoretical phase
As adherence plays a significant role in hemodialysis patients' treatment and is characterized by a lack of clarity in its definitions, dimensions, and characteristics, the abovementioned concept was chosen for analysis. This stage involved identifying related studies and reviewing existing knowledge (From 2012 to 2023 due to the addition of adherence to treatment to MeSH terms in 2018 and the ability to manage data) regarding the studied concept in databases such as PubMed, Web of Science, ProQuest, EBSCO, Scopus, Google Scholar, SID, and Magiran, utilizing keywords "Adherence,” “Adherence to Treatment,” “Medication Adherence,” “Hemodialysis Patients,” “Continuous Renal Replacement Therapy,” “Hemodialysis Renal Dialysis,” “Adherence to Therapy,” “Patient Compliance,” “Concordance,” “Regimen Compliance,” “Compliance to Treatment,” and “Drug Regimen Adherence." Inclusion criteria included full-text articles published in Farsi or English with related keywords in the title, abstract, and keyword list. Since peritoneal dialysis requires no continuous hospital visits and home care patterns vary, all articles about the treatment were excluded. In total, 2224 articles were found, reduced to 23 after reviewing and examining the research objectives and article titles (Figure 1).
The rise in chronic illnesses and aging populations has prompted healthcare organizations to focus on these patients (1). The key to successful chronic disease management is adherence to treatment (AT) (2), which is associated with reduced complications, an increased life expectancy, an improved quality of life, and lower healthcare costs (3). A critical component of AT is developing and refining methods for assessing and intervening across various chronic patient groups (2).
In the medical literature, AT is often confused with terms such as "concordance" and "compliance"(3-5), causing confusion and a lack of consensus as to its definition and characteristics. AT is a context-based concept emphasizing the importance of understanding and measuring specific settings (2,6). Cohen et al. (2009) define AT as "persistence in practice and maintenance of desired health behaviors" influenced by social, cultural, and economic factors (7).
There is evidence that AT for chronic illnesses is variable depending on several factors, including the nature of the condition, the complexity of the treatment, the health consequences, lifestyle implications, and long-term consequences (8,9). For example, post-stroke patients are recommended to undergo rehabilitation programs followed by monthly outpatient follow-ups (9,10), while diabetic patients are advised to change their lifestyles and take medications at regular intervals to control their disease (8).
There is a distinct trajectory regarding adherence to treatment (AT) in cases of comorbidity or chronic conditions resulting from underlying health conditions (11,12). Patients with chronic kidney disease (CKD), often caused by non-adherence to treatment regimens, have difficulty adapting to a new lifestyle, coping with renal replacement therapy (RRT), and managing additional health issues, such as anemia and cardiac problems (13,14).
In CKD, adherence is commonly associated with treating the underlying causes, but this oversimplifies the intricate nature of AT (15). As part of their CKD management, hemodialysis (HD) patients must adhere to dietary restrictions, fluid management, medication plans, and regular facility visits, sometimes thrice weekly (16,17). In HD, adherence is monitored, and underlying diseases and complications associated with the procedure are addressed comprehensively (11). Ignoring these dimensions can lead to severe consequences such as mortality and hospital readmissions (17,18).
Despite interventions for improving adherence to treatment (AT) among hemodialysis patients (19), challenges remain due to a lack of understanding of this concept among nurses (20). A lack of straightforward assessment methods contributes to uncertainty in nursing care strategies (19,21). Furthermore, clinical practice gaps related to AT in HD patients, including medication adherence, dietary restrictions, and fluid intake management, further complicate the situation. In this study, we analyzed "AT in HD patients," utilizing Schwartz-Barkot and Kim's integrated framework to identify defining characteristics of the condition and clarify its meaning. The hybrid model was divided into three phases: theoretical, fieldwork, and integration.
Methods
Study design
Hybrid models are powerful tools for concept analysis because they combine empirical observation with theoretical exploration. Incorporating real-world experiences into definitions and identifying key attributes helps researchers better understand concepts' multifaceted nature. According to Schwartz-Barcott and Kim, the hybrid model consists of three phases: theory, fieldwork, and integration. This concept analysis was conducted between May and August 2024 utilizing Schwartz-Barkot and Kim's hybrid model (22). There were three phases in this model, namely the theoretical, the fieldwork, and the final analysis.
