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Mapping Patients’ Perceived Facilitators and Barriers to In-Center Hemodialysis Attendance to the Health Belief Model: Insights from a Qualitative Study

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Previous research has shown that deliberate withdrawal, skipping, and/or shortening hemodialysis sessions has become a major health problem associated with poor clinical outcomes and early mortality in patients with end-stage renal disease (ESRD). However, patients’ experiences with this treatment remain largely unexplored. This study aimed to explore patients’ perceived facilitators and barriers to in-center hemodialysis attendance and map these findings to the Health Belief Model.


A qualitative exploratory study was conducted with a purposive sample. Semi-structured interviews were conducted and submitted to thematic analysis.


Twenty-four patients (66.2 ± 12.3 years old; length of time on hemodialysis: 35.2 ± 51.5 months) were interviewed. Five major facilitators (social support, perceived benefits, self-efficacy, time on dialysis, and risk/susceptibility perception) and two barriers (lack of knowledge about ESRD and hemodialysis, and psychosocial costs) were identified.


Adherence to the prescribed regimen of hemodialysis attendance is a complex and multidimensional phenomenon that involves an interaction between modifying factors (social support, disease and treatment knowledge, time on dialysis) and patients’ perceived benefits, perceived risks, self-efficacy, and treatment costs. This study findings expand knowledge by suggesting that perceiving health benefits from the beginning of treatment, self-efficacy to deal with dialysis demands, and purpose in life are important facilitators of adherence to in-center hemodialysis sessions. Furthermore, it suggests that the impact of the hemodialysis regimen on the emotional well-being of family members is an important barrier. Future interventions should focus on skills training to promote self-efficacy and family coping with the demands of in-center hemodialysis, improve disease and treatment knowledge, and help balance perceived benefits with dialysis costs.

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The authors would like to thank the head nurses of the dialysis centers where the recruitment took place and the participants for their time and availability to share their experiences with us.


This work was supported by the project POCI-01–0145-FEDER-030228, funded by FEDER, through COMPETE2020- Programa Operacional Competitividade e Internacionalização (POCI), and by national funds (OE), through FCT/MCTES. Additionally, Helena Sousa has a PhD grant scholarship (reference number DFA/BD/4821/2020) financed by FCT (Fundação para a Ciência e Tecnologia) through FSE (Fundo Social Europeu).

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Conceptualization, data curation, and formal analysis: Daniela Figueiredo, Oscar Ribeiro, Helena Sousa; funding acquisition: Daniela Figueiredo, Helena Sousa; investigation, methodology and project administration: Daniela Figueiredo; supervision: Daniela Figueiredo, Oscar Ribeiro, Alan J. Christensen; writing—original draft: Helena Sousa; writing—review & editing: Daniela Figueiredo, Oscar Ribeiro, Alan J. Christensen.

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Correspondence to Helena Sousa.

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Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from all individual participants for whom identifying information is included in this article. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Sousa, H., Ribeiro, O., Christensen, A.J. et al. Mapping Patients’ Perceived Facilitators and Barriers to In-Center Hemodialysis Attendance to the Health Belief Model: Insights from a Qualitative Study. Int.J. Behav. Med. 30, 97–107 (2023).

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