Table 2.

Supporting quotations

Theme	Quotations
Primary commitment to caregiving
Coordinating care	The spouse is an active partner in the shared decision making, she’s an active partner in making sure they get to CKD classes and education. (04, woman) The wife plays a very important role in supporting the patient. I’d have had patients on dialysis for 13 years and in fact they were alive because of their wives. (09, man) Women more frequently go with men, go with them to the outpatient clinic, […] and that is not so for men that they probably don’t go as much if the patient is women. (13, woman)
Taking charge of health management	She will look after the man but not of herself. (02, woman) Some male patients don’t know what pills they take. The only one that knows this is the wife. (13, woman) The wives may help with their dialysis, […] for the home hemo patients that I have who are male patients. These male patients really fall apart when their female partners become sick […]. (22, woman)
Deprioritizing own health	Women forget that they need to take care of themselves first. (04, woman) She would miss out on at least once a week dialysis session because she felt that she had to be at home to run the errands and etc. for the young children. (22, woman) For the mother to leave the child without another carer available and come to the clinic is a big deal. That might result in presenting later as they otherwise would. (43, man) Women might be sometimes a little bit disadvantaged just because they’re the ones left at home with the children and don’t have time then to focus on themselves […]. (45, woman)
Centrality of family in decision-making	The woman’s goals. Many of them do involve goals that goes beyond them as a person. Their goals, a lot of the time, involves being the caring grandmother or the caring spouse or this and that. (04, woman) She’s more passive. It’ll be more about what’s right for that family unit. (14, man) If say childcare or getting kids to school is an issue then that’s something we’ll discuss. It comes up more often with women. (15, woman)
Vigilance and self-reliance
Diligence and conscientiousness	The females are more likely to be the ones who are there every day, and same thing with like clinic visits, they tend to show up more regularly for appointments. (08, man) Women go to the outpatient clinics more frequently than men. Women tend to go to the doctor more frequently and perhaps to be diagnosed earlier and just to go more frequently. (13, woman) Perhaps women are more likely to submit to the doctors or tend to believe them more. Men are perhaps more stubborn. (32, man)
Stoicism in tolerating symptoms	Women feel like […] all the other responsibilities take priority. Sometime they just get so adapted to like really poor quality of life […] pushing through all this while men are not going to do that. (04, woman) It’s socialization. Women are less likely to shout “Here am I!” and demand attention. Or they negate symptoms. (31, woman) Maybe women are sometimes tougher, and so they are not dialysed as early as men. (39, woman)
Avoiding burden on the family	Women don’t want to burden others with what’s going on with them. There are woman who I will explicitly ask, do your kids know […] […] trying to avoid burdening the family. (04, woman) I’ve certainly heard women more often say things like they don’t want to be a burden on people. (15, woman) They don’t want to be a burden, particularly the older ones. They don’t want to be a burden on their families because they […] realize that it may be labour-intensive. (24, woman)
Isolation and coping alone	Women in dialysis are less cared for […] less support from partners […] not appreciated […] abandoned by the husband because […] not performing as a women, […] (01, man) When I see that the female patient is not in good shape, the husband is not taking care of her correctly or doesn’t believe that she’s so bad. Then I talk to the family. (09, man) Women […] left alone. The husband never comes and they never, with few exceptions, provide supports […] on PD. […] women more depressed because […] really on their own. (18, man)
Stereotyping, stigma, and judgment
Body image	Women patients, some of them, especially on the younger side, are afraid of de-feminization. That they’re not really women and they’re not attractive any longer. (11, man) For women, it’s harder to have this discussion about weight loss. They obviously feel worse about their bodies in general, they feel more judged if they haven’t lost weight, or gained weight. Women […] more humiliated, more embarrassed, more uncomfortable with these things than the men do. (45, woman) Women may not want a catheter or a fistula for cosmetic reasons. Or they don’t want to be initiated on dialysis because of those reasons like the cosmetic reasons. (51, woman)
Dismissed as anxiety	A woman has had high blood pressure reported for two years and nothing has been done because it’s been attributed to stress. Even the physicians. There may be stereotyping, […] dismissed as psychosomatic. (04, woman) A woman with chronic kidney disease presenting with acute coronary syndrome can just present with maybe extreme anxiety. (36, woman) Women are more often dismissed by cardiology as not having real cardiac disease […] Increasing physician and patient awareness that there may be unconscious biases in the way that people ask questions, or hear the answers […], or contextualized symptoms […] important. (46, woman)
Shame and embarrassment	There is that level of judgment, particularly around fertility issues. In this particular Bhutanese community, your fertility is directly relevant to your value in that society. (24, woman) Sexuality is a topic that often comes up for me. […] Male doctors would never ask a woman if this is a problem. Although men do bring it up with me. But maybe they’d rather talk to a male […]. (31, woman)