Theoretical phase
As adherence plays a significant role in hemodialysis patients' treatment and is characterized by a lack of clarity in its definitions, dimensions, and characteristics, the abovementioned concept was chosen for analysis. This stage involved identifying related studies and reviewing existing knowledge (From 2012 to 2023 due to the addition of adherence to treatment to MeSH terms in 2018 and the ability to manage data) regarding the studied concept in databases such as PubMed, Web of Science, ProQuest, EBSCO, Scopus, Google Scholar, SID, and Magiran, utilizing keywords "Adherence,” “Adherence to Treatment,” “Medication Adherence,” “Hemodialysis Patients,” “Continuous Renal Replacement Therapy,” “Hemodialysis Renal Dialysis,” “Adherence to Therapy,” “Patient Compliance,” “Concordance,” “Regimen Compliance,” “Compliance to Treatment,” and “Drug Regimen Adherence." Inclusion criteria included full-text articles published in Farsi or English with related keywords in the title, abstract, and keyword list. Since peritoneal dialysis requires no continuous hospital visits and home care patterns vary, all articles about the treatment were excluded. In total, 2224 articles were found, reduced to 23 after reviewing and examining the research objectives and article titles (Figure 1).
.PNG)
Fieldwork phase
The study collected qualitative data from HD patients and nurses at Shahrekord Hajar Hospital, Iran. For nurses, the inclusion criteria included a bachelor's degree or higher and six months of experience in an HD ward. For patients, the inclusion criteria included a minimum of six months of HD treatment. A purposeful sampling process was used to select participants for the study. The research team selected the first participant based on the participant's experience and willingness to participate. For a wide range of experiences, maximum variation in sampling was used. The study involved eight participants, including four nurses (Three clinical nurses and one head nurse), four patients, and two family members.
Data collection
Ten semi-structured in-depth interviews were conducted with ten participants. The time and location of the meeting were coordinated in advance according to the participants' preferences. A brief explanation of the research was provided to the participants before the interview began, and their written consent was obtained. Interviews began and continued according to the interview guide prepared by the research team. Questions were specifically designed for each participant's role. For instance, clinical nurses were asked, "What factors influence AT in HD patients?" and the question was posed to hemodialysis patients: "What changes did you notice when strictly adhering to the therapeutic care instructions?" We asked the patients' families: "What are your understandings of the concept of adherence to treatment in patients, and how do they demonstrate it?". As a result of participant responses, the following questions were formulated differently. After each interview, the interviewer was asked, “Is there anything else you would like to add?”. Depending on the participant's preferences, the interview lasted between 45 and 60 minutes.
Data analysis
This study analyzed the data using the five stages of Graneheim and Lundman's conventional content analysis. As a first step, the recorded interviews were transcribed verbatim. The transcripts were read several times to fully comprehend the meaning of the interviews. The interview text was read, abstracted, and coded into meaning units. The main context and the whole meaning were considered when coding and labeling meaning units. The codes were compared based on differences and similarities and sorted into categories. The tentative categories were discussed by the research team and revised. Lastly, themes were formulated from the latent content of the categories. Interviews continued until no new categories or relevant themes were identified, and the categories evolved in conceptualization (23).
Rigor
The four Lincoln and Guba (1985) principles of credibility, confirmability, dependability, and transferability were utilized to ensure rigor (24). Credibility was enhanced through maximum variation sampling, prolonged engagement (5 months), triangulation, and member checks. Confirmability was achieved by accurately documenting all research stages for external review. Dependability was enhanced by recording, transcribing, and analyzing the data immediately after collection. The transferability of the results was addressed by providing detailed descriptions of the participants' experiences and characteristics.
Final analysis phase
During the final analysis phase, all research team members compared the results from the theoretical and fieldwork phases to define an integrated concept (22). This process entailed integrating the theoretical underpinnings with empirical observations to identify the concept's antecedents, attributes, and consequences. Ultimately, this integrative approach led to formulating a novel definition that encapsulated the concept's essence.
Results
Theoretical phase
At the theoretical phase, attributes, antecedents, and consequences of the "AD in HD patients" concept were collected from various databases and sources.
Meanings derived from the literature review
There are a variety of meanings associated with AT, depending on the source. Webster's dictionary defines it as "fidelity through steady or faithful attachments" (2). Taber's Medical Dictionary describes it as "the degree to which a patient's behavior is in accordance with medical advice"(25). The World Health Organization comprehensively describes it as encompasses medication intake, dietary choices, and lifestyle adjustments aligned with a healthcare provider's recommendations (26).
AT, which means loyalty, has historical roots in the 15th century and is also rooted in English, French, and Latin (2). The Oxford Dictionary defines it as "behaving according to a set of rules or following a set of beliefs"(27).
