title: Knowledge, barriers and facilitators of exercise in dialysis patients: a qualitative study of patients, staff and nephrologists.
abstract: Despite growing evidence on benefits of increased physical activity in hemodialysis (HD) patients and safety of intra-dialytic exercise, it is not part of standard clinical care, resulting in a missed opportunity to improve clinical outcomes in these patients. To develop a successful exercise program for HD patients, it is critical to understand patients', staff and nephrologists' knowledge, barriers, motivators and preferences for patient exercise.
  
  
  
  In-depth interviews were conducted with a purposive sample of HD patients, staff and nephrologists from 4 dialysis units. The data collection, analysis and interpretation followed Criteria for Reporting Qualitative Research guidelines. Using grounded theory, emergent themes were identified, discussed and organized into major themes and subthemes.
  
  
  
  We interviewed 16 in-center HD patients (mean age 60 years, 50% females, 63% blacks), 14 dialysis staff members (6 nurses, 3 technicians, 2 dietitians, 1 social worker, 2 unit administrators) and 6 nephrologists (50% females, 50% in private practice). Although majority of the participants viewed exercise as beneficial for overall health, most patients failed to recognize potential mental health benefits. Most commonly reported barriers to exercise were dialysis-related fatigue, comorbid health conditions and lack of motivation. Specifically for intra-dialytic exercise, participants expressed concern over safety and type of exercise, impact on staff workload and resistance to changing dialysis routine. One of the most important motivators identified was support from friends, family and health care providers. Specific recommendations for an intra-dialytic exercise program included building a culture of exercise in the dialysis unit, and providing an individualized engaging program that incorporates education and incentives for exercising.
  
  
  
  Patients, staff and nephrologists perceive a number of barriers to exercise, some of which may be modifiable. Participants desired an individualized intra-dialytic exercise program which incorporates education and motivation, and they provided a number of recommendations that should be considered when implementing such a program.
authors.affiliation: Renal-Electrolyte Division, University of Pittsburgh School of Medicine, 200 Lothrop St, PUH C-1101, Pittsburgh, PA, 15213, USA. jhambm@upmc.edu.
authors.forename: Manisha
authors.initials: M
authors.lastname: Jhamb
authors.affiliation: Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Mary L
authors.initials: ML
authors.lastname: McNulty
authors.affiliation: Community member receiving hemodialysis, Pittsburgh, PA, USA.
authors.forename: Gerald
authors.initials: G
authors.lastname: Ingalsbe
authors.affiliation: Department of Medicine, Hospice and Palliative Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Julie W
authors.initials: JW
authors.lastname: Childers
authors.affiliation: Renal-Electrolyte Division, University of Pittsburgh School of Medicine, 200 Lothrop St, PUH C-1101, Pittsburgh, PA, 15213, USA.|Department of Medicine, Hospice and Palliative Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Jane
authors.initials: J
authors.lastname: Schell
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Molly B
authors.initials: MB
authors.lastname: Conroy
authors.affiliation: Geriatric Cardiology Section, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.|Geriatric Research, Education, Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Forman
authors.affiliation: Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Andrea
authors.initials: A
authors.lastname: Hergenroeder
authors.affiliation: Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.|Departments of Psychology, Epidemiology, and Biostatistics, University of Pittsburgh, Pittsburgh, PA, USA.
authors.forename: Mary Amanda
authors.initials: MA
authors.lastname: Dew
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D002983:Clinical Competence; D015897:Comorbidity; D015444:Exercise / Q000523:psychology; D005081:Exercise Therapy / Q000009:adverse effects / Q000379:methods; D005221:Fatigue / Q000209:etiology; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D009042:Motivation; D009398:Nephrology; D010353:Patient Education as Topic; D036301:Qualitative Research; D006435:Renal Dialysis / Q000009:adverse effects; D012944:Social Support
keywords: Dialysis patients; Exercise; Qualitative study