Psychosocial factors affecting the adherence of chronic kidney disease patients to undergo a hemodialysis program: a cross-sectional study

Introduction: : Chronic kidney disease (CKD) patients are often not adherent to undergoing hemodialysis programs. Psychosocial factors, such as knowledge, motivation, coping skills, support from the family and health workers, and depression are the main factors that influence hemodialysis program adherence, which has an impact on successful treatment. This study aims to analyze the effect of psychosocial factors on hemodialysis program adherence. Methods: The study was cross-sectional, with a sample size of 90 respondents, obtained through simple random sampling. The study’s dependent variable was hemodialysis program adherence and the independent variables were knowledge, motivation, coping, depression, perceived family support and health worker support. Data were collected using a questionnaire and analyzed using multiple linear regression. Results: Most respondents adhered to the hemodialysis program (90%). The level of knowledge, motivation, coping, family support, and health worker support was in the good category (93.3%; 100%; 91.1%; 90%; 88.9%, respectively), and did not experience depression (90%). The independent variables (knowledge, motivation, coping, family support, health worker support) simultaneously significantly affected the dependent variable, namely adherence to the hemodialysis program by 94.5% (R2 = 0.945; F = 236.613; p = 0.001). Partially, the factors of knowledge, motivation, coping, family support, health workers support, and depression also had a significant effect on hemodialysis program adherence (t = 2.234, t = 5.344, t = 3.473, t = -4.190, t = 6.457, t = 4.887, t = 4.190, respectively; p = 0.001). Conclusions: The study results showed that psychosocial factors (knowledge, motivation, coping, family support, health worker support, and depression) simultaneously or partially influenced the adherence of CKD patients to undergo a hemodialysis program, with the most dominant factor affecting adherence to hemodialysis as perceived family support. Nurses must pay attention to the psychosocial factors of CKD patients in hemodialysis services to increase their adherence to the hemodialysis program and improve the outcomes.


