Age Difference in Adherence to a Renal Therapeutic Regimen: The Perspectives of Chinese Patients Undergoing Continuous Ambulatory Peritoneal Dialysis

Purpose:

Patients suffering from end-stage renal disease (ESRD) have to rely on renal replacement therapy (RRT) to sustain life. Due to global shortage of donor organs (Baid-Agrawal & Frei, 2007), all new patients requiring RRT are prescribed continuous ambulatory peritoneal dialysis (CAPD) in Hong Kong unless this is contraindicated (Li & Szeto 2008). It is generally believed that successful management of ESRD and its related treatment depends on patients’ continuous adherence to the four components of the renal therapeutic regimen, which include dietary and fluid restrictions, and medication and dialysis prescriptions (Denhaerynck et al., 2007). As such, studies have been conducted to investigate patients’ adherence rates to different components of the renal therapeutic regimen and factors associate with their adherence. In addition to the various adherence rates reported, younger patients are persistently found to be more non-adherent than older patients (Kara et al., 2007; Kugler et al., 2005; Lam et al., 2010). Due to the study design, patients were not asked to provide explanations for their adherence. This study aimed to identify age difference in adherence to a renal therapeutic regimen from the perspectives of Chinese patients undergoing CAPD. 

Methods:

A qualitative exploratory design was employed. Purposive sampling was used to recruit participants from a renal unit of an acute hospital in Hong Kong. The inclusion criteria were adult patients who were performing home CAPD independently. Thirty-six participants of different genders (18 male participants), ages (35–76 years), and lengths of dialysis experiences (11–103 months) were recruited. Semi-structured one-to-one interviews were conducted using an interview guide. Examples of the interview questions are: “After the commencement of CAPD, what changes have taken place in your daily living?” and “How do you feel about having to adhere to all the advice that you have been given?” The interviews were conducted in individual participant’s home with each lasted for 40 to 80 minutes. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously. Subgroup analysis was carried out to identify age difference in adherence to the therapeutic regimen. The 36 participants were categorised into 2 groups, with age below 60 as the younger group and age equal to or above 60 as the older group. There were 21 and 15 participants in the younger and older groups, respectively. Findings from both groups were compared to identify similarities and differences. 

Results:

Participants in both groups unanimously described how they sacrificed their freedom to struggle to live with strict adherence, particularly in the first few months of dialysis. Participants in the younger group expressed more intense feelings about “disruption of social life” after the commencement of dialysis and “the need for permanent strict adherence”. Being fixed up by the dialysis schedules, younger participants complained about the inability to maintain their previous lifestyles, such as joining social gathering with friends and travelling aboard. Although the majority of these participants’ primary hope for the future was to receive a kidney transplant, they also realised that the chance was very slim. Anticipating that they had to undergo long-term dialysis , the younger participants kept saying that permanent strict adherence was impossible. Most of them perceived life as boring and expressed that they seemed to live for doing dialysis. Despite realising the need for long-term strict adherence, younger participants provided more justifications for “adopting an easy-going approach to adherence” and “modifying their treatment regimen more readily”. Participants in the older group were comparatively more concerned about maintaining their stable health condition to avoid becoming ill. Several older participants repeatedly claimed that longevity was not their priority and they were not afraid of death. Instead, their major concern was not to suffer from a prolonged process of death and become a burden to their family. Therefore, they were more willing to endure hardship in order to adhere to instructions to prevent complications. 

Conclusion:

This is the first study to explain from patients’ perspectives the reasons why younger patients are more non-adherent to the renal therapeutic regimen than older patients. The participants’ journey of learning to live with adherence was full of thorns and obstacles. To adopt strict adherence, regardless of patients’ age, they have to make radical changes to their former lifestyles and endure hardship (Lam et al., in press). The traditional Chinese culture of submission to authority might have caused the older participants to conform more readily (Bond, 1991). On the contrary, participants in the younger group were more concerned about the restrictions imposed on them and attempted to regain their normality. After receiving dialysis for several months, participants in both groups started to adopt an easy-going approach of various degrees to adherence by trial and error. To facilitate patients to come to terms with the extensive lifestyle limitations imposed by the disease, additional professional support is needed, particularly in the initial stage of dialysis. While devising guidelines for patients to adhere, healthcare professionals have to take into consideration individual patients’ personal needs, lifestyles and goals for care. Allowing some flexibility in the regimen enables patients to participate in their former social activities. Helping them integrate the therapeutic regimen into their daily living facilitate them to live with the disease with greater ease.