TABLE OF CONTENT

No Content Page number

1 Introduction 3
2 Non- Adherence to treatments and dietary 4
restrictions among ESRF patients
3 Patient Related Factors. 4
4 Psychological Factors 5
5 Social Economic Factors 6
6 Health Care System Factors 7
7 Therapy Related Factors 7
8 Disease Related Factors 8
9 Strategies to improve and support treatment and 9
dietary restrictions adherence so that ESKD patients
achieve the full benefits of their treatment.
10 Conclusion 12
11 References 13

1.0 Introduction

“Drugs won’t work in patients, who don’t take them” is a famous quote by former US
surgeon General C.Everret Coop which hits the heart of all health care provider worldwide.
World Health Organization 2017, reports that, long-term therapy adherence for chronic
illnesses in developed countries averages only 50% and the rates developing in countries, are
even lower. As for ESRD (End stage renal failure) it remains as an expending worldwide
health concern and non-adherence to the treatments and dietary restrictions has corelated with
poorer morbidity, poorer health outcome and increased mortality (Cukor et al, 2019). This
public growing health issue has implications on patient, family and community. The grouped
factors that identified as contributing factors of non-adherence to treatment and dietary
restrictions are patient related, phycological, socioeconomic, therapy related, disease related
and health care system related factors (Chironda and Bhengu, 2016). Thus, in this write up,
the author will be discussing further on each factor that lead to non-adherence of patient to
the treatment provided and the restriction of dietary that causes poor outcome in patient’s
disease progress that leads to undesirable’s outcome as well as the strategies to overcome the
non-adherence issues among ESRF patients.

A population-based study was conducted recently in Malaysia reported that 9.1% of

Malaysians are diagnosed with CKD (Hooi Ls et al, 2013), with 0.24% consist of stage 4
CKD and 0.36% consist of stage 5 of CKD which requires renal replacement therapy (Hill
NR et al, 2016). The types of renal replacement that available in Malaysia are haemodialysis
(HD) with pervasiveness of 1059 patients per million population (pmp), peritoneal dialysis
(PD) 127 patients pmp and followed by renal transplant 59 patients pmp (MSN,2015). In
order to slow down the progress and complications of ESRF, the provision of comprehensive
care in terms of dialysis plan, medications, fluid and dietary restrictions are crucial to be
followed (Griva Ket al,2014). However, evidence from several researches indicated that vast
percentage of ESRF patients were found to diverge from treatment, prescribed dialytic, fluid
restrictions, medications and dietary recommendations (Griva K et al,2014) resulting in
continuous threat in health care.

2.0 Non- Adherence to treatments and dietary restrictions among ESRF patients

Studies done by Griva K in 2014 based in Malaysia reveals that non adherence of
ESRF patients to their dialysis regime rates from 2%-98% while non adherence to fluid
restrictions and dietary recommendations ranging from 9.7% to 72%;. In addition, Tolkof-
Rubin 2018, highlighted that non-adherence to haemodialysis increases the risk of
complications like pulmonary, bones problems, congestive heart failure, chronic anaemia,
brain dysfunctions, severe infections and bleeding. Mortality rates among ESRF patients are
high due to non-adherence to the treatment and dietary restrictions that causes fluid overload
and build-up of waste products. The grouped factors that identified as contributing factors of
non-adherence to treatment and dietary restrictions are patient related, phycological,
socioeconomic, therapy related, disease related and health care system related factors
(Chironda and Bhengu, 2016). In coming segment, the author will elaborate further on each
factor.

2.1 Patient Related Factors.

Patient related factors influence the adherence of ESRF patients and the main reason age
of a patient (Al-Aktari, 2014). Patient whom are younger are less adherent while, older
patients are found to be more adherence. Adding to this,Wong MM et al,2017 stated that
gender is also a factor where male is being consistently associated with non-adherence while
women’s are tend to be more adherence. A patient’s level of education also determines the
level adherence to their treatments. Lower education level, leads to poorer adherence to
treatment and dietary restrictions.. A patient’s knowledge is the principal promoter of a
positive adherence to the treatment or dialysis regime, fluid restrictions and dietary
restrictions with precise self-assessment. It has been reported that, low health literacy among
dialysis patients contribute to non-adherence when combined with regimen complexity of a
treatment (Qobadi et al,2015). Furthermore, low health literacy often associated with worst
health status, higher mortality and frequent hospitalisations. On the other hand, a patient
background which is their culture, traditions and health beliefs often influence treatment
adherence, mainly dietary restrictions.

Out of nine, six studies found that, health beliefs and culture of a patients influences the
phosphate binder adherence as well as dietary restrictions where different races basic food
intake are different. For example, Indians food intake consist more of salt based and dietary
products, while the Chinese consumes foods that are high in potassium.

