Table 4.

Description of each of the barrier categories

Barrier	Barrier description
Financial	Patients in home dialysis require a personal dialysis machine (either home hemodialysis or peritoneal dialysis) and a constant supply of clean water (mainly for home hemodialysis), energy, and various machine consumables. Because the practice of home dialysis is new in many countries, many current health care financing and reimbursement models do not enable or support home therapies of this nature. Thus, many patients currently cannot afford the costs associated with setting up, running, and maintaining dialysis equipment in their homes.
Technological	Home hemodialysis machines and peritoneal dialysis machines are complex to set up and operate. Patients often struggle with self-cannulation and lack support in setting up, operating, and/or troubleshooting problems encountered during dialysis. The complex nature of home dialysis technology, in combination with poor technical support, often results in challenges when implementing home dialysis on a wide scale.
Infrastructural	Home dialysis requires patients to have dedicated space in their homes in addition to appropriate water, sewage, and electrical infrastructure. Several countries covered in this project do not provide the necessary infrastructure, requiring patients to cover the costs to establish the minimum requirements for home dialysis. Clinicians require dedicated clinical space to educate and train patients on operating the equipment and performing dialysis on their own. Limited resources in some of these hospitals prevents the establishment of home dialysis programs.
Governance and political	Government and policies largely influence the success of home dialysis programs. The availability of government funding support, regulations, and standards in home dialysis care can greatly encourage or discourage patients and clinicians to consider home dialysis. Unfortunately, some governing bodies regard home dialysis as a luxury and prioritize other treatment methods, discouraging the implementation of home dialysis programs.
Institutional and cultural	Home dialysis requires the collaboration of a diverse team of clinicians, patients, and their families. Because of some deeply rooted cultural views and practices, some home dialysis programs around the world experience difficulties recruiting and/or training patients to independently perform self-dialysis. Some examples include staff being skeptical of prescribing home dialysis to patients and skeptical letting patients take a more active role in their therapy. The cultural norm of the sick having to be taken care of may introduce cultural barriers to home dialysis, as home dialysis requires the patient to play a more active role in the therapy. A successful home dialysis program must consider the influence of patient, institutional, and societal culture during development and implementation.
Patient	Because home dialysis relies on patients and caregivers to independently operate and troubleshoot dialysis equipment, the success and uptake of home dialysis heavily depends on how comfortable patients are with the procedures and technology. Patients may be uncomfortable or afraid of having problems at home while performing home dialysis and not having a clinician available to help. The age and education level of the patient population may vary from country to country, which will influence how open patients are to home dialysis. Patients’ families may or may not be supportive of home dialysis due to the added load on the family as caregivers. Consequently, negative patient and caregiver perceptions toward home dialysis can greatly discourage patients from transferring into home dialysis programs.