Qualitative research on the needs status of patients undergoing automated peritoneal dialysis based on behavior change wheel theory
Yiqing Gao and Xinyu Pan contributed equally to this study.
Abstract
Introduction
This article aimed to explore the needs status of patients undergoing automated peritoneal dialysis (APD) based on the behavior change wheel (BCW) theory (and associated improvement strategies) to clarify the obstacles that affect patients' behavior choices. Furthermore, it aimed to explore practical countermeasures to improve the quality of life of patients undergoing APD.
Methods
Eleven patients undergoing APD were selected for a semi-structured in-depth interview using the purposive sampling method, and the phenomenological qualitative research method was used to organize and analyze the content of the interviews and to consider reasonable interventions under the guidance of the BCW theory.
Results
The study identified three themes and six sub-themes that guide patients on peritoneal dialysis to choose APD as a behavior change: opportunity needs (a desire to diversify access to information and patients' desire to try APD if physically possible); motivation needs (a desire to better fulfill family responsibilities and a desire to return to society); and capability needs (a desire to have some social skills and a desire to have self-management capability).
Conclusion
Medical staff should design personalized intervention strategies according to patients' abilities, opportunities and motivation needs, including optimizing information transmission, improving technical support, promoting patient health management efficiency and improving the acceptance of APD through social support and publicity, to improve patients' quality of life.
1 INTRODUCTION
Peritoneal dialysis (PD) is one of the important renal replacement therapies for patients with end-stage renal disease (ESRD). It has been widely used to remove toxins and water from the body by utilizing the patient's peritoneum as a semi-permeable membrane, with good residual renal protection, a low cross-infection rate, and a high early survival rate [1]. According to data from the China Research Data Service Platform, as of December 2023, there were 152 000 patients undergoing PD in China, with an increase of 22 000 in 2023 [2]. With the development of dialysis technology, automated PD (APD), as an advanced dialysis mode, realizes the automatic replacement of peritoneal dialysate through a fully automatic PD machine, providing patients with more convenient and efficient treatment options [3]. Compared with traditional manual PD, APD has many advantages, including a flexible treatment schedule, higher quality of life, lower risk of infection, and better toxin removal [4].
However, although APD has shown significant advances in technology, its utilization rate in China has been at a low level for a long time. According to recent international statistics, the utilization rate of APD in developed countries, such as the United States, Canada, and Australia, has exceeded 50%, with some regions reaching as high as 70%. In contrast, the utilization rate in mainland China remains below 1%, which is significantly lower than the global average of approximately 15% [5]. This stark disparity exists despite similar clinical indications and potential benefits across different patient populations. Analysis of data from major dialysis centers across China reveals that even in first-tier cities with advanced medical resources, APD implementation rarely exceeds 5%, highlighting a persistent gap in adoption compared with international standards.
Studies have pointed out that patients undergoing APD face multiple obstacles in the treatment process, including financial burden, single access to information, insufficient confidence in equipment operation, and a weak family support system [6]. These factors not only limit the promotion and application of APD but also directly affect patients' treatment compliance and long-term prognosis. A systematic review by Driehuis et al. revealed that patient-related barriers to APD adoption included fear of technology, concerns about nighttime alarms, and uncertainty about managing complications independently [6]. In addition, healthcare system barriers included inadequate training resources, limited equipment availability, and insufficient financial support mechanisms.
In recent years, patient needs-oriented personalized care has gradually become an important direction to improve the effectiveness of chronic disease management. In APD treatment in particular, a deep understanding of patients' needs and designing interventions for their behavior choice disorders have been regarded as key strategies to improve patients' quality of life and optimize treatment outcomes [7]. Zhang et al. demonstrated that targeted interventions addressing individual barriers to APD adoption significantly improved treatment adherence and patient satisfaction; however, such approaches remain underutilized in clinical practice [7].
Current research on the needs status of patients undergoing APD predominantly focuses on economic aspects, medical resource allocation, and technical parameters of the treatment. For instance, studies by Cao et al. centered primarily on evaluating machine specifications, safety profiles, and clinical efficacy metrics [5]. Although these aspects are important, they provide limited insight into the psychosocial factors influencing patients' acceptance of and adherence to APD. Notably lacking is systematic research addressing individual patients' behavior patterns, decision-making processes, and adaptation challenges in transitioning to and maintaining APD treatment. This research gap is particularly significant given that behavioral factors are increasingly recognized as critical determinants of successful long-term management of chronic conditions.
The behavior change wheel (BCW) theory is a comprehensive framework for the systematic analysis and design of behavior intervention proposed by Michie and other scholars. It is based on the “capability, opportunity, motivation” model [8], which holds that the individual's target behavior is affected by three factors: capability—the individual's physical capability and psychological capability to perform the target behavior; opportunity—the external conditions or resources that support the behavior; and motivation—the intrinsic motivation that drives individuals to take actions, including reflective motivation (such as beliefs and attitudes) and automatic motivation (such as emotions) [9].
