The Burden of Decisional Regret in Haemodialysis in South Asian Lower Middle Income Countries

The Burden of Decisional Regret in Haemodialysis in South Asian Lower Middle Income Countries | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Burden of Decisional Regret in Haemodialysis in South Asian Lower Middle Income Countries Mohammad Ahad Qayyum, Jyoti Baharani, Tayyaba Hafeez, Sarah Damery, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6306598/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Haemodialysis (HD) is the primary renal replacement therapy available to patients with end-stage kidney disease (ESKD) in low- and middle-income countries (LMICs), but the financial and emotional burdens can lead to significant decisional regret. Although decisional regret has been explored in patients from high-income countries, little is known about the experiences of regret in HD patients in LMICs. Objective: This study aimed to explore the prevalence and pre dictors of decisional regret among HD patients in four South Asian LMICs (Pakistan, India, Bangladesh, and Nepal). Methods: A cross-sectional study was conducted across Pakistan, India, Bangladesh, and Nepal. Data were collected using validated scales to assess quality of life, and the Decision Regret Score (DRS) used to measure decisional regret. Sociodemographic, clinical, and treatment-related data were also gathered. Results: A total of 1048 responses were received. The mean age of the cohort was 52.6 years, with 54.2% being male. Decisional regret, defined as a DRS score ≥50, was reported by 14.1% of respondents, with 4.4% expressing extreme regret (scores ≥75). Younger age (<50 years), use of temporary vascular access, emergency dialysis initiation, and feelings of being a burden to others were all significantly associated with higher levels of regret (p<0.001). Patients who discussed multiple treatment options prior to starting dialysis reported lower levels of regret. Conclusion: Decisional regret is prevalent among HD patients in LMICs, with younger patients and those initiating dialysis in suboptimal conditions at greater risk. The findings suggest that early interventions, including timely nephrology referrals, optimal vascular access planning, and comprehensive pre-dialysis education, are crucial to reducing regret. Dialysis Regret Lower income countries Figures Figure 1 Figure 2 Figure 3 Lay Summary Starting haemodialysis, a treatment for severe kidney disease, can be a tough decision, especially for patients in less wealthy countries. This study looked at over 1,000 patients to understand why some regret starting this treatment. Regret was more common in younger people, those who had to start dialysis suddenly in emergencies, or those using temporary devices to access the treatment. Feeling like a burden to family also made regret more likely. However, patients who talked about different treatment options beforehand were less likely to regret their decision. This shows that better preparation, planning, and support could make the process easier and help patients feel more positive about their choice. Introduction For most patients in low- and middle-income countries (LMICs), haemodialysis (HD) remains the most accessible and affordable form of Kidney replacement therapy 1 . The financial burden of dialysis is significant; many patients can only afford treatment if it is provided freely by the health system 2 . If dialysis is not freely available, many will have to decide between affording dialysis or other daily living expenses 3 . This financial strain can contribute to feelings of regret among patients who have had to commence therapy 4 . Even in high-income countries where dialysis is free or heavily subsidised, regret at having to start dialysis is prevalent in some patient groups 5 . This may be due to several reasons, including dependency on caregivers and loss of physical independence 6 . Regret is a complex, unpleasant emotion that has been studied in a variety of contexts and is elicited when patients feel that an alternative may have resulted in a more favourable outcome than their current choice 7 . In the context of chronic HD patients, regret can be defined as the feeling of sadness or disappointment that arises from the perception of missed opportunities or poor decisions related to their healthcare 8 . Understanding if patients on dialysis are experiencing regret is crucial, as HD is a lifelong treatment that requires ongoing compliance and patient involvement 9 . If regret is a significant issue, healthcare professionals should engage with patients and carers to acknowledge and address these feelings 10 . Chronic HD patients experience significant physical and emotional challenges and exploring regret in this population could help to improve their quality of life 11 . Little is known about decisional regret regarding dialysis decisions in LMICs 12 . Our objective was to explore and understand experiences and sources of regret among HD patients in four LMICs. By identifying the factors contributing to regret, we aim to develop strategies that healthcare providers can use to support patients better, potentially alleviating some of the emotional burdens associated with long-term dialysis treatment. This understanding could lead to improved patient outcomes and a higher quality of life for those undergoing HD. Methodology A cross-sectional study was conducted in four South Asian countries; Pakistan, India, Bangladesh, and Nepal, with the objective to study and explore Dialysis Regret in patients on chronic dialysis. A questionnaire was developed following multiple rounds of revision to agree a final 22-item version. (supplement 1) The questionnaire was subsequently agreed upon by representative nephrologists from Pakistan, India, Bangladesh, Nepal and the United Kingdom. A Gantt chart was constructed to give a proposed timeline for data collection across all four countries and to streamline collaboration. This ensured timely completion of each phase, alongside regular online meetings to monitor progress. Data collection took place between May 2023 and March 2024. Individual ethical approval was obtained from each participating country and questionnaires were translated into local languages (Urdu, Hindi, Marathi, Tamil, Bengali, Nepali) to ensure comprehensibility and clarity. Patients older than 18 years of age, on dialysis for longer than 3 months, and able to verbally give informed consent were included in the study. Centers approached all patients under their care and if the patient consented, questionnaire data were collected by a clinician during a one-to-one interview session with each participant. Participants were assured of the confidentiality and anonymity of their responses and no identifiable data were collected. 387 patients were interviewed from seven centers in Pakistan, 158 from two centers in India, 470 patients from a single center in Bangladesh, and 33 from two centers in Nepal. Patients were interviewed either while they underwent their dialysis, or when they were seen for follow up appointments in the clinic and responses were collected on Google Forms. Patients that were ill or had speech/hearing disabilities were not included nor were those who did not provide consent, were younger than 18 years of age, or on dialysis for less than 3 months. Demographic data including age, sex, marital status, and country of residence were collected. To assess level of education, years of schooling were recorded as all four countries had different educational systems. Additionally, we collected information on dialysis vintage, initial dialysis access, type of dialysis, mode of presentation at start of dialysis, decisional autonomy, and spiritual/religious motivation in the context of patients’ dialysis treatment. Validated scales were utilized to assess Decisional Regret 13 and Quality of Life (EQD-5D-5L) 14 . Patients were also asked to provide a subjective assessment of their health on the day their dialysis was started and on the day of the interview, these responses were collected on a scale of 0 to 10, where 0 denoted “the worst health”, and 10 denoted “the best health” 15 . Data analysis used descriptive statistics and binary logistic regression (with DRS scores dichotomised into ‘no regret’ (scores < 50) and ‘some regret’ (scores ≥ 50)) to explore the association between patient characteristics and regret about starting dialysis. Results Sociodemographic and Cultural Characteristics A total of 1048 responses were collected across the four countries. Table 1 outlines the sociodemographic details of respondents. The largest proportion of respondents (39.3%) were aged between 51 and 65 years, while 30.7% were between 36 and 50 years. The mean age was 52.6 