Educational support programs for individuals with end-stage renal disease on hemodialysis: a scoping review

Abstract

Background

The global prevalence of End-Stage Renal Disease (ESRD) is increasing, with estimates suggesting that more than 5 million people worldwide require renal replacement therapy (RRT), and this burden falls disproportionately on low- and middle-income countries (LMICs), highlighting the urgent need for effective strategies to support patient self-management. This scoping review synthesizes evidence on the types, delivery methods, and reported outcomes of educational support programs for individuals with ESRD undergoing hemodialysis (HD).

Methods

This review followed the six-stage methodological framework by Arksey and O’Malley and adhered to the PRISMA Extension for Scoping Reviews guidelines. Studies examining educational interventions for ESRD patients on HD were included. A comprehensive search of MEDLINE, CINAHL, Scopus, PubMed, and Web of Science was conducted for English-language articles published between 2011 and 2021. Search terms included combinations of “end-stage renal disease,” “ESRD,” “hemodialysis,” and “haemodialysis” with “educational program,” “support program,” “patient education,” and related terms. Pairs of reviewers independently screened titles and abstracts and assessed full-text articles, resolving discrepancies through group discussion. Data were extracted using a standardized form capturing key study characteristics and synthesized using descriptive statistics and content analysis.

Results

Eighteen studies (n = 18) from ten countries met the inclusion criteria. All studies reported that educational interventions, regardless of delivery mode or design, positively influenced quality of life (QOL) and treatment adherence among ESRD patients. Specifically, improvements were documented in serum phosphate control, intradialytic weight gain, psychological well-being (anxiety, depression, stress), self-esteem, dietary knowledge, and physical functioning. Structured self-management programs, particularly those incorporating nutritional education and psychological support, demonstrated the greatest breadth of benefit across clinical and psychosocial domains.

Conclusion

This review maps the evidence on educational support programs for HD patients, revealing variability in intervention types, delivery methods, study designs, and outcome measures. These inconsistencies highlight the need for more rigorous, standardized research particularly in LMICs to determine the most effective educational strategies. The findings provide a foundation for developing evidence-based, patient-centered educational programs adaptable to diverse global populations.

Introduction

End-stage renal disease (ESRD) is a progressive condition in which the kidneys can no longer maintain normal physiological functions, necessitating renal replacement therapy (RRT) such as hemodialysis (HD) or renal transplantation.

Globally, ESRD represents a significant and growing health burden. Current estimates indicate that over 5 million people require RRT worldwide, with incidence rates rising by approximately 4–7% annually in many regions [1]. The condition contributes substantially to morbidity, mortality, and healthcare costs, accounting for a disproportionate share of chronic disease expenditure globally. The global prevalence of ESRD is rising primarily due to increasing rates of non-communicable diseases such as diabetes and hypertension, as well as aging populations [2]. This rising trend is most pronounced in LMICs, where limited access to RRT and healthcare resources exacerbate the challenges faced by individuals with ESRD [3].

HD remains the most common form of RRT for ESRD, particularly in LMICs where renal transplantation is less accessible due to organ donor shortages, high costs, and limited healthcare infrastructure [4]. However, adherence to the strict regimen required for HD including regular dialysis sessions, fluid and dietary restrictions, medication adherence, and lifestyle changes is often suboptimal [5, 6]. Non-adherence is associated with poorer health outcomes, including increased hospitalization rates, cardiovascular events, metabolic disturbances, and premature death.

Educational support is widely recognized as a cornerstone of effective patient care for individuals with chronic conditions such as ESRD. Providing individuals with the knowledge and skills needed to manage their condition and make informed decisions about their health can improve both adherence and QOL [7]. Research has shown that educational interventions can improve treatment adherence, reduce complications, and improve QOL for ESRD patients undergoing HD [8, 9]. Patient education can address barriers to adherence by enhancing understanding of the condition, the benefits of treatment, and the consequences of non-compliance [10].

Despite the growing recognition of the importance of education in managing ESRD, there is limited understanding of the most effective types of educational support programs, especially in low-resource settings. Several reviews have noted that such programs are inconsistently developed and implemented across regions, with Africa and other LMICs being particularly underserved [11]. The lack of structured educational support programs, alongside inadequate healthcare infrastructure, poverty, and social stigma, compounds the challenges faced by individuals with ESRD in these regions.