The BCW theory emphasizes that, by identifying the obstacle factors in the above three aspects, targeted interventions can be designed to promote the realization of target behavior. In clinical practice, this theory has been widely used in the fields of chronic disease management, health education, and psychological support. For example, in diabetes management, the BCW theory is used to analyze the influencing factors of patient glucose monitoring compliance and thus design personalized educational and behavior support schemes [10]. Furthermore, the theory has been applied to optimize exercise rehabilitation programmes for patients with chronic obstructive pulmonary disease and symptom management for patients with cancer [11, 12].
Although the BCW theory shows wide application potential in the field of chronic diseases, related studies on behavior choice disorders in patients undergoing APD have not been reported. As a treatment method that has a significant impact on patients' quality of life, the popularization and promotion of APD urgently require an in-depth analysis from the perspective of patient behavior. Based on this, this research aims to analyze systematically the needs status and behavior disorders of patients undergoing APD by using the BCW theory through qualitative research to design practical intervention strategies for patients.
2 RESEARCH PARTICIPANTS AND METHOD
2.1 Research participants
Using the purposive sampling method [13], patients who received APD treatment in the PD center of a tertiary A-grade hospital in Wuxi between April 2023 and January 2024 were selected as the research participants and were assigned English capital letters as identifiers. The implementation process of purposive sampling involved several steps: first, the medical records of all patients undergoing PD in the center were reviewed to identify those who had been using APD for >3 months. Second, the healthcare team was consulted to select patients from diverse backgrounds in terms of age, gender, education level, and primary disease to ensure representativeness. Third, potential participants were contacted via telephone or during their regular clinic visits to explain the study's purpose and invite their participation. Finally, enough participants were recruited to achieve information saturation, as evidenced by repetitive information and no new themes emerging from subsequent interviews.
The inclusion criteria were as follows: (1) diagnosis of ESRD; (2) undertaking APD treatment for >3 months; (3) aged ≥18 years; (4) capable of cooperating with the interview and having basic expression skills; (5) signed the informed consent. The exclusion criteria were as follows: (1) suffering from severe mental or cognitive impairment; (2) recently switched to other dialysis modes due to changes in their condition; (3) presence of malignant tumors or severe cardiac, cerebral, or lung complications. The general information of the research participants is shown in Table 1.
| Serial number | Gender | Age (years) | Duration of dialysis (months) | Education level | Work status | Marital status | Medical payment method | Primary disease |
|---|---|---|---|---|---|---|---|---|
| A | Male | 61 | 18 | Junior high school | Retired | Married | Medical insurance | Hepatitis B associated nephropathy |
| B | Male | 50 | 10 | High School | Retired because of illness | Married | Medical insurance | Diabetic nephropathy |
| C | Female | 65 | 16 | Primary School | Unemployed | Married | Self-pay | Chronic glomerulonephritis |
| D | Male | 45 | 8 | Junior high school | Full-time | Married | Rural insurance | Chronic glomerulonephritis |
| E | Male | 60 | 17 | High School | Full-time | Married | Medical insurance | Diabetic nephropathy |
| F | Male | 39 | 6 | Junior college | Retired because of illness | Married | Medical insurance | Chronic glomerulonephritis |
| G | Female | 34 | 5 | Regular college course | Full-time | Married | Medical insurance | IgA nephropathy |
| H | Male | 32 | 6 | Regular college course | Full-time | Single | Medical insurance | Chronic glomerulonephritis |
| I | Female | 55 | 24 | Junior high school | Retired | Widowed | Medical insurance | Chronic glomerulonephritis |
| J | Male | 44 | 11 | Junior high school | Full-time | Divorced | Rural insurance | Chronic glomerulonephritis |
| K | Male | 50 | 22 | High School | Full-time | Married | Medical insurance | IgA nephropathy |
This research has been approved by the ethics committee of a tertiary A-grade hospital. All research participants signed written informed consent before participating in the interview; the research team promised to keep the patients' personal information strictly confidential, and the research was only used for academic purposes.
2.2 Research method
2.2.1 Composition of interviewers
The interview team consisted of researchers, nursing specialists, and social psychology specialists. The researchers were responsible for the organization and implementation of the interview; nursing specialists provided support on the clinical relevance of the interview content; social psychology experts advised on interview design and data analysis from the perspective of the patients' psychological needs and behavior disorders. All interviewers had been trained in qualitative research and interview techniques, with specific preparation including workshops on open-ended questioning, active listening, and non-judgmental responses to ensure high-quality data collection.
2.2.2 Interview method
A phenomenological research methodology [14] was used to conduct the semi-structured in-depth interview with 11 interviewees. The interview was conducted in the independent quiet consulting room of the PD center. Interview appointments were scheduled at times convenient for patients, typically coinciding with their regular clinic visits to minimize additional travel burden. Each interview lasted 45–90 min, with an average duration of 60 min, and was conducted in a comfortable, private environment to encourage open communication.
Before the interview began, the researchers established rapport with participants through casual conversation and clearly explained the purpose, process, and confidentiality measures of the study. The patients were informed of the principle of confidentiality of the information, and the patients' consent was obtained. Participants were assured that they could pause or terminate the interview at any time without any impact on their medical care.
Before the interview, based on BCW theory, this research defined the patients' needs from three dimensions (capability, opportunity and motivation), formulated an outline as an interview guide, and continuously improved it during the interview process. The interview outline included key questions corresponding to each dimension of the BCW theory.
