
==== Front
Sci Rep
Sci Rep
Scientific Reports
2045-2322
Nature Publishing Group UK London

39294250
72366
10.1038/s41598-024-72366-3
Article
Knowledge, attitude, and practice toward nutrition support and management among hemodialysis patients
Peng Yuan 12
Huang Qin 12
Yu Yan 12
Zhu Linfang 12
Yuan Huaihong yuanhuaihong@wchscu.cn

12
1 https://ror.org/007mrxy13 grid.412901.f 0000 0004 1770 1022 Department of Nephrology, Institute of Kidney Diseases, West China Hospital of Sichuan University, Chengdu, Sichuan China
2 https://ror.org/011ashp19 grid.13291.38 0000 0001 0807 1581 West China School of Nursing, Sichuan University, Chengdu, Sichuan China
18 9 2024
18 9 2024
2024
14 2182524 4 2024
6 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Nutrition support is an important care component for patients on hemodialysis. Also, patient self-management is important to maintaining proper nutritional intake during hemodialysis. This cross-sectional study investigated the knowledge, attitude, and practice (KAP) towards nutrition support and management among hemodialysis patients treated at the West China Hospital of Sichuan University between January and March 2023. Among 445 (95.91%) valid questionnaires, 58.43% were filled out by male patients. The knowledge, attitude, and practice scores were 11.44 ± 1.80 (possible range: 0–13), 30.29 ± 3.22 (possible range: 8–40), and 31.27 ± 5.67 (possible range: 8–40), respectively. Age > 60 years (OR = 0.487, 95%CI: 0.260–0.913, P = 0.025) and junior college or undergraduate or above (OR = 2.606, 95%CI: 1.621–4.189, P < 0.001) were independently associated with adequate knowledge. The knowledge (OR = 1.151, 95%CI: 1.024–1.294, P = 0.018) and female gender (OR = 0.632, 95%CI: 0.419–0.953, P = 0.029) were independently associated with positive attitude. The knowledge (OR = 1.404, 95%CI: 1.221–1.614, P < 0.001), attitude (OR = 1.146, 95%CI: 1.069–1.227, P < 0.001), age 51–60 years (OR = 1.879, 95%CI: 1.093–3.229, P = 0.022), and BMI of 24.0–27.9 kg/m2 (OR = 0.434, 95%CI: 0.269–0.700, P = 0.001) were independently associated with proactive practice. Hemodialysis patients showed adequate knowledge, positive attitudes, and proactive practice; however, there were also several gaps in knowledge and misconceptions regarding proper nutritional self-management. Accordingly, addressing these gaps and misconceptions through carefully designed and effectively implemented education is crucial for providing comprehensive guidance on optimal nutrition and self-management strategies.

Keywords

Attitude
Practice
Hemodialysis
Knowledge
Nutrition management
Subject terms

Medical research
Nephrology
Sichuan University West China nursing discipline development special fund projectHXHL21015 Yuan Huaihong issue-copyright-statement© Springer Nature Limited 2024
==== Body
pmcIntroduction

Hemodialysis is a renal replacement therapy for end-stage renal disease (ESRD)1,2. Malnutrition is one of the most critical factors affecting morbidity and mortality in patients with ESRD, and hemodialysis treatment has been reported to cause significant imbalances in electrolytes and fluid levels, as well as the depletion of specific nutrients, particularly potassium, proteins, and amino acids3–5. Indeed, protein-energy wasting (PEW), which results from the depletion of protein and energy stores and has been associated with poor quality of life (QoL) and increased morbidity and mortality, is common among ESRD patients on hemodialysis6,7. Because of the catabolic nature of hemodialysis and the decreased dietary intake, patients have high requirements for protein and energy8,9. Maintaining adequate nutrition during hemodialysis is essential to prevent nutrient deficits10–12. A proper protein intake helps counterbalance the loss of electrolytes (while avoiding electrolyte excess), proteins, and amino acids4, limits complications, and improves patient outcomes13,14. Healthcare professionals can help mitigate the adverse consequences of malnutrition and enhance the overall well-being and outcomes of patients on hemodialysis. Still, even though healthcare providers have an essential role in providing nutritional counseling before and during hemodialysis, patients are responsible for their nutrition at home. Therefore, patient self-management, which requires adequate knowledge and attitude, is vital to maintaining proper nutritional intake during hemodialysis.

Proper KAP15–18, including caretaker management, is essential for adequate self-management during hemodialysis19. A previous study showed a poor KAP toward self-management among Iranian patients with type 2 diabetes on hemodialysis15. In India, most patients were unfamiliar with the renal diet and failed to adhere to it16. In South Africa, patients on hemodialysis had a poor KAP toward the renal diet and rarely consulted dietitians for their diet management17. In Singapore, patients with type 2 diabetes on hemodialysis were reported to have a high knowledge of self-management but poor actual practices18. Caregivers have a central role in the self-management of patients on hemodialysis, including preparing meals and managing medications and supplements20. In China, the KAP data on nutrition support during hemodialysis are lacking. Hence, this study aimed to explore the KAP of hemodialysis patients toward nutrition support and management.

Results

Demographic characteristics

Among a total of 464 initially collected questionnaires, there were 14 with the same option selected for all questions in KAP, 3 without informed consent forms, and 2 with illogical responses that were eventually excluded, resulting in 445 (95.91%) valid questionnaires finally included in the analysis. The highest frequencies were observed for the following variables: male (58.43%), age < 40 years (31.69%), BMI of 18.5–23.9 kg/m2 (56.40%), urban residence (75.28%), lower education (60.00%), unemployed (74.16%), income of < 5,000 CNY (50.34%), basic medical insurance for urban employees (60.45%), hypertensive kidney injury (28.09%), hemodialysis vintage of < 36 months (51.69%), and > 3 days of hemodialysis each week (88.99%) (Table 1). Table 1 Characteristics of the participants.