This scoping review was conducted to map the evidence on educational support programs for individuals with ESRD undergoing HD, with the aim of synthesizing evidence on: (i) the types and characteristics of educational interventions used; (ii) the delivery methods employed; and (iii) the outcomes reported, specifically in relation to QOL and treatment adherence. By identifying patterns across the literature and highlighting gaps, this review provides a foundation for developing and implementing evidence-based educational strategies for this population.

Methods

A scoping review was conducted following the six-stage methodological framework proposed by Arksey and O’Malley [12]. The PRISMA Extension for Scoping Reviews checklist guided the summarization and reporting of the evidence (Fig. 1) [13]. No formal protocol was registered for this review; this is acknowledged as a limitation.

Fig. 1.

PRISMA techniques for the data collection. Source: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71. https://doi.org/10.1136/bmj.n7

Search strategy

Studies examining educational programs for individuals with ESRD undergoing HD were eligible for inclusion. A comprehensive search was conducted across five electronic databases: MEDLINE, CINAHL, Scopus, PubMed, and Web of Science, covering articles published from 2011 to 2021. These databases were selected to ensure broad and diverse coverage of relevant literature across nursing, medicine, and health sciences.

The search was developed by the research team in consultation with a multidisciplinary clinical panel (nephrologists, nurse specialists, nephrology technicians, and nutritionists). Both MeSH terms and free-text keywords were used. The search combined ESRD-related terms—including “end-stage renal disease,” “ESRD,” “chronic kidney disease,” “hemodialysis,” “haemodialysis,” and “renal dialysis”—using the Boolean operator OR, and these were then combined with education-related terms—including “educational program,” “educational intervention,” “patient education,” “support program,” and “educational support program”—using AND. Searches were applied to title, abstract, and keyword fields. No research librarian was formally involved; this represents a limitation. The search was conducted between December 2020 and December 2021. An example of the search strategy used in PubMed is provided in Table 1.

Table 1.

Example PubMed search strategy

Search Component	Terms Used
ESRD/CKD terms (combined with OR)	“end-stage renal disease” OR “ESRD” OR “chronic kidney disease” OR “CKD” OR “kidney failure”
HD terms (combined with OR)	“hemodialysis” OR “haemodialysis” OR “renal dialysis” OR “HD”
Education terms (combined with OR)	“educational program” OR “educational intervention” OR “patient education” OR “support program” OR “educational support program” OR “self-management education”
Boolean combination	(ESRD/CKD terms) AND (HD terms) AND (education terms)
Date range	2011–2021
Language	English

The time restriction (2011–2021) was chosen to capture contemporary HD educational practices aligned with current HD care guidelines; the review was not updated after 2021, which is a further limitation.

Eligibility criteria

Studies were included if they: (i) examined educational interventions or programs for individuals with ESRD on HD; (ii) included adult participants aged 18 years or older; (iii) were published in English between 2011 and 2021; and (iv) reported outcomes related to QOL, treatment adherence, or self-management. Studies involving populations other than adults with ESRD on HD, or those not reporting educational program outcomes, were excluded.

Study selection and data extraction

Pairs of reviewers independently screened titles and abstracts, and any discrepancies between reviewers were resolved through discussion among all authors. Two different reviewers conducted full-text screening independently; disagreements were resolved by a third reviewer. As only pairs rather than all four reviewers screened each record, the risk of inter-rater inconsistency is acknowledged as a limitation.

Data were extracted using a standardized extraction sheet capturing: study identification (year, title, authors, country); study design and sample size; sampling method; educational program description, type, duration, and delivery mode; data collection methods and instruments; data analysis techniques; and key outcomes (QOL and adherence measures).

The extracted data were synthesized descriptively to identify patterns, similarities, and differences across studies. Findings were analyzed using descriptive statistics and content analysis, and presented in both narrative and tabular formats. Since this is a scoping review, formal quality appraisal was not conducted. The column labeled “measures to minimize bias” in Table 2 reflects information reported by authors in the original studies, not a formal quality assessment; studies not reporting such measures were recorded as “not reported.”

Table 2.