The terms "concordance" and "compliance" have been used interchangeably. Compliance refers to patients following the instructions of healthcare professionals (28). "Compliance" is replaced by "adherence" in Tetorn (1990), who views non-adherence as a conscious refusal to comply. In contrast to "concordance," AT is designed to reduce power imbalances in the doctor-patient relationship (29). Diet, medication, lifestyle choices, promotion of independence, self-determination, and prevention of disease recurrence are all included in this concept (26).
Adherence is influenced by various factors, including health conditions, individual characteristics, cultural behaviors, and treatment duration (30). No uniform definition applies to all patients, especially those with chronic conditions, underscoring the dynamic nature of AT. There are various AT forms, including medication adherence and physical activity adherence (31).
AT is a process for enhancing quality of life and well-being that involves actively maintaining a treatment regimen that is beneficial to the patient and accepted by them (32). HD patients must adhere to dietary restrictions, fluid restrictions, consistent medication intake, and regular attendance in dialysis sessions (33,34).
Identifying the attributes of AT in HD patients
A literature review identified four categories and 10 subcategories of attributes of adherence (AT) in HD patients.
1. Active participation
Active participation is one of the fundamental characteristics of AT in patients with chronic kidney disease. The patient is encouraged to take an active role in their care and treatment, engage with their healthcare team, be involved in their care processes, and exert control over their treatment regimen (35,36).
1.1. Patient-healthcare team interactions
Patient and healthcare team communication is essential for addressing concerns and enhancing AT through tailored education and treatment plans (37). Grandinetti's study (2018) revealed that patient choice, control, and interactive communication were positively associated with acceptance and adherence among HD patients (37). Due to the chronic nature of their condition, active engagement is fundamental for gaining a better understanding of AT regimens, recognizing risks, and establishing a foundation for bolstering AT (38).
Patients who proactively participate in their treatment plan can articulate their challenges, enabling healthcare providers to provide tailored solutions and support, resulting in enhanced AT and improved health outcomes (38,39).
1.2. Patient's active engagement
HD patients' self-care participation significantly impacts AT (38). Howren et al. (2017) noted that active engagement in treatment decisions, education, and addressing patient concerns promote AT and ownership over health. Doing so raises awareness about adhering to HD treatment regimens, deepens understanding, and reinforces responsibility (36).
1.3. Empowerment through control
Managing HD effectively requires maintaining control over the treatment regimen (40). According to Howren et al. (2017), healthcare providers are essential in crafting patient-centric treatment plans, involving patients in decision-making, and fostering adherence to treatment (36). Regular communication, education, and information regarding risks and positive outcomes enhance control over illness and promote AT (41). Patients with HD who are empowered and well-informed are more likely to actively participate in their care and adhere to the recommended treatment regimen.
2. Responsibility
Another characteristic identified among patients is their "responsibility". HD patients who can regulate their care regimen and exercise discretion in managing it demonstrate aspects of AT (2,42). As a result, patients should be willing to take responsibility and make lifestyle changes aligned with treatment requirements.
2.1. Self-regulation
Self-regulation involves understanding and managing behavior and responding appropriately to circumstances. Melastuti et al. (2022) highlighted that encouraging patients to monitor health parameters empowers them to make informed decisions, enhancing AT (43). Patients with self-regulatory potential can collaborate with healthcare professionals to identify objectives, prioritize, and employ problem-solving skills to enhance adherence, thereby bolstering AT (44).
2.2. Autonomy in therapeutic care
Attributing autonomy to HD patients enhances their satisfaction with the treatment process. Patient discretion allows tailoring of treatment according to preferences, lifestyle, and individual needs, thus reflecting the patient's values. The personalized approach increases the likelihood of AT and fosters a long-term commitment to the treatment process. Empowering patients can enhance their adherence to their regimen (45).
3. Commitment to treatment.
Commitment to treatment is a prominent aspect of the literature on AT, encompassing subcategories such as following healthcare provider recommendations, sustained action, and embracing limitations (42,46). According to Chironda and Bhengu's study (2016), self-care abilities and active adherence are pivotal factors defining AT (47).
3.1. Following health care provider recommendations
Adhering to healthcare providers' recommendations is essential for HD patients to foster their commitment to treatment. An effective patient-provider relationship and utilizing positive reinforcement, collaborative decision-making techniques, and similar approaches are pivotal in initiating and sustaining AT (48).
3.2. Sustained action
Continually engaging in the treatment regimen is crucial for the success of AT in HD patients (43). AT is achieved through implementing well-structured routines, creating a supportive environment, and adapting to a new lifestyle (18). A consistent schedule for HD sessions, medication administration, and dietary restrictions allows seamless integration of AT into daily life. Therapeutic care continuity can be reinforced using calendars and similar aids (49).