years, reflecting a middle-aged population. Males comprised 54.2% of the cohort. Marital status was married (83.7%), and 11.5% reported being single. Most respondents were from Bangladesh (44.8%) and Pakistan (36.9%), with smaller proportions from India (15.1%) and Nepal (3.1%). Educational attainment varied, with 24.8% of respondents having less than five years of formal education, while 23.2% reported undergraduate or postgraduate education. Table 1 Socio-demographic characteristics of respondents Characteristic Number of respondents (%) Age group < 20 years 19 (1.8) 21 to 35 years 159 (15.2) 36 to 50 years 322 (30.7) 51 to 65 years 412 (39.3) 66 to 80 years 131 (12.5) 81 + years 5 (0.5) Sex Male 568 (54.2) Female 480 (45.8) Marital status Married 877 (83.7) Single 120 (11.5) Divorced 16 (1.5) Widowed 35 (3.3) Country of respondent Pakistan 387 (36.9) Bangladesh 470 (44.8) Nepal 33 (3.1) India 158 (15.1) Level of education < 5 years 260 (24.8) 5 to 10 years 247 (23.6) Secondary school 298 (28.4) Undergraduate 150 (14.3) Postgraduate 93 (8.9) Clinical and Treatment Characteristics Respondents had a mean time on dialysis of 3.3 years (SD 3.8), with durations ranging from 3 months to 28 years. Haemodialysis (HD) was the most reported treatment modality, with 97.7% of respondents on HD, and only 2.2% on peritoneal dialysis (PD). A small number (1%) reported using a hybrid approach. Temporary catheters were the most used vascular access type, reported by 78.2% of respondents, while 18.6% had a fistula. Permanent catheters and PD catheters were rare, used by 1.9% and 1.2% of respondents, respectively. Regarding the financial aspect of treatment, 48.4% of respondents reported paying part of the cost of dialysis, while 19.4% paid the full cost. Notably, only 37.9% of respondents stated that starting dialysis was their own decision, with the majority (62.1%) indicating that a physician or family member had made the decision. Specifically, 54.5% of patients reported that their physician made the decision, while 21.5% said the decision was made by a family member. Most respondents (74.9%) had seen a nephrologist before starting dialysis, and half (44.8%) reported feeling like a burden to others due to their treatment. Decision-Making and Treatment Options Respondents were asked about the treatment options discussed prior to starting dialysis. Most respondents (95.4%) reported discussing haemodialysis, while fewer discussed transplantation (62.7%), conservative care (25%), or peritoneal dialysis (15.6%). Among respondents, 30.1% discussed only a single treatment option, usually haemodialysis, while 46.5% discussed two options, primarily haemodialysis and transplantation. A smaller group (18.3%) discussed three options, and only 5.2% of respondents reported discussing all four options (haemodialysis, PD, transplantation, and conservative care). A significant negative correlation was found between the number of treatment options discussed and DRS score (Pearson correlation − 0.67; p = 0.030), indicating that patients who discussed more treatment options before starting dialysis had lower levels of regret. Figure 1 demonstrates that patients from Nepal were more likely to have discussed fewer options before starting dialysis, with a high proportion of respondents having discussed only a single option. Conversely, respondents from India and Pakistan were more likely to have discussed a broader range of treatment options. Quality of Life and Health Perception Figure 2 outlines the EQ5D-5L quality of life responses. Approximately 57.2% of respondents reported no problems with self-care, while 42.6% reported no issues with mobility. Pain was not a major issue for over half of the respondents, with 51.3% reporting no pain or discomfort. However, 48.5% of respondents reported experiencing anxiety or depression to some degree, and 12.8% indicated that they were unable to perform their usual activities. Mobility issues were also notable, with 57.4% reporting some degree of difficulty, including 4.5% who were unable to walk. Perceived health state at the time of starting dialysis was lower, with a mean score of 5.08 (SD 3.07), compared to a mean score of 7.46 (SD 2.06) at the time of the questionnaire, reflecting a significant improvement in perceived health (p < 0.001). Dialysis Regret Of the 1,048 respondents, 14.1% expressed some degree of regret about starting dialysis, scoring 50 or higher on the DRS. The mean DRS score for the cohort was 26.8 (SD 22.4), with a median score of 30.0 (IQR 0–35). Only 4.4% of respondents expressed extreme regret (scores of 75+). The distribution of DRS scores was skewed towards lower scores, with most respondents expressing little to no regret about their decision to start dialysis (Shapiro-Wilk test p < 0.001) as depicted in Fig. 3 . Predictors of Regret Univariate analysis identified several significant predictors of regret. Younger age (< 50 years) was strongly associated with higher DRS scores (p < 0.001). Patients presenting for dialysis as an emergency were significantly more likely to express regret than those who had an elective start (OR 2.42, 95% CI 1.69–3.47). Not seeing a nephrologist before dialysis initiation was also linked to regret (OR 2.51, 95% CI 1.75–3.60), as was having a temporary catheter (OR 1.82, 95% CI 1.08–3.01). Furthermore, respondents who reported feeling like a burden to others had a significantly higher likelihood of expressing regret (OR 2.06, 95% CI 1.44–2.93). Difficulty adhering to dialysis was another key predictor of regret, with lower adherence scores (indicating more difficulty) strongly correlated with higher DRS scores (p < 0.001). Patients who discussed fewer treatment options prior to starting dialysis were also more likely to regret their decision, though this was not significant in the multivariate model. Multivariate binary logistic regression confirmed that younger age, having a temporary catheter, emergency presentation, and feeling like a burden were significant predictors of regret. Additionally, higher perceived current health status was associated with lower regret (OR 0.70, 95% CI 0.62–0.79; p < 0.001) (Table 2 ) Table 2 Multivariate binary logistic regression for decision regret. Variable Odds ratio 95% CI P value Age group <20 years Reference 21 to 35 years 0.34 0.09 to 1.25 0.104 36 to 50 years 0.20 0.05 to 0.81 0.024 51 to 65 years 0.22 0.05 to 0.92 0.038 66 to 80 years 0.20 0.04 to 0.89 0.035 81 + years 7.13 0.00 to 1708.57 0.621 Marital status Single Reference Married 1.74 0.80 to 3.78 0.165 Divorced 0.79 0.15 to 4.08 0.775 Widowed 2.51 0.73 to 8.61 0.143 Location of respondent Pakistan Reference Bangladesh 0.09 0.02 to 0.35 < 0.001 Nepal 0.17 0.03 to 0.92 0.039 India 0.98 0.49 to 1.97 0.960 Highest level of education < 5 years Reference 5 to 10 years 1.37 0.77 to 2.44 0.287 Secondary school 1.13 0.60 to 2.13 0.703 Undergraduate 0.52 0.24 to 1.10 0.086 Postgraduate 0.44 0.15 to 1.33 0.145 Time on dialysis 0.98 0.93 to 1.04 0.578 Pay for dialysis? No Reference Yes 0.83 0.48 to 1.42 0.490 Partially 0.87 0.30 to 2.56 0.800 Catheter type Fistula Reference PD catheter 1.14 0.16 to 8.20 0.896 Permanent catheter 0.00 0.00 0.998 Temporary catheter 2.12 1.08 to 4.15 0.029 Presentation Elective Reference Emergency 1.06 0.62 to 1.81 0.832 See nephrologist before dialysis? Yes 1.41 0.84 to 2.35 0.190 No Reference Own decision to start treatment Yes 0.76 0.44 to 1.30 0.310 No Reference Difficulty adhering to dialysis 0.81 0.74 to 0.89 < 0.001 Feel like a burden to others? Yes 1.88 1.16 to 3.05 0.011 No Reference Quality of life Mobility 0.60 0.35 to 1.02 0.060 Pain 0.93 0.56 to 1.53 0.768 Anxiety 1.20 0.69 to 2.10 0.513 Health state when starting dialysis 1.01 0.90 to 1.13 0.915 Health state now 0.70 0.62 to 0.79 < 0.001 Discussion The findings from this cross-sectional study on decisional regret among chronic haemodialysis (HD) patients in low- and middle-income countries (LMICs) provide crucial insights into the complex psychological, physiological, and socioeconomic factors that influence patient outcomes. Haemodialysis, while a critical life-sustaining modality for patients with end-stage renal disease (ESRD), presents multifactorial challenges that can contribute to a substantial emotional burden, which manifests as decisional regret 16 . Understanding the determinants of regret is vital for optimizing therapeutic interventions, improving patient adherence, and ultimately enhancing the quality of life for HD patients 17 . One significant outcome from this study is the marked association between younger age and higher levels of decisional regret. Patients under 20 years of age reported the highest incidence of regret, a finding that may be attributed to the profound life disruptions