Variables	N (%)	Knowledge score	Attitude score	Practice score	
Mean ± SD	P	Mean ± SD	P	Mean ± SD	P	
Total	445	11.44 ± 1.80		30.29 ± 3.22		31.27 ± 5.67		
Gender			0.277		0.203		0.878	
 Male	260 (58.43)	11.22 ± 1.83		30.45 ± 3.21		31.30 ± 5.62		
 Female	185 (41.57)	11.03 ± 1.76		30.06 ± 3.22		31.22 ± 5.77		
Age (years)			0.003		0.359		0.038	
 < 40	141 (31.69)	11.37 ± 1.77		30.33 ± 2.87		30.16 ± 6.19		
 40–49	110 (24.72)	11.18 ± 1.98		30.07 ± 3.39		32.05 ± 5.27		
 50–59	124 (27.87)	11.23 ± 1.50		30.10 ± 3.40		31.75 ± 5.15		
 ≥ 60	70 (15.73)	10.43 ± 1.91		30.87 ± 3.27		31.41 ± 5.87		
Body mass index (kg/m2)			0.331		0.365		0.045	
 < 18.5	51 (11.46)	11.22 ± 1.83		30.57 ± 3.00		29.78 ± 6.26		
 18.5–23.9	251 (56.40)	11.25 ± 1.74		30.40 ± 3.22		31.86 ± 5.53		
 24.0–27.9	118 (26.52)	10.90 ± 1.98		30.14 ± 3.33		30.58 ± 5.48		
 > 28.0	25 (5.62)	10.96 ± 1.43		29.32 ± 3.05		31.56 ± 6.21		
Residence			0.012		0.01		0.021	
 Urban	335 (75.28)	11.26 ± 1.70		30.51 ± 3.18		31.62 ± 5.05		
 Rural	110 (24.72)	10.76 ± 2.04		29.61 ± 3.25		30.18 ± 7.18		
Education			 < 0.001		0.008		0.698	
 High school/technical secondary school and below	267 (60.00)	10.80 ± 1.94		29.96 ± 3.35		31.18 ± 5.88		
 Junior college/undergraduate and above	178 (40.00)	11.65 ± 1.42		30.78 ± 2.95		31.39 ± 5.36		
Working status			0.039		0.082		0.614	
 Employed	115 (25.84)	11.43 ± 1.54		30.74 ± 2.90		31.50 ± 5.35		
 Unemployed	330 (74.16)	11.03 ± 1.87		30.13 ± 3.31		31.18 ± 5.79		
Monthly household income (CNY)			0.139		0.289		0.348	
 < 5000	224 (50.34)	11.02 ± 2.02		30.08 ± 3.57		31.08 ± 5.99		
 5000–10,000	149 (33.48)	11.38 ± 1.54		30.38 ± 2.72		31.79 ± 4.86		
 ≥ 10,000	72 (16.18)	11.01 ± 1.53		30.75 ± 3.00		30.75 ± 6.23		
Type of medical insurance (multiple choice)								
 Basic medical insurance for urban employees	269 (60.45)							
 Basic medical insurance for urban residents	108 (24.27)							
 New Cooperative Medical Insurance	75 (16.85)							
 Commercial Insurance	9 (2.02)							
Indication for hemodialysis			0.401		0.184		0.175	
 Glomerular disease	115 (25.84)	11.28 ± 1.90		30.05 ± 2.99		30.59 ± 5.92		
 Hypertensive kidney injury	125 (28.09)	11.02 ± 1.70		29.92 ± 3.08		30.88 ± 4.96		
 Diabetic nephropathy	64 (14.38)	10.89 ± 1.59		30.61 ± 3.48		32.23 ± 4.81		
 Other	141 (31.69)	11.24 ± 1.88		30.67 ± 3.37		31.72 ± 6.35		
Hemodialysis vintage (months)			0.235		0.937		0.341	
 ≤ 36	230 (51.69)	11.04 ± 1.84		30.28 ± 3.01		31.51 ± 5.52		
 > 36	215 (48.31)	11.24 ± 1.75		30.30 ± 3.43		31.00 ± 5.84		
Hemodialysis protocol (days per week)			0.414		0.632		0.182	
 2	49 (11.01)	10.94 ± 1.55		30.08 ± 3.54		32.29 ± 6.54		
 ≥ 3	396 (88.99)	11.16 ± 1.83		30.32 ± 3.18		31.14 ± 5.55		

Knowledge, attitudes, and practice

The knowledge score was 11.44 ± 1.80 (possible range: 0–13). Higher knowledge scores were observed in participants who were ≤ 60 years old (P = 0.003), living in urban areas (P = 0.012), with higher education (P < 0.001), and employed (P = 0.039) (Table 1). Poor knowledge was observed for K8 (58.43%; “Foods such as whole grains, roughage, animal offal, shrimp and dairy products do not contain phosphorus”) and K12 (59.55%; “Body Mass Index (BMI) = Weight (kg) ÷ Height2 (m)”) (Table S1).

The mean attitude score was 30.29 ± 3.22 (possible range: 8–40). Higher attitude scores were observed in participants living in cities (P = 0.010) and with higher education (P = 0.008) (Table 1). Table S2 presents the distribution of the attitudes.

The mean practice score was 31.27 ± 5.67 (possible range: 8–40). Higher practice scores were observed in participants who were 40–50 years old (P = 0.038), with a BMI of 18.5–23.9 kg/m2 (P = 0.045), and living in urban areas (P = 0.021) (Table 1). Table S3 presents the distribution of the practice responses.

Correlation analysis

The knowledge scores were correlated with the attitude (r = 0.241, P < 0.001) and practice (r = 0.365, P < 0.001) scores, while the attitude scores were correlated with the practice scores (r = 0.311, P < 0.001) (Table 2). Table 2 Correlation analysis of knowledge, attitude, and practice.

	Knowledge	Attitude	Practice	
Knowledge	1			
Attitude	0.241 (P < 0.001)	1		
Practice	0.365 (P < 0.001)	0.311 (P < 0.001)	1	

Multivariable analysis

The multivariable logistic regression analysis showed that age > 60 years (OR = 0.487, 95% CI: 0.260–0.913, P = 0.025) and junior college or undergraduate education or above (OR = 2.606, 95% CI: 1.621–4.189, P < 0.001) were independently associated with adequate knowledge (Table 3). Knowledge (OR = 1.151, 95% CI: 1.024–1.294, P = 0.018) and female sex (OR = 0.632, 95% CI: 0.419–0.953, P = 0.029) were independently associated with positive attitudes (Table 4). Knowledge (OR = 1.404, 95% CI: 1.221–1.614, P < 0.001), attitude (OR = 1.146, 95% CI: 1.069–1.227, P < 0.001), age 51–60 (OR = 1.879, 95% CI: 1.093–3.229, P = 0.022), and BMI of 24.0–27.9 kg/m2 (OR = 0.434, 95% CI: 0.269–0.700, P = 0.001) were independently associated with proactive practice (Table 5). The evaluation indicators for multivariable logistic regression models are shown in the Tables S4–5. Table 3 Multivariable analysis of knowledge.

Variables	Univariable logistic regression	Multivariable logistic regression	
OR (95%CI)	P	OR (95%CI)	P	
Gender	
 Male	1				
 Female	0.797 (0.546–1.163)	0.239			
Age (years)	
 < 40	1		1		
 40–49	1.035 (0.627–1.708)	0.894	1.176 (0.703–1.968)	0.537	
 50–59	0.858 (0.529–1.392)	0.536	0.939 (0.568–1.552)	0.806	
 ≥ 60	0.407 (0.223–0.740)	0.003	0.487 (0.260–0.913)	0.025	
Body mass index (kg/m2)	
 < 18.5	0.894 (0.489–1.632)	0.714			
 18.5–23.9	1				
 24.0–27.9	0.725 (0.467–1.125)	0.151			
 > 28.0	0.483 (0.260–1.135)	0.095			
Residence	
 Urban	1.502 (0.973–2.319)	0.067			
 Rural	1				
Education	
 High school/ technical secondary school and below	1		1		
 Junior college/ undergraduate and above	2.443 (1.654–3.610)	 < 0.001	2.606 (1.621–4.189)	 < 0.001	
Working status	
 Employed	1		1		
 Unemployed	0.650 (0.423–0.998)	0.049	1.330 (0.773–2.286)	0.303	
Mean monthly household income (CNY)	
 < 5000	1				
 5000–10,000	1.224 (0.808–1.855)	0.341			
 ≥ 10,000	0.714 (0.418–1.222)	0.219			
Indication for hemodialysis	
 Glomerular disease	1				
 Hypertensive kidney injury	0.817 (0.492–1.357)	0.435			
 Diabetic nephropathy	0.567 (0.305–1.056)	0.074			
 Other	1.096 (0.669–1.797)	0.716			
Hemodialysis vintage (months)	
 ≤ 36	1				
 > 36	1.324 (0.912–1.922)	0.14			
Hemodialysis protocol (days per week)	
 2	1				
 ≥ 3	1.695 (0.923–3.111)	0.089			

Table 4 Multivariable analysis of attitude.

Variables	Univariable logistic regression	Multivariable logistic regression	
OR (95%CI)	P	OR (95%CI)	P	
Knowledge Score	1.184 (1.057–1.325)	0.003	1.151 (1.024–1.294)	0.018	
Gender	
 Male	1		1		
 Female	0.662 (0.452–0.970)	0.034	0.632 (0.419–0.953)	0.029	
Age (years)	
 < 40	1				
 40–49	0.905 (0.548–1.495)	0.697			
 50–59	0.817 (0.502–1.330)	0.416			
 ≥ 60	1.388 (0.781–2.468)	0.263			
Body mass index (kg/m2)	
 < 18.5	0.897 (0.490–1.641)	0.724			
 18.5–23.9	1				
 24.0–27.9	0.860 (0.554–1.335)	0.502			
 > 28.0	0.425 (0.171–1.052)	0.064			
Residence	
 Urban	1.817 (1.161–2.843)	0.009	1.561 (0.962–2.532)	0.071	
 Rural	1		1		
Education	
 High school/ technical secondary school and below	1		1		
 Junior college/ undergraduate and above	1.527 (1.042–2.237)	0.03	1.194 (0.778–1.830)	0.417	
Working status	
 Employed	1				
 Unemployed	0.726 (0.474–1.111)	0.14			
Mean monthly household income (CNY)	
 < 5000	1				
 5000–10,000	1.282 (0.845–1.946)	0.243			
 ≥ 10,000	1.574 (0.923–2.684)	0.096			
Indication for hemodialysis	
 Glomerular disease	1		1		
 Hypertensive kidney injury	1.145 (0.684–1.918)	0.607	1.257 (0.734–2.151)	0.404	
 Diabetic nephropathy	1.373 (0.740–2.545)	0.315	1.340 (0.706–2.544)	0.371	
 Other	1.718 (1.043–2.831)	0.034	1.969 (1.169–3.317)	0.011	
Hemodialysis vintage (months)	
 ≤ 36	1				
 > 36	1.015 (0.699–1.474)	0.939			
Hemodialysis protocol (days per week)	
 2	1				
 ≥ 3	1.122 (0.616–2.044)	0.706			

Table 5 Multivariable analysis of practice.

Variables	Univariable logistic regression	Multivariable logistic regression	
OR (95%CI)	P	OR (95%CI)	P	
Knowledge Score	1.429 (1.260–1.621)	 < 0.001	1.404 (1.221–1.614)	 < 0.001	
Attitude Score	1.172 (1.100–1.249)	 < 0.001	1.146 (1.069–1.227)	 < 0.001	
Gender	
 Male	1				
 Female	0.775 (0.531–1.131)	0.775			
Age (years)	
 < 40	1		1		
 40–49	1.599 (0.968–2.642)	0.067	1.708 (0.984–2.963)	0.057	
 50–59	1.659 (1.020–2.698)	0.042	1.879 (1.093–3.229)	0.022	
 ≥ 60	1.388 (0.781–2.467)	0.263	1.738 (0.891–3.392)	0.105	
Body mass index (kg/m2)	
 < 18.5	0.374 (0.201–0.697)	0.002	0.378 (0.191–0.747)	0.005	
 18.5–23.9	1		1		
 24.0–27.9	0.432 (0.276–0.675)	 < 0.001	0.434 (0.269–0.700)	0.001	
 > 28.0	0.581 (0.255–1.326)	0.197	0.834 (0.344–2.021)	0.688	
Residence	
 Urban	1.593 (1.032–2.459)	0.035	1.351 (0.836–2.182)	0.219	
 Rural	1				
Education	
 High school/ technical secondary school and below	1				
 Junior college/ undergraduate and above	1.447 (0.988–2.121)	0.058			
Working status	
 Employed	1				
 Unemployed	0.836 (0.546–1.281)	0.412			
Mean monthly household income (CNY)	
  < 5000	1				
 5000–10,000	1.376 (0.907–2.088)	0.133			
 ≥ 100,00	1.158 (0.681–1.971)	0.588			
Indication for hemodialysis	
 Glomerular disease	1				
 Hypertensive kidney injury	0.905 (0.545–1.502)	0.698			
 Diabetic nephropathy	1.076 (0.583–1.984)	0.815			
 Other	1.209 (0.738–1.983)	0.451			
Hemodialysis vintage (months)	
 ≤ 36	1				
 > 36	1.092 (0.752–1.584)	0.645			
Hemodialysis protocol (days per week)	
 2	1				
 ≥ 3	0.733 (0.401–1.339)	0.312			

Discussion

This study showed that the patients on hemodialysis had adequate knowledge, positive attitudes, and proactive practices toward nutritional support; however, there were several gaps in knowledge and misconceptions regarding proper nutritional self-management.

Men were over-represented in the present study, which is consistent with the higher frequency of renal replacement therapy in men than in women observed worldwide21,22. The knowledge, attitude, and practice scores were relatively high in the present study. They were higher than those reported in a study conducted in South Africa that identified poor knowledge in 49.4% of the participants, negative attitudes in 60.0%, and poor adherence to the renal diet in 61.4%17. Similar results were observed in Iran among patients with type 2 diabetes mellitus on hemodialysis15. A study in India showed that although most hemodialysis patients had excellent renal diet-related knowledge, most did not adhere to it16. A study in Fiji showed high knowledge, attitude, and practice levels in 61.8%, 63.6%, and 88.4% of their participants, respectively18.

In this study, most participants had good knowledge regarding the nutrients they needed to avoid or consume to enrich their diets, which is similar to studies in the United Kingdom23 and South Africa17. On the other hand, approximately half of the participants showed inadequate knowledge of the phosphorus content in specific foods, which is important since excess minerals can cause side effects23. At the same time, previous studies have shown that knowledge of proper nutrition is relatively low in the general population in China24–26. Hyperphosphatemia is one of the most common and severe complications of ESRD27; however, the participants in the present study showed good knowledge of potassium intake. Although the score for knowledge regarding adequate daily protein intake was > 70%, this aspect might require improvements.

This study found that three-fifths of the participants had a low education level, and higher education was independently associated with higher knowledge scores. Health literacy is well known to be associated with socioeconomic status27,28, so this could explain low health literacy. Older age was also independently associated with lower knowledge, as supported by a review highlighting older age as a risk factor for low health literacy29, which could also be related to the differences in the education older people received when they were young, the use of modern technologies, and interest in the outside world.

In the present study, most participants had good attitudes toward nutrition support during hemodialysis. The knowledge score was independently associated with the attitude scores, as supported by the KAP framework that proper knowledge helps cultivate positive attitudes30,31. Nevertheless, it has been suggested that patients with a poor attitude should receive nutrition education, irrespective of their knowledge level32. Indeed, 29–35% of the patients in the United States of America had a good knowledge of the renal diet but considered that the renal diet interferes with their life (i.e., negative attitudes)33. This was also observed in the present study, where 37.53% of the participants considered it hard to change their dietary habits (item A6), and 34.18% thought that the restrictions made them anxious and irritable (item A7). The female gender was also independently associated with lower attitude scores. A previous review showed that women generally had better attitudes toward the renal diet than males34. In fact, only one study showed that males were more likely to adhere to the diet35. The present study did not examine the causes of these differences, which would be an interesting avenue for future studies. Being overweight was associated with lower practice scores, which is possibly related to a lower willingness to change dietary habits. Excess weight is a well-known barrier to lifestyle changes36,37. The knowledge and attitudes scores were independently associated with the practice scores. These results are in line with the KAP framework, stating that knowledge is the basis for practice while attitude is the force driving practice30,31. Age 51–60 was independently associated with higher practice, which could be related to a will to prolong life and quality of life.

The present study suggested that the KAP scores were correlated with each other, the knowledge scores were independently associated with the attitude and practice scores, and the attitude scores were independently associated with the practice scores. An interventional study reported that a KAP-based educational intervention improved patients’ knowledge of hemodialysis38. Hence, improving knowledge should theoretically also improve attitudes and practice; however, this is somewhat debatable since some studies have found a relationship between knowing dietary restrictions and support, while others have not32,33,39. Nonetheless, accurate nutrition knowledge may be fundamental when patients are ready to make dietary changes23.

The present study has several limitations. Although it was performed at a high-volume hemodialysis center, this was a single-center study with a limited number of participants from a single city, limiting the generalizability of the results. Local investigators developed the questionnaire according to the local reality, which further limits the external validity of the questionnaire. In addition, there were no questions on other aspects of CKD management, such as drugs. KAP studies provide insight into a given population at a precise time. This was a cross-sectional study, and as such, it could not identify the risk factors for poor adherence, but the results could serve as a baseline to evaluate the effect of future education interventions30,31. In addition, all KAP surveys are at risk of social desirability bias, as the participants can be tempted to answer what is socially expected instead of what is real40,41.