This food tradition in different races makes it hard for end stage renal failure patients to stick
to their dietary requirements. Besides this, Brekke Hk et al, 2014 states that, forgetfulness of
a patient is major contributor to non-adherence where they tend to forget to take their
phosphate binder together with their meal.

2.2 Psychological Factors

It is known that anxiety, depression and burn out syndrome are the prevalent mental
illness among the ESRF patients. ESRF patients faces countless challenges that leads to these
mental illness and failure to cope with their disease. Studies have shown that the rate of
psychological disorder among ESRF patient are higher than other chronic illness (National
Kidney Foundation, 2019). According to Leung, 2013 once a patient been diagnosed as
ESRF, it creates chaos at affect the patient’s emotions and life. Being a ESRF patient, is
challenging and the patient is forced to confront it in a personal way. Psychosocial stressors
influence patients and their families, including their response to treatment. Smith et al 2013,
cited that the barriers to adherence to fluid restrictions are psychological factors and mainly
lack of motivation. It is reported in a study that 30% of CKD patients shows symptoms of
depression which was found out later, that these patients are likely to be non-adherent with
dialysis treatment endorsement compared to those who are not depressed (Chilcot et al,
2011). In additions, patient whom undergoing CAPD are found out to be more depressed and
likely to have burn out syndrome than patients that undergoing haemodialysis treatment.
Those CAPD patients that suffers from burnt out syndrome are most likely to be non-
adherence to their treatment (Chicot et al, 2011).

Elsevier 2011, stated in an article that, patient’s acceptance about their health is
important due to it will influence patient’s adherence to their dialysis treatment regime. Study
conducted by Khalil AA et al, 2011 to analyse connection between adherence to dietary and
fluid restrictions and depressive symptoms, identified that depression or depressive
symptoms are the cause that contributes to patients on adherence. In other studies, done by
Al-Khattabi GH, 2014 reveals that certain conditions such as denial form of coping, cognitive
trickery, altered risk perceptions and irrational are reported as a factor for non-adherence
among ESRF patients.

Medical & Clinical

2.3 Social Economic Factors

Social support of families, income and employment status has been linked to the
reason of non-adherence among ESRF patients. Poverty surge the predispose complications
and it becomes worst when the patients are already progressing into renal failure. Several
studies done by Magacho et al., Chironda et al., and Assounga et al., reported that most of the
CKD patients are from low socio-economic status and most of them are unemployed or
unable to work when diagnosed as ESRF. Vivekanand JHA et al., 2013 cited that, poverty
and low socio-economic people are in risk of 60% to suffer from ESRF than those who are
not. Once a patient is diagnosed as ESRF, their life is not productive and their ability to work
is hampered (Harillal B et al.,2011). Similarly, Kaitelidou et al. reported that unemployment
due to CKD is a cause of stress among CKD patients. This is due to the complex dialysis
regime that patients have to go through. For example, if patients choose haemodialysis, they
have to stick to 3 days schedule in a week for their dialysis regime while CAPD patients need
to continue their dialysis 4 times a day where they have to be away from work for a while to
perform their CAPD. Most of the employers are unable giving space or alteration for these
patients that leads them to be non-adherence to their dialysis treatment due to they need to
work to provide income for their families Currently in Malaysia, the cost of haemodialysis
per session in private dialysis unit or private hospital ranges from Rm60 to Rm280 per
dialysis session, while CAPD costs RM100 per month. Those patients undergoing HD if
unable to find subsidy or sponsorship from NGO or Pusat Zakat Negara needs to bear the cost
by themselves (National Kidney Foundation, 2018). In other scenario, some patients need to
pay half of the amount of the dialysis treatment. Since dialysis is expensive, it leads to non-
adherence and most patients skips their dialysis to safe cost or stops the treatment due to cost
restraint.

2.4 Health Care System Factors

Health care systems contribute to non-adherence among ESRF patients due to the inadequacy
of resources which makes the middle-income countries RRT unavailable or hard to reach.
The main point needed to be highlighted here is the accessibility and availability of
haemodialysis centres which influence adherence of regime of treatment that has been
prescribed (Fink JC, 2010). In a research done by Sayed M et. al, it is shown that ESRF
patients in United States funded by Medicare, while countries like South Africa the resources
are limited. The demand is greater than supply in poor country makes the RRT hard to reach
and resulting in dialysis inadequacy.