imposed by chronic dialysis, which interferes with career ambitions, educational pursuits, and social engagements 18 . Younger patients are at a critical stage in psychosocial development, and the onset of a chronic illness requiring lifelong treatment can lead to significant emotional distress 19 . From a developmental psychology perspective, these patients may be at a heightened risk of anxiety and depression due to the perceived limitations imposed on their autonomy and life trajectory 20 . The higher levels of regret in this cohort suggest that patient-centred interventions, including tailored psychological counseling and social support systems, are essential to mitigate the negative psychosocial impacts and foster resilience in younger HD patients 21 . Geographical disparities in decisional regret were another key finding, with patients from Pakistan reporting significantly higher regret levels compared to those in Bangladesh and Nepal. This may reflect variations in healthcare infrastructure, availability of renal replacement therapies (RRT), and economic barriers to accessing optimal care 22 . The healthcare delivery systems in LMICs often face resource limitations, leading to inconsistent access to high-quality care 23 . The financial burden of dialysis, as observed in this study, remains a significant stressor, particularly in countries where patients must bear out-of-pocket expenses for treatment 24 . This aligns with the concept of healthcare inequity, where patients in resource-constrained environments may experience heightened regret due to inadequate healthcare resources and financial insecurity 25 . This underscores the urgent need for health policy reforms aimed at reducing the financial burden of dialysis, improving healthcare access, and promoting equitable distribution of medical resources across LMICs 26 . Implementing universal health coverage for dialysis could mitigate these disparities, improving not only clinical outcomes but also the psychosocial well-being of patients 27 . Another notable determinant of regret was the type of vascular access used for dialysis, with patients utilizing temporary catheters exhibiting significantly higher levels of regret compared to those with arteriovenous fistulas or permanent vascular access 28 . Temporary catheters, associated with higher rates of infection, thrombosis, and other complications, may contribute to increased patient discomfort and dissatisfaction with treatment 29 . This finding emphasizes the need for early planning and placement of permanent vascular access, such as fistulas, which are associated with better long-term outcomes and fewer complications 30 . The use of permanent access is consistent with best practices in nephrology, which advocate for timely creation of arteriovenous fistulas to reduce morbidity and mortality associated with temporary catheters 31 . As such, enhancing vascular access protocols could reduce treatment-related regret, improve patient satisfaction, and decrease the incidence of adverse events in HD patients 32 . Psychological factors, particularly feelings of being a burden to others, were also strongly correlated with decisional regret 33 . This emotional burden can arise from the dependence on caregivers for transportation to dialysis sessions, assistance with daily activities, and the general sense of loss of independence 34 . Such findings resonate with the concept of caregiver burden and patient guilt, both of which have been extensively documented in the literature as contributors to emotional distress in chronic illness 35 . The provision of comprehensive psychosocial support, including counselling and respite care for caregivers, is critical in addressing these issues 36 . Structured caregiver support programs, psychological interventions, and peer support networks can alleviate the emotional strain experienced by both patients and caregivers, improving the overall quality of life and reducing decisional regret 37 . Lastly, the patients' perception of their current health status emerged as a critical factor influencing regret. Those who perceived their health to be better at the time of the questionnaire reported significantly lower levels of regret 38 . This highlights the importance of comprehensive disease management strategies that focus not only on dialysis but also on the broader aspects of health, including the management of comorbidities, nutrition, and physical fitness 39 . Interventions that aim to improve overall health, such as regular physical activity, dietary modifications, and psychological support, may help enhance patients' perceived well-being, thereby reducing feelings of regret 40 . The association between improved health status and reduced decisional regret aligns with the biopsychosocial model of health, which underscores the importance of addressing physical, psychological, and social factors in the management of chronic disease 41 . This study has several strengths, including its large, multinational sample across four South Asian LMICs, providing valuable insight into the prevalence and predictors of decisional regret among haemodialysis patients in diverse, resource-limited settings. The use of validated scales for measuring both quality of life and decisional regret enhances the reliability of findings, and the inclusion of sociodemographic and clinical factors enables a robust analysis of associations with regret. Additionally, the multilingual approach in questionnaire distribution ensures inclusivity and comprehensibility across regions with varied primary languages, adding depth to the findings. However, certain limitations must be acknowledged. The cross-sectional design restricts causal inferences, as associations observed between variables and regret may not imply direct causation. Data collection relied on self-reported measures, which are susceptible to recall and response biases, particularly in subjective assessments of health states and regret. Furthermore, with data gathered from predominantly hospital-based or urban centres, findings may not fully reflect the experiences of rural or underserved populations, where access to dialysis and support structures may differ significantly. Despite these limitations, the study provides a valuable foundation for understanding decisional regret in HD patients in LMICs, underscoring the need for targeted support and early intervention strategies in these settings. In conclusion, this study provides important insights into the multifactorial nature of decisional regret among HD patients in LMICs. By identifying key variables such as age, geographic location, vascular access type, psychological burden, and health perception, this research offers a framework for developing targeted, evidence-based interventions to mitigate regret and improve patient outcomes. Future research should focus on longitudinal studies to assess the long-term impact of interventions aimed at reducing regret and improving the overall quality of life for HD patients 41 . Additionally, health policy changes in LMICs that improve access to dialysis, reduce financial burdens, and promote early and optimal vascular access could have a transformative effect on reducing decisional regret and enhancing patient care 42 Declarations The authors declare no conflicts of interest. There is no intent to share data apart from submitting it to BMC Nephrology and we are happy for it to be used open access. We did not receive any funding of any kind for this project. The study was approved by the IRBEC Committee of Bahria Town International Hospital, Lahore, Pakistan. Free and informed consent was taken from all patients. The study did not involve any intervention including drug, diagnostic investigation or any clinical examination of the participant. It is not a clinical train hence Clinical trial number: not applicable. Every human participant gave their free and informed consent to participate in the study beforehand. The study did not involve any intervention including drug, diagnostic investigation or any clinical examination of the participant. Our research is conducted in accordance with the Declaration of Helsinki. References Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet . 2015;385(9981):1975-1982. Garcia-Garcia G, Jha V. Chronic kidney disease in disadvantaged populations. Clin Kidney J . 2015;8(1):3-6. Crews DC, Bello AK, Saadi G. 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L., Zicarelli, M., Duni, A., & Baciga, F. (2025). Comprehensive insights into sarcopenia in dialysis patients: Mechanisms, assessment, and therapeutic approaches. Medicina, 61(3), 449. DOI: 10.3390/medicina6103449 Masoudi, R., & Lotfizade, M. (2020). Evaluating the effect of Pender’s health promotion model on self-efficacy and treatment adherence behaviors among patients undergoing hemodialysis. Journal of Education and Health Promotion, 9 , 196.Engel GL. The Need for a New Medical Model: A Challenge for Biomedicine. Science. 