Conclusion

Patients on hemodialysis showed adequate knowledge, positive attitudes, and proactive practices; however, there were several gaps in knowledge and misconceptions regarding proper nutritional self-management. Older age was associated with poorer knowledge, while higher education was associated with a higher level of knowledge. Better knowledge was associated with more positive attitudes, while female gender was associated with more negative attitudes. A higher level of knowledge and attitude and age 51–60 were associated with better practice, while a higher BMI was associated with poorer practice. It is crucial to address these gaps and misconceptions through carefully designed and effectively implemented education to provide comprehensive guidance on optimal nutrition and self-management strategies.

Methods

Study design and participants

This cross-sectional study enrolled hemodialysis patients treated at the West China Hospital of Sichuan University between January and March 2023. The inclusion criteria were: age ≥ 18 years (i.e., the age of majority in China), regular outpatient maintenance hemodialysis (MHD) treatment duration of ≥ 3 months, clear consciousness, ability to read and understand Chinese, and providing informed consent. The exclusion criteria were critical condition, physical mobility impairment, emergency hemodialysis, or inability to complete the questionnaire due to severe visual and hearing dysfunction.

This study was approved by the Biomedical Ethics Committee of West China Hospital, Sichuan University [2021–1194], and all participants provided written informed consent. All methods were performed following the relevant guidelines and regulations.

Questionnaire

A self-administered questionnaire was developed based on the previous literature42,43. The questionnaire was pretested on 52 participants, revealing a Cronbach’s α of 0.770 and Kaiser–Meyer–Olkin (KMO) of 0.832, indicating good internal consistency. The pretest results were not included in the final analysis.

The final version of the questionnaire was in the Chinese language (a version translated into English was attached as an Appendix), and it contained four dimensions: demographic characteristics (11 items), knowledge dimension, attitude dimension, and practice dimension. The knowledge dimension consisted of 13 questions, where 1 point was assigned for the correct answer and 0 points for the wrong or unclear answer, with a final score ranging from 0 to 13 points. The attitude dimension included eight questions that were evaluated on a 5-point Likert scale, with the positive attitude questions being forward-assigned from strongly agree to strongly disagree on a scale of 5 points to 1 point and the negative attitude questions (items A5‒A7) being reverse-assigned, with scores ranging from 8 to 40 points. The practice dimension consisted of eight questions evaluated on a 5-point Likert scale, where 5 to 1 points were assigned from always to never, with a final score range of 8‒40 points. Adequate knowledge, positive attitude, and proactive practice were defined by a score > 70%44 of the maximum range of the total score for each dimension.

Questionnaire distribution and quality control

The questionnaires were administered to patients visiting the hospital through convenience sampling. Convenience sampling was used because the patients were enrolled when they presented at the hospital for treatments or consultation, and it was convenient for the personnel to enroll the patients without disturbing the clinical activities. It was also convenient for the patient to complete the questionnaire. No active prescreening or patient identification was performed. No active effort was made to contact a patient who was absent on a given day. Only their availability and that of the study staff were considered. During the investigation, the researchers avoided bothering patients during eating, treatment, and rest time. They explained the purpose, content, and significance of the study to the survey subjects and obtained informed consent from them. All patients participated voluntarily and had the right to withdraw at any time. The questionnaire was completed independently by the respondents. If there were any difficulties in understanding the questionnaire, the participants were instructed to ask the researchers who would explain all the uncertainties. All questionnaires were issued on the spot, recovered, and checked. The missing or wrong items were supplemented in a timely manner to ensure the accuracy, authenticity, and integrity of data. The electronic questionnaires were created using Sojump (https://www.wjx.cn/) and distributed to the study participants. A QR code for the electronic questionnaire was generated, and the participants could log in and fill in the questionnaire by scanning the QR code sent via WeChat. In order to ensure the quality and completeness of the questionnaire results, each IP address could only submit one questionnaire, and all items were made mandatory. The researcher assisted in answering the queries from the study participants and checked all questionnaires for completeness, internal consistency, and reasonableness. Questionnaires with any contradictory logic or incomplete responses were considered invalid.

Statistical analysis

SPSS 22.0 (IBM Corp., Armonk, NY, USA) was used for analysis. Continuous variables with a normal distribution were expressed as the mean ± standard deviation (SD) and were analyzed using Student’s t-test or one-way analysis of variance (ANOVA). Participants were divided into age groups as follows: < 40 years, including the children (0–19 years old) and the youth group (20–39 years old); 40–49 and 50–59 years, including the adult group grouped for every decade (40–59); ≥ 60 years, including older individuals (> 60 years old), according to the “Age-Based Grouping Criteria in Medicine45”. Categorical data were presented as n (%) and were analyzed using the chi-square test. Variables in univariable analysis with P < 0.0546 were included in multivariable logistics regression analysis. Multivariable logistic regression (enter method) was conducted to analyze the risk factors associated with KAP. Two-sided P < 0.05 was considered statistically significant46.

Supplementary Information

Supplementary Information 1.

Supplementary Information 2.

Supplementary Information 3.

Supplementary Information 4.

Supplementary Information 5.

Supplementary Information 6.

Supplementary Information

The online version contains supplementary material available at 10.1038/s41598-024-72366-3.

Acknowledgements

None.

Author contributions

Y.P. conceived and designed the study and contributed to the writing and revision. Q.H. and Y.Y. performed data collection and data analysis. L.Z. assisted in data analysis and made contributions to visualization. H.Y. supported funding acquisition and revised the manuscript.

Funding

This work was supported by the Sichuan University West China Nursing Discipline Development Special Fund Project [HXHL21015] and the 1.3.5 Project for Disciplines of Excellence from West China Hospital of Sichuan University [ZYGD23015].

Data availability

The published article and related supplementary information files include all data generated or analyzed during this study.