3.3. Embracing limitations
Embracing therapeutic regimen constraints involves finding solutions to align with and adapt to limitations, thereby optimizing AT. By providing support and cooperation, healthcare providers and HD patients can achieve the best treatment outcomes and prepare patients for a new lifestyle (50,51).
4. Process-oriented
The last characteristic of adherence (AT) in HD patients is its "process-oriented" nature.
4.1. Multidimensionality and complexity
The concept of AT in HD patients is multi-dimensional. CKD patients must navigate a complex network of treatment and self-management, considering treatment complexities, lifestyle adjustments, emotional and cognitive influences, cultural factors, and health literacy (3,13). Healthcare providers need a comprehensive and personalized approach to address these factors. This can be achieved through patient education, emotional support, individualized treatment plans, and ongoing communication (44).
4.2. Requirement for maturation
AT is dynamic and evolving, with patients progressing from acceptance to adherence (48). Adherence levels vary depending on factors such as educational background, continuity of treatment, access to support systems, and adaptive mechanisms (41). There is evidence that the history of HD treatment can influence adherence levels, with patients showing higher adherence under conducive conditions (42,46).
Working definition
Based on the characteristics discussed above, the following is a comprehensive working definition of AT in HD patients:
“AT is a dynamic concept which focuses on the individual needs of HD patients. The patient's sense of responsibility is derived from his or her commitment to therapeutic care behaviors and active engagement in the treatment process. CKD patients can benefit from AT by actively participating in their treatment planning, gaining essential insight into their condition, and collaborating with their treatment team.”
Case study
Model case
The case of a 65-year-old man who has recently been referred to an HD center due to CKD that requires replacement of renal function is presented. According to his latest clinic visit, he had gained 3 kg between HD sessions, had a blood pressure of 172/94 mmHg, and had a creatinine level of 4.9 mg/dL. The medical team, including a doctor and a nurse, discussed managing his condition. The decision involved three weekly HD sessions and lifestyle changes, including exercise, dietary modifications, fluid control, and adherence to the dialysis schedule. In addition to regular monitoring, a follow-up clinic visit was scheduled a month later. In the follow-up, the patient reported adhering to medication, exercising, adjusting his work schedule, eating a low-sodium diet, and drinking fluids based on his urine output. He participated in a weekly educational program to enhance his knowledge of CKD management. He had a blood pressure of 136/80, a weight loss of 2.73 kg, and a creatinine level of 2.3 mEq/L. It was expressed to the patient that he was committed to maintaining these changes.
Fieldwork phase
Four nurses, four patients, and two families participated in the study's second phase; the average age of the patients was 65, and the average age of the nurses was 38 (Table 1).
The study's results revealed five categories and 15 subcategories. The main categories were process orientation, active engagement in therapeutic care, patient-centered approach, taking responsibility for treatment, and commitment to the care process (Table 2).
The study collected qualitative data from HD patients and nurses at Shahrekord Hajar Hospital, Iran. For nurses, the inclusion criteria included a bachelor's degree or higher and six months of experience in an HD ward. For patients, the inclusion criteria included a minimum of six months of HD treatment. A purposeful sampling process was used to select participants for the study. The research team selected the first participant based on the participant's experience and willingness to participate. For a wide range of experiences, maximum variation in sampling was used. The study involved eight participants, including four nurses (Three clinical nurses and one head nurse), four patients, and two family members.
Data collection
Ten semi-structured in-depth interviews were conducted with ten participants. The time and location of the meeting were coordinated in advance according to the participants' preferences. A brief explanation of the research was provided to the participants before the interview began, and their written consent was obtained. Interviews began and continued according to the interview guide prepared by the research team. Questions were specifically designed for each participant's role. For instance, clinical nurses were asked, "What factors influence AT in HD patients?" and the question was posed to hemodialysis patients: "What changes did you notice when strictly adhering to the therapeutic care instructions?" We asked the patients' families: "What are your understandings of the concept of adherence to treatment in patients, and how do they demonstrate it?". As a result of participant responses, the following questions were formulated differently. After each interview, the interviewer was asked, “Is there anything else you would like to add?”. Depending on the participant's preferences, the interview lasted between 45 and 60 minutes.