1977;196(4286):129-136. Chahal, J. S., Saini, S., Bansal, P., & Arora, J. (2025). Impact of psychosocial interventions on depression in chronic kidney disease: A systematic review and meta-analysis. Journal of Psychiatry in Medicine. DOI: 10.1177/00912174251326009 World Health Organization (WHO). Universal Health Coverage and Renal Replacement Therapy: Addressing Disparities in Access to Dialysis in LMICs. Geneva: WHO; 2019. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6306598","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470524409,"identity":"5d1081a1-9d38-44ef-9475-14cb5ddc3b36","order_by":0,"name":"Mohammad Ahad Qayyum","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8ElEQVRIiWNgGAWjYDCCAwxsDCAEBh+AmI2dFC2MM0BamEnRwswDJgno4Lt9+NmDH2XW8gY3ckw32/zaJs/HzMD44WMObi2S59LMDXvOpRtuuJFjdju377ZhGzMDs+TMbbi1GJxhMJPgbTvMCNHSc5sRqIWNmRevFvZvkn/bDtuDtVj23LYnQguPmTTQlkSwFoYftxMJapE8w1MmLXMuPXnmmWdlN3sbbie3MTM24/UL3xn2bZJvyqxt+44nb7vx489t2/ntzQc/fMSjBQqYGRQuJADjsg3EYWwgqB6sRb7/AJD+Q4ziUTAKRsEoGGkAALGXVzAweu9TAAAAAElFTkSuQmCC","orcid":"","institution":"Bahria Town International Hospitals Lahore","correspondingAuthor":true,"prefix":"","firstName":"Mohammad","middleName":"Ahad","lastName":"Qayyum","suffix":""},{"id":470524410,"identity":"524747fe-4f53-4a02-99a7-64d19c8e4d1d","order_by":1,"name":"Jyoti Baharani","email":"","orcid":"","institution":"University Hospitals Birmingham NHS Foundation Trust","correspondingAuthor":false,"prefix":"","firstName":"Jyoti","middleName":"","lastName":"Baharani","suffix":""},{"id":470524411,"identity":"b2202d16-6441-4050-8dd5-a18bff94aa7f","order_by":2,"name":"Tayyaba Hafeez","email":"","orcid":"","institution":"Bahria Town International Hospitals Lahore","correspondingAuthor":false,"prefix":"","firstName":"Tayyaba","middleName":"","lastName":"Hafeez","suffix":""},{"id":470524412,"identity":"c60269ee-3561-4733-85d3-7553d3996071","order_by":3,"name":"Sarah Damery","email":"","orcid":"","institution":"University of Birmingham, National Institute for Health and Care Research Applied Research Collaboration West Midlands Birmingham","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Damery","suffix":""},{"id":470524413,"identity":"ff5c0970-11fe-440d-8013-e064f624b3d8","order_by":4,"name":"Farnaz Nobi","email":"","orcid":"","institution":"Kidney Foundation Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Farnaz","middleName":"","lastName":"Nobi","suffix":""},{"id":470524414,"identity":"3c981409-12a6-4cfc-a130-1478f2dc38c0","order_by":5,"name":"Divya Bajpai","email":"","orcid":"","institution":"Seth G.S.M.C. and K.E.M. Hospital","correspondingAuthor":false,"prefix":"","firstName":"Divya","middleName":"","lastName":"Bajpai","suffix":""},{"id":470524415,"identity":"5e7308be-8aed-4969-bc7e-23bd4db29b86","order_by":6,"name":"Rajeevalochana Parthasarathy","email":"","orcid":"","institution":"Madras Medical Mission, Department of Nephrology, Chennai, Tamil Nadu, India","correspondingAuthor":false,"prefix":"","firstName":"Rajeevalochana","middleName":"","lastName":"Parthasarathy","suffix":""},{"id":470524416,"identity":"65de5577-869c-4335-97b2-9966ca36144c","order_by":7,"name":"Klara Paudel","email":"","orcid":"","institution":"Charak Memorial Hospital","correspondingAuthor":false,"prefix":"","firstName":"Klara","middleName":"","lastName":"Paudel","suffix":""},{"id":470524417,"identity":"de1d3a59-e7fd-4a85-97e0-89e12d9ef855","order_by":8,"name":"Harun Ur Rashid","email":"","orcid":"","institution":"Kidney Foundation Hospital and Research Institute","correspondingAuthor":false,"prefix":"","firstName":"Harun","middleName":"Ur","lastName":"Rashid","suffix":""},{"id":470524418,"identity":"9c25da7b-2a2b-4e70-9d35-56ce05443b54","order_by":9,"name":"Monisha Ravi","email":"","orcid":"","institution":"Madras Medical Mission, Department of Nephrology, Chennai, Tamil Nadu, India","correspondingAuthor":false,"prefix":"","firstName":"Monisha","middleName":"","lastName":"Ravi","suffix":""}],"badges":[],"createdAt":"2025-03-25 20:08:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6306598/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6306598/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84699296,"identity":"1665d18a-5b10-479b-b4c6-5600a35f9ac7","added_by":"auto","created_at":"2025-06-16 11:09:07","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":244280,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eNumber of treatment options discussed before starting dialysis, by country.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6306598/v1/753dc95bef095eb6c923f1d1.jpeg"},{"id":84699300,"identity":"ca776026-2512-4930-aa80-0d63015583be","added_by":"auto","created_at":"2025-06-16 11:09:07","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":300757,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eResponses by domain of the EQ5D-5L scale.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6306598/v1/4d5f7b91eab753a99c47de9b.jpeg"},{"id":84699299,"identity":"f09bef0d-6271-418a-b7b7-957e64045862","added_by":"auto","created_at":"2025-06-16 11:09:07","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":129087,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eHistogram of DRS score by number of respondents\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(higher scores indicate more regret).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 3\u003c/strong\u003e shows the breakdown of responses for the individual components of the DRS. Most respondents (85.9%) strongly agreed or agreed that starting dialysis was the right decision. A similar proportion (81.1%) stated that they would make the same choice again. However, 14.0% of respondents felt that their choice had done them harm, and 13.0% regretted their decision.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6306598/v1/976abdfe88801f25b1c0d165.jpeg"},{"id":87300532,"identity":"ad239a46-86fe-4dc8-80fa-a123b23e961e","added_by":"auto","created_at":"2025-07-22 13:16:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1496055,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6306598/v1/7ae7aa23-b674-4850-9c14-f8a3165a5147.pdf"},{"id":84699302,"identity":"a0a4b9c2-05d9-4a3b-8f63-5289ae289149","added_by":"auto","created_at":"2025-06-16 11:09:07","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":3036345,"visible":true,"origin":"","legend":"","description":"","filename":"Questionnare.docx","url":"https://assets-eu.researchsquare.com/files/rs-6306598/v1/be63ea357e47469ee8cc082a.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eThe Burden of Decisional Regret in Haemodialysis in South Asian Lower Middle Income Countries\u003c/p\u003e","fulltext":[{"header":"Lay Summary","content":"\u003cp\u003eStarting haemodialysis, a treatment for severe kidney disease, can be a tough decision, especially for patients in less wealthy countries. This study looked at over 1,000 patients to understand why some regret starting this treatment. Regret was more common in younger people, those who had to start dialysis suddenly in emergencies, or those using temporary devices to access the treatment. Feeling like a burden to family also made regret more likely. However, patients who talked about different treatment options beforehand were less likely to regret their decision. This shows that better preparation, planning, and support could make the process easier and help patients feel more positive about their choice.