2.2.3 Interview outline
(1) Opportunity needs refers to whether the patient has the external support needed for treatment, including physical opportunity (such as whether the home environment is suitable for dialysis operation or whether the supply of equipment and consumables is timely; key questions include “How suitable is your home environment for conducting APD treatment?” and “What challenges do you face with equipment and supplies?”), social opportunity (such as whether family members provide support, whether the medical team provides timely guidance or whether the community provides resources [9]; key questions include “How do your family members participate in your treatment process?” and “What kind of support do you receive from healthcare providers?”) and opportunity needs, which reflect whether the patient is in an environment where treatment can be completed; insufficient external resources can be an important barrier to behavior choice; (2) motivation needs refer to the patient's intrinsic motivation to receive treatment, which is divided into reflective motivation (such as the patient's attitude, beliefs and goal expectations about treatment; key questions include “What do you believe about the effectiveness of APD treatment?” and “What are your expectations for your health in the future?”) and automatic motivation (such as the patient's emotional response and habits to the treatment process [15]; key questions include “How do you feel emotionally about using the APD machine?” and “Have you established any routines around your treatment?”). Motivation needs directly affect the patient's treatment compliance and adherence and are the core driving force of behavior change; (3) capability needs refer to the knowledge, skills and psychological cognition required by the patient to complete APD treatment and include physical capability (such as proficiency in operating APD equipment and changing dialysate; key questions include “How comfortable are you with operating the APD machine?” and “What aspects of the equipment operation do you find challenging?”) and psychological capability (cognitive abilities such as understanding treatment-related knowledge and correctly responding to equipment failures [16]; key questions include “How well do you understand how APD treatment works?” and “What would you do if you encountered an equipment malfunction?”). Capability needs emphasize whether a patient has the basic conditions to complete treatment; the lack of this capability may lead to reduced treatment compliance or erroneous operation.
Each interview was organized around the outline, recorded accurately, and supplemented by a brief transcript. During the interview, the researchers carefully observed non-verbal information, such as facial expressions, tone, and emotional changes of the interviewees, analyzed it, and supplemented the transcript. The interviewers used active listening techniques, reflective questioning, and empathetic responses to encourage participants to share their experiences in depth. At the end of the interview, they gave the patients affirmation and encouragement and gave them small gifts to express their gratitude. The sample size was based on the fact that the information stated by the interviewees became repeated and no new themes were presented in the integration and analysis of the data [17]. Information saturation was determined to be reached after the ninth interview; however, two additional interviews were conducted to confirm saturation.
2.3 Data collation and analysis
The researchers compiled the recorded data into written words within 24 h after each interview to ensure the timeliness of data analysis and facilitate the adjustment of the next interview strategy. Colaizzi's [18] seven-step analysis method on phenomenological data was used to analyze the data. The specific analysis steps were as follows: (1) read all the data carefully—each transcript was read multiple times by at least two researchers to gain a comprehensive understanding of the content. This immersive reading allowed researchers to become familiar with the overall narrative and emotional tone of each interview; (2) extract significant statements—researchers identified and extracted statements that directly related to the research questions about APD needs and behavior choices. For example, when a participant stated “I definitely can't lose my job. I choose automatic peritoneal dialysis just to do treatment at night and work during the day,” this was extracted as a significant statement about motivation needs; (3) code recurring viewpoints—similar statements were grouped and assigned preliminary codes. For instance, statements about family roles were coded as “family responsibility,” and statements about work continuation were coded as “professional identity maintenance”; (4) gather the coded viewpoints—codes were organized into broader categories based on the BCW framework components (capability, opportunity, motivation). For example, all codes related to external support systems were grouped under “opportunity needs”; (5) write a detailed and complete description—for each category, researchers developed comprehensive descriptions that captured the essence of participants' experiences. These descriptions included both the manifest content (what was explicitly stated) and latent content (underlying meanings); (6) identify similar viewpoints—the categories were further refined into themes and sub-themes through team discussion and consensus. For instance, “desire to better fulfil family responsibilities” and “desire to return to society” emerged as distinct sub-themes under “motivation needs”; (7) return to the participant for verification—the researchers shared the analyzed results with five participants to verify whether the interpretations accurately reflected their experiences. Participants confirmed that the themes captured their perspectives, with minor clarifications incorporated into the final analysis. To ensure analytical rigor, the research team held regular meetings to discuss coding discrepancies and reach a consensus. An audit trail of the analytical process was maintained, including memos documenting analytical decisions and reflections.
2.4 Quality control
According to the reliability standard of qualitative research put forward by Lincoln et al. [19], the 11 interviewees selected in this research were as representative as possible in terms of gender, age, duration of dialysis, education level, work status, marital status, medical payment method, and primary disease, so that samples with different characteristics could be evenly distributed and the overall trend of patients undergoing APD could be better reflected. The researchers had long-term contact with patients through the PD clinic and WeChat platform, established a good relationship, and gained the trust of patients. For questionable interview information, timely feedback and repeated confirmation were provided to guarantee the authenticity and validity of the information.