Introduction
Chronic kidney disease (CKD) is an enormous global health problem, with the number of sufferers reaching 850 million people by 2022, or 10% of the world population, an increase compared to 2017, when there were only 697.5 million people.Indonesia is one of the countries in the Oceania and South East Asia-ISN region with an estimated prevalence of 10.44% (International Society of Nephrology, 2023).Based on the Indonesian Basic Health Research (RISKESDAS), in 2018, 713,783 CKD cases were reported, and East Java was ranked second nationally with 113,045 cases (Ministry of Health Republic of Indonesia, 2019).In the condition of kidney failure, which is the fifth stage or end stage of CKD, patients need kidney replacement therapy, namely transplant or dialysis (hemodialysis or peritoneal dialysis).However, many CKD patients still do not get the proper treatment, namely hemodialysis programs, especially in lower-middle-income countries such as Indonesia (International Society of Nephrology, 2023).Only 19.33% received hemodialysis treatment in Indonesia; for the province of East Java, it was higher, namely 23.14% (Ministry of Health Republic of Indonesia, 2019).However, the percentage shows that hemodialysis services in East Java province are higher than the national percentage.However, there are still 76.86% of CKD patients who have not received hemodialysis services.Limited access to hemodialysis causes enhanced mortality in CKD patients.The mortality rate was higher in lower-middle-income countries than the global mortality rate (2.6% vs. 2.4%).The mortality rate among CKD patients in Indonesia was 2.47%, which shows that the mortality rate is higher than the global mortality rate (International Society of Nephrology, 2023).The Secretary of the Directorate General of Disease Prevention and Control, Ministry of Health of the Republic of Indonesia said that the death rate in 2019 was 2.35% (1.4 million people), increasing to 3.5% (8.7 million people) in 2023 (Quality Division of PKMK FK UGM, 2024) A hemodialysis program's success in achieving positive health outcomes in CKD patients is due to their adherence.Low adherence to undergoing a hemodialysis program causes failure to achieve the goals of the hemodialysis program, thus increasing morbidity and mortality (International Society of Nephrology, 2023).Several previous studies showed that adherence of CKD patients undergoing a hemodialysis program is still low, that is only 49.6 -55.96% (Naalweh et al., 2017;Mukakarangwa et al., 2020;Alzahrani and Al-Khattabi, 2021;Jemali, Munyua and Atoni, 2023).Previous studies in Indonesia also showed the same results, with only 44.2 -60% of CKD patients undergoing a hemodialysis program (Alisa and Wulandari, 2019;Agu and Tambunan, 2024).Previous studies showed that psychosocial factors were the most dominant influencing CKD patients' adherence to hemodialysis (Cardol et al., 2022;Wen et al., 2023;Yasin et al., 2024).Good knowledge enhances CKD patients' adherence to undergoing a hemodialysis program (Alisa and Wulandari, 2019;Cardol et al., 2022;Mirzaei-Alavijeh et al., 2023;Xu et al., 2023;Yasin et al., 2024).Motivation can influence the behavior of CKD patients.Higher motivation in undergoing a hemodialysis program then will increase adherence to hemodialysis program (Ok and Kutlu, 2021;Cardol et al., 2022;Mirzaei-Alavijeh et al., 2023;Agu and Tambunan, 2024).
However, several other previous studies have shown different results with research results stating that knowledge is unrelated to attitude when undergoing hemodialysis (Xu et al., 2023) and improved adherence in CKD patients (Alikari et al., 2019;Dsouza et al., 2023).Motivation does not always relate to treatment adherence with previous studies having mentioned that motivation is unrelated to the coping of CKD patients undergoing hemodialysis (Melastuti et al., 2022;Zher and Bahari, 2022).Moreover, neither does coping has a positive relationship with adherence to hemodialysis and positive attitude to hemodialysis did not have a significant relationship with hemodialysis adherence (Sheikh et al., 2022;Alhamad et al., 2023).Experience of depression by CKD does not influence their adherence to hemodialysis (Fotaraki et al., 2022;Zher and Bahari, 2022;Jemali, Munyua and Atoni, 2023).Previous studies also showed that social support does not always relate to adherence of CKD patients undergoing hemodialysis.High family support is not always correlated with positive adherence (Al atawi and Alaamri, 2021;Sultan, Fouad and Zaki, 2022).Likewise, support from health workers is not always correlated positively with adherence to CKD patients undergoing hemodialysis (Alhamad et al., 2023).Based on the results of several previous studies, it shows that there was inconsistency in the influence of psychosocial factors, namely knowledge, motivation, coping, depression, family support and support from health workers on the adherence of CKD patients undergoing hemodialysis.Therefore, the study aims to analyze the influence of psychosocial factors on adherence of CKD patients undergoing hemodialysis.

Instruments
Data were collected using a questionnaire.CKD patients' adherence to a hemodialysis program was measured using the adherence to undergo hemodialysis questionnaire adapted from The Greek Simplified Medication Adherence Questionnaire for Hemodialysis Patients (Alikari et al., 2017).The questionnaire was translated into Indonesian and was then back-translated by the researcher.The result of the validity test showed that all items were valid (r = 0.512 -0.888 > r table = 0.361 (n = 30) and reliable (Cronbach's alpha = 0.872).This questionnaire consists of eight (8) items, namely medication adherence (4 items), presence session hemodialysis (2 items), diet and fluid management adherence (2 items), with a Guttman scale (yes/no) and Likert (0 -2).Hemodialysis program adherence was categorized into non-adherence (<4) and adherence (4).

Data collection
At the data collection stage, the researcher determines candidate respondents based on criteria inclusion and exclusion study.The researcher explains to the candidate respondents a description of the general study, aims, benefits, research procedures, and data confidentiality, and there is no coercion for the following involved in the study.The researcher gives an informed consent form to the candidate respondents as a form of agreement.Assuming the candidate respondent agrees to participate in the study, the researcher asks the candidate respondent to sign the consent form as a study respondent.The data were collected once through an interview directly with the respondents (the researcher read each question in the questionnaire to the respondents).Respondents underwent the hemodialysis process, and patients stated that they were allowed to go home to home by a doctor.There was no bias in data collection; respondents were in compos mentis and not uremic conditions (normal blood urea nitrogen level: 5 to 20 mg/dl or 1.8 to 7.1 mmol/L).Respondents did not fill in the questionnaire by themselves; however, the researcher read every question to the respondents, then noted down and filled in every answer given by respondents in the questionnaire.Duration time of data collection for each respondent was  30 -45 minutes.

Data analysis
The researcher analyzed the data using descriptive statistics and inferential statistics.The researcher conducted descriptive statistics to describe the respondents' sociodemographic data and study variables, categorized as frequency distributions.The researcher also performed inferential statistics with multiple linear regression tests to analyze the effect of independent variables on the dependent variable (numeric data).Thus, the researcher used categorical data for descriptive analysis, and numerical data (total score of each respondent) for statistical analysis.In addition, the researcher also conducted a chi-square test to explore differences in adherence to undergoing hemodialysis programs based on independent factors that had been categorized (categorical data) to enrich the discussion.The researcher carried out classic assumption tests, multicollinearity, heteroscedasticity, autocorrelation and normality as multiple linear regression test requirements.After testing the classic assumptions test, the researcher continued with the multiple linear regression test (= 0.05).

Ethical consideration
The study was conducted by upholding human rights and applying ethical principles.The researcher provided direct explanations to prospective respondents about the general description, objectives, benefits, risks, right to withdraw, and rewards and compensation given to respondents.If prospective respondents agreed to participate in the research, respondents could sign the consent form.There was no coercion on respondents to participate in the study.This study has obtained ethical eligibility from the Health Research Ethics Commission (KEPK) of the Faculty of Nursing, Universitas Jember, with certificate number 246/UN25.1.14/KEPK/2023.

Respondents' characteristics
Table 1 shows the average age of respondents was 46.82 years, with most respondents being in the categories of early elderly (46 -55 years) and elderly (56 -65 years) (28.89%), women (63.33%), primary education level, namely elementary school (33.33%), and had undergone a hemodialysis program for 25 -72 months (55.56%).The research results also showed that most respondents had hemodialysis program adherence in the high category (90%).Psychosocial variables show that most respondents had good knowledge about hemodialysis (93.33%), good coping (91.11%), did not experience depression (90%), had perceived family support and perceived health worker support in the high category (90%; 88.89 %), and all respondents had high motivation to undergo a hemodialysis program (100%) (Table 1).
Differences in CKD patients' adherence to a hemodialysis program based on psychosocial factors (knowledge, motivation, coping, depression, perceived family support, and perceived health worker support) The results of cross-tabulation and chi-square tests show significant differences in adherence of CKD patients to hemodialysis programs based on knowledge, motivation, coping, depression, family support and perceived health worker support (p = 0.001) (Table 2).The study results also showed that 3.33% of CKD patients had good knowledge but did not adhere to hemodialysis programs.Based on motivation, it was seen that, although 10% of CKD patients had high motivation, they did not adhere to undergo hemodialysis programs.Based on the depression variable, it showed that CKD patients who were not depressed showed adherence to undergoing hemodialysis programs (90%).Furthermore, CKD patients who had low perceived family support and health worker support showed non-adherence to undergoing hemodialysis programs (10%; 10%).

Multiple linear regression test results
The results of the classical assumption test show that all variables in this study have met the classical assumption test, namely that the data for each variable have a normal distribution (p > = 0.05), and there is no multicollinearity between independent variables (tolerance value > 0.10; VIF < 10).The autocorrelation test results showed that there was no autocorrelation (Value DW statistics = 1.940 > DW table = 1.8041 (n=90; Independent variables = 6), dL = 1.518,DW= 1.8041).There is no autocorrelation because the value of dU < DW < 4 -dU is 1.8014 < 1.940 < 2.1986.Apart from that, the data also do not show symptoms of heteroscedasticity (p > = 0.05) (Table 3).
The results of the Fisher's test show that the estimated regression model is a fit model that is suitable for use to explain the influence of independent variables simultaneously on the dependent variable (F value = 236.631;p = 0.001 < = 0.05) (Table 4).It means knowledge, motivation, coping, depression, perceived family support, and perceived health worker support simultaneously influence variable adherence of CKD patients to undergo a hemodialysis program.The adjusted R-square value is 0.941.It means the independent variables (knowledge, motivation, coping, depression, perceived family support, and perceived health worker support) influenced the dependent variable (adherence of CKD patients to a hemodialysis program), which amounted to 94.1%.In contrast, other variables outside the model explain the rest, 5.9 % (1 -0.941).Successively, variable knowledge contributed to 8.3%, motivation contributed to 15.2%, coping contributed to 9.6%, depression contributed to 17.2%, perceived family support contributed to 26.7%, and perceived health worker support contributed to 13.9% on adherence of CKD patients undergoing hemodialysis program.The most dominant variable influencing CKD patients' adherence to hemodialysis programs is perceived family support (26%; t = 6.457; p = 0.001), whereas the least dominant variable is knowledge

Discussions
The results show that most respondents aged 46 -65 years, with an average of 46.82 years, were female, had a low education level, and had a history of undergoing a hemodialysis program of 25 -72 months.Most respondents adhered to undergo a hemodialysis program, with most respondents having good knowledgeabout CKD disease and its management, good coping, no experience of depression, high perceived family support and perceived health worker support, and all respondents had high motivationin undergoing a hemodialysis program (Table 1 and Table  2).The study follows previous studies showing that the average age of CKD patients is 45.78 (Zher and Bahari, 2022), with most CKD patients aged over 45 -65 years (Xu et al., 2023).Previous studies stated that the older the CKD patient, the lower the adherence to a hemodialysis program (Zher and Bahari, 2022).Younger CKD patients have a good knowledge, attitudes, and practice of hemodialysis (Xu et al., 2023).However, other studies have stated that poor coping is related to younger age, which impacts lower adherence (Hwang et al., 2018;Ulusoy and Kal, 2020).The study result aligns with previous study, which stated that female CKD patients (Zher and Bahari, 2022) have better hemodialysis adherence than men (Hwang et al., 2018;Sheikh et al., 2022;Alhamad et al., 2023).The study results align with the previous study, which stated that most CKD patients have a low level of education (Mirzaei-Alavijeh et al., 2023).Low education level causes low adherence in CKD patients undergoing hemodialysis (Hwang et al., 2018;Nielsen et al., 2023).
Higher education patients adhere more to hemodialysis (Alhamad et al., 2023;Mirzaei-Alavijeh et al., 2023;Xu et al., 2023).The study aligns with a previous study that stated that most CKD patients have a hemodialysis duration of less than six years, with an average of 5.4 years (Niihata et al., 2017).DCKD patients with a long history of hemodialysis are associated with low adherence (Zher and Bahari, 2022;Alhamad et al., 2023).Patients with a more extended history of hemodialysis had lower hemodialysis practices than those with a shorter history of hemodialysis (Xu et al., 2023).

The Influence of Knowledge on Adherence of CKD Patients to Undergo a Hemodialysis Program
Results show that knowledge significantly affected CKD patients' adherence to hemodialysis programs (Table 4), with most respondents having good knowledge (Table 1).The results align with previous studies stating that knowledge determines adherence to hemodialysis programs.The better their knowledge, the adherence to hemodialysis will be (Alisa and Wulandari, 2019;Cardol et al., 2022;Mirzaei-Alavijeh et al., 2023;Xu et al., 2023;Yasin et al., 2024).Adequate hemodialysis knowledge can be the capital for determining behavior (Sousa et al., 2023;Xu et al., 2023), clarifying appropriate behavior related to hemodialysis so can they increase adherence (Mirzaei-Alavijeh et al., 2023;Mailani et al., 2024).Knowledge about hemodialysis (benefits, therapy schedule, and the impact of non-adherence, etc.) can enhance patient adherence to hemodialysis program (Alisa and Wulandari, 2019;Cardol et al., 2022;Yasin et al., 2024) to improve hemodialysis outcomes (Stømer et al., 2020).Knowledge had a significant influence, but knowledge has a minor impact on adherence to undergoing a hemodialysis program compared to other variables.It can also be seen that there were still three respondents with high knowledge but who had non-adherence to the hemodialysis program (Table 2).Sociodemographic analysis showed that the three respondents were elderly (> 56 years) with a duration of hemodialysis of more than 73 months and low perceived health worker Older age is connected with difficulty accessing health information (Hwang et al., 2018;Mirzaei-Alavijeh et al., 2023).More specifically, even though respondents' overall level of knowledge is high, the knowledge component analysis shows that understanding and awareness of medical resources is of low value.Therefore, it is essential to pay attention to efforts to comprehensively increase patient knowledge by increasing understanding of the results of laboratory tests that have been carried out and their impact on health, as well as increasing CKD patients' knowledge of medical resources, such as access to information and education from health workers so that they can increase positive perceptions of health workers thereby increasing compliance and better outcomes.Health literacy can increase positive perception, adherence, and quality of life (Alzahrani and Al-Khattabi, 2021;Mailani et al., 2024).

The Influence of Motivation on Adherence of CKD Patients to Undergo a Hemodialysis Program
The results show that motivation significantly affected CKD patients' adherence to hemodialysis programs (Table 4), with all respondents having high motivation (Table 1).The study follows previous studies, which stated that motivation can influence the behavior of CKD patients so that it can determine adherence to a hemodialysis program (Ok and Kutlu, 2021;Cardol et al., 2022;Mirzaei-Alavijeh et al., 2023;Agu and Tambunan, 2024).Motivation is the strongest predictor of hemodialysis adherence (Mirzaei-Alavijeh et al., 2023).Enhancement motivation for undergoing treatment facilitates behavior change through positive and supportive treatment (Ok and Kutlu, 2021;Cardol et al., 2022) to achieve positive clinical outcomes (Mukakarangwa et al., 2020).Study results show that, although all respondents have high motivation, nine (9) still did not adhere to a hemodialysis program (Table 2).Sociodemographic analysis showed that non-adherence respondents were CKD patients who were older and male.A previous study stated younger CKD patients have better adherence than older (Sheikh et al., 2022).Besides that, women adhere more than men (Hwang et al., 2018;Alzahrani and Al-Khattabi, 2021;Alhamad et al., 2023).More specifically, although the overall motivation of all respondents is in the high category, based on the components, it was found, however, that some components still need to be improved, namely the goal behavior component.Therefore, more intensive efforts are required from health workers to educate CKD patients about the benefits of hemodialysis for their health.Health workers should continuously improve the quality of service for CKD patients undergoing hemodialysis therapy to increase patient motivation in undergoing hemodialysis (Agu and Tambunan, 2024).Besides that, the nurse's caring behavior must continually improve to increase patient motivation in undergoing hemodialysis therapy.Enhancement motivation can become positive energy and increase adherence to hemodialysis (Cardol et al., 2022) and outcomes (Naalweh et al., 2017;Mukakarangwa et al., 2020).

The Influence of Coping on Adherence of CKD Patients to Undergo a Hemodialysis Program
The results show that coping has significantly affected CKD patients' adherence to hemodialysis programs (Table 4), with most respondents having high coping (Table 1).This study's results align with previous studies stating that coping affects hemodialysis adherence (Niihata et al., 2017;Hwang et al., 2018;Ulusoy and Kal, 2020;Melastuti et al., 2022).Positive coping increases perceived behavioral control, reduces negative stressors, and enhances disease selfmanagement (Niihata et al., 2017;Sheikh et al., 2022).Good coping can reduce symptom depression connection with burden management disease, increase obedience to treatment that impacts positive outcomes, and improve the quality of life of CKD patients (Ulusoy and Kal, 2020).The study result shows that one respondent still has positive coping but does not adhere to the hemodialysis program (Table 2).Sociodemographic analysis shows that respondents have a hemodialysis duration of more than 73 months, namely 120 months.Patients with a history of longer duration of the hemodialysis program and poor clinical results can cause non-adherence (Mirzaei-Alavijeh et al., 2023).The use of emotion-focused coping is associated with a reduced risk of depressive disorders.However, longer duration of hemodialysis had a negative correlation with emotion-focused coping strategies (Ulusoy and Kal, 2020).The study shows all the respondents' coping is in the moderate-good category, and none is in the poor category.However, coping components need to be improved, especially problemsolving behavior.Therefore, it is necessary to develop an appropriate strategy to enhance the proper behavior of CKD patients to overcome problems related to hemodialysis (Hwang et al., 2018;Ulusoy and Kal, 2020), reducing mortality and increasing quality of life (Niihata et al., 2017).One of the efforts made is education and counseling to improve disease management motivation (Ok and Kutlu, 2021) or involving the family in disease management so that the burden of disease management can be distributed to other family members, ultimately increasing adherence to undergo a hemodialysis program (Sousa et al., 2023).