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eFor most patients in low- and middle-income countries (LMICs), haemodialysis (HD) remains the most accessible and affordable form of Kidney replacement therapy\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The financial burden of dialysis is significant; many patients can only afford treatment if it is provided freely by the health system\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. If dialysis is not freely available, many will have to decide between affording dialysis or other daily living expenses\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. This financial strain can contribute to feelings of regret among patients who have had to commence therapy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eEven in high-income countries where dialysis is free or heavily subsidised, regret at having to start dialysis is prevalent in some patient groups\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. This may be due to several reasons, including dependency on caregivers and loss of physical independence\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Regret is a complex, unpleasant emotion that has been studied in a variety of contexts and is elicited when patients feel that an alternative may have resulted in a more favourable outcome than their current choice\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn the context of chronic HD patients, regret can be defined as the feeling of sadness or disappointment that arises from the perception of missed opportunities or poor decisions related to their healthcare\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Understanding if patients on dialysis are experiencing regret is crucial, as HD is a lifelong treatment that requires ongoing compliance and patient involvement\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIf regret is a significant issue, healthcare professionals should engage with patients and carers to acknowledge and address these feelings\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. Chronic HD patients experience significant physical and emotional challenges and exploring regret in this population could help to improve their quality of life\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Little is known about decisional regret regarding dialysis decisions in LMICs\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOur objective was to explore and understand experiences and sources of regret among HD patients in four LMICs. By identifying the factors contributing to regret, we aim to develop strategies that healthcare providers can use to support patients better, potentially alleviating some of the emotional burdens associated with long-term dialysis treatment. This understanding could lead to improved patient outcomes and a higher quality of life for those undergoing HD.\u003c/p\u003e"},{"header":"Methodology","content":"\u003cp\u003eA cross-sectional study was conducted in four South Asian countries; Pakistan, India, Bangladesh, and Nepal, with the objective to study and explore Dialysis Regret in patients on chronic dialysis. A questionnaire was developed following multiple rounds of revision to agree a final 22-item version. (supplement 1)\u003c/p\u003e \u003cp\u003eThe questionnaire was subsequently agreed upon by representative nephrologists from Pakistan, India, Bangladesh, Nepal and the United Kingdom. A Gantt chart was constructed to give a proposed timeline for data collection across all four countries and to streamline collaboration. This ensured timely completion of each phase, alongside regular online meetings to monitor progress. Data collection took place between May 2023 and March 2024. Individual ethical approval was obtained from each participating country and questionnaires were translated into local languages (Urdu, Hindi, Marathi, Tamil, Bengali, Nepali) to ensure comprehensibility and clarity.\u003c/p\u003e \u003cp\u003e Patients older than 18 years of age, on dialysis for longer than 3 months, and able to verbally give informed consent were included in the study. Centers approached all patients under their care and if the patient consented, questionnaire data were collected by a clinician during a one-to-one interview session with each participant. Participants were assured of the confidentiality and anonymity of their responses and no identifiable data were collected. 387 patients were interviewed from seven centers in Pakistan, 158 from two centers in India, 470 patients from a single center in Bangladesh, and 33 from two centers in Nepal. Patients were interviewed either while they underwent their dialysis, or when they were seen for follow up appointments in the clinic and responses were collected on Google Forms. Patients that were ill or had speech/hearing disabilities were not included nor were those who did not provide consent, were younger than 18 years of age, or on dialysis for less than 3 months.\u003c/p\u003e \u003cp\u003eDemographic data including age, sex, marital status, and country of residence were collected. To assess level of education, years of schooling were recorded as all four countries had different educational systems. Additionally, we collected information on dialysis vintage, initial dialysis access, type of dialysis, mode of presentation at start of dialysis, decisional autonomy, and spiritual/religious motivation in the context of patients\u0026rsquo; dialysis treatment. Validated scales were utilized to assess Decisional Regret\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e and Quality of Life (EQD-5D-5L) \u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e. Patients were also asked to provide a subjective assessment of their health on the day their dialysis was started and on the day of the interview, these responses were collected on a scale of 0 to 10, where 0 denoted \u0026ldquo;the worst health\u0026rdquo;, and 10 denoted \u0026ldquo;the best health\u0026rdquo; \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. Data analysis used descriptive statistics and binary logistic regression (with DRS scores dichotomised into \u0026lsquo;no regret\u0026rsquo; (scores\u0026thinsp;\u0026lt;\u0026thinsp;50) and \u0026lsquo;some regret\u0026rsquo; (scores\u0026thinsp;\u0026ge;\u0026thinsp;50)) to explore the association between patient characteristics and regret about starting dialysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSociodemographic and Cultural Characteristics\u003c/h2\u003e \u003cp\u003eA total of 1048 responses were collected across the four countries. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e outlines the sociodemographic details of respondents. The largest proportion of respondents (39.3%) were aged between 51 and 65 years, while 30.7% were between 36 and 50 years. The mean age was 52.6 years, reflecting a middle-aged population. Males comprised 54.2% of the cohort. Marital status was married (83.7%), and 11.5% reported being single. Most respondents were from Bangladesh (44.8%) and Pakistan (36.9%), with smaller proportions from India (15.1%) and Nepal (3.1%). Educational attainment varied, with 24.8% of respondents having less than five years of formal education, while 23.2% reported undergraduate or postgraduate education.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-demographic characteristics of respondents\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of respondents (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19 (1.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21 to 35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e159 (15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 to 50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e322 (30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51 to 65 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e412 (39.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66 to 80 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131 (12.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e81\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5 (0.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e568 (54.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e480 (45.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e877 (83.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e120 (11.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (3.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCountry of respondent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e387 (36.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e470 (44.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNepal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (3.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e158 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e260 (24.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e247 (23.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e298 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e150 (14.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e93 (8.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eClinical and Treatment Characteristics\u003c/h3\u003e\n\u003cp\u003eRespondents had a mean time on dialysis of 3.3 years (SD 3.8), with durations ranging from 3 months to 28 years. Haemodialysis (HD) was the most reported treatment modality, with 97.7% of respondents on HD, and only 2.2% on peritoneal dialysis (PD). A small number (1%) reported using a hybrid approach. Temporary catheters were the most used vascular access type, reported by 78.2% of respondents, while 18.6% had a fistula. Permanent catheters and PD catheters were rare, used by 1.9% and 1.2% of respondents, respectively.