Additional quality control measures included triangulation of data sources (comparing information from interviews, medical records and healthcare provider notes), researcher triangulation (multiple analysts reviewing the same data) and peer debriefing (presenting preliminary findings to colleagues not involved in the research for critical feedback). An external qualitative research expert also reviewed the methodological approach and analytical process to ensure adherence to best practices in qualitative inquiry.
3 RESULTS
Through the in-depth interviews with 11 patients undergoing APD, based on the BCW theory, this research extracted the summary points of patients' needs and behavior disorders from three dimensions: capability, opportunity and motivation. The results were developed around three core themes and systematically analyzed patients' needs and obstacle factors combined with the characteristics of the BCW theory. Each theme and its corresponding subthemes are presented below.
3.1 Theme 1: Opportunity needs—Insufficient external support and resources
This theme encompasses the external factors that influence patients' ability to access and use APD treatment effectively. Two sub-themes emerged: a desire to diversify access to information and patients' desire to try APD if physically possible.
3.1.1 Desire to diversify access to information
The pre-dialysis education of medical staff mainly focuses on hemodialysis and PD. The promotion and guidance of APD are too simple, and patients lack the opportunity to understand APD. Most patients have difficulty operating APD equipment at the initial stage, especially in dialysate replacement, equipment disinfection, and response to failures. Some patients reported that the existing form of operation training was relatively simplistic and failed to meet their individualized learning needs.
Patient I: “When I first found out about this disease, the doctor said that I needed dialysis, either haemodialysis or peritoneal dialysis, and then said that haemodialysis required three trips to the hospital per week, while peritoneal dialysis could be done at home. At that time, I didn't know that I could use a machine to perform peritoneal dialysis, and maybe fewer people did it. There was little information on this.”
This statement reveals a fundamental gap in pre-treatment education, where patients are not fully informed about all available options, particularly the existence and benefits of APD. The lack of awareness at the crucial decision-making stage significantly impacts patients' ability to make informed choices about their treatment modality.
Some patients lack an in-depth understanding of treatment principles, complication prevention measures, and long-term effects, resulting in reduced compliance during treatment.
Patient A: “The hospital had a promotional paper for choosing dialysis before surgery, but it didn't say anything about automatic peritoneal dialysis machines. I didn't have a doctor tell me I could get an automated peritoneal dialysis until after my surgery. At that time, I especially hoped that an expert would tell me about the machine.”
This response highlights the delayed introduction of APD information in the patient journey, occurring only after initial treatment decisions had already been made. The patient's expression of wishing for expert guidance demonstrates the perceived value of specialized knowledge and the emotional impact of receiving information too late in the decision process.
Underlying this sub-theme is the limitation in healthcare communication systems, where standardized education protocols may not adequately address newer treatment options. Patients' frustration stems not only from the lack of information but also from the sense that potentially beneficial treatment options were withheld (intentionally or not), affecting their autonomy in healthcare decisions.
3.1.2 Patients want to try automated peritoneal dialysis if physically possible
The use of APD is a treatment option for all patients except those who have extensive peritoneal fibrosis and adhesions, those who have severe skin disease or extensive infection of the abdominal wall, those who have burns to the abdomen that make it impossible to find a suitable site to implant a PD catheter, those who have surgically unrepairable hernias, protruding umbilical cords, abdominal clefts, bladder exstrophy, and other mechanical problems that are difficult to correct, and those who have severe peritoneal defects. Patients also want to choose APD when the indications are met after comprehensively considering the advantages, such as flexibility in treatment scheduling and improved quality of life.
Patient H: “This disease came suddenly. I didn't expect to have dialysis so soon. On the choice of dialysis method, taking into account the need to work, the doctor recommended automatic peritoneal dialysis, which I think is quite suitable for me.”
This statement reflects a positive response to appropriate medical guidance when APD is presented as an option that accommodates the patient's lifestyle needs. It demonstrates how properly timed information about APD's compatibility with work responsibilities can positively influence treatment acceptance. The patient's response indicates that when properly matched to individual circumstances, APD can be perceived as a solution rather than a burden.
The underlying factor here is the alignment between treatment modality and patient lifestyle priorities. When healthcare providers recognize and address these priorities through appropriate treatment recommendations, patient acceptance increases. However, this also suggests that without such personalized recommendations, patients may not recognize APD as a viable option for their specific circumstances.
Combined with the BCW theory, opportunity emphasizes the external environmental conditions under which the behavior occurs. The core of opportunity needs lies in improving the equipment operation capability and treatment knowledge level of patients. In response to this need, it is suggested to optimize the content of health education, adopt diversified training methods (such as video teaching and interactive learning) and design personalized training programmes according to the specific conditions of patients.
3.2 Theme 2: Motivation needs—Intrinsic motivation
This theme explores the internal factors that drive patients to accept and adhere to APD treatment. Two distinct sub-themes emerged: a desire to better fulfill family responsibilities and a desire to return to society.
3.2.1 Desire to better fulfill family responsibilities
Most of the research participants do not want to lose family roles because of their diseases, so they hope that the use of the APD room will allow them to take on family responsibilities and reduce the burden on the family. Some patients mentioned that, due to the lack of confidence in the treatment effect, there was insufficient motivation to adhere to treatment. Some patients' concerns about the long-term efficacy and complications of APD had also undermined their willingness to be treated.