2.5 Therapy Related Factors

Haemodialysis procedure is affected due to the complications or side effects of the

procedure which could affect the adherence. Intradialytic complication such as hypotension,
chest pain and muscle cramps cause the dialysis to be terminated (Lyn PG et. al, 2014). Fidan
et al. and Figueiredo noted that, 20% of haemodialysis patient has muscle cramp during
dialysis which leads to non-adherence of treatment that affect the total ultrafiltration and
creatinine clearance. Muscle cramps usually occurs at the end of dialysis and sometimes leads
to hypotension, when this happens frequently it leads to noncompliance to prescribed dialysis
regime (Lynch PG et al, 2014). Next, will be the intradialytic hypotension that causes the
dialysis to be terminated halfway. Pain and physical weakness or fatigue are considered as
major health problem in ESRF patients, mainly haemodialysis and CAPD patients. Most of
them experiences severe to moderate level of pain. Harirall B noted that, around 90% of
dialysis patients complains of lack of energy, nausea, cramps and feeling extreme tried post
dialysis session which makes them to skip the following session. While CAPD patients often
experiences, hypotension during their regular exchange, makes them to alter their CAPD
fluid regime without consulting doctor. Furthermore, in haemodialysis and CAPD patients
during the process of their dialysis, large molecules like proteins and potassium are filtered
out, this leads to malnutrition thus causing patient to have poor appetite that leads to non-
adherence to their therapeutic dietary intake.

2.6 Disease Related Factors

Zalai D et al, in his studies reveals that disease related factors have implicated to
malnutrition’s among ESRF patients. As for patients it is difficult to convince to be actively
involve in medical treatments regime and therapeutic diets due to their predisposing disease
related. The previous studies have been proved that gastrointestinal problems as a main
culprit to the problems of decreased intake, malnutrition and non-adherence to therapeutic
diet among ESRF patients (Vivekanad JH et al, 2013). In addition, patients that suffers from
ESRF will be having increased leptin serum and serum acute phase mediators that will results
in decreased oral intake (Vivekanad JH et al, 2013). Other than that, presence of high urea in
patients bosy will also decreased the appetite which contributes to non-adherence. It is known
that mostly the diet of renal patient contains low salt which is identified as tasteless, which
makes the patients tempted to eat normal diet (Khalil AA, 2011).

3.0 Strategies to improve and support treatment and dietary restrictions adherence so
that ESKD patients achieve the full benefits of their treatment.

ESRF patients can avoid complications from their diseases by adhering to the prescribed
treatments regime, medications, dietary restrictions and lifestyle modifications. In earlier
segments, the factors of non-adherence are identified, thus now it is vital to explore strategies
to improve and support ESRF patients so that they can benefits their treatments. To support
ESRF patients, a collaborative approach is needed (Osterberg & Blaschke, 2015. Mainly,
assessment must be done to identify and understand the cause intended to make a change in
the patients. Basically, the main strong tool is communications and the treatment relationship
between healthcare provider and patient. Several literatures describe the characteristic of
treatment relationship as a vital encouragement of adherence among patients. This
characterized by a situation where discussions are done, prescribed regime are negotiated,
issues of adherence discussed and proper follow up planned (Sabate, 2011). Nurse spends
more interactive time with the patient when they come for their haemodialysis treatment,
follow up or even when a patient is admitted. These golden hours are when, a nurse can
utilize their role to communicate and educate patient using skills such as active listening and
empathy to help increase the adherence. Sabate 2011 stated, patients must agree to the
recommendations that suggested in order to achieve adherence. HCP and patients must be
active partners and maintain a good rapport with good communication skills applied. It refers
to patients own self but supported by HCP mainly nurses in charge in perusing patient to
adhere prescribed regimen and other restrictions. By this approach, the involvement of
patients in their own health care will help themselves to realize and regain measure to control
and acquire understanding of how one’s does character and behaviour affects their disease
and health. HCP mainly nurses needs to explain and make patients understand that, they need
to be actively participate in their own health care regime. For instance ,CAPD patients’
needs to monitor their weigh, blood pressure and the amount of ultrafiltration during
exchange (RRT,2017). This is to detect any complication such as poor UF or hypotension
that could lead to non-adherence.

3.1 Strategies

Health care provider mainly nurses needs to identify poor adherence among patient which
are under their care or during hospitalization. There are several markers of poor and non-
adherence that can be used to detect such as biochemical and behavioural (Osterberg &
Blaschke, 2015). These includes missed dialysis treatment, poor urea clearance, excess
IDWG, poor ultrafiltration, high potassium and phosphate levels, poor family support and
financial burdens ( Hooi Ls et al, 2013).Nurse needs to highlight the importance of
medication and prescribed treatment regime as well as emphasize the value of positive effect
of adherence (Hooi Ls et al, 2013). Next, as been mentioned earlier, active listening and
communication plays a vital part. HCP must listen to patients and modify the treatment and
medication plan as well as referring patient to dietician based on patient’s agreement and
needs (Lynch PG et al, 2014). In other words, create a personalized and individualize patient
care based of patient’s background such as income, socioeconomic, transportation, financial
and family support so that patient can fully benefits their treatment.