Educational interventions, outcomes, and ethical details

Author & Year	Type of Intervention	Population (allocation/blinding/randomization)	Duration	Bias Minimization Measures	Results	Ethical Issues
Afrasiabifar et al., 2013	Educational program on self-care for HD patients (Roy’s adaptation model)	n = 31 study group; n = 28 control group	8 weeks (eight 1-hour sessions)	Not reported	Significant difference in mean scores of physiologic, self-concept, and role-function modes before and after education	Research ethics approval obtained. Confidentiality and risk minimization not discussed
Arad et al., 2021	Educational booklet on diet, medication use, and fluid restrictions; nurse-led telephone follow-up	Control (n = 33) and intervention (n = 33); sealed envelope randomization	3 months	Not reported	Significant difference in treatment adherence scores between groups at immediately, 1 month, and 3 months post-intervention	Ethics Committee and Vice-Chancellor for Research, Urmia University of Medical Science. Written informed consent obtained; confidentiality assured
Bakarman et al., 2019	Introduction to CKD, HD explanation, importance of compliance with HD	Randomly assigned: control (n = 50) and intervention (n = 50)	8 weeks	Not reported	Intervention group showed significantly greater QOL in role-physical (35.5 ± 24.7 vs. 24.5 ± 23.9, p < 0.02), role-emotional (58.6 ± 40.1 vs. 44.6 ± 43.4, p < 0.001), and general health (76.6 ± 16 vs. 62.9 ± 19.4, p < 0.001)	Biomedical Ethics Research Committee, Faculty of Medicine, King Abdulaziz University, Jeddah
Birdee et al., 2014	Intradialytic yoga protocol with yoga instructions vs. educational program (printed materials)	n = 13 yoga intervention; n = 13 educational intervention; RCT	12 weeks	Not reported	Educational program supported positive effects on patients’ knowledge and QOL	Approved by university ethics committee, Shahroud University of Medical Sciences
Ebrahimi et al., 2016	Nutritional education pamphlet covering dietary importance, consequences of non-adherence, food and fluid restrictions	n = 99 HD patients; randomization/blinding/allocation not reported	12 weeks	Not reported	Educational intervention on diet improved both knowledge and QOL	Approved by ethics committee, Shahroud University of Medical Sciences
Farragher et al., 2020	Self-care educational program: face-to-face and video formats	n = 120; randomly assigned to control, face-to-face, or video group	2 months	Not reported	Face-to-face and video education improved QOL; video education recommended alongside face-to-face	Ethics committee, Urmia University of Medical Sciences
Fernandes & D’Almeida, 2013	Information, emotional support, and mutual reciprocity in groups of 10–12 persons	n = 65: control (n = 33), intervention (n = 32)	3 weeks	Not reported	Peer support programs increased self-management in ESRD individuals	Approved by Health Research Ethics Committee, Tugurejo Hospital Semarang (No. 57/KEPK.EC/IV/2019)
Maslakpak & Shams, 2015	Nutritional Educational Program including general nutritional knowledge, culinary recommendations, and balanced menus	n = 120; three-group design	4 months	Simple random allocation	Nutritional knowledge increased in all participants (p < 0.05); decrease in malnutrition prevalence	Protocols approved by Catholic University of Murcia Ethics Committee
Kusuma & Johan, 2020	Pre-dialysis educational program combined with exercise and follow-up	n = 150; Block I (Mon/Wed/Fri) and Block II (Tue/Thu/Sat)	2 months	Blocked randomization (experimental and control groups)	Pre-dialysis education and exercise with follow-up reduced disease burden and improved self-management	Conducted according to ethical protocol
Morante et al., 2014	Educational program on kidney function, disease types and causes, consequences, treatment modalities	n = 80; Group 1 (n = 40) intervention; Group 2 (n = 40) control; restricted randomization	2 weeks	Restricted randomization	Significant increases in knowledge and communication; positive attitude toward HD and transplant donation	Medical Ethical Committee, Erasmus Medical Centre (MEC-2010-290); Declaration of Helsinki; registered in Dutch Trial Registry
Lazarus, 2019	Self-care and self-esteem educational program combined with exercise	Purposive sampling; n = 25 intervention, n = 25 control	3 months	Random allocation	Self-care program positively increased self-esteem	Approved by ethics committee, Jahrom University of Medical Science; other ethical aspects not discussed
Massey et al., 2016	Educational intervention to improve fluid restriction adherence and RRT knowledge	n = 17	Not reported	Not reported	Improved knowledge of dietary and fluid management; improved adherence to fluid restrictions	Not reported
Poorgholami et al., 2016a	Adaptation Training Programme (ATP) to cope with illness-related stress, alleviate depression, improve QOL	n = 57; experimental (ATP + usual care) vs. control (usual care)	5 months	Experimental and control group allocation	ATP effective at decreasing stress/depression and improving QOL	Institutional review board approval obtained; written consent from participants; 3 hospitals in northern Taiwan
Poorgholami et al., 2016b	Educational nursing intervention to reduce hyperphosphatemia	CKD individuals on HD (n = 63)	90 days	Not reported	Educational nursing intervention effective in reducing phosphate and decreasing pruritus	Approved by Ethics Committee, Federal University of São Paulo
Parker, 2019	Education on pathophysiology of renal failure, HD, medications, complications, nutrition, fluid restriction, thirst management, stress	n = 32 intervention, n = 32 control; blind randomization	6 months	Blind randomization experimental design	Experimental group weight gains decreased gradually; control group decreased only slightly	Ethics review board approval; anonymity and confidentiality assured; written consent
Lai et al., 2021	Adaptation Training Programme (ATP) focused on coping with illness-related stress and improving QOL	n = 57 ESRD persons; experimental design; sampling method not reported	5 months	Sampling method not reported; experimental design	ATP effective at decreasing stress/depression and improving QOL of HD patients	Institutional review board approval; written consent; 3 dialysis centres in northern Taiwan
Stumm et al., 2017	Educational nursing intervention to reduce hyperphosphatemia	CKD individuals on HD (n = 63); quasi-experimental	90 days	Not reported	Educational intervention effective in reducing phosphate and decreasing pruritus in hyperphosphatemia patients	Approved by Ethics Committee, Federal University of São Paulo
D’souza et al., 2018	Education on pathophysiology of renal failure, HD, medications, complications, nutrition, fluid restriction, thirst and urge management, stress management	n = 32 control, n = 32 intervention; blind randomization	6 months	Blind randomization experimental design	Experimental group weight gains decreased gradually; control group decreased only slightly	Ethics Review Board approval; anonymity and confidentiality assured; written consent