Patient K: “Usually, I'm in charge of my family, but I don't expect to get this disease in middle age. My son hasn't married yet. How can I, a father, hold my son back? Since there is such advanced technology, I will try my best.”
This response reveals how family role identity serves as a powerful motivator for treatment adherence. The patient expresses both the emotional impact of potentially failing in paternal responsibilities and the determination to utilize advanced technology to maintain this role. The reference to his unmarried son highlights how family milestones create specific motivational frameworks for treatment decisions.
Patient F: “My kids know that I am sick, but because I receive treatment at night and work normally during the day, I am still the brave father in their eyes. The kids are still so young, and I want to raise them up. This treatment method has a great effect on me.”
This statement demonstrates how APD enables the maintenance of parental identity and strength in the eyes of dependent children. The nocturnal treatment schedule allows the patient to preserve a “brave father” image during daytime interactions, creating powerful emotional reinforcement for treatment adherence. The desire to raise young children provides long-term motivation that outweighs the challenges of treatment.
The underlying psychological mechanism here involves identity preservation and role fulfillment. Automated PD's flexibility allows patients to maintain valued social roles, particularly within the family, which creates strong intrinsic motivation for treatment adherence. This motivation is further strengthened by the visible benefits of being able to fulfill family responsibilities despite illness.
3.2.2 Desire to return to society
Patients undergoing APD can choose their own dialysis time. Most patients choose dialysis at night and continue to work during the day. Most patients reported that family members had limited participation in APD treatment and lacked the capability to assist. In addition, the frequency of follow-up visits by the medical team was low, and patients could not get timely professional guidance in daily operations.
Patient F: “I am the breadwinner of my family. My wife just gave birth to the second child when I was diagnosed with this disease. The child is still young, and now one son has to go to school, and the other needs to be taken care of, my wife is too busy on her own. I definitely can't lose my job. I choose automatic peritoneal dialysis just to do treatment at night and work during the day so that there is no delay.”
This statement highlights economic necessity as a key motivator for APD adoption. The patient emphasizes his role as the family's financial provider and the practical impact of losing employment given his family's dependency structure. The nocturnal treatment schedule of APD represents a pragmatic solution that allows continued employment rather than being merely a preference.
Patient H: “I'm still young. My parents have only one son, and their retirement salaries are only that little, all of which are spent on me. If I do treatment at night, it won't affect my work, and I have a fixed income every month, which can also reduce the burden on my parents.”
This response reveals how financial independence and reducing the burden on caregivers motivate treatment choices. The young patient's awareness of being his parents' only child and their financial sacrifice creates a desire to minimize dependence through continued employment. Automated PD's compatibility with work schedules directly addresses this motivational need.
The underlying factors in this sub-theme involve both economic necessity and the psychological need for independence and social contribution. Automated PD's flexibility allows patients to maintain economic productivity and social integration, addressing both practical needs and deeper psychological needs for autonomy and social value.
Combined with the characteristics of the BCW theory, motivation is the core driving force of behavior change, which is divided into reflective motivation (such as beliefs and attitudes) and automatic motivation (such as emotional response). Studies show that negative emotions and belief bias are the important causes of patients' behavior disorders. Through psychological support, health promotion and emotional management intervention, patients' internal motivation can be effectively enhanced, and their treatment compliance can be improved.
3.3 Theme 3: Capability needs—Knowledge, skills, and adaptive strategies
This theme addresses patients' abilities to implement and maintain APD treatment effectively. Two sub-themes emerged: a desire to have certain social skills and a desire to have self-management capability.
3.3.1 Desire to have certain social skills
Using rest time at night for APD not only reduces the impact of dialysis on work, life, and family but also enables patients to better integrate into society and improve their quality of life.
Patient I: “Now that I am retired, I should enjoy my life in my later years. Automatic peritoneal dialysis is very good. I can often get together with my old friends, and the timing is very appropriate. They used to hear that I had this disease, knew that I had to be treated every day, and they didn't dare to ask me to participate in many activities. Now, since I'm not affected at all, I'm asked to join their group again.”
This statement demonstrates how APD facilitates social reintegration and maintenance of friendship networks. The retired patient values social connections as a key component of quality of life in retirement, and APD's flexible schedule allows participation in social activities that would otherwise be limited. The contrast between previous social exclusion and current inclusion highlights APD's impact on social well-being.
Patient A: “I've been doing automatic peritoneal dialysis from the very beginning. I have no problem with my financial situation, and it affects me very little. I love to travel, and I've taken the automatic peritoneal dialysis machine out to the farmhouse three times. It's very convenient.”
This response reveals how APD can support lifestyle continuity and valued leisure activities. The patient's ability to maintain travel interests represents a significant quality-of-life preservation. The portability of the APD machine transforms what could be a treatment limitation into an enabler of continued lifestyle preferences.
The underlying factor in this sub-theme is the preservation of social identity and participation. Automated PD's schedule flexibility and relative portability allow patients to maintain valued social connections and activities, addressing the psychological need for belongingness and social engagement, which may otherwise be compromised by chronic illness treatment requirements.