Competing interests

The authors declare no competing interests.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
==== Refs
References

1. National Kidney F KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update Am. J. Kidney Dis. 2015 66 884 930 10.1053/j.ajkd.2015.07.015 26498416
National Kidney, F. KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update. Am. J. Kidney Dis. 66, 884–930 (2015).26498416
2. Himmelfarb J Ikizler TA Hemodialysis N. Engl. J. Med. 2010 363 1833 1845 10.1056/NEJMra0902710 21047227
Himmelfarb, J. & Ikizler, T. A. Hemodialysis. N. Engl. J. Med. 363, 1833–1845 (2010).21047227
3. Wiser NA Shane JM McGuigan AT Memken JA Olsson PJ The effects of a group nutrition education program on nutrition knowledge, nutrition status, and quality of life in hemodialysis patients J. Ren. Nutr. 1997 7 187 193 10.1016/S1051-2276(97)90017-0
Wiser, N. A., Shane, J. M., McGuigan, A. T., Memken, J. A. & Olsson, P. J. The effects of a group nutrition education program on nutrition knowledge, nutrition status, and quality of life in hemodialysis patients. J. Ren. Nutr. 7, 187–193 (1997).
4. Sahathevan S Understanding development of malnutrition in hemodialysis patients: A narrative review Nutrients 2020 12 3147 10.3390/nu12103147 33076282
Sahathevan, S. et al. Understanding development of malnutrition in hemodialysis patients: A narrative review. Nutrients 12, 3147 (2020).33076282
5. Choi HY Ha SK Potassium balances in maintenance hemodialysis Electrolyte Blood Press. 2013 11 9 16 10.5049/EBP.2013.11.1.9 23946760
Choi, H. Y. & Ha, S. K. Potassium balances in maintenance hemodialysis. Electrolyte Blood Press. 11, 9–16 (2013).23946760
6. Anderson J Peterson K Bourne D Boundy E VA Evidence Synthesis Program Reports. Evidence Brief: Use of Intradialytic Parenteral Nutrition (IDPN) to Treat Malnutrition in Hemodialysis Patients 2011 Department of Veterans Affairs (US)
Anderson, J., Peterson, K., Bourne, D. & Boundy, E. VA Evidence Synthesis Program Reports. Evidence Brief: Use of Intradialytic Parenteral Nutrition (IDPN) to Treat Malnutrition in Hemodialysis Patients (Department of Veterans Affairs (US), 2011).
7. Sabatino A Dietary protein and nutritional supplements in conventional hemodialysis Semin. Dial. 2018 31 583 591 10.1111/sdi.12730 29909606
Sabatino, A. et al. Dietary protein and nutritional supplements in conventional hemodialysis. Semin. Dial. 31, 583–591 (2018).29909606
8. Ikizler TA Prevention and treatment of protein energy wasting in chronic kidney disease patients: A consensus statement by the International Society of Renal Nutrition and Metabolism Kidney Int. 2013 84 1096 1107 10.1038/ki.2013.147 23698226
Ikizler, T. A. et al. Prevention and treatment of protein energy wasting in chronic kidney disease patients: A consensus statement by the International Society of Renal Nutrition and Metabolism. Kidney Int. 84, 1096–1107 (2013).23698226
9. Kistler BM Eating during hemodialysis treatment: A consensus statement from the international society of renal nutrition and metabolism J. Ren. Nutr. 2018 28 4 12 10.1053/j.jrn.2017.10.003 29249295
Kistler, B. M. et al. Eating during hemodialysis treatment: A consensus statement from the international society of renal nutrition and metabolism. J. Ren. Nutr. 28, 4–12 (2018).29249295
10. Stark S Nutritional intake in adult hemodialysis patients Top. Clin. Nutr. 2011 26 45 56 10.1097/TIN.0b013e3181faba4c 25104876
Stark, S. et al. Nutritional intake in adult hemodialysis patients. Top. Clin. Nutr. 26, 45–56 (2011).25104876
11. Günes FE Hiromichi S Medical nutrition therapy for hemodialysis patients Hemodialysis 2013 IntechOpen Ch. 2
Günes, F. E. Medical nutrition therapy for hemodialysis patients. In Hemodialysis (ed. Hiromichi, S.) Ch. 2 (IntechOpen, 2013).
12. Piccoli GB Intradialytic nutrition and hemodialysis prescriptions: A personalized stepwise approach Nutrients 2020 12 785 10.3390/nu12030785 32188148
Piccoli, G. B. et al. Intradialytic nutrition and hemodialysis prescriptions: A personalized stepwise approach. Nutrients 12, 785 (2020).32188148
13. Badrasawi M Prevalence and correlates of malnutrition among hemodialysis patients at hebron governmental hospital, Palestine: Cross-sectional study BMC Nephrol. 2021 22 214 10.1186/s12882-021-02413-y 34098899
Badrasawi, M. et al. Prevalence and correlates of malnutrition among hemodialysis patients at hebron governmental hospital, Palestine: Cross-sectional study. BMC Nephrol. 22, 214 (2021).34098899
14. Visiedo L The impact of nutritional status on health-related quality of life in hemodialysis patients Sci. Rep. 2022 12 3029 10.1038/s41598-022-07055-0 35194119
Visiedo, L. et al. The impact of nutritional status on health-related quality of life in hemodialysis patients. Sci. Rep. 12, 3029 (2022).35194119
15. Ghannadi S Evaluating the effect of knowledge, attitude, and practice on self-management in type 2 diabetic patients on dialysis J. Diabetes Res. 2016 2016 3730875 10.1155/2016/3730875 27478845
Ghannadi, S. et al. Evaluating the effect of knowledge, attitude, and practice on self-management in type 2 diabetic patients on dialysis. J. Diabetes Res. 2016, 3730875 (2016).27478845
16. Kanagarajah S Velraja S Arambakkam H Knowledge, attitude, and practices of renal diets among hemodialysis patients Biomed. Biotech. Res. J. 2022 6 86 10.4103/bbrj.bbrj_200_21
Kanagarajah, S., Velraja, S. & Arambakkam, H. Knowledge, attitude, and practices of renal diets among hemodialysis patients. Biomed. Biotech. Res. J. 6, 86 (2022).
