Demographic, clinical and laboratory characteristics
ESRD is not only a public health burden but also an economic burden [
19]. Most of our patients were still of working age given the retirement age in Vietnam is 55 years old for female and 60 for male [
20]. However, just less than three quarters of the surveyed participants were unemployed at the timed diagnosis of ESRD. The gross national income per capita is US$1730 [
21], while the current cost for thrice-weekly hemodialysis treatment is on average $3600 per year ($25 per session). To encourage this treatment regimen, Vietnam national health insurance system covered 80 % of dialysis care in 1996 [
6]. This proportion is now up to 100 % but only for certain patient groups such as revolutionary contributors and social protection group [
22]. The government has also introduced a special insurance scheme for underprivileged households [
6]. In our participants, 80 % coverage was the most common insurance type. Even in countries with good social health insurance system, such as Australia, a high rate of CKD patients has been found to have financial hardship [
23]. Therefore, the gap in costs for hemodialysis, medical supply and medication remains important challenges for adherence by patients to their hemodialysis plan. To reduce costs, reprocessing dialyzers was a common practice. This has immeasurable consequences to patients’ health, economic security and Vietnam’s prosperity.
HCV and HBV infections pose a severe impact on patients’ health and financial issues. We found a prevalence of 8 % for each of HCV and HBV infection and 1 % for co-infection. The HCV and HBV prevalence among blood donors in the same region are just 0.8 and 3.7 % respectively [
24]. This suggests that HCV and HBV infections are endemic in our hemodialysis patients. The associated complications not only impact on morbidity and mortality [
25] but also incur treatment cost that patients cannot meet.
Given the government’s efforts to improve community health including the treatment and prevention of CKD, poor attitude towards health remains a major barrier. Self-medication accounts for three quarters of all episodes of illness each year in Vietnam [
26]. Traditional care-seeking behavior is also popular among Vietnamese people [
27]. Through our observations, patients usually utilize health services when having obvious illnesses or when self-mediation does not relieve their symptoms. Self-medication is more common among the elderly, low-income people or those who live in rural area [
26]. As a further complication, this community also accesses to health services infrequently [
26]. In addition, early detection of CKD requires a high level of awareness and knowledge of vague presentations in early stages of the disease among both the community and healthcare staffs [
28,
29]. Several studies have shown a strong relationship between late nephrology referral, unplanned hemodialysis treatment and poor outcomes consisting of increased hospitalization rate, emergency hemodialysis, early death risk and more temporary vascular access [
30,
31]. In contrast, survival in CKD patients is improved when treatment is provided by a nephrologist for at least 1 year before the initiation of hemodialysis [
32]. We found more than half of our patients had been referred to a nephrologist and commenced hemodialysis within 10 months following their diagnosis of CKD. We did not collect the reasons for late presentation of CKD patients to the nephrologists yet this may be associated with common presentations of vague symptoms of CKD or the common practice of self-medication.
Late CKD diagnosis results in the ineffective treatment to delay progression to end stage. This also induced insufficient preparation for the life-long hemodialysis including timely placement of FAV. The most common presenting symptoms in our study were chronic tiredness, edema and dyspnea. These are usual symptoms of ESRD complications comprising anemia, hypervolemia and pulmonary edema [
33,
34]. Indeed, more than half of our patients had a Hb concentration of less than the recommended level, 9 g/dl [
35], and more than one-third needed emergency hemodialysis on admission. Therefore, ESAs, blood and intravenous iron transfusion along with emergency hemodialysis were immediately commenced to stabilize the patients’ severe condition. Preparation for the first hemodialysis vascular access was still problematic since over half of patients had been using temporary vascular access instead of FAV. This resulted in an increase in hospitalization and length of hospital stay during the first hemodialysis treatment. Although hemodialysis services are being decentralized in Vietnam, several district and provincial centers are still unable to perform FAV operation due to limited surgical resources. As a result, patients are referred to tertiary hospitals where they are charged a high treatment fee.
Characteristics and determinants of non-compliant behaviors
It is accepted that treatment non-compliance adversely affects patient outcomes and augments healthcare costs [
36]. Apart from self-harm, noncompliant behavior impacts the normal work-load of the hemodialysis unit [
37]. Noncompliance with treatment plan in our patients was problematic as nearly half of patients missed their sessions while 11 % required extra treatment and 12 % shortened their sessions. Young age, male and longer duration on hemodialysis have been reported to be associated with skipping and shortening the dialysis sessions [
12,
36]. We found that duration of hemodialysis of patients missing dialysis sessions was lower than that for patients who did not miss any sessions while age and gender were not related to missing sessions. Patients new to dialysis were not always compliant with their treatment plan. The reason for non-compliance was not examined but personal observations suggested that this may be due to lack of mental and physical preparation and the discomfort derived from the first hemodialysis sessions. These issues can be addressed during pre-education program in the early diagnosis stage. After a long treatment duration, patients’ perception towards the efficacy of hemodialysis improved. In view of this, a pre-dialysis preparation program is essential to enhance treatment compliance. In 2012, Chan YM et al. emphasized the effect of financial constraint on patients’ compliance [
12]. We did not assess the relationship between patients’ financial status and treatment adherence but we noted that most of our patients were unemployed. This financial hardship may have attributed to their noncompliance with treatment plan.
Non-adherence to dietary restrictions and medication were present in 39 % and 27 % of our patients. We found a relationship between older age and medication adherence. In addition, dietary non-adherence was more common among male than female patients. These associations were also reported elsewhere [
12,
38].
Since patients were not well-prepared for hemodialysis including timely placement of permanent vascular access [
39], catheterization was common during their first treatments. This made professional instruction about care of the temporary vascular access crucial. In this study patients with shorter duration between CKD diagnosis and hemodialysis initiation were more likely to inappropriately care for their dialysis access. It is not surprising patients referred to nephrologists earlier had better preparedness for hemodialysis treatment.
Verbal and physical abuse and non-cooperation during treatment were not conducive to a safe working environment or treatment conditions [
37]. Staffs were ill-prepared for abuse and as might respond improperly in such situations [
40]. Our patients who were verbally or physically abusive had longer duration of hemodialysis than patients who were not. Junior nurses have more frequent patient contact than senior ones and as a result report having experienced abuse from patients more often [
41]. In our study we found that patients with a longer history of hemodialysis had more contact with healthcare workers over a long period of time than new patients. In some unfavorable conditions, such as being made to wait for treatments patients often responded aggressively to instructions. Our nurses reported more verbal and physical abuse than physicians. One explanation may be patients were less likely to be aggressive with physicians if they believed treatment could be withheld [
41].