The Influence of Depression on Adherence of CKD Patients to Undergo a Hemodialysis Program
The results show that depression significantly affected CKD patients' adherence to hemodialysis programs (Table 4), with most respondents having no depression and respondents who experience depression having non-adherence to undergoing hemodialysis program (Table 1; Table 2).Respondents who experienced severe depression also experienced increased non-compliance (Table 4).This study's results align with previous studies that stated that depression experienced by CKD patients could also worsen adherence to hemodialysis (Pretto et al., 2020;Cardol et al., 2022;Nielsen et al., 2023).An increase in the burden associated with managing a disease that cannot be managed well can cause depression, which can reduce hemodialysis adherence (Nielsen et al., 2023).The results of the further analysis show that CKD patients who experience depression are younger CKD patients of the male gender, thus increasing non-adherence (Hwang et al., 2018).Younger age is linked with poor coping and increasing non-adherence (Ulusoy and Kal, 2020).It may be related to their role as heads of families obliged to earn a living for their families.Failure to play the role can worsen coping, resulting in non-adherence.Previous study explains that poor coping is related to low resilience and high cognitive distortions, giving rise to depression (González-Flores et al., 2021).Emotional well-being and psychological stress that can be managed well can increase CKD patient' adherence to controlling their disease.Symptoms of depression experienced by CKD patients, as well as the lack of social support, cause non-adherence to undergo hemodialysis (Pretto et al., 2020;Cardol et al., 2022) and decrease quality of life (Ulusoy and Kal, 2020).

The Influence of Family Support on Adherence of CKD Patients to Undergo a Hemodialysis Program
The results show that family support significantly affected CKD patients' adherence to undergoing hemodialysis programs.Perceived family support is the most dominant factor influencing CKD patients' adherence to undergoing hemodialysis program (Table 4).The result aligns with previous studies, which stated that family support had a positive influence on the adherence of CKD patients in hemodialysis (Al Husna, Yetti and Sukmarini, 2019;Alisa and Wulandari, 2019;Mundakir et al., 2019;Mukakarangwa et al., 2020;Alhamad et al., 2023;Gebrie et al., 2023).Families who participate in disease management, fulfilling the physical, emotional and social needs of CKD patients undergoing hemodialysis, can increase perceived family support (Gebrie et al., 2023), so it can increase adherence to hemodialysis (Sousa et al., 2023).Most respondents perceived family support to be in the high category (Table 1).However, nine (9) respondents still perceived family support in the low category (Table 2).More specifically, the components of family support that are still low are the components of support for managing diet, fluids and medicines, and informational support.
Moreover, support for attendance at hemodialysis sessions, motivation and emotional support is high.Efforts to increase health literacy in families must be improved so that families can understand the problem and how to manage it well.In the end, the family can appraise the issues faced by the patient and provide accurate information.Apart from that, families can also be actively involved in managing disease, especially in managing diet, fluids and medication needed by the patient.A previous study stated that good family support is essential for helping CKD patients overcome problems connected with the disease (Mukakarangwa et al., 2020), especially from a spouse, can reduce low interdialytic weight gain in hemodialysis patients (Mundakir et al., 2019).Family involvement in disease management can balance the disease management burden among family members, thereby increasing adherence to hemodialysis (Kerr et al., 2024).Therefore, family-focused interventions for CKD patients with an interdisciplinary approach combining psychosocial support can increase family involvement through providing emotional support in overcoming problems that arise in connection with disease management as well as providing instrumental support (Alhamad et al., 2023), so can increase adherence (Sousa et al., 2023), and improve the quality of life of CKD patients (Isdiarti and Ardian, 2020).

