Exercising while on hemodialysis (intradialytic exercise, IDE) is associated with positive health outcomes for people living with end stage kidney disease including improved functional status, aerobic capacity, and dialysis clearance. Though there is growing evidence supporting the benefits of IDE, larger-scale trials are needed to demonstrate feasibility and inform clinical practice. Few studies have comprehensively assessed barriers and enablers across multiple sites or have addressed how identified barriers and enablers can be addressed using strategies rooted in behaviour change theory. We aimed to identify barriers and enablers to taking part in, and supporting, an intradialytic cycling program, and to develop fit for purpose strategies to optimise the design and delivery of a planned Ontario-wide cluster trial of IDE.
Guided by the Theoretical Domains Framework, we used semi-structured interviews to gain an in-depth understanding of the factors that may enable or impede IDE from the perspective of unit staff (e.g., nurses, administrators, nephrologists, exercise specialists) and adults on hemodialysis. Data were analyzed using a directed content analysis. We then identified possible strategies for addressing barriers, informed by the Behaviour Change Techniques taxonomy, and developed a feasibility assessment tool to enable trialists to identify potential ways to optimise IDE delivery across units in future trials.
We conducted 43 interviews (September 2018 to October 2019) across twelve Ontario hospitals. We interviewed 17 people who were on hemodialysis and 26 health care providers, including nurses (n = 10), nephrologists (n = 6), clinical managers and administrators (n = 5), exercise specialists (n = 3) and personal support workers and technicians (n = 2).
We identified eight relevant theoretical domains (knowledge, skills, beliefs about consequences, beliefs about capabilities, environmental context and resources, goals, social/professional role and identity, and social influences) represented by three overarching categories: 1) Knowledge, skills and expectations: this category represented concerns over staff lacking expertise to oversee exercise, potential exercise risks, minimal patient interest, uncertainty regarding expected benefits, and knowledge gaps regarding exercise eligibility; 2) Human, material and logistical resources: this category captured concerns over staff workload, the belief that exercise professionals should supervise IDE, and challenges related to space constraints, access to equipment, and scheduling conflicts; 3) Social dynamics of the unit: this category described how local champions and patient stories were thought to contribute to IDE sustainability.
We developed a list of actionable solutions by mapping the identified barriers and enablers to IDE to established behavior change techniques. To facilitate IDE delivery in diverse settings, we developed a feasibility checklist of 47 questions identifying key factors to be addressed prior to launching IDE programs.
Barriers that may seem insurmountable at face value may be modifiable when associated factors influencing behaviour change are considered. This study describes a first attempt at generating evidence-based solutions to identified barriers and enablers to IDE. The developed strategies and feasibility checklist may help recruit and support units, staff, and patients and address key challenges to the delivery of IDE in diverse clinical and research settings.