Data analysis
This study analyzed the data using the five stages of Graneheim and Lundman's conventional content analysis. As a first step, the recorded interviews were transcribed verbatim. The transcripts were read several times to fully comprehend the meaning of the interviews. The interview text was read, abstracted, and coded into meaning units. The main context and the whole meaning were considered when coding and labeling meaning units. The codes were compared based on differences and similarities and sorted into categories. The tentative categories were discussed by the research team and revised. Lastly, themes were formulated from the latent content of the categories. Interviews continued until no new categories or relevant themes were identified, and the categories evolved in conceptualization (23).
Rigor
The four Lincoln and Guba (1985) principles of credibility, confirmability, dependability, and transferability were utilized to ensure rigor (24). Credibility was enhanced through maximum variation sampling, prolonged engagement (5 months), triangulation, and member checks. Confirmability was achieved by accurately documenting all research stages for external review. Dependability was enhanced by recording, transcribing, and analyzing the data immediately after collection. The transferability of the results was addressed by providing detailed descriptions of the participants' experiences and characteristics.
Final analysis phase
During the final analysis phase, all research team members compared the results from the theoretical and fieldwork phases to define an integrated concept (22). This process entailed integrating the theoretical underpinnings with empirical observations to identify the concept's antecedents, attributes, and consequences. Ultimately, this integrative approach led to formulating a novel definition that encapsulated the concept's essence.
Results
Theoretical phase
At the theoretical phase, attributes, antecedents, and consequences of the "AD in HD patients" concept were collected from various databases and sources.
Meanings derived from the literature review
There are a variety of meanings associated with AT, depending on the source. Webster's dictionary defines it as "fidelity through steady or faithful attachments" (2). Taber's Medical Dictionary describes it as "the degree to which a patient's behavior is in accordance with medical advice"(25). The World Health Organization comprehensively describes it as encompasses medication intake, dietary choices, and lifestyle adjustments aligned with a healthcare provider's recommendations (26).
AT, which means loyalty, has historical roots in the 15th century and is also rooted in English, French, and Latin (2). The Oxford Dictionary defines it as "behaving according to a set of rules or following a set of beliefs"(27).
The terms "concordance" and "compliance" have been used interchangeably. Compliance refers to patients following the instructions of healthcare professionals (28). "Compliance" is replaced by "adherence" in Tetorn (1990), who views non-adherence as a conscious refusal to comply. In contrast to "concordance," AT is designed to reduce power imbalances in the doctor-patient relationship (29). Diet, medication, lifestyle choices, promotion of independence, self-determination, and prevention of disease recurrence are all included in this concept (26).
Adherence is influenced by various factors, including health conditions, individual characteristics, cultural behaviors, and treatment duration (30). No uniform definition applies to all patients, especially those with chronic conditions, underscoring the dynamic nature of AT. There are various AT forms, including medication adherence and physical activity adherence (31).
AT is a process for enhancing quality of life and well-being that involves actively maintaining a treatment regimen that is beneficial to the patient and accepted by them (32). HD patients must adhere to dietary restrictions, fluid restrictions, consistent medication intake, and regular attendance in dialysis sessions (33,34).
Identifying the attributes of AT in HD patients
A literature review identified four categories and 10 subcategories of attributes of adherence (AT) in HD patients.
1. Active participation
Active participation is one of the fundamental characteristics of AT in patients with chronic kidney disease. The patient is encouraged to take an active role in their care and treatment, engage with their healthcare team, be involved in their care processes, and exert control over their treatment regimen (35,36).
1.1. Patient-healthcare team interactions
Patient and healthcare team communication is essential for addressing concerns and enhancing AT through tailored education and treatment plans (37). Grandinetti's study (2018) revealed that patient choice, control, and interactive communication were positively associated with acceptance and adherence among HD patients (37). Due to the chronic nature of their condition, active engagement is fundamental for gaining a better understanding of AT regimens, recognizing risks, and establishing a foundation for bolstering AT (38).
Patients who proactively participate in their treatment plan can articulate their challenges, enabling healthcare providers to provide tailored solutions and support, resulting in enhanced AT and improved health outcomes (38,39).
1.2. Patient's active engagement
HD patients' self-care participation significantly impacts AT (38). Howren et al. (2017) noted that active engagement in treatment decisions, education, and addressing patient concerns promote AT and ownership over health. Doing so raises awareness about adhering to HD treatment regimens, deepens understanding, and reinforces responsibility (36).
1.3. Empowerment through control
Managing HD effectively requires maintaining control over the treatment regimen (40). According to Howren et al. (2017), healthcare providers are essential in crafting patient-centric treatment plans, involving patients in decision-making, and fostering adherence to treatment (36). Regular communication, education, and information regarding risks and positive outcomes enhance control over illness and promote AT (41). Patients with HD who are empowered and well-informed are more likely to actively participate in their care and adhere to the recommended treatment regimen.