Results

Article Characteristics (Table 3)

Table 3.

Characteristics of Included Studies

Author & Year	Country	Study Aim	Setting	Design	Population & Sample Size	Sampling	Data Collection	Main Findings
Afrasiabifar et al., 2013	Iran	Examine effect of Roy’s adaptation model-based patient education	Dialysis ward, Shahid Beheshti Hospital, Yasuj	Quasi-experimental	ESRD individuals (n = 59)	Convenience	Adherence ESRD questionnaire; descriptive statistics	Significant difference in mean scores of physiologic, self-concept, and role-function modes before and after education
Arad et al., 2021	Iran	Determine effects of educational program and nurse-led telephone follow-up on HD adherence	Taleghani Hospital, Urmia	Single-blinded RCT	ESRD individuals on HD (n = 66)	Not reported	ESRD Adherence questionnaire; laboratory results; ANCOVA	Significant difference in treatment adherence scores between groups immediately, 1 month, and 3 months after intervention
Bakarman et al., 2019	Saudi Arabia	Assess health-related QOL following educational program	4 government hospital dialysis units, Jeddah	RCT	ESRD individuals on HD (n = 100)	Random	QOL questionnaire; laboratory results; t-test, KS test	Intervention group showed significantly greater QOL in role-physical, role-emotional, and general health domains
Birdee et al., 2014	USA	Assess feasibility of 12-week intradialytic yoga vs. educational intervention	Academic dialysis centre	Pilot RCT	ESRD individuals (n = 26)	Random	Checklist; inferential statistics	Positive effects of educational program on patients’ knowledge and QOL supported
Ebrahimi et al., 2016	Iran	Determine effects of educational instructions on HD patients’ knowledge and QOL	Imam Hossein Hospital, Shahroud	Experimental	ESRD individuals on HD (n = 99)	Not reported	QOL questionnaire; medical records; ANOVA, t-tests	Educational intervention on diet improved both knowledge and QOL
Farragher et al., 2020	Canada	Explore acceptability of educational program in ESRD individuals	Dialysis units, academic hospital, Toronto	Educational intervention development; qualitative	ESRD individuals (n = 5)	Purposive	System Usability Scale; descriptive statistics	Face-to-face and video education improved QOL in HD patients; video education recommended alongside face-to-face
Fernandes & D’Almeida, 2013	Not reported	Assess effectiveness of Individual Educational Intervention on attitude and compliance	Not reported	Pre-test post-test	ESRD individuals on HD (n = 50)	Not reported	Attitude scale; compliance scale; chi-square	Educational programs improved self-management in ESRD individuals
Maslakpak & Shams, 2015	Iran	Compare effectiveness of face-to-face vs. video self-care education on QOL	Two general hospitals (Imam Khomeini, Ayatollah Taleghani)	Quasi-experimental	ESRD individuals (n = 120)	Simple random	KDQOL-SF questionnaire; ANOVA	Nutritional knowledge increased in all participants after 4 months; QOL improved
Kusuma & Johan, 2020	Indonesia	Determine effects of peer support programs on self-management	Public hospital, Semarang	Pre-test/post-test quasi-experimental	ESRD individuals on HD ≥ 3 months (n = 65; control n = 33, intervention n = 32)	Consecutive	Self-management measurement; paired t-test and independent t-test	Peer support and exercise reduce disease burden and improve self-management