The Influence of Health Worker Support on Adherence of CKD Patients to Undergo a Hemodialysis Program
The results show that health worker support significantly affected the adherence of CKD patients in hemodialysis programs (Table 4).The study results align with previous studies, which stated that social support from health workers could increase adherence to hemodialysis programs (Mukakarangwa et al., 2020;Alzahrani and Al-Khattabi, 2021;Sapkota et al., 2022;Gebrie et al., 2023).Most respondents perceived health worker support to be in a high category (Table 1).However, nine (9) respondents stated that support of health workers was still low, which impacted hemodialysis adherence (Table 2).The item analysis results show that components are still low in health worker support, including communication, counseling/education, and health monitoring.A previous study stated that health workers are responsible for assessing and managing individual symptoms of CKD patients based on existing needs and resources (Mehrotra et al., 2023).Health workers must be aware of and consider the factors that can be facilitators and barriers in providing effective hemodialysis therapy for better health outcomes (Mukakarangwa et al., 2020).Health workers should create tailored and customized health information plans to inform patients of the critical components they need to manage chronic kidney disease (Mailani et al., 2024).As much as possible, health workers provide interventions tailored to CKD patients' sociodemographic and psychological factors to increase their understanding of the disease and how to manage it (Alhamad et al., 2023).A supportive social environment, where family and health workers constantly interact with patients, can increase CKD patients' adherence.Good relationships with dialysis center staff and the fact that they receive good care, which makes them comfortable when they come for routine care, can increase adherence to the hemodialysis program (Gebrie et al., 2023).Discussions with patients about their adherence with a focus on managing the patient-health worker relationship need to be carried out by assessing the patient's experience of symptoms so they can participate in finding solutions to overcome existing problems (Nielsen et al., 2023).Health worker support through motivation and counseling can increase adherence to undergo hemodialysis with dialysis (Sapkota et al., 2022).Development of a multidisciplinary team with family involvement to better meet the physical, emotional and social needs of patients while undergoing hemodialysis to increase patient adherence is needed (Gebrie et al., 2023;Sousa et al., 2023;Yasin et al., 2024) The strength of this study is that it is one of the few studies that analyze how psychosocial factors influence CKD patient compliance to undergo hemodialysis using a multiple regression model.This study method allows researchers to simultaneously investigate the influence of independent variables on the dependent variable.In addition, the method used can also partially analyze the influence of each independent variable on the dependent variable.The use of this method can confirm the inconsistency of the results of previous studies, namely, on the one hand, stating that psychosocial factors influence CKD patient compliance to undergo hemodialysis.However, it states that there is no influence.The results of this study confirm that psychosocial factors, such as knowledge, motivation, coping, depression, family support and health worker support have a significant influence on CKD patient compliance to undergo hemodialysis both simultaneously and partially.The variable that has the most considerable influence on compliance to undergo hemodialysis is perceived family support, while the factor that has the smallest influence is knowledge.However, this study has several limitations.This study was conducted with a small sample size and only in Jember.Variations in CKD patient compliance to undergo hemodialysis programs between regions in Indonesia may occur.Further studies using large sample sizes and multi-centers are needed.In our study, we did not exclude other comorbidities such as diabetes, cardiovascular disease, and other comorbidities that are usually present in CKD patients.

Conclusion
The study results show that the psychosocial factors of CKD patients, namely knowledge, motivation, coping, depression, perceived family support, and perceived support from health workers, had a significant effect on their adherence to the hemodialysis program.The most dominant variable influencing hemodialysis compliance is perceived family support.To improve services for CKD patients undergoing hemodialysis, nurses should pay attention to psychosocial factors, especially perceived family support.Family involvement in managing CKD disease can increase CKD patient compliance in undergoing hemodialysis programs to improve the quality of hemodialysis services.

Table 1 .
Respondents' characteristics, psychosocial factors and adherence of CKD patients to undergo a hemodialysis program at RSD Dr. Soebandi Jember in the period June -July 2023 (n = 90)

Table 2 .
Results of cross-tabulation between adherence of CKD patients to undergo hemodialysis program with psychosocial factors at RSD Dr. Soebandi Jember in the period June -July 2023 (n= 90)

Table 4 .
Results of multiple regression rest