Help must be given to patients with transportation problem to come for dialysis by
encouraging them to use the NGO helps that are available such as free ambulance services for
follow ups and dialysis treatments (NKF, 2014). There are several NGO that can help poor
patients whom in needs of financial support such as Tzu Chi community. National kidney
foundation, Jabatan Kebajikan Masyakarat and Zakat as well. This will help the patient
whom are not adherence due to transportation and financial problems. Next will be provide
more information to patients based on their intellectual level. Provide material that are patient
appropriate which are instruction and instructional (Chironda and Bhengu, 2016). Since,
Malaysia is a multiracial country, and most of the ESRF patients are old, language barrier can
be one of the reason for patients not understanding the instructions (NKF, 2014). Having a
nurse whom understand the patient language can help make a big difference. Oral
reinforcement counselling and usage of materials contains picture can help the older patients
to understand better and remember longer. Patients with problem of non-compliance to
dietary restrictions and fluid restriction needs to be referred to dietitian so that a personalize
diet based on patient’s financial status, race and belief can be created (Khalil AA, 2011).
Patient must be also taught about how to read food labelling, food additives and pamphlets
regarding fast food must be given to patient (Chironda and Bhengu, 2016).

Referring to patient’s adherence to medications regimes, HCP must identify a simpler

way and decrease the complicatedness if the medication regimen by focusing in simpler
dosing and the usage of extended release medications (Anand et al. 2013). Setting up cues
within patient’s daily routine to help patient compliance to their medication intake mainly
their phosphate binder. Providing phosphate binder crusher to older patients that can’t chew
will help them adherence to the medication (Alkatheri AM et al, 2014) Along that, patient
must be given feedback continuously on their actions and the benefits that they are receiving
from their actions taken for instance comparison of their phosphate level when they were
non-adherence and after they were adherence. In a research it was proven that, HCP whom
does not explain or talks to their dialysis patients leads to non-adherence among them
intentionally or unintentionally ( Bakas et al, 2013) .In each dialysis centre, there must be
educational talk done two or three times a week to reinforce patients about their health.
Lastly, social support, family and support are vital in helping these patients to always adhere
to their treatment (Khalil AA, 2011). Encouragement of patient’s family members in
patients’ health care will further boost patient’s confidence and their involvement in taking
care of their health ( Bakas et al, 2013).Creating a peer group with same disease will also be
an encouragement and support them. With these strategies, it is belief that patient will be
adherence to their prescribed regime and benefits fully from their treatment.

4.0 Conclusions

Countless information and lessons has been learned from research regarding adherence.
The most important hint is, patient have to be supported not blamed on their non-adherence.
Regardless, of the evidences there is tendency that patient related factors as the main reason
for the non-adherence but not the neglect of provider and health system related cause ( Cukor
et al, 2019) Patients must be helped regarding their adherence due to the consequences
caused including bad health outcome and raised cost of health care. Looking at economic
perspectives, this issue is critical where it increased the financial burden and compromises the
treatment effectiveness (Daniels et al, 2015). When a patient non-adherence is higher, it
creates a positive impact on patient. The number of patients that has been hospitalized
reduced when, patients are offered and been actively involved in their self-management
combined with disease specific education (Ibrahim et al, 2015). Identifying, the real non-
adherence factor in each patient is the cornerstone for ESRF patients. The best and excellent
care of ESRF patients requires further intervention than only to diagnose and treat. For that
reason, the need for persuasive strategies are vital to combat factors of non-adherence.

Since the factors are identified, it takes the collaboration of several team to apply
strategies to help the patients adherence. Nurses, pharmacists, dietitian and social workers
collaboration are vital. (Tolkof-Rubin N,2018). The important factor here is the
communication and the nurse patient relationship and the usage of positive talking and
explaining skills as well as active listening ( Khalil AA, 2011) .The very first step will be the
right assessment of patients and their background. Other than that, HCP also plays role to
help patients in identifying the route of getting help to constrict any financial burden that may
be the cause of non-adherence among patients (Ibrahim et al, 2015). With the right
assessment, identification of factors and applying the right strategies, patients whom suffers
from ESRD will benefits fully their treatments. When a patient benefits fully their treatments
it can bring down the mortality and morbidity rate of ESRF patients as well as hospitalization
that caused by non-adherence.

3227 WORDS
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