Knowledge, Attitude, and Practice on Arteriovenous Fistula Care Among End‐Stage Kidney Disease Patients Receiving Maintenance Hemodialysis: A Single‐Center, Prospective Cohort Study in Nepal

Abstract

ABSTRACT

Background and Aims

The majority of complications arising from the arteriovenous fistula (AVF) site for hemodialysis (HD) can be prevented through the implementation of a daily self‐care plan. This study aimed to assess the knowledge, attitude, and practice (KAP) of hemodialysis patients with end‐stage kidney disease (ESKD) regarding AVF self‐care preoperative, postoperative, and during follow‐up.

Methods

This prospective cohort study was conducted at a tertiary referral center in Nepal. It included ESKD patients over 18 years with AVF. Patients were interviewed preoperative, postoperative, and at 2, 4, and 6 weeks. KAP was assessed as percentages, and associations were analyzed using the χ² test. Score comparisons over time used the paired t‐test, with p < 0.05 considered significant.

Results

Among 173 AVF patients, 98.8% had poor knowledge preoperative, while 98.3% had good knowledge postoperative, with significant improvement in the overall score of knowledge (p < 0.001). Initially, 97.1% were motivated towards self‐care, but this dropped to 78.0% by the 6th week. Most patients practiced weight‐bearing prevention, cleaning, and drying, but fewer practiced daily verification of fluid thrill and exercise with malleable balls. Postoperative knowledge acquisition significantly correlated with male sex and higher socioeconomic status.

Conclusion

Although the majority of patients undergoing HD planned for AVF exhibited a favorable attitude towards fistula care, their knowledge was poor. Knowledge significantly improved with follow‐ups, but motivation for self‐care decreased over time. Patients' practices generally aligned with knowledge scores, emphasizing the importance of regular reminders and periodic evaluations by healthcare workers for practical aspects of AVF care for all ESKD patients undergoing HD.

Introduction

The incidence and prevalence of end-stage kidney disease (ESKD) are rising globally and disproportionately affect patients in low- and middle-income countries (LMICs) [1]. A hospital-based study from Nepal reported that the prevalence of ESKD is 11.36%, comparable to other countries in South Asia [2, 3]. Among available treatments for ESKD, hemodialysis is the most widely accepted and utilized treatment modality worldwide and in Nepal [3–5]. The cornerstone of efficient hemodialysis (HD) is a reliable vascular access via arteriovenous fistula (AVF) or arteriovenous grafts or central venous catheters [6]. AVF access is regarded as the optimal access for dialysis due to superior potency rates, reduced complication rates, lower mortality rates, and it is considered more cost-effective [7]. However, it is still prone to several complications, including stenosis, thrombosis, infection, aneurysm formation, and cardiac overload. Therefore, preventing these complications requires diligent care from healthcare professionals and patients [3].

Given that patients with AVF are at risk of experiencing complications, patients' knowledge, attitudes, and practices (KAP) are pivotal in reducing complications and hospitalizations associated with AVF [4, 8]. The Government of Nepal offers subsidies to financially disadvantaged individuals for HD and transplant recipients [9]. Hemodialysis facilities in our settings are often too busy to meet the dialysis needs of patients with acute kidney injury or ESKD, lacking the infrastructure to support extensive outpatient dialysis and managed by non-nephrologists, raising concerns about the adequacy of professional oversight [10].

Several previous studies have evaluated KAP among HD patients in different countries, often reporting insufficient or inadequate knowledge [11]. Liu et al. highlighted the knowledge–attitude–behavior model as an effective framework for educating on HD [12]. Identifying gaps in KAP can provide insights into barriers affecting treatment adherence and behavior modification in maintenance HD patients [13]. However, studies on Nepalese patients remain limited, and research on KAP specifically related to AVF is scarce. Since long-term dialysis patients may have greater exposure to AVF education, KAP may improve with increasing dialysis experience. Therefore, this study aims to longitudinally explore KAP regarding AVF self-care preoperatively, postoperatively, and during follow-up among ESKD patients undergoing HD.

Materials and Methods

Setting and Study Design

The study was a quantitative prospective cohort study conducted at the hemodialysis unit and department of Cardiothoracic and Vascular Surgery in a tertiary referral center in Nepal from August 2022 to July 2023. It is reported by following the STROBE guidelines [14].

Study Population and Sampling

All patients with CKD-V or ESKD, aged more than 18 years on HD, who were undergoing creation of primary radio-cephalic, brachiobasilic, or brachiocephalic fistulae were included. Patients > 85 years, with psychiatric conditions, an inability to self-care, coagulopathy, previous ipsilateral AVF creation, and unwillingness or unable to provide informed consent were excluded. All consecutive patients meeting the above criteria were enrolled. The sample size of 173 was calculated based on a 95% confidence level, a 5% margin of error, and an expected percentage of patients with good knowledge of AVF self-care at 89.9% from a previous study [15].

Study Instrument

A structured proforma (Supporting Information S1: Appendix) was developed to assess the KAP related to AVF care among ESKD patients on HD. This questionnaire was based on prior studies [15–17]. The proforma was translated into Nepalese, the local language, to ensure better understanding. For accessing knowledge, 12 questions (Supporting Information S1: Appendix) were asked preoperatively, postoperatively, at 2nd, 4th, and 6th week with each positive response scoring one point. Out of a total score of 12, we categorized less than < 6 as “poor knowledge”, 6–8 as “adequate knowledge”, and > 8 as “good knowledge” [18]. For assessing attitude, four questions (Supporting Information S1: Appendix) were asked preoperatively, postoperatively, and at 2, 4, and 6 weeks, and the response was recorded as “yes” or “no”. For assessing practice, 12 questions (Supporting Information S1: Appendix) were asked postoperatively and at 2, 4, and 6 weeks, with positive responses scored one for each question for each visit. Therefore, for a total of 4 points for each question, the score of 0 was categorized as “never practicing”, 1–3 as “occasionally practicing,” and 4 as “always practicing”.

Study Variables

Demographic information, including age, sex, weight, height, body mass index (BMI), and comorbidities, socioeconomic status (Modified Kuppuswamy socioeconomic class) [19], and education (uneducated: No formal education or did not complete primary school, educated). Information regarding KAP was collected.

Outcomes

The primary outcome was to assess the KAP of patients preoperatively and during follow-up. Secondary outcomes were to analyze changes over time and identify factors influencing them.

Data Collection

Data collection was carried out with ethical clearance from the Ethics review committee of the Institute of Medicine. Informed written consent (Supporting Information S2: Questionnaire) was obtained from each patient, and data were collected through interviewer-administered questionnaires during routine dialysis sessions, with minimal interference in treatment. The patients were interviewed before surgery and after surgery. All patients were followed up at 2, 4, and 6 weeks. Medical records were reviewed to collect their demographics and other characