title: The dynamic process of adherence to a renal therapeutic regimen: perspectives of patients undergoing continuous ambulatory peritoneal dialysis.
abstract: BACKGROUND
  The nature of end-stage renal disease and the need for continuous ambulatory peritoneal dialysis require patients to manage various aspects of the disease, its symptoms and treatment. After attending a training programme, patients are expected to adhere to the renal therapeutic regimen and manage their disease with the knowledge and skills learned. While patients are the stakeholders of their health and related behaviour, their perceptions of adherence and how they adhere to their renal therapeutic regimen remains unexplored.
  
  
  OBJECTIVE
  To understand adherence from patients' perspectives and to describe changes in adherence to a therapeutic regimen among patients undergoing continuous ambulatory peritoneal dialysis.
  
  
  METHODS
  This study used a mixed methods design with two phases - a survey in phase I and semi-structured interviews in phase II. This paper presents phase II of the study.
  
  
  METHODS
  The study was conducted at a renal unit of an acute hospital in Hong Kong.
  
  
  METHODS
  Based on the phase I survey results, maximum variation sampling was employed to purposively recruit 36 participants of different genders (18 males, 18 females), ages (35-76 years), and lengths of dialysis experience (11-103 months) for the phase II interviews.
  
  
  METHODS
  Data were collected by tape-recorded semi-structured interviews. Content analysis was employed to analyse the transcribed data. Data collection and analysis were conducted simultaneously.
  
  
  RESULTS
  Adherence was a dynamic process with three stages. At the stage of initial adherence, participants attempted to follow instructions but found that strict persistent adherence was impossible. After the first 2-6 months of dialysis, participants entered the stage of subsequent adherence, when they adopted selective adherence through experimenting, monitoring and making continuous adjustments. The stage of long-term adherence commenced after 3-5 years of dialysis, when participants were able to assimilate the modified therapeutic regimen into everyday life.
  
  
  CONCLUSIONS
  The process of adherence was dynamic as there were fluctuations at each stage of the participants' adherence. With reference to each stage identified, nursing interventions can be developed to help patients achieve smooth transition throughout all the stages.
authors.affiliation: The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong. Electronic address: lwlam@cuhk.edu.hk.
authors.forename: Lai Wah
authors.initials: LW
authors.lastname: Lam
authors.affiliation: The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Diana T F
authors.initials: DT
authors.lastname: Lee
authors.affiliation: The Nethersole School of Nursing, The Chinese University of Hong Kong, Hong Kong.
authors.forename: Ann T Y
authors.initials: AT
authors.lastname: Shiu
mesh_terms: D006801:Humans; D007676:Kidney Failure, Chronic / Q000628:therapy*; D010349:Patient Compliance; D010531:Peritoneal Dialysis, Continuous Ambulatory / Q000523:psychology*
keywords: Adherence; Continuous ambulatory peritoneal dialysis; Dynamic process; End-stage renal disease; Mixed methods research; Nursing; Renal therapeutic regimen