3.3.2 Desire to have self-management capability
Patients undergoing PD are predominantly treated with home dialysis; therefore, the home dialysis environment for patients is more demanding. The operating environment of some patients' homes is not ideal due to issues such as restricted space and insufficient light, which affect the convenience of using the equipment. Some patients mentioned the untimely supply of consumables and equipment maintenance, which increased the burden of treatment. Luo Suping [11] pointed out that the independent working space at home and the frequency of ultraviolet air disinfection were related to the occurrence of peritonitis. However, the interviews revealed that patients undergoing APD did not fulfill the requirements of the home environment—both the subjective lack of attention and objective limitations.
Patient C: “My bedroom is not big. Now that I have a machine, the place is even smaller. I usually share the bedroom with my lover. It's good to take care of each other, and there's no infection or anything.”
This statement reveals potential gaps in patient understanding regarding infection control requirements for home dialysis. The patient's acceptance of a suboptimal environment (a small, shared bedroom) and lack of concern about infection risk suggest insufficient knowledge about environmental requirements for safe treatment. The positive framing of proximity to a partner demonstrates how social benefits can override safety concerns when knowledge is limited.
Diet management is also of great significance in controlling the disease progression and prognosis of patients undergoing PD. In the interview, six patients showed confusion about dietary knowledge. During hospitalization, medical staff trained patients undergoing dialysis on diet-related content; however, the information provided in written form was relatively abstract and not easy to understand.
Patient L: “The doctor and nurse told me not to eat salty food, high phosphorus food, high potassium food and not to drink water. Anyway, I can't eat anything, so what can I eat?”
This response demonstrates frustration with negative dietary instructions without practical alternatives. The patient's interpretation that “I can't eat anything” reveals how restriction-focused education can lead to confusion and potentially poor dietary adherence. The question “What can I eat?” indicates a desire for practical, actionable dietary guidance rather than just restrictions.
During dialysis, timely detection and correct handling of abnormal situations could effectively protect patients' peritoneal function and prolong dialysis years. During the interview, it was found that due to the lack of knowledge, patients' alertness to the occurrence of dialysis abnormalities and their capability to cope with them was low.
Patient D: “I had been weak for a while and felt very tired, so I went to a blood test and found out that my potassium was low. I used to have high potassium, but now my potassium is low?”
This statement demonstrates a limited understanding of the dynamic nature of electrolyte management in dialysis. The patient's confusion about changing potassium levels reflects inadequate education about how treatment and dietary factors continuously affect biochemical parameters. The reactive approach (seeking care after prolonged weakness) rather than proactive monitoring suggests gaps in self-management education.
The underlying factors in this sub-theme involve knowledge gaps in three critical areas: environmental safety, dietary management, and complication recognition. These gaps stem from both educational shortcomings (overly abstract information and a focus on restrictions without alternatives) and possibly cognitive barriers to processing complex medical information. The result is a compromised self-management capability that may affect treatment safety and effectiveness.
Combined with the characteristics of the BCW theory, capability needs emphasize the importance of an internal driving force. It is recommended to help patients establish a positive attitude toward treatment through psychological counseling, emotional management courses, and patient support groups. At the same time, health promotion should be strengthened to enhance patients' confidence in the effectiveness of treatment.
4 DISCUSSION
Based on the BCW theory, this research systematically analyzed the needs status and behavior disorders of patients undergoing APD from three dimensions: capability, opportunity, and motivation. The results showed that patients had obvious deficiencies in operational skills, external support, and intrinsic motivation, which significantly affected patients' treatment compliance and quality of life. This section provides an in-depth discussion of the results in the context of the current status of the research and suggests appropriate interventions structured around the three dimensions of the BCW theory.
4.1 Opportunity needs and necessity of operational skills training
Under the opportunity dimension of the BCW theory, our findings identified significant gaps in information access and skills training, which created barriers to APD adoption and adherence.
It was found that some patients undergoing APD had insufficient knowledge of equipment operation and treatment, which was an important factor affecting their treatment compliance. Information support is an indispensable part of the needs status of patients undergoing PD, and the most suitable intervention function in the BCW theory is education. The content of education should include the relevant knowledge of patients' diseases, the current best treatment plan, the choice of dialysis plan, the recommendation of dialysis instruments, the preparation of the dialysis environment and the preparation of dialysis materials. At the same time, a survey has found that the tendency of nephrology medical staff to dialysis mode affects the adequacy of dialysis information transmission by medical staff and affects the mastery of information related to various dialysis modes by patients with uraemia before dialysis [12]. Due to the late entry of APD into China's dialysis market, medical staff lack relevant experience and the capability to promote and guide patients undergoing APD [20].
The interviews revealed that the APD-related information that patients obtained mainly came from medical staff, and the choice of dialysis methods was also influenced by medical staff. Although they knew the advantages and disadvantages of various dialysis modes through other means, most of them followed the professional advice of medical staff. Therefore, medical staff should be constantly updated with new treatment technologies and concepts in this field—both domestic and international—and help patients receive comprehensive and high-quality dialysis knowledge learning before dialysis treatment. This would enable patients to better understand APD and provide a scientific basis for them to choose the dialysis mode independently. When patients no longer have doubts and worries and are even full of hope, the treatment effect is significantly improved.