\u003c/p\u003e \u003cp\u003eRegarding the financial aspect of treatment, 48.4% of respondents reported paying part of the cost of dialysis, while 19.4% paid the full cost. Notably, only 37.9% of respondents stated that starting dialysis was their own decision, with the majority (62.1%) indicating that a physician or family member had made the decision. Specifically, 54.5% of patients reported that their physician made the decision, while 21.5% said the decision was made by a family member. Most respondents (74.9%) had seen a nephrologist before starting dialysis, and half (44.8%) reported feeling like a burden to others due to their treatment.\u003c/p\u003e\n\u003ch3\u003eDecision-Making and Treatment Options\u003c/h3\u003e\n\u003cp\u003eRespondents were asked about the treatment options discussed prior to starting dialysis. Most respondents (95.4%) reported discussing haemodialysis, while fewer discussed transplantation (62.7%), conservative care (25%), or peritoneal dialysis (15.6%). Among respondents, 30.1% discussed only a single treatment option, usually haemodialysis, while 46.5% discussed two options, primarily haemodialysis and transplantation. A smaller group (18.3%) discussed three options, and only 5.2% of respondents reported discussing all four options (haemodialysis, PD, transplantation, and conservative care).\u003c/p\u003e \u003cp\u003eA significant negative correlation was found between the number of treatment options discussed and DRS score (Pearson correlation \u0026minus;\u0026thinsp;0.67; p\u0026thinsp;=\u0026thinsp;0.030), indicating that patients who discussed more treatment options before starting dialysis had lower levels of regret. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e demonstrates that patients from Nepal were more likely to have discussed fewer options before starting dialysis, with a high proportion of respondents having discussed only a single option. Conversely, respondents from India and Pakistan were more likely to have discussed a broader range of treatment options.\u003c/p\u003e\n\u003ch3\u003eQuality of Life and Health Perception\u003c/h3\u003e\n\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e outlines the EQ5D-5L quality of life responses. Approximately 57.2% of respondents reported no problems with self-care, while 42.6% reported no issues with mobility. Pain was not a major issue for over half of the respondents, with 51.3% reporting no pain or discomfort. However, 48.5% of respondents reported experiencing anxiety or depression to some degree, and 12.8% indicated that they were unable to perform their usual activities. Mobility issues were also notable, with 57.4% reporting some degree of difficulty, including 4.5% who were unable to walk.\u003c/p\u003e \u003cp\u003ePerceived health state at the time of starting dialysis was lower, with a mean score of 5.08 (SD 3.07), compared to a mean score of 7.46 (SD 2.06) at the time of the questionnaire, reflecting a significant improvement in perceived health (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDialysis Regret\u003c/h2\u003e \u003cp\u003eOf the 1,048 respondents, 14.1% expressed some degree of regret about starting dialysis, scoring 50 or higher on the DRS. The mean DRS score for the cohort was 26.8 (SD 22.4), with a median score of 30.0 (IQR 0\u0026ndash;35). Only 4.4% of respondents expressed extreme regret (scores of 75+). The distribution of DRS scores was skewed towards lower scores, with most respondents expressing little to no regret about their decision to start dialysis (Shapiro-Wilk test p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) as depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePredictors of Regret\u003c/h3\u003e\n\u003cp\u003eUnivariate analysis identified several significant predictors of regret. Younger age (\u0026lt;\u0026thinsp;50 years) was strongly associated with higher DRS scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients presenting for dialysis as an emergency were significantly more likely to express regret than those who had an elective start (OR 2.42, 95% CI 1.69\u0026ndash;3.47). Not seeing a nephrologist before dialysis initiation was also linked to regret (OR 2.51, 95% CI 1.75\u0026ndash;3.60), as was having a temporary catheter (OR 1.82, 95% CI 1.08\u0026ndash;3.01). Furthermore, respondents who reported feeling like a burden to others had a significantly higher likelihood of expressing regret (OR 2.06, 95% CI 1.44\u0026ndash;2.93).\u003c/p\u003e \u003cp\u003eDifficulty adhering to dialysis was another key predictor of regret, with lower adherence scores (indicating more difficulty) strongly correlated with higher DRS scores (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients who discussed fewer treatment options prior to starting dialysis were also more likely to regret their decision, though this was not significant in the multivariate model.\u003c/p\u003e \u003cp\u003eMultivariate binary logistic regression confirmed that younger age, having a temporary catheter, emergency presentation, and feeling like a burden were significant predictors of regret. Additionally, higher perceived current health status was associated with lower regret (OR 0.70, 95% CI 0.62\u0026ndash;0.79; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultivariate binary logistic regression for decision regret.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOdds ratio\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21 to 35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09 to 1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.104\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e36 to 50 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 to 0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e51 to 65 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05 to 0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.038\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e66 to 80 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.04 to 0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.035\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e81\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00 to 1708.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.80 to 3.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.165\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15 to 4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.775\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.73 to 8.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.143\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of respondent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePakistan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBangladesh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.02 to 0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNepal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.03 to 0.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.039\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.49 to 1.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.960\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHighest level of education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt; 5 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 to 10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.77 to 2.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.287\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.60 to 2.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.703\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.24 to 1.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.086\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostgraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15 to 1.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime on dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93 to 1.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.578\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePay for dialysis?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.83\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.48 to 1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.490\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartially\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.30 to 2.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCatheter type\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePD catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.16 to 8.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.896\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePermanent catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.998\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTemporary catheter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.08 to 4.