2. Responsibility
Another characteristic identified among patients is their "responsibility". HD patients who can regulate their care regimen and exercise discretion in managing it demonstrate aspects of AT (2,42). As a result, patients should be willing to take responsibility and make lifestyle changes aligned with treatment requirements.
2.1. Self-regulation
Self-regulation involves understanding and managing behavior and responding appropriately to circumstances. Melastuti et al. (2022) highlighted that encouraging patients to monitor health parameters empowers them to make informed decisions, enhancing AT (43). Patients with self-regulatory potential can collaborate with healthcare professionals to identify objectives, prioritize, and employ problem-solving skills to enhance adherence, thereby bolstering AT (44).
2.2. Autonomy in therapeutic care
Attributing autonomy to HD patients enhances their satisfaction with the treatment process. Patient discretion allows tailoring of treatment according to preferences, lifestyle, and individual needs, thus reflecting the patient's values. The personalized approach increases the likelihood of AT and fosters a long-term commitment to the treatment process. Empowering patients can enhance their adherence to their regimen (45).
3. Commitment to treatment.
Commitment to treatment is a prominent aspect of the literature on AT, encompassing subcategories such as following healthcare provider recommendations, sustained action, and embracing limitations (42,46). According to Chironda and Bhengu's study (2016), self-care abilities and active adherence are pivotal factors defining AT (47).
3.1. Following health care provider recommendations
Adhering to healthcare providers' recommendations is essential for HD patients to foster their commitment to treatment. An effective patient-provider relationship and utilizing positive reinforcement, collaborative decision-making techniques, and similar approaches are pivotal in initiating and sustaining AT (48).
3.2. Sustained action
Continually engaging in the treatment regimen is crucial for the success of AT in HD patients (43). AT is achieved through implementing well-structured routines, creating a supportive environment, and adapting to a new lifestyle (18). A consistent schedule for HD sessions, medication administration, and dietary restrictions allows seamless integration of AT into daily life. Therapeutic care continuity can be reinforced using calendars and similar aids (49).
3.3. Embracing limitations
Embracing therapeutic regimen constraints involves finding solutions to align with and adapt to limitations, thereby optimizing AT. By providing support and cooperation, healthcare providers and HD patients can achieve the best treatment outcomes and prepare patients for a new lifestyle (50,51).
4. Process-oriented
The last characteristic of adherence (AT) in HD patients is its "process-oriented" nature.
4.1. Multidimensionality and complexity
The concept of AT in HD patients is multi-dimensional. CKD patients must navigate a complex network of treatment and self-management, considering treatment complexities, lifestyle adjustments, emotional and cognitive influences, cultural factors, and health literacy (3,13). Healthcare providers need a comprehensive and personalized approach to address these factors. This can be achieved through patient education, emotional support, individualized treatment plans, and ongoing communication (44).
4.2. Requirement for maturation
AT is dynamic and evolving, with patients progressing from acceptance to adherence (48). Adherence levels vary depending on factors such as educational background, continuity of treatment, access to support systems, and adaptive mechanisms (41). There is evidence that the history of HD treatment can influence adherence levels, with patients showing higher adherence under conducive conditions (42,46).
Working definition
Based on the characteristics discussed above, the following is a comprehensive working definition of AT in HD patients:
“AT is a dynamic concept which focuses on the individual needs of HD patients. The patient's sense of responsibility is derived from his or her commitment to therapeutic care behaviors and active engagement in the treatment process. CKD patients can benefit from AT by actively participating in their treatment planning, gaining essential insight into their condition, and collaborating with their treatment team.”
Case study
Model case
The case of a 65-year-old man who has recently been referred to an HD center due to CKD that requires replacement of renal function is presented. According to his latest clinic visit, he had gained 3 kg between HD sessions, had a blood pressure of 172/94 mmHg, and had a creatinine level of 4.9 mg/dL. The medical team, including a doctor and a nurse, discussed managing his condition. The decision involved three weekly HD sessions and lifestyle changes, including exercise, dietary modifications, fluid control, and adherence to the dialysis schedule. In addition to regular monitoring, a follow-up clinic visit was scheduled a month later. In the follow-up, the patient reported adhering to medication, exercising, adjusting his work schedule, eating a low-sodium diet, and drinking fluids based on his urine output. He participated in a weekly educational program to enhance his knowledge of CKD management. He had a blood pressure of 136/80, a weight loss of 2.73 kg, and a creatinine level of 2.3 mEq/L. It was expressed to the patient that he was committed to maintaining these changes.