17. Spies HC van den Berg VL Nel M Knowledge, attitude and practices of patients receiving maintenance haemodialysis in Bloemfontein, South Africa S. Afr. J. Clin. Nutr. 2021 34 116 122
Spies, H. C., van den Berg, V. L. & Nel, M. Knowledge, attitude and practices of patients receiving maintenance haemodialysis in Bloemfontein, South Africa. S. Afr. J. Clin. Nutr. 34, 116–122 (2021).
18. Zibran MA Mohammadnezhad M Management of type 2 diabetes and chronic kidney disease in Fiji in 2018: Knowledge, attitude, and practice of patients Rev. Diabet. Stud. 2019 15 26 34 10.1900/RDS.2019.15.26 31132078
Zibran, M. A. & Mohammadnezhad, M. Management of type 2 diabetes and chronic kidney disease in Fiji in 2018: Knowledge, attitude, and practice of patients. Rev. Diabet. Stud. 15, 26–34 (2019).31132078
19. Sahu G The act of prevention: Knowledge, attitudes, and perception among caretakers of kidney disease patients in Rural Wardha District of Central India Cureus 2022 14 e23058 35419237
Sahu, G. et al. The act of prevention: Knowledge, attitudes, and perception among caretakers of kidney disease patients in Rural Wardha District of Central India. Cureus 14, e23058 (2022).35419237
20. Eirini G Georgia G Mollaoglu M Caregivers of patients on haemodialysis Caregiving and Home Care 2017 IntechOpen
Eirini, G. & Georgia, G. Caregivers of patients on haemodialysis. In Caregiving and Home Care (ed. Mollaoglu, M.) (IntechOpen, 2017).
21. Fernandez-Prado R Fernandez-Fernandez B Ortiz A Women and renal replacement therapy in Europe: Lower incidence, equal access to transplantation, longer survival than men Clin. Kidney J. 2018 11 1 6 10.1093/ckj/sfx154 29423194
Fernandez-Prado, R., Fernandez-Fernandez, B. & Ortiz, A. Women and renal replacement therapy in Europe: Lower incidence, equal access to transplantation, longer survival than men. Clin. Kidney J. 11, 1–6 (2018).29423194
22. Hecking M Sex-specific differences in mortality and incident dialysis in the chronic kidney disease outcomes and practice patterns study Kidney Int. Rep. 2022 7 410 423 10.1016/j.ekir.2021.11.018 35257054
Hecking, M. et al. Sex-specific differences in mortality and incident dialysis in the chronic kidney disease outcomes and practice patterns study. Kidney Int. Rep. 7, 410–423 (2022).35257054
23. Durose CL Holdsworth M Watson V Przygrodzka F Knowledge of dietary restrictions and the medical consequences of noncompliance by patients on hemodialysis are not predictive of dietary compliance J. Am. Diet. Assoc. 2004 104 35 41 10.1016/j.jada.2003.10.016 14702581
Durose, C. L., Holdsworth, M., Watson, V. & Przygrodzka, F. Knowledge of dietary restrictions and the medical consequences of noncompliance by patients on hemodialysis are not predictive of dietary compliance. J. Am. Diet. Assoc. 104, 35–41 (2004).14702581
24. Huang Z Huang B Huang J The relationship between nutrition knowledge and nutrition facts table use in China: A structural equation model Int. J. Environ. Res. Public Health 2021 18 6307 10.3390/ijerph18126307 34200804
Huang, Z., Huang, B. & Huang, J. The relationship between nutrition knowledge and nutrition facts table use in China: A structural equation model. Int. J. Environ. Res. Public Health 18, 6307 (2021).34200804
25. Sun Y Dong D Ding Y The impact of dietary knowledge on health: Evidence from the China Health and Nutrition Survey Int. J. Environ. Res. Public Health 2021 18 3736 10.3390/ijerph18073736 33918505
Sun, Y., Dong, D. & Ding, Y. The impact of dietary knowledge on health: Evidence from the China Health and Nutrition Survey. Int. J. Environ. Res. Public Health 18, 3736 (2021).33918505
26. Cui B Correlation between dietary information sources and knowledge of adequate diets in Eastern China Front. Public Health 2022 10 955766 10.3389/fpubh.2022.955766 36249194
Cui, B. et al. Correlation between dietary information sources and knowledge of adequate diets in Eastern China. Front. Public Health 10, 955766 (2022).36249194
27. Svendsen MT Associations of health literacy with socioeconomic position, health risk behavior, and health status: A large national population-based survey among Danish adults BMC Public Health 2020 20 565 10.1186/s12889-020-08498-8 32345275
Svendsen, M. T. et al. Associations of health literacy with socioeconomic position, health risk behavior, and health status: A large national population-based survey among Danish adults. BMC Public Health 20, 565 (2020).32345275
28. Zimmerman, E. & Woolf, S. H. Understanding the relationship between education and health. NAM Perspect. Discussion Paper, National Academy of Medicine, (Washington,DC, 2014).
29. Chesser AK Keene Woods N Smothers K Rogers N Health literacy and older adults: A systematic review Gerontol. Geriatr. Med. 2016 2 2333721416630492 10.1177/2333721416630492 28138488
Chesser, A. K., Keene Woods, N., Smothers, K. & Rogers, N. Health literacy and older adults: A systematic review. Gerontol. Geriatr. Med. 2, 2333721416630492 (2016).28138488
30. Andrade C Menon V Ameen S KumarPraharaj S Designing and conducting knowledge, attitude, and practice surveys in psychiatry: Practical guidance Indian J. Psychol. Med. 2020 42 478 481 10.1177/0253717620946111 33414597
Andrade, C., Menon, V., Ameen, S. & KumarPraharaj, S. Designing and conducting knowledge, attitude, and practice surveys in psychiatry: Practical guidance. Indian J. Psychol. Med. 42, 478–481 (2020).33414597
