Assessing the Effectiveness of Psychosocial Interventions for Treatment Adherence in Adults Receiving Hemodialysis: A Systematic Review

Background and Purpose: End-stage kidney disease (ESKD) is the final stage of chronic kidney disease (CKD), requiring renal replacement therapy such as hemodialysis to sustain life. Despite the life-sustaining role of hemodialysis, necessary treatment adherence to medication and dietary regimens remains a significant challenge. Non-adherence is reported in over 50% of patients and is linked to increased morbidity, hospitalization, and healthcare costs. Given the emotional, social, and behavioral complexities of managing hemodialysis care, researchers and practitioners have increasingly explored the role of psychosocial interventions such as motivational interviewing and cognitive-behavioral therapy promoting adherence. However, existing systematic reviews have primarily focused on mental health outcomes rather than adherence. The purpose of this systematic review is to examine the effectiveness of psychosocial interventions in promoting medication and dietary adherence among adults with ESKD receiving hemodialysis. This review aims to determine whether psychosocial interventions improve adherence outcomes to identify the most effective approaches and to guide future research and clinical practice.

Methods: A systematic review was conducted following the Cochrane Handbook for Systematic Reviews of Interventions and reported according to PRISMA guidelines. A computer-based search was completed across nine databases for randomized controlled trials (RCTs) published in English from August 2018 to February 2025. Eligible studies included those with adult participants receiving hemodialysis for ESKD who participated in any psychosocial interventions with reported medication and/or dietary adherence outcomes, compared to routine care. Studies focused only on mental health or biomedical outcomes, educational-only intervention, or non-adult populations were excluded. Screening and data extraction were conducted using Covidence, and study quality was assessed using the Cochrane RoB 2 tool. Intervention types were categorized using the World Health Organization’s adherence framework. Adherence outcomes, collected through self-report tools, were extracted as means, standard deviations, and p-values, and used to compute effect sizes (Cohen’s d).

Results: Six randomized controlled trials were included. Four studies reported significant improvements in dietary adherence (p < .001 to .003), with large effects (Cohen’s d = .52 to 11.26). Three studies showed improvements in medication adherence; two demonstrated significant between-groups improvement (p <.001, p =.041, d = .33 to .92), and one displayed within-group improvement (d = .30). One study had a combined adherence score, restricting interpretation on domain-specific effects. Dietary adherence outcomes were more consistent compared to medication adherence, with Cohen’s d ranging from small to large. Risk of bias assessments rated two studies with some concerns and four as high risk.

Conclusions and Implications: Psychosocial interventions significantly improved adherence among hemodialysis patients, particularly to diet. Several interventions showed large and sustained effects, with limited study quality. Findings support the use of psychosocial strategies in clinical practice and highlight the need for higher quality trials. By further exploring intervention components, researchers will be able to tailor the approaches to diverse populations, thus strengthening adherence outcomes and clinical decision-making.