Weakness and frailty	Because women are on average smaller than men, sometimes there are assumptions about how sick an older woman may be compared to […] an older man […]. This little lady is too frail to do home therapy […] more likely to be offered palliative care […] look at her as being sicker. (06, woman) Females, particularly older females, probably are assessed more quickly to be frail. (25, woman)
Protecting masculinity
Safeguarding the provider role	Males want to be dialysis free until they retire. (12, man) Particularly young Polynesian men or minor Pacific men, they’re often trying really hard to be the man of the family and that’s not compatible with being sick, so they can’t be sick. […] (14, man) If I now have a man who has to feed his family, he may pay less attention to his blood pressure, […] than a woman who is not responsible for maintaining the family budget. (33, woman)
Clinging to control	Men, they feel that they lose control. They depend on another person. They don’t like that.(13, woman) The men frequently they disappear for a long time and return very bad. He said his life was not good because he had to go three times a week, […] (17, man) Men think I’m strong and I don’t need help type thing. Especially in the early stages of CKD, until they crash and burn, and end up on dialysis. (19, man) In the lead up to the disease, men are in denial but once they accept their diagnosis, they’re gunning for best treatment options and so they are a bit more focused towards outcome. (24, woman)
Self-regard and entitled	A wife will change her schedule because it’s her husband’s surgery but doesn’t happen as often when the roles are reversed. (04, woman) They think about themselves first before thinking about the greater good of the family. (24, woman) Very often there is a patriarchy. The man says that the woman has to do something. He involves her in his own illness. (31, woman) So whether I treat male patients better? Men are perhaps the more demanding, more tiresome patients who ask questions, who don’t let you off so quickly. (32, man)
Decisional power and ownership
Male dominance in decision-making	In some cultures, men tend to make the decisions and the women go with it. Often the men will speak for the women even during the consultation. They do all the talking. (09, man) Pacific women are potentially much more deferential. (21, woman) It’s certainly a difference with a male dominated culture. Women will defer to the male person to make decisions around dialysis and getting to a treatment endpoint. (24, woman) There are a lot of European countries included which have a clearly patriarchal system. The husband says his wife can’t go for dialysis three times a week. (34, woman)
Analytical approach	Women are more conservative and more willing to take advice on and more willing potentially, they appear to be more deliberative and collaborative. (21, woman) Most of my women patients will accept their diagnosis earlier but be more hesitant about treatment options. They often take longer to make decisions. (24, woman) Men tend to take a lot as “given” […] guided by our recommendations, […] in contrast to women, who also talk to patients or get information from the Internet or elsewhere. (30, man)
Inequities compounded by social disadvantage
Financial and transport barriers	Many women do not have a driving licence, they are dependent on neighbourhood help or public transport. (31, woman) Those women who cannot afford childcare and are tied up at home […] are at a disadvantage, especially in the lower social classes. […] money flows more often to the man (31, woman) […] there isn’t really money often for the women to go to the hospital. […] In certain places like Africa and possibly India and whatever there’s definitely systematic disadvantage of women. (45, woman)
Without social security	To have social security, you have to work. It’s more likely that the men are working and therefore have social security than women. So there are delays for women or no [dialysis] therapy. (90, man) […] they might more easily make the decision to not go on dialysis if it’s a female. Whereas, if it’s a male in question, they might really try to raise resources in order to […] provide dialysis. (35, man) Women are less likely to go onto dialysis, but not really because of choice, but because of cost. […] What happens? The outcome is poor because you’re going to die. (37, woman) Men are the ones who tend to show up in hospital because there isn’t really money often for the women to go to the hospital. (45, woman)
Limited literacy	I have to spend a lot of time explaining it, getting an interpreter involved, depending on which country they come from, they can have different perceptions about […] their trust in the system. (16, woman) Those who have no education and no network are left empty-handed and are not getting the medicine. (31, woman) These ladies are busy looking after the children, cleaning the house, doing all these things, [.] don’t have time to integrate themselves into society, […] don’t always understand their disease. (45, woman)
Entrenched discrimination and vulnerability	There is the old, conservative role model, where the man is more important than the woman. That also goes back to the Sharia, where it says that the woman is worth half as much as the man. (31, woman) Women are typically disadvantaged socially, they don’t have, in many societies, an equal social status as men. […] women’s health is often the one that often goes on the chopping block. (35, man) If a family has a precarious situation, they might more easily make the decision to not go on dialysis if it’s a female. If it’s a male […], they might really try to raise resources […] provide dialysis. (35, man)

CKD, chronic kidney disease; ID, identification; PD, peritoneal dialysis.

Number indicates participant ID.