31. World Health Organization. Advocacy, communication and social mobilization for TB control: A guide to developing knowledge, attitude and practice surveys. http://whqlibdoc.who.int/publications/2008/9789241596176_eng.pdf. Accessed November 22, 20222008.
32. Macias, Y. F. & Glasauer, P. Guidelines for assessing nutrition-related knowledge, attitudes and practices manual. www.fao.org/docrep/019/i3545e/i3545e00.htm. (2014).
33. Lopez CM Burrowes JD Gizis F Dietary adherence in Hispanic patients receiving hemodialysis J. Ren. Nutr. 2007 17 138 147 10.1053/j.jrn.2006.12.004 17321954
Lopez, C. M., Burrowes, J. D. & Gizis, F. Dietary adherence in Hispanic patients receiving hemodialysis. J. Ren. Nutr. 17, 138–147 (2007).17321954
34. Lambert K Mullan J Mansfield K An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease BMC Nephrol. 2017 18 318 10.1186/s12882-017-0734-z 29061163
Lambert, K., Mullan, J. & Mansfield, K. An integrative review of the methodology and findings regarding dietary adherence in end stage kidney disease. BMC Nephrol. 18, 318 (2017).29061163
35. Saran R Nonadherence in hemodialysis: Associations with mortality, hospitalization, and practice patterns in the DOPPS Kidney Int. 2003 64 254 262 10.1046/j.1523-1755.2003.00064.x 12787417
Saran, R. et al. Nonadherence in hemodialysis: Associations with mortality, hospitalization, and practice patterns in the DOPPS. Kidney Int. 64, 254–262 (2003).12787417
36. Helland MH Nordbotten GL Dietary changes, motivators, and barriers affecting diet and physical activity among overweight and obese: A mixed methods approach Int. J. Environ. Res. Public Health 2021 18 10582 10.3390/ijerph182010582 34682331
Helland, M. H. & Nordbotten, G. L. Dietary changes, motivators, and barriers affecting diet and physical activity among overweight and obese: A mixed methods approach. Int. J. Environ. Res. Public Health 18, 10582 (2021).34682331
37. Taylor WC Readiness to change physical activity and dietary practices and willingness to consult healthcare providers Health Res. Policy Syst. 2004 2 2 10.1186/1478-4505-2-2 15191611
Taylor, W. C. et al. Readiness to change physical activity and dietary practices and willingness to consult healthcare providers. Health Res. Policy Syst. 2, 2 (2004).15191611
38. Liu L Liu YP Wang J An LW Jiao JM Use of a knowledge-attitude-behaviour education programme for Chinese adults undergoing maintenance haemodialysis: Randomized controlled trial J. Int. Med. Res. 2016 44 557 568 10.1177/0300060515604980 26951842
Liu, L., Liu, Y. P., Wang, J., An, L. W. & Jiao, J. M. Use of a knowledge-attitude-behaviour education programme for Chinese adults undergoing maintenance haemodialysis: Randomized controlled trial. J. Int. Med. Res. 44, 557–568 (2016).26951842
39. St-Jules DE Woolf K Pompeii ML Sevick MA Exploring problems in following the hemodialysis diet and their relation to energy and nutrient intakes: The balance wise study J. Ren. Nutr. 2016 26 118 124 10.1053/j.jrn.2015.10.002 26586249
St-Jules, D. E., Woolf, K., Pompeii, M. L. & Sevick, M. A. Exploring problems in following the hemodialysis diet and their relation to energy and nutrient intakes: The balance wise study. J. Ren. Nutr. 26, 118–124 (2016).26586249
40. Bergen N Labonte R "Everything is perfect, and we have no problems": Detecting and limiting social desirability bias in qualitative research Qual. Health Res. 2020 30 783 792 10.1177/1049732319889354 31830860
Bergen, N. & Labonte, R. “Everything is perfect, and we have no problems”: Detecting and limiting social desirability bias in qualitative research. Qual. Health Res. 30, 783–792 (2020).31830860
41. Latkin CA Edwards C Davey-Rothwell MA Tobin KE The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland Addict. Behav. 2017 73 133 136 10.1016/j.addbeh.2017.05.005 28511097
Latkin, C. A., Edwards, C., Davey-Rothwell, M. A. & Tobin, K. E. The relationship between social desirability bias and self-reports of health, substance use, and social network factors among urban substance users in Baltimore, Maryland. Addict. Behav. 73, 133–136 (2017).28511097
42. Ikizler TA KDOQI clinical practice guideline for nutrition in CKD: 2020 update Am. J. Kidney Dis. 2020 76 S1 S107 10.1053/j.ajkd.2020.05.006 32829751
Ikizler, T. A. et al. KDOQI clinical practice guideline for nutrition in CKD: 2020 update. Am. J. Kidney Dis. 76, S1–S107 (2020).32829751
43. Chan W Chronic kidney disease and nutrition support Nutr. Clin. Pract. 2021 36 312 330 10.1002/ncp.10658 33734473
Chan, W. Chronic kidney disease and nutrition support. Nutr. Clin. Pract. 36, 312–330 (2021).33734473
44. Doshi D Reddy BS Kulkarni S Karunakar P Breast self-examination: Knowledge, attitude, and practice among female dental students in Hyderabad City, India Indian J. Palliat. Care 2012 18 68 73 10.4103/0973-1075.97476 22837614
Doshi, D., Reddy, B. S., Kulkarni, S. & Karunakar, P. Breast self-examination: Knowledge, attitude, and practice among female dental students in Hyderabad City, India. Indian J. Palliat. Care 18, 68–73 (2012).22837614
45. Yu W Zhang ZZ Age-based grouping criteria in medicine Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2023 45 285 289 37157077
Yu, W. & Zhang, Z. Z. Age-based grouping criteria in medicine. Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 45, 285–289 (2023).37157077
46. Thiese MS Ronna B Ott U P value interpretations and considerations J. Thorac. Dis. 2016 8 E928 e931 10.21037/jtd.2016.08.16 27747028
Thiese, M. S., Ronna, B. & Ott, U. P value interpretations and considerations. J. Thorac. Dis. 8, E928-e931 (2016).27747028