		Implement nutritional educational program and evaluate effectiveness vs. oral supplementation	Fresenius Medical Care Clinic; Catholic University of Murcia	Longitudinal prospective	ESRD individuals on HD (n = 87)	Not reported	Blood record sheet; paired t-test	Significant increases in nutritional knowledge and communication; improved attitudes toward HD
Morante et al., 2014	Spain	Evaluate effectiveness of educational and exercise intervention on QOL	12-bedded dialysis center, metropolitan hospital	Evaluative intervention (control and intervention pre-test/post-test)	ESRD individuals on HD (n = 150)	Not reported	Interview guide; paired t-test; chi-square	Self-care program positively increased self-esteem in individuals on HD
Lazarus, 2019	India	Investigate effectiveness of educational program to improve fluid restriction and knowledge	Pre-dialysis clinics, 4 hospitals, Rotterdam	Cross-over RCT	Individuals on HD (n = 80)	Not reported	Rotterdam Renal Replacement Knowledge Test (5-point scale); chi-square, t-tests, ANOVA	Educational interventions improved knowledge of dietary and fluid management and aided adherence to fluid restrictions
Massey et al., 2016	Netherlands	Assess influence of educational interventions on QOL of HD patients (continuous care model)	HD ward, Ostad Motahri Hospital, Jahrom	Controlled clinical trial	ESRD individuals on HD (n = 50)	Purposive	Powers QOL Index Dialysis Version; paired t-test and independent t-test	Adaptation training programme effective at decreasing stress/depression and improving QOL
Poorgholami et al., 2016a	Iran	Investigate effect of self-care education on self-esteem of HD patients	HD Unit, Motahari Hospital, Jahrom	Quasi-experimental	HD patients with advanced CKD (n = 75)	Purposive	Rosenberg Self-Esteem Scale; chi-square, t-tests	Educational nursing intervention effective in increasing self-esteem among HD patients
Poorgholami et al., 2016b	Iran	Evaluate improvement of fluid restriction adherence in ESRD individuals	HD centre, south-western USA	Pretest-posttest	ESRD individuals on HD (n = 17)	Not reported	Chronic HD Knowledge Survey (CHeKs); electronic medical records; descriptive and inferential statistics	Experimental group weight gains decreased gradually following self-efficacy training; control group decreased only slightly
Parker, 2019	USA	Examine effectiveness of adaptation training programme (ATP) to help ESRD individuals cope with stress	Dialysis units, 3 medical centres, northern Taiwan	RCT	ESRD individuals on HD (n = 57)	Not reported	HD Stressor Scale; Beck Depression Inventory; SF-36; ANCOVA	ATP effective at decreasing stress/depression levels and improving QOL
Lai et al., 2021	Taiwan	Evaluate educational nursing intervention to reduce hyperphosphatemia in HD individuals	Renal dialysis unit, Rio Grande do Sul	Quasi-experimental	Hyperphosphatemia ESRD patients on HD (n = 63)	Not reported	Clinical, laboratory, and sociodemographic form; descriptive statistics	Educational nursing intervention effective in reducing phosphate and decreasing pruritus
Stumm et al., 2017	Brazil	Examine effectiveness of self-efficacy training on fluid intake compliance	HD centres, major hospitals	Experimental (blind randomization)	ESRD individuals (n = 62; n = 32 control, n = 32 intervention)	Blind randomization	Weight gain measurement before/after dialysis; ANOVA	Experimental group weight gains decreased gradually; control group decreased only slightly
D’souza et al., 2018	India	Self-efficacy training	HD centres	Experimental RCT	ESRD patients (62)	Blind randomization	Weight gain measures	Improved fluid adherence