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.029\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePresentation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmergency\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.62 to 1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.832\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSee nephrologist before dialysis?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.84 to 2.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOwn decision to start treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.44 to 1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulty adhering to dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.74 to 0.89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFeel like a burden to others?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.16 to 3.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuality of life\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.35 to 1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.060\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.56 to 1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.768\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnxiety\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.69 to 2.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.513\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth state when starting dialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90 to 1.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.915\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealth state now\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.62 to 0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings from this cross-sectional study on decisional regret among chronic haemodialysis (HD) patients in low- and middle-income countries (LMICs) provide crucial insights into the complex psychological, physiological, and socioeconomic factors that influence patient outcomes. Haemodialysis, while a critical life-sustaining modality for patients with end-stage renal disease (ESRD), presents multifactorial challenges that can contribute to a substantial emotional burden, which manifests as decisional regret\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Understanding the determinants of regret is vital for optimizing therapeutic interventions, improving patient adherence, and ultimately enhancing the quality of life for HD patients\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOne significant outcome from this study is the marked association between younger age and higher levels of decisional regret. Patients under 20 years of age reported the highest incidence of regret, a finding that may be attributed to the profound life disruptions imposed by chronic dialysis, which interferes with career ambitions, educational pursuits, and social engagements\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Younger patients are at a critical stage in psychosocial development, and the onset of a chronic illness requiring lifelong treatment can lead to significant emotional distress\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. From a developmental psychology perspective, these patients may be at a heightened risk of anxiety and depression due to the perceived limitations imposed on their autonomy and life trajectory\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. The higher levels of regret in this cohort suggest that patient-centred interventions, including tailored psychological counseling and social support systems, are essential to mitigate the negative psychosocial impacts and foster resilience in younger HD patients\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGeographical disparities in decisional regret were another key finding, with patients from Pakistan reporting significantly higher regret levels compared to those in Bangladesh and Nepal. This may reflect variations in healthcare infrastructure, availability of renal replacement therapies (RRT), and economic barriers to accessing optimal care\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. The healthcare delivery systems in LMICs often face resource limitations, leading to inconsistent access to high-quality care\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. The financial burden of dialysis, as observed in this study, remains a significant stressor, particularly in countries where patients must bear out-of-pocket expenses for treatment\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. This aligns with the concept of healthcare inequity, where patients in resource-constrained environments may experience heightened regret due to inadequate healthcare resources and financial insecurity\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e. This underscores the urgent need for health policy reforms aimed at reducing the financial burden of dialysis, improving healthcare access, and promoting equitable distribution of medical resources across LMICs\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. Implementing universal health coverage for dialysis could mitigate these disparities, improving not only clinical outcomes but also the psychosocial well-being of patients\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAnother notable determinant of regret was the type of vascular access used for dialysis, with patients utilizing temporary catheters exhibiting significantly higher levels of regret compared to those with arteriovenous fistulas or permanent vascular access\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. Temporary catheters, associated with higher rates of infection, thrombosis, and other complications, may contribute to increased patient discomfort and dissatisfaction with treatment\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. This finding emphasizes the need for early planning and placement of permanent vascular access, such as fistulas, which are associated with better long-term outcomes and fewer complications\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. The use of permanent access is consistent with best practices in nephrology, which advocate for timely creation of arteriovenous fistulas to reduce morbidity and mortality associated with temporary catheters\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. As such, enhancing vascular access protocols could reduce treatment-related regret, improve patient satisfaction, and decrease the incidence of adverse events in HD patients\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003ePsychological factors, particularly feelings of being a burden to others, were also strongly correlated with decisional regret\u003csup\u003e33\u003c/sup\u003e. This emotional burden can arise from the dependence on caregivers for transportation to dialysis sessions, assistance with daily activities, and the general sense of loss of independence\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Such findings resonate with the concept of caregiver burden and patient guilt, both of which have been extensively documented in the literature as contributors to emotional distress in chronic illness\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. The provision of comprehensive psychosocial support, including counselling and respite care for caregivers, is critical in addressing these issues\u003csup\u003e36\u003c/sup\u003e. Structured caregiver support programs, psychological interventions, and peer support networks can alleviate the emotional strain experienced by both patients and caregivers, improving the overall quality of life and reducing decisional regret\u003csup\u003e37\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eLastly, the patients' perception of their current health status emerged as a critical factor influencing regret. Those who perceived their health to be better at the time of the questionnaire reported significantly lower levels of regret\u003csup\u003e38\u003c/sup\u003e. This highlights the importance of comprehensive disease management strategies that focus not only on dialysis but also on the broader aspects of health, including the management of comorbidities, nutrition, and physical fitness\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e. Interventions that aim to improve overall health, such as regular physical activity, dietary modifications, and psychological support, may help enhance patients' perceived well-being, thereby reducing feelings of regret\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e. The association between improved health status and reduced decisional regret aligns with the biopsychosocial model of health, which underscores the importance of addressing physical, psychological, and social factors in the management of chronic disease\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThis study has several strengths, including its large, multinational sample across four South Asian LMICs, providing valuable insight into the prevalence and predictors of decisional regret among haemodialysis patients in diverse, resource-limited settings. The use of validated scales for measuring both quality of life and decisional regret enhances the reliability of findings, and the inclusion of sociodemographic and clinical factors enables a robust analysis of associations with regret. Additionally, the multilingual approach in questionnaire distribution ensures inclusivity and comprehensibility across regions with varied primary languages, adding depth to the findings.