Fieldwork phase
Four nurses, four patients, and two families participated in the study's second phase; the average age of the patients was 65, and the average age of the nurses was 38 (Table 1).
The study's results revealed five categories and 15 subcategories. The main categories were process orientation, active engagement in therapeutic care, patient-centered approach, taking responsibility for treatment, and commitment to the care process (Table 2).
.PNG)
Integration Phase
In analyzing the literature review and fieldwork, the characteristics of AT in HD patients were described as "process-oriented, active participation in therapeutic care, patient-centered, accepting responsibility for the treatment, commitment to the care process" (Table 3, Figure 2). Therefore, the following operational definition can be provided:
"In HD patients, AT is a multifaceted, patient-centered process that relies on a patient's willingness to participate in the therapeutic care process actively. One of its most significant attributes is the patient's active participation in the therapeutic care process."
Antecedents of AT
According to the study's findings, AT in HD patients depends upon antecedents, which can be divided into three categories: patient-related, community, and healthcare system factors (Figure 2).
Patient-related antecedents included acceptance of the nature of chronic diseases, knowledge, education level, health literacy, experience with complications, aspiration for a kidney transplant, and individual self-evaluation. Higher education and transplant aspirations are often associated with increased AT (35,43). A higher level of health literacy facilitates lifestyle adjustments (3,37). In the field, Participant 5 mentioned, "reproductive age or family responsibility is associated with improved adherence." Participant 3 mentioned, "I am literate, I read the dialysis manual, I calculate nutrition, and I am concerned about my health."
Social factors included physical and psychological support, socioeconomic assistance, social stigmas, and Iranian food culture. Strong support networks, conflict resolution, and psychological support improve acceptance and performance (52-54). The stigma associated with HD treatment can undermine AT (55). Participant 7 stated, "I lost my job due to dialysis; no one wants us." Participant 4 stated, "Children's support encourages me to avoid complications."
Healthcare system-related factors include supportive policies, specific theories, workforce, staff training, and patient follow-up. Health insurance coverage and special patient categorization can improve living conditions, thereby encouraging AT (46). Participant 7 stated, "Insurance covers the cost of medication, which helps ease concerns." Participant 3 stated, "I appreciate Ms.who educates us; she is very knowledgeable."
Consequences of AT
AT has two main consequences in HD patients. The first concerns the patient, and the second concerns the healthcare system (Figure 2).
Several patient-related outcomes have been identified, including increased social participation, increased self-confidence, increased self-efficacy, enhanced decision-making skills, increased patient commitment, improved communication skills, improved physical and mental performance, increased responsibility, reduced disease recurrence, enhanced disease control, improved adaptability skills, and reduced patient social isolation (43,56).
The nurse on the HD ward stated, "Patients who adhere to their treatment often experience positive outcomes and require fewer dialysis sessions." Participant 3 added, "I feel better when I adhere to my treatment plan, attend appointments punctually, and feel more valued."
An organizational consequence includes increased job satisfaction for healthcare professionals, higher patient satisfaction, reduced treatment costs, and decreased mortality rates. Participant 2 stated, "Patients adhering to treatment require fewer sessions, avoid emergency appointments, and streamline the process in general."
In analyzing the literature review and fieldwork, the characteristics of AT in HD patients were described as "process-oriented, active participation in therapeutic care, patient-centered, accepting responsibility for the treatment, commitment to the care process" (Table 3, Figure 2). Therefore, the following operational definition can be provided:
"In HD patients, AT is a multifaceted, patient-centered process that relies on a patient's willingness to participate in the therapeutic care process actively. One of its most significant attributes is the patient's active participation in the therapeutic care process."
Antecedents of AT
According to the study's findings, AT in HD patients depends upon antecedents, which can be divided into three categories: patient-related, community, and healthcare system factors (Figure 2).
Patient-related antecedents included acceptance of the nature of chronic diseases, knowledge, education level, health literacy, experience with complications, aspiration for a kidney transplant, and individual self-evaluation. Higher education and transplant aspirations are often associated with increased AT (35,43). A higher level of health literacy facilitates lifestyle adjustments (3,37). In the field, Participant 5 mentioned, "reproductive age or family responsibility is associated with improved adherence." Participant 3 mentioned, "I am literate, I read the dialysis manual, I calculate nutrition, and I am concerned about my health."
Social factors included physical and psychological support, socioeconomic assistance, social stigmas, and Iranian food culture. Strong support networks, conflict resolution, and psychological support improve acceptance and performance (52-54). The stigma associated with HD treatment can undermine AT (55). Participant 7 stated, "I lost my job due to dialysis; no one wants us." Participant 4 stated, "Children's support encourages me to avoid complications."