The search identified 18 eligible studies (n = 18) from ten countries. Four studies (n = 4; 22.2%) were published in 2016, three (n = 3; 16.5%) in 2019, and two (n = 2; 11.1%) each in 2013, 2014, and 2020. Iran published the highest number of studies (n = 6; 33.3%), followed by Taiwan (n = 2; 11.1%) and the USA (n = 2; 11.1%); all other countries contributed one study each (n = 1; 5.6%).

The 18 included studies represented 1,999 individuals with ESRD on HD, with an average sample size of 63 participants per study. Sampling methods included random sampling (n = 6; 33.3%), purposive sampling (n = 4; 22.2%), and convenience sampling (n = 4; 22.2%); the remaining four studies did not report their sampling method.

50% of studies employed randomized controlled trial (RCT) designs (n = 9; 50%), followed by quasi-experimental (n = 6; 33.2%) and other designs. Of the studies including both intervention and control groups, only six reported using randomization [14–19]. Two studies focused on developing and piloting educational interventions and did not report participant allocation [20, 21]. Duration of interventions ranged from 2 weeks to 5 months, with most lasting approximately 2 months.

Educational interventions (Table 2)

Some studies incorporated educational interventions with more than one component. Two main intervention types were most frequently used across the studies (n = 10 studies): self-care interventions (n = 5) and nutrition/diet-related interventions (n = 5). An additional two studies focused exclusively on educational programs targeting treatment adherence. Interventions were delivered through various methods, including peer support networks, educational pamphlets, individual face-to-face counseling, video-based education, and group educational workshops.

Types of available interventions

Five studies focused on self-care education [14, 17, 23, 24]. Two studies included components on medication use [14, 25], while three provided direct education about ESRD pathophysiology [23, 25, 26]. Four studies addressed fluid restrictions [14, 15, 25, 27]. Five studies covered nutrition and dietary restrictions [20, 25, 27, 28, 29]. Four studies emphasized the importance of adherence to HD [16, 18, 25, 30]. Three studies addressed exercise and energy management [21, 22, 31], and one study included a session on intradialytic yoga [32].

Study outcomes

All 18 included studies reported that educational interventions regardless of mode or design positively influenced QOL and treatment adherence for patients with ESRD. These interventions ranged from structured self-management programs to targeted nutritional education and psychological support, demonstrating effectiveness across clinical and psychosocial domains. A synthesis of the evidence is presented in Table 2.

Quality of life outcomes

Across the included studies, educational interventions contributed to improvements in multiple QOL domains. The following outcomes were most consistently reported:

Reduction in hyperphosphatemia-related symptoms

Multiple studies [17, 18] reported that education on dietary phosphate control led to significant reductions in serum phosphate levels, accompanied by a decrease in associated symptoms such as pruritus, thereby enhancing patient comfort and skin health.

Controlled intradialytic weight gain

Studies focusing on self-efficacy training and fluid restriction education [15, 27, 31] reported that patients progressively reduced intradialytic weight gain, reflecting improved adherence to fluid intake guidelines and contributing to cardiovascular stability.

Psychological well-being

Several interventions resulted in reductions in stress, anxiety, and depressive symptoms among patients undergoing HD [15, 17, 25]. These findings highlight the importance of integrating cognitive-behavioral approaches and stress management within ESRD educational programs.

