title: Barriers to Increasing Use of Peritoneal Dialysis in Bangladesh: A Survey of Patients and Providers.
abstract: Despite a lower requirement for technology and equipment than hemodialysis (HD), peritoneal dialysis (PD) is an underutilized modality in low- and middle-income countries (LMICs). Bangladesh hasthelowest use of PD in the world (fewer than 2% of prevalent patients). We evaluated nephrologists' attitudes toward PD and examined differences between patients on HD and PD in Dhaka. We asked nephrologists to fill out an English-language questionnaire. Using convenience sampling but targeting both public and private hospitals in Dhaka, we asked trained nurses to administer a Bangla-language questionnaire to patients on HD (n= 116) and PD (n= 41). We validated the questionnaires on a sub-sample (n= 10 for each group). Of the 43 nephrologists surveyed, 27 (63%) had patients on PD. When compared with nephrologists without patients on PD, those with patients on PD were less likely to believe that survival and quality of life on PD was worse than on HD (odds ratio [OR] = 0.21, 95% confidence interval [CI] 0.05 - 0.83 and OR = 0.11, 95% CI 0.02 - 0.67 respectively) but werenotmore likely to have received training for PD. Nephrologists named cost of PD as the predominant barrier to increasing use of PD, followed by concerns about patient hygiene and lack of trained nurses. Fifty-two HD patients (45%) did not know about a home-based modality. When compared with patients on HD, patients on PD were more likely to have been educated by non-nephrologists about dialysis, to be "forewarned" about the need for dialysis, to be paying fully, and to be living in a permanent home with a non-communal water source. Some barriers to increasing access to PD-i.e., patient living conditions and cost-are unique to LMICs. Our study also highlights that issues encountered in high-income countries-i.e., nephrologists' subjective preference and lack of patient knowledge about an alternate modality to HD-may play a role as well.
authors.affiliation: Icahn School of Medicine at Mt. Sinai, New York, NY, USA dipal.savla@icahn.mssm.edu.
authors.forename: Dipal
authors.initials: D
authors.lastname: Savla
authors.affiliation: Dhaka Medical College Hospital, Dhaka, Bangladesh.
authors.forename: Sweety
authors.initials: S
authors.lastname: Ahmed
authors.affiliation: Queen's University Department of Medicine, Kingston, ON, Canada.
authors.forename: Karen
authors.initials: K
authors.lastname: Yeates
authors.affiliation: Hofstra Northwell School of Medicine, Great Neck, NY, USA.
authors.forename: Anna
authors.initials: A
authors.lastname: Matthew
authors.affiliation: Stanford University School of Medicine, Palo Alto, CA, USA.
authors.forename: Shuchi
authors.initials: S
authors.lastname: Anand
mesh_terms: D000328:Adult; D001459:Bangladesh; D003906:Developing Countries; D005260:Female; D017048:Health Care Costs; D019538:Health Care Surveys; D006282:Health Personnel / Q000191:economics; D006295:Health Resources / Q000191:economics*; D006301:Health Services Needs and Demand; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010530:Peritoneal Dialysis / Q000379:methods / Q000706:statistics & numerical data*; D006435:Renal Dialysis / Q000706:statistics & numerical data; D018570:Risk Assessment; D012959:Socioeconomic Factors; D011795:Surveys and Questionnaires
keywords: Resource constraints; South Asia; barriers to access