The existing literature suggests that the lack of operational skills of patients undergoing PD is closely related to the form of training they receive. Studies pointed out that the traditional one-time centralized training tended not to meet the long-term learning needs of patients, whereas the gradual and hierarchical training mode could significantly improve the operation proficiency and self-confidence of patients [21]. In addition, skills training should take into account individualized needs by, for example, designing more intuitive videos or illustrated teaching materials for older patients or groups with lower education levels. Combined with the results of this research, we propose that the medical team adopt a phased and continuous training mode in patient training while providing operational guidance and knowledge popularization through a combination of online and offline forms. This can not only improve the operational skills of patients but also help to enhance their cognitive level, thus promoting treatment compliance.
Specific interventions to address opportunity barriers include the following.
Diversify information channels
Establish a multi-platform APD educational system, including WeChat or social media groups dedicated to APD information sharing, video tutorials demonstrating equipment operation and troubleshooting, simplified illustrated guides for different educational levels, and regular APD information sessions at dialysis centers.
Implement staged training programmes
Replace one-time instruction with a graduated approach, comprising initial basic operation training before beginning APD, follow-up skills reinforcement sessions at 1, 3, and 6 months, advanced troubleshooting training after patients master the basics and personalized refresher sessions based on individual learning needs.
Create supportive home environments
Provide practical assistance, such as home assessment visits to evaluate space requirements before APD initiation, guidance on room modifications to accommodate equipment safely, provision of equipment storage solutions for limited spaces, and regular supply chain management to ensure timely delivery of consumables.
These targeted interventions directly address the opportunity barriers identified in our findings and align with the BCW framework by creating physical and social environments conducive to successful APD implementation.
4.2 Motivation needs and the importance of psychological intervention
Under the motivation dimension of the BCW theory, our research revealed that intrinsic factors related to family roles, social identity, and emotional well-being significantly influenced patients' acceptance of and adherence to APD.
The patients' intrinsic motivation, including reflective motivation (such as beliefs about treatment effects) and automatic motivation (such as emotional status), plays a key role in the treatment process. This research found that patients' negative emotions (such as anxiety and depression) significantly affected their treatment compliance, which was consistent with the existing research results. The research of Lee et al. showed that the psychological health status of patients undergoing PD was closely related to their quality of life, and compliance and psychological intervention were important means to improve their treatment effect [22].
Our findings particularly emphasized how family role preservation and social reintegration serve as powerful motivators for APD adoption. When patients perceive that APD enables them to maintain valued roles—as providers, parents, friends, or community members—their commitment to treatment increases. This aligns with self-determination theory, which suggests that intrinsic motivation is strengthened when activities support basic psychological needs for autonomy, competence, and relatedness.
The specific interventions to address motivation barriers include the following.
Enhance treatment confidence through evidence and narratives
Share success stories and testimonials from current patients undergoing APD, present clear, understandable data on APD outcomes and benefits, address specific concerns about complications with factual information, and conduct patient peer mentoring programmes connecting new and experienced APD users.
Provide psychological support systems
Implement regular emotional assessments during clinic visits, offer individual psychological counseling services focused on adaptation to chronic illness, develop group therapy sessions addressing common emotional challenges, and train healthcare providers in basic psychological support techniques.
Connect treatment to personal goals and values
Help patients identify how APD aligns with their life priorities (family, work, leisure), guide patients in setting achievable short-term and long-term health goals, create visual reminders of personal motivations for treatment adherence, and celebrate treatment milestones and achievements to reinforce progress.
By addressing both reflective motivation (beliefs, goals) and automatic motivation (emotions, habits), these interventions create a comprehensive approach to strengthening patients' internal drive for treatment adherence.
4.3 Capability needs and optimization direction of external support
Under the capability dimension of the BCW theory, our findings highlighted significant gaps in both physical capability (operational skills) and psychological capability (knowledge and decision-making), which impacted successful APD implementation.
This research found that some patients' family environment, medical resource support and social support were insufficient, which was also widely reported in the existing literature. For example, some studies pointed out that family support was a key factor in improving the compliance and quality of life of patients undergoing APD, but family members' participation was often limited by their lack of relevant knowledge as well as time and energy [23]. At the same time, inadequate follow-up by the medical team and delays in the supply chain of consumables also hindered patients' treatment behavior.
Of particular concern were the knowledge deficits regarding infection control, dietary management, and complication recognition. Our interviews revealed that patients often lacked the practical knowledge needed to implement theoretical guidance – understanding what constitutes a safe environment, translating dietary restrictions into actual meal plans, or recognizing the significance of changing clinical parameters.
Specific interventions to address capability barriers include the following.
Enhance knowledge through practical education
Develop skill-based training that emphasizes hands-on practice rather than theory, create visual diet guides showing allowed foods rather than just restricted items, implement simulation training for troubleshooting common equipment problems, and provide decision trees for responding to alarming symptoms or machine warnings.
Strengthen family member capabilities
Offer family-focused training sessions on basic APD operation and monitoring, create family caregiver support groups to share experiences and strategies, provide simplified emergency response protocols for family members, and develop role-specific guidance for different family members (spouses, children, parents).