Enhanced self-esteem

Interventions that included psychosocial support and coping strategy education were associated with increased self-esteem among HD patients [22, 32, 33], suggesting that educational programs can foster emotional resilience.

Improved dietary knowledge

A significant number of studies demonstrated that patients who received tailored nutritional education [16, 20, 24, 34] gained improved understanding of dietary restrictions, which is essential for controlling disease progression and minimizing complications.

Physical well-being

Studies such as Afrasiabifar et al. (2013) and Lazarus (2019) reported improved physical functioning and reduced fatigue following lifestyle and exercise-focused education, indicating that structured interventions can enhance physical capacity and daily living.

Across multiple QOL domains

Several studies demonstrated broad improvements across physical, emotional, and social well-being dimensions following educational interventions [35], consistent with a holistic benefit beyond isolated clinical parameters.

Treatment adherence outcomes

Educational interventions also showed a consistent positive relationship with improved treatment adherence across the included studies:

Improved dietary and fluid management knowledge

Four studies (n = 4; 22.2%) documented that targeted education led to greater awareness of dietary and fluid restrictions, enabling more informed decision-making [16].

Adherence to fluid restrictions

Seven studies (n = 7; 38.8%) specifically reported improvements in patients’ adherence to fluid intake guidelines, with implications for reducing complications such as hypertension and fluid overload [14].

Enhanced self-management

Two studies (n = 2; 11.1%) demonstrated improved self-management skills among patients [29], including goal-setting, symptom monitoring, and communication with healthcare providers.

Overall treatment adherence

Five studies (n = 5; 27.7%) reported greater consistency in following prescribed treatment regimens, including medication schedules, dietary plans, and dialysis attendance [14].

Discussion

This scoping review mapped evidence on educational support programs for individuals with ESRD undergoing HD, synthesizing findings from 18 studies across 10 countries. All included studies reported that educational interventions delivered through diverse methods and designs were associated with improvements in QOL and treatment adherence. The most consistently reported outcomes included reduced intradialytic weight gain, lower serum phosphate levels, improved psychological well-being, enhanced dietary knowledge, and better adherence to fluid and dietary restrictions. These findings underscore the broad value of educational support in ESRD care, while also revealing important gaps in the literature regarding intervention standardization, methodological rigor, and geographic representation.

The geographic distribution of included studies is noteworthy. Most studies (n = 11; 61.1%) were conducted in Asia, with Iran accounting for the highest proportion (n = 6; 33.3%). This concentration may be partly explained by structural factors: in many Asian countries, HD is government-funded, which may facilitate greater institutional interest in educational programs aimed at improving adherence and reducing downstream costs [36]. The global ESRD burden is heavily concentrated in Asia, with Asian patients representing approximately 60% of the global ESRD population and 90% of those undergoing HD [35]. Future research and publication efforts should aim for greater geographic diversity to strengthen the generalizability of findings.

Notably, no studies from Africa were identified. In many African settings, most individuals with ESRD discontinue HD and die prematurely, due to a combination of financial barriers, limited dialysis infrastructure, and low health literacy regarding HD [37]. A well-developed, culturally adapted educational program could improve understanding of HD, help reconcile traditional healing practices with biomedical approaches, and potentially increase the duration of treatment adherence. This represents an urgent priority for future research, and is directly relevant to the stated aims of improving educational programs for underserved populations in LMICs.

From a methodological perspective, this review identified a diverse range of study designs, including RCTs and quasi-experimental approaches. However, many studies provided insufficient detail on randomization procedures, blinding, and bias minimization, only three of the 18 studies reported specific bias reduction measures [15, 16, 22]. This limits confidence in the certainty of reported outcomes. Future educational intervention studies should adhere to higher standards of reporting, particularly those employing experimental designs, and should follow established reporting guidelines such as CONSORT.

The review identified a variety of educational delivery approaches, including peer support networks, printed educational materials, individual face-to-face sessions, video-based instruction, and group seminars [38, 39]. All delivery modalities were associated with positive outcomes, suggesting flexibility in implementation. However, this review was unable to directly compare the effectiveness of individual programs due to heterogeneity in educational content, delivery frequency, and study design. An important gap therefore remains: identifying which educational program configurations are most effective from clinical, QOL, and cost perspectives including for use in resource-limited settings.