Healthcare system-related factors include supportive policies, specific theories, workforce, staff training, and patient follow-up. Health insurance coverage and special patient categorization can improve living conditions, thereby encouraging AT (46). Participant 7 stated, "Insurance covers the cost of medication, which helps ease concerns." Participant 3 stated, "I appreciate Ms.who educates us; she is very knowledgeable."
Consequences of AT
AT has two main consequences in HD patients. The first concerns the patient, and the second concerns the healthcare system (Figure 2).
Several patient-related outcomes have been identified, including increased social participation, increased self-confidence, increased self-efficacy, enhanced decision-making skills, increased patient commitment, improved communication skills, improved physical and mental performance, increased responsibility, reduced disease recurrence, enhanced disease control, improved adaptability skills, and reduced patient social isolation (43,56).
The nurse on the HD ward stated, "Patients who adhere to their treatment often experience positive outcomes and require fewer dialysis sessions." Participant 3 added, "I feel better when I adhere to my treatment plan, attend appointments punctually, and feel more valued."
An organizational consequence includes increased job satisfaction for healthcare professionals, higher patient satisfaction, reduced treatment costs, and decreased mortality rates. Participant 2 stated, "Patients adhering to treatment require fewer sessions, avoid emergency appointments, and streamline the process in general."
.PNG)
.PNG)
.PNG) Figure 2. The conceptual model of the adherence to treatment in hemodialysis patients concept |
Discussion
This study identified five characteristics of AT in HD patients: "Process-oriented, active participation in care, patient-centered, accepting responsibility for the treatment, and commitment to the care process."
"Process-oriented" refers to individuals transitioning from accepting dialysis to adhering wholeheartedly, emphasizing the unique dimensions of adherence in HD patients (48,49). "A patient-centered approach" emphasizes the importance of individualized approaches within HD units, tailoring treatment decisions daily based on the patient's needs and enhancing AT (44).
"Active participation in care" is essential for achieving AT. By participating in treatment decisions, HD patients are empowered by routine ward visits to assist them in achieving their unique level of engagement (10,30).
"Commitment to the care process" refers to an attitude characterized by a sense of personal responsibility for maintaining health, which can lead to improved adherence, quality of life, and positive health outcomes (51,57).
AT, "accepting responsibility for treatment," entails acknowledging the consequences of individual actions, motivating patients to lead healthier lives, and increasing their commitment to the treatment process. Higher levels of responsibility are correlated with increased acceptance and adherence among HD patients (19,31,47).
This study employed a hybrid concept analysis method to better understand adherence to treatment (AT) in Iranian hemodialysis (HD) patients. It aimed to identify the factors influencing AT behavior among Iranian patients by combining theoretical and empirical approaches. The findings of this study can provide a foundation for future research to explore the determinants of AT in this population further. However, the study was limited by the restricted access to all relevant literature and the exclusion of non-Persian and non-English language studies, which may have impacted the comprehensiveness of the analysis.
Conclusion
This research defined characteristics of AT in HD patients, providing a foundation for healthcare assessment and application in this population. The antecedents identified can give insight into the development of AT strategies. Based on these findings, future research should focus on developing effective health interventions, enhancing the quality of care, and improving quality of life, thereby mitigating the financial burdens associated with non-AT treatments. The authors wish to extend their sincere gratitude to the patients who participated in this study and freely shared their experiences and opinions. Additionally, we want to acknowledge the cooperation of the hospital officials at Hajar Hospital.
Acknowledgement
The authors would like to express their sincere gratitude to the patients who took part in this study and generously shared their experiences and opinions. We would also like to recognize the collaboration of the hospital officials at Hajar Hospital.
Funding sources
None.
Ethical statement
The present study was approved by the Ethics Committee of the University of Rehabilitation Sciences and Social Health (Project number 2988 and ethical code: IR.USWR.REC.1403.007). In this study, the researcher adhered to ethical considerations such as maintaining the confidentiality of participants' names, recording interviews, obtaining informed written consent, and allowing participants to withdraw from the study at any time.
Conflicts of interest
The authors declare that they have no competing interests.
Author contributions
FMS and LRV made significant contributions to the design of the review protocol. LRV and HKh developed the search strategy and drafted the initial protocol. KNT conducted the searches and was responsible for data selection and extraction. LRV and FMS were involved in data analysis and the interpretation of the results. LRV, FMS, and KNT collaborated on drafting, revising, and approving the final manuscript.
Type of study: Original Article |
Subject:
Nursing
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