Implement comprehensive follow-up systems
Establish regular telephone check-ins during the first 3 months of APD, create a tiered response system with clear escalation pathways for problems, develop digital monitoring platforms for remote assessment when possible, and schedule more frequent in-person evaluations for patients with learning difficulties.
These capability-focused interventions address the fundamental skills and knowledge gaps identified in our research while acknowledging the social context in which treatment occurs.
4.4 Preferential policies are also indispensable in promoting the development of automatic peritoneal dialysis
Social support includes the support of medical insurance policies and social charities. Medical insurance policy guidance is an effective means to promote the clinical dialysis mode and choice of dialysis mode for patients [24]. It should strive to help patients undergoing APD by promoting the inclusion of APD treatment into the medical security system. At the same time, the relevant guidelines of APD treatment plans should be updated regularly to help medical staff better guide patients and formulate personalized treatment plans. During the interviews, we found that patients' social support needs involve various aspects. Due to the different conditions of patients undergoing dialysis, such as education level and economic conditions, the emphasis on social support needs will also be different. Therefore, medical staff need to prioritize the most urgent needs of patients by coordinating and providing social support according to their needs [25]. In addition, communication should be used as an important form of social support to bring together patients undergoing dialysis of similar ages, experiences, cultures, and social statuses or who, for some reason, share a common language. This would allow them to exchange information, experience, or skills, which can reasonably reduce the utilization of medical resources while ensuring multi-channel information communication, which is a powerful supplement for medical staff providing evaluation support.
4.5 Research status, limitations, and future directions
Existing research mostly focused on the analysis of macro-level obstacles affecting patients undergoing APD, such as economic and medical resource allocation, with few systematic researches on individual needs and behavioral choices. By combining the BCW theory, this research comprehensively analyzed the needs status of patients undergoing APD from three dimensions—capability, opportunity, and motivation—which not only verified the applicability of this theory in the needs status analysis of patients undergoing dialysis but also provided a theoretical basis for designing targeted interventions.
However, this study has several limitations that should be acknowledged. First, as a qualitative study with a relatively small sample size (n = 11) from a single center, the generalizability of findings to broader populations of patients undergoing APD may be limited. The experiences of patients in different healthcare systems, cultural contexts, or geographical regions may differ substantially from our findings. Second, our study included only patients who had already adopted APD, excluding those who had declined this treatment option or discontinued it. Including these perspectives may have provided additional insights into barriers to adoption. Third, the cross-sectional nature of our data collection means we captured patients' experiences at a single time point rather than tracking changes in needs and barriers throughout the treatment journey.
Future research should address these limitations through several approaches. Larger multicenter studies employing mixed methods could validate our findings across diverse patient populations and healthcare settings. Longitudinal research following patients from pre-dialysis education through treatment initiation and maintenance would provide valuable insights into how needs evolve. Comparative studies examining differences between APD users, those who declined APD, and those who discontinued treatment would offer a comprehensive understanding of adoption barriers. Finally, intervention studies based on the BCW framework could test the effectiveness of the targeted approaches suggested by our findings.
The results suggested that the nursing intervention for patients undergoing APD should start from the following three aspects: (1) improve patients' skills and knowledge levels and optimize operation training; (2) strengthen family and medical support and improve access to treatment; (3) provide psychological intervention and emotional support to enhance treatment motivation. The comprehensive implementation of these measures would help to improve the promotional effect of APD and the long-term quality of life of patients.
5 CONCLUSION
Through in-depth discussion on the needs status of 11 patients undergoing APD based on the BCW theory, this research identified three key themes related to opportunity, motivation, and capability needs. These findings provide a theoretical basis for developing targeted interventions to improve APD adoption and adherence.
Our results demonstrate that patients undergoing APD face complex challenges, including insufficient information access, limited training opportunities, a desire to maintain family and social roles, and a need for enhanced self-management skills. The BCW framework effectively organized these challenges into a coherent structure that guides intervention development.
Based on these findings, healthcare providers should implement comprehensive strategies focused on ensuring accessible, diverse information channels about APD options and benefits, providing structured, personalized skills training that evolves with patient experience, acknowledging and supporting patients' desires to maintain family responsibilities and social integration, developing practical self-management education that translates theory into actionable knowledge, and creating supportive environments through improved family training and healthcare system responsiveness.
Beyond clinical practice, broader system-level changes are needed, including the inclusion of APD in medical insurance coverage, updated clinical guidelines, and increased social support resources. These coordinated efforts can address the multidimensional barriers to APD adoption identified in our research.
By addressing capability, opportunity, and motivation needs simultaneously, healthcare providers can significantly improve patients' quality of life and treatment outcomes. Future research should focus on developing and testing interventions based on this framework across diverse patient populations and healthcare settings.
ACKNOWLEDGMENTS
Project Y20232006 of Wuxi Science and Technology Bureau, Jiangsu Province, Research on Predictive Model and Precise Intervention Strategies for Supportive Care Needs of Elderly Peritoneal Dialysis Patients from a Multidimensional Health Perspective WMCHL202309 project at Nanjing Medical University Wuxi Medical Center, research on predictive model and precise intervention strategy for supportive care needs of elderly peritoneal dialysis patients from a multidimensional health perspective.
CONFLICT OF INTEREST STATEMENT
The authors declare no conflicts of interest.