\u003c/p\u003e \u003cp\u003eHowever, certain limitations must be acknowledged. The cross-sectional design restricts causal inferences, as associations observed between variables and regret may not imply direct causation. Data collection relied on self-reported measures, which are susceptible to recall and response biases, particularly in subjective assessments of health states and regret. Furthermore, with data gathered from predominantly hospital-based or urban centres, findings may not fully reflect the experiences of rural or underserved populations, where access to dialysis and support structures may differ significantly. Despite these limitations, the study provides a valuable foundation for understanding decisional regret in HD patients in LMICs, underscoring the need for targeted support and early intervention strategies in these settings.\u003c/p\u003e \u003cp\u003eIn conclusion, this study provides important insights into the multifactorial nature of decisional regret among HD patients in LMICs. By identifying key variables such as age, geographic location, vascular access type, psychological burden, and health perception, this research offers a framework for developing targeted, evidence-based interventions to mitigate regret and improve patient outcomes. Future research should focus on longitudinal studies to assess the long-term impact of interventions aimed at reducing regret and improving the overall quality of life for HD patients\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e. Additionally, health policy changes in LMICs that improve access to dialysis, reduce financial burdens, and promote early and optimal vascular access could have a transformative effect on reducing decisional regret and enhancing patient care\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e The authors declare no conflicts of interest.\u003c/p\u003e\n\u003cp\u003eThere is no intent to share data apart from submitting it to BMC Nephrology and we are happy for it to be used open access.\u003c/p\u003e\n\u003cp\u003eWe did not receive any funding of any kind for this project.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the IRBEC Committee of Bahria Town International Hospital, Lahore, Pakistan. Free and informed consent was taken from all patients. The study did not involve any intervention including drug, diagnostic investigation or any clinical examination of the participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIt is not a clinical train hence Clinical trial number: not applicable.\u003c/p\u003e\n\u003cp\u003eEvery human participant gave their free and informed consent to participate in the study beforehand. The study did not involve any intervention including drug, diagnostic investigation or any clinical examination of the participant.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur research is conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLiyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. \u003cem\u003eLancet\u003c/em\u003e. 2015;385(9981):1975-1982.\u003c/li\u003e\n\u003cli\u003eGarcia-Garcia G, Jha V. 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KDOQI clinical practice guideline for vascular access. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2006;48(Suppl 1)\u003c/li\u003e\n\u003cli\u003eLok CE, Huber TS, Lee T, et al. KDOQI clinical practice guideline for vascular access: 2019 update. \u003cem\u003eAm J Kidney Dis\u003c/em\u003e. 2020;75(4 Suppl 2)\u003c/li\u003e\n\u003cli\u003eGhenaati, N., Zendehtalab, H. R., Namazinia, M., \u0026amp; Zare, M. (2024). Peer support groups and care burden in hemodialysis caregivers: A RCT in an Iranian healthcare setting. BMC Nephrology, 25, 38. DOI: 10.1186/s12882-024-03811-8 \u003c/li\u003e\n\u003cli\u003eHamler, T. C., Cutforth, A., O\u0026apos;Donnell, K., \u0026amp; Others. (2025). \u0026quot;I Won\u0026apos;t Put Myself or My Family Through That\u0026quot;: Decision Preferences, Family Experiences, and Kidney Disease Decision-Making. The Gerontologist. \u003c/li\u003e\n\u003cli\u003eAbdalrahim, M., \u0026amp; Al-Sutari, M. (2025). 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L., Zicarelli, M., Duni, A., \u0026amp; Baciga, F. (2025). Comprehensive insights into sarcopenia in dialysis patients: Mechanisms, assessment, and therapeutic approaches. Medicina, 61(3), 449. DOI: 10.3390/medicina6103449 \u003c/li\u003e\n\u003cli\u003eMasoudi, R., \u0026amp; Lotfizade, M. (2020). Evaluating the effect of Pender\u0026rsquo;s health promotion model on self-efficacy and treatment adherence behaviors among patients undergoing hemodialysis. \u003cem\u003eJournal of Education and Health Promotion, 9\u003c/em\u003e, 196.Engel GL. The Need for a New Medical Model: A Challenge for Biomedicine. \u003cem\u003eScience.\u003c/em\u003e 1977;196(4286):129-136.\u003c/li\u003e\n\u003cli\u003eChahal, J. S., Saini, S., Bansal, P., \u0026amp; Arora, J. (2025). Impact of psychosocial interventions on depression in chronic kidney disease: A systematic review and meta-analysis. Journal of Psychiatry in Medicine. DOI: 10.1177/00912174251326009 \u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Universal Health Coverage and Renal Replacement Therapy: Addressing Disparities in Access to Dialysis in LMICs. Geneva: WHO; 2019.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Dialysis, Regret, Lower income countries","lastPublishedDoi":"10.21203/rs.3.rs-6306598/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6306598/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Haemodialysis (HD) is the primary renal replacement therapy available to patients with end-stage kidney disease (ESKD) in low- and middle-income countries (LMICs), but the financial and emotional burdens can lead to significant decisional regret. Although decisional regret has been explored in patients from high-income countries, little is known about the experiences of regret in HD patients in LMICs.\u003c/p\u003e\n\u003cp\u003eObjective: This study aimed to explore the prevalence and pre\u003c/p\u003e\n\u003cp\u003edictors of decisional regret among HD patients in four South Asian LMICs (Pakistan, India, Bangladesh, and Nepal).\u003c/p\u003e\n\u003cp\u003eMethods: A cross-sectional study was conducted across Pakistan, India, Bangladesh, and Nepal. Data were collected using validated scales to assess quality of life, and the Decision Regret Score (DRS) used to measure decisional regret. Sociodemographic, clinical, and treatment-related data were also gathered.\u003c/p\u003e\n\u003cp\u003eResults: A total of 1048 responses were received. The mean age of the cohort was 52.6 years, with 54.2% being male. Decisional regret, defined as a DRS score ≥50, was reported by 14.1% of respondents, with 4.4% expressing extreme regret (scores ≥75). Younger age (\u0026lt;50 years), use of temporary vascular access, emergency dialysis initiation, and feelings of being a burden to others were all significantly associated with higher levels of regret (p\u0026lt;0.001). Patients who discussed multiple treatment options prior to starting dialysis reported lower levels of regret.\u003c/p\u003e\n\u003cp\u003eConclusion: Decisional regret is prevalent among HD patients in LMICs, with younger patients and those initiating dialysis in suboptimal conditions at greater risk. The findings suggest that early interventions, including timely nephrology referrals, optimal vascular access planning, and comprehensive pre-dialysis education, are crucial to reducing regret.\u003c/p\u003e","manuscriptTitle":"The Burden of Decisional Regret in Haemodialysis in South Asian Lower Middle Income Countries","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 11:09:01","doi":"10.21203/rs.3.rs-6306598/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a57778b1-9c8c-40f3-8216-12db8635f026","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-07-22T13:08:50+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 11:09:01","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6306598","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6306598","identity":"rs-6306598","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}