Patient engagement in the design of educational programs is a recognized element of patient-centered care [40]. Involving patients in curriculum development enables the creation of content tailored to their specific needs and priorities [41–43]. Notably, 10 of the 18 educational programs included patient engagement in their development [14, 15, 17, 20, 23–26, 28, 29], which may have contributed to their reported effectiveness. It is recommended that future programs systematically incorporate patient engagement in both development and evaluation phases.

Across all included studies, improvement in QOL was reported; however, standardized QOL measurement instruments were not consistently used. The variety of QOL instruments employed including disease-specific tools (e.g., KDQOL) and generic measures (e.g., SF-36) limits the comparability and generalizability of findings. Future research should adopt standardized QOL measurement frameworks, ideally using instruments validated for HD populations across diverse cultural contexts, to allow more meaningful comparisons and meta-analyses.

Limitations

Several limitations should be acknowledged. First, no formal scoping review protocol was registered prior to commencement. Second, the search was limited to English-language publications, which may have excluded relevant studies published in other languages. Third, the search was conducted up to December 2021 and has not been updated; evidence published since then is not captured. Fourth, as pairs rather than all four reviewers screened each record, there is a risk of residual inter-rater inconsistency. Fifth, the small sample sizes of most included studies (average n = 63) limit the generalizability of findings. Sixth, the concentration of included studies from Iran warrants caution in applying findings to other contexts. Seventh, this review was unable to make direct comparisons between the effectiveness of individual programs due to heterogeneity in intervention design, outcomes, and measurement. These limitations should be considered when interpreting findings.

Conclusion

This scoping review demonstrates that educational interventions have broad value in ESRD care, with consistent benefits reported across clinical, psychological, and behavioral outcomes. These programs empower patients with the knowledge and skills needed to manage their condition, improve their QOL, and enhance adherence to complex treatment protocols. However, the evidence base is limited by variability in intervention types, study designs, outcome measures, and geographic representation. Future research should prioritize the development of rigorously designed, culturally adapted, and patient-centered educational programs, particularly in LMICs, including African settings using standardized outcome measures to enable meaningful cross-study comparisons. Identifying the most effective program configurations from clinical, QOL, and cost perspectives remains a critical next step.

Author contributions

P.M. developed the scoping review proposal, conducted data collection, and drafted the initial version of the manuscript. J.E.M, A.M.T, and M.S.K. provided critical feedback and contributed to the review and editing of the manuscript.Priscille Musabirema PhD, MSN, RNDr. Musabirema is the Postgraduate Program Coordinator at the School of Nursing and Midwifery in the College of Medicine and Health Sciences at University of Rwanda, in Kigali, Rwanda. PhD graduate, Department of Nursing Education at the School of Therapeutic Sciences in the University of the Witwatersrand in Johannesburg, South Africa. Her research is focused on end-stage renal disease in low resource areas.Johanna Elizabeth Maree PhD, MSN, RNDr. Maree is a Visiting Associate Professor of Oncology and Palliative Nursing in the Department of Nursing Education at the School of Therapeutic Sciences in the University of the Witwatersrand in Johannesburg, South Africa. She acted as the Department Head of Nursing Education at the University of the Witwatersrand in Johannesburg, South Africa.Amme Mardulate Tshabalala PhD, MPH, RNDr. Tshabalala is a Lecturer in the Department of Nursing Education in the School of Therapeutic Sciences at the University of the Witwatersrand, Johannesburg, South Africa. Her research is focused on quality of life assessment and improvement in healthcare.Maryellen S. Kelly DNP, MSN, MHSc, CPNPDr. Kelly is an Assistant Professor within the Division of Healthcare of Women and Children in the School of Nursing at Duke University in Durham, North Carolina, USA. She is also a practicing pediatric nurse practitioner in the Department of Urology at Duke Health in Durham, North Carolina, USA, and is the current Chair of the Pediatric Urology Nurses and Specialists Society in the USA.

Funding

CARTA (Consortium for Advanced Research Training in Africa), grant No. G-19-57145.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.