American journal of kidney diseases : the official journal of the National Kidney Foundation · 2026
Barriers to and Facilitators of the Adoption of Peritoneal Dialysis: A Systematic Review of Qualitative Studies.
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Shankar Ravi, Bundele Anjali, Yap Amanda, Goh Aaron, Rao Aanya, Low Joshua, Yeo See Cheng
Аннотация
RATIONALE & OBJECTIVE: Despite evidence supporting peritoneal dialysis (PD) as an effective first-line therapy with outcomes comparable to hemodialysis, global PD utilization remains at only approximately 11%. We systematically reviewed qualitative evidence on barriers and facilitators to PD adoption using the Social Ecological Model (SEM) framework to identify multi-level intervention opportunities.
STUDY DESIGN: Systematic review of qualitative studies.
SETTING & STUDY POPULATIONS: Adults with chronic kidney disease (CKD), caregivers, and healthcare providers involved in dialysis decision-making across 9 countries.
SEARCH STRATEGY & SOURCES: Qualitative or mixed-methods studies exploring barriers and/or facilitators to PD adoption published in peer-reviewed journals from database inception through March 2025.
DATA EXTRACTION: Two reviewers independently extracted study characteristics, participant demographics, and findings related to PD adoption barriers and facilitators.
ANALYTICAL APPROACH: Thematic synthesis with findings mapped to five SEM levels (individual, interpersonal, organizational, community, policy). Quality assessment using the Critical Appraisal Skills Program checklist.
RESULTS: From 7,390 records, 13 studies (595 participants) met inclusion criteria. Individual-level barriers included fear of infection (77% of studies), low self-efficacy (62%), and lifestyle disruption (69%). Interpersonal factors included provider influence (69%) and family dynamics (62%). Organizational barriers centered on education quality (85%) and urgent dialysis starts (38%). Community factors included infrastructure limitations (46%) and cultural considerations (31%). Policy barriers included financial constraints (38%) and hemodialysis-centric systems (54%). Facilitators operated synergistically across levels, with autonomy preference and convenience prominent individually, while structured support was prominent organizationally.
LIMITATIONS: Heterogeneity of populations and healthcare systems; cross-sectional nature of most studies; potential incomplete capture of all relevant influences on choice of dialysis modality.
CONCLUSIONS: PD adoption is influenced by complex, interconnected factors spanning all SEM levels. Effective interventions must address the full ecological context, with particular attention to vulnerable populations facing multiple barriers. Multi-level approaches targeting education restructuring, provider training, support infrastructure, and policy reform may improve PD access and utilization.
STUDY DESIGN: Systematic review of qualitative studies.
SETTING & STUDY POPULATIONS: Adults with chronic kidney disease (CKD), caregivers, and healthcare providers involved in dialysis decision-making across 9 countries.
SEARCH STRATEGY & SOURCES: Qualitative or mixed-methods studies exploring barriers and/or facilitators to PD adoption published in peer-reviewed journals from database inception through March 2025.
DATA EXTRACTION: Two reviewers independently extracted study characteristics, participant demographics, and findings related to PD adoption barriers and facilitators.
ANALYTICAL APPROACH: Thematic synthesis with findings mapped to five SEM levels (individual, interpersonal, organizational, community, policy). Quality assessment using the Critical Appraisal Skills Program checklist.
RESULTS: From 7,390 records, 13 studies (595 participants) met inclusion criteria. Individual-level barriers included fear of infection (77% of studies), low self-efficacy (62%), and lifestyle disruption (69%). Interpersonal factors included provider influence (69%) and family dynamics (62%). Organizational barriers centered on education quality (85%) and urgent dialysis starts (38%). Community factors included infrastructure limitations (46%) and cultural considerations (31%). Policy barriers included financial constraints (38%) and hemodialysis-centric systems (54%). Facilitators operated synergistically across levels, with autonomy preference and convenience prominent individually, while structured support was prominent organizationally.
LIMITATIONS: Heterogeneity of populations and healthcare systems; cross-sectional nature of most studies; potential incomplete capture of all relevant influences on choice of dialysis modality.
CONCLUSIONS: PD adoption is influenced by complex, interconnected factors spanning all SEM levels. Effective interventions must address the full ecological context, with particular attention to vulnerable populations facing multiple barriers. Multi-level approaches targeting education restructuring, provider training, support infrastructure, and policy reform may improve PD access and utilization.