Knowledge and Self-care practice of Arteriovenous Fistula among Hemodialysis patients

INTRODUCTION

The kidneys are one of the most important organs in the human body, they are responsible for the extracellular fluid equilibrium. (Iqbal et al., 2018) The best vascular access for operating hemodialysis for patients with kidney disease is an arteriovenous (AV) fistula. (Sousa et al., 2020) Creating an AV fistula involves a surgical procedure in which an artery and a vein are connected to facilitate dialysis access. (Marsh, et al., 2023)

Over 10% of the global population is affected by a degenerative disease which is chronic kidney disease (CKD), encompassing more than 800 million individuals. Predominantly prevalent in older adults, women, racial minorities, and those with diabetes and hypertension. (Hinkle et al., 2021) CKD poses a significant burden, particularly in low- and middle-income countries, which often lack adequate resources to address its implications. Alarmingly, CKD ranks among the leading causes of mortality worldwide, with a notable increase in associated deaths observed over the past two decades. (Muthusamy et al., 2021)

In Iran, the prevalence of end-stage renal disease (ESRD) was reported at 680 per million people in 2017, according to the Iran Consortium of Dialysis (ICD) report. ESRD, characterized by chronic and progressive kidney dysfunction leading to the accumulation of metabolic waste products, poses profound personal and national repercussions. (Institute for Health Metrics and Evaluation (IHME), 2018) Despite its incurable nature, life expectancy can be extended through treatments such as hemodialysis (HD), peritoneal dialysis, or kidney transplantation, with hemodialysis being the most prevalent method for managing advanced renal failure. (Xu et al., 2023)

Hemodialysis relies on various access points, including fistula, graft, and catheter, with AV fistula emerging as a preferred option. (Abd Alfatah et al., 2013) AV fistulas are susceptible to complications such as blood hypo-flow, edema, thrombosis, aneurysms, and infection (Marsh, et al., 2023) Self-care practices among patients were less focused on AV fistula infection and thrombosis prevention. (Sousa et al., 2020) Preventive measures, including proper care and patient education, play pivotal roles in mitigating these risks. (Pessoa and Linhares, 2015)

Patients' engagement in self-care practices is essential for maintaining AV fistula health and longevity. During the fistula maturation period, specific care strategies, such as arm elevation, daily exercises, and vigilant blood flow assessment, are imperative to enhance durability. Moreover, adherence to precautions such as adequate compression for hemostasis and blood pressure monitoring is crucial for optimizing fistula function. Knowledge dissemination regarding self-care practices significantly influences patients' attitudes and behaviors toward AV fistula management. (Iqbal et al., 2018)

Investigating the knowledge and self-care practices pertaining to AV fistulas in hemodialysis patients is instrumental in fostering patient empowerment and improving healthcare delivery. By identifying gaps in knowledge and their self-care practice, healthcare professionals can facilitate informed decision-making and promote proactive self-care behaviors among hemodialysis patients, ultimately leading to enhanced vascular access management and improved patient outcomes. This study aimed to assess the knowledge and self-care practices related to AV fistula among hemodialysis patients.

PATIENTS AND METHODS

A quantitative, descriptive study designed to assess the knowledge and practice regarding self-care of AV fistula among hemodialysis patients in Hawler Teaching Hospitals, Erbil city, Iraq. The study population comprised 112 patients undergoing hemodialysis with an AV fistula in the selected setting from September 2023 to January 2024. Inclusion criteria encompassed patients aged 14 and older, of both genders, undergoing hemodialysis for a period of six months to two years with AV fistula, and proficient in either Kurdish or Arabic. Patients classified as critically or mentally ill were excluded from the study. Non-probability convenient sampling was employed to select participants meeting the specified criteria.

Data were collected using a semi-structured questionnaire designed to gather clinical and demographic information. The questionnaire included 20 structured multiple-choice items to assess knowledge. Each correct response was assigned a score of '1', while each incorrect response received a score of '0'. The total knowledge score ranged from 0 to 20. The percentage was calculated based on the total score obtained by each participant, with interpretations categorized as follows: Adequate (>75% correct responses), Moderately adequate (51% to 75% correct responses), and Inadequate (≤50% correct responses).

Additionally, a three-point Likert scale with 30 statements was utilized to evaluate self-reported practices. For positive statements, responses were scored as follows: Never (0), Sometimes (1), Always (2). For negative statements, responses were scored inversely: Never (2), Sometimes (1), Always (0). The total practice score ranged from 0 to 60. The percentage was calculated based on the total score obtained by each participant, with interpretations categorized as follows: Good (>75% of maximum possible score), Moderate (51% to 75% of maximum possible score), and Poor (≤50% of maximum possible score).

The questionnaire was validated by two nephrologists and three medical-surgical nursing experts. Test-retest reliability analysis yielded scores of 0.83 and 0.87 for the knowledge and practice tools, respectively.

Ethical approval was obtained from the Hawler Medical University College of Nursing ethical committee, and verbal informed consent was obtained from all participants. Confidentiality and anonymity of participants were maintained throughout the data collection process.

Data were analyzed using SPSS software version 27. Descriptive statistics, including frequency and percentage distribution, were employed to assess the level of knowledge and practice regarding self-care of AV fistula among patients receiving hemodialysis. The chi-square test was utilized to explore associations between knowledge and self-care practice regarding AV fistula among hemodialysis patients.

RESULTS

Table 1 Shows that the majority of patients age were between (53 to 65 years old) which presented (%32.1) with mean age and standard deviation of 53.79 ± 16.923, and most of them were female 60 (%53.6). The majority of the participants in this study were residents of urban (%77.7). Moreover, (%44.6) of them were illiterate. More than half of the participants were married (%63.4). All samples that enrolled in this study were Muslim (99.1%) except only one patient (0.9%) was Christian. The majority of females were housewives (42.9%) and males were Unemployed (25%).

Table 1 presents the sociodemographic characteristics of the study participants. The majority of patients fell within the age range of 53 to 65 years old, constituting 32.1% of the total sample. The mean age was 53.79 years with a standard deviation of 16.923. Gender distribution showed that 53.6% of the participants were female, while 46.4% were male.

Regarding the area of residence, the majority of participants (77.7%) resided in urban areas. In terms of educational levels, 44.6% of participants were illiterate, while 25.0% had completed secondary school. Marital status analysis revealed that 63.4% of participants were married, followed by 21.4% who were single and 13.4% who were widowed.

Religiously, almost all participants (99.1%) identified as Muslim, with only one participant (0.9%) identifying as Christian. The occupational distribution showed that the largest proportion of females (42.9%) were housewives, while the largest proportion of males (25.0%) were unemployed. Other occupations included government employees (5.4%), students (6.3%), retired individuals (10.7%), and those working in various other sectors (5.4%).

Table 1 Sociodemographic Variables of Patients Undergoing Hemodialysis

Table 2 provides an overview of the clinical variables among the study participants. The majority of participants (41.1%) were diagnosed with chronic kidney disease between the ages of 53 to 65 years. Regarding the duration of undergoing hemodialysis, a significant proportion (39.3%) had been undergoing hemodialysis for more than 2 years. Similarly, 41.1% of participants had been living with an AV fistula for more than 2 years.

Regarding comorbid diseases, a substantial majority of participants reported having hypertension (80.4%), followed by diabetes mellitus (40.2%) and cardiac disease (32.1%). In terms of the frequency of receiving hemodialysis, the majority of participants (61.6%) received treatment twice per week.

The location of the AV fistula was predominantly in the elbow of the non-dominant arm (75.9%). Most participants (75.9%) reported no history of AV fistula failure and were aware of its care. Additionally, a majority of participants (69.6%) obtained information about AV fistula care from healthcare providers.

Table 2 Distribution of clinical variables of patients undergoing hemodialysis

Table 3 shows that the majority of patients (48.2%) demonstrated inadequate knowledge, while 31.3% exhibited moderately adequate knowledge. Additionally, 20.5% of patients demonstrated adequate knowledge regarding self-care of AV fistula.

Table 3 Knowledge regarding self-care of AV fistula among hemodialysis Patients.

Table 4 illustrates the distribution of self-reported practice levels among the study participants regarding the self-care of AV fistula. The assessment of practice levels was based on a scale ranging from poor to good.

The findings reveal that a significant majority of patients (85.7%) reported having moderate levels of practice in self-care of AV fistula. Conversely, a smaller proportion (14.3%) indicated poor self-reported practice in this regard. Notably, none of the participants reported achieving a level of good practice.

Table 4 Level of Practice regarding self-care of AV fistula among hemodialysis Patients.

Table 5 presents the association between the level of knowledge regarding self-care of AV fistula and various sociodemographic characteristics of the patients. Statistical analysis was conducted to examine potential associations using the chi-square test.

The findings indicate a statistically significant association between the level of knowledge and educational levels (p = 0.040). Specifically, participants' educational backgrounds showed a significant influence on their level of knowledge regarding self-care of AV fistula.

However, for other sociodemographic variables such as age group, gender, area of residence, marital status, religion, occupation, age of diagnosis of chronic kidney disease, duration of undergoing hemodialysis, duration of having AV fistula, site of AV fistula, and history of AV fistula failure, no statistically significant association was observed with the level of knowledge regarding self-care of AV fistula.

Table 5 Association of Level of Knowledge with Sociodemographic Variables

Table 6 presents the association between the level of self-reported practice regarding self-care of AV fistula and various sociodemographic characteristics of the patients. Statistical analysis was conducted to assess potential associations using the chi-square test.

The results indicate that there was no statistically significant association observed between the level of self-reported practice and most demographic variables, including age group, gender, area of residence, marital status, religion, occupation, age of diagnosis of chronic kidney disease, duration of undergoing hemodialysis, duration of having AV fistula, site of AV fistula, and history of AV fistula failure. However, a statistically significant association was found between the level of self-reported practice and educational levels (p = 0.030). Specifically, participants' educational backgrounds demonstrated a significant influence on their level of self-reported practice regarding self-care of AV fistula.

These findings suggest that educational levels may play a crucial role in determining the level of self-reported practice of self-care of AV fistula among the study participants, while other sociodemographic characteristics do not exhibit a significant association with practice levels.

Table 6 Association of Level of Self-reported Practice with Sociodemographic Variables

DISCUSSION

The findings of the study revealed a notable prevalence of inadequate knowledge (48.2%) among patients regarding self-care of AV fistula, with a significant portion (31.3%) demonstrating moderately adequate knowledge and a minority (20.5%) possessing adequate knowledge. Similarly, the majority of patients (85.7%) reported moderate levels of self-reported practice, while a smaller proportion (14.3%) indicated poor practice, with none demonstrating good practice. These results are similar to the previous research done by Ozen et al. (2017), Yang et al.,  (2019) and Natti Krishna et al. (2024), which similarly highlighted inadequate knowledge and practice levels among hemodialysis patients.

It is noteworthy that a statistically significant association was observed between the level of knowledge regarding self-care of AV fistula and educational levels. This aligns with findings from Devi and Sengupta (2022) and Natti Krishna et al. (2024), suggesting that higher educational attainment is linked to better knowledge scores. Similarly, the study findings revealed a significant association between self-reported practice levels and educational level, consistent with previous research by Spies et al., (2021) and Bulbul et al., (2023). These findings underscore the influence of education on patients' approaches to self-care practices, emphasizing the importance of tailored educational interventions.

Although no statistically significant associations were found with clinical variables, such as age, gender, and duration of hemodialysis, it's essential to recognize the potential impact of these factors on patient outcomes. These results are consistent with previous research by Ray et al. (2021) and Grace et al., (2021). Further exploration of these variables could provide valuable insights into optimizing care delivery for hemodialysis patients with AV fistula.

The absence of challenges during the study process indicates the feasibility of conducting such research in similar settings. However, future studies could benefit from expanding the research to a larger population to explore the lived experiences of AV fistula patients undergoing hemodialysis comprehensively. Additionally, investigating the barriers patients face in adhering to self-care practices could inform the development of innovative strategies to enhance patient knowledge and adherence to self-care practices related to AV fistula maintenance during hemodialysis.

CONCLUSION

In conclusion, this study sheds light on the knowledge and self-reported practice levels among hemodialysis patients regarding AV fistula self-care. The findings underscore a prevalent inadequacy in both knowledge and practice, with a substantial proportion of patients demonstrating suboptimal levels in these domains.

The significant association observed between educational levels and both knowledge and practice highlight the pivotal role of education in influencing patients' understanding and adherence to self-care practices related to AV fistula maintenance during hemodialysis. Tailored educational interventions targeting patients with varying educational backgrounds could improve knowledge acquisition and promote better self-care practices.

While no significant associations were found with clinical variables, such as age and duration of hemodialysis, further investigation into these factors is warranted to better understand their potential impact on patient outcomes and inform personalized care approaches.

Overall, the study underscores the importance of enhancing patient education and implementing tailored interventions to address the observed gaps in knowledge and practice among hemodialysis patients with AV fistula. By empowering patients with the necessary knowledge and skills, healthcare providers can contribute to optimizing patient outcomes and improving the overall quality of care for individuals undergoing hemodialysis.