Barriers to and Facilitators of the Adoption of Peritoneal Dialysis: A Systematic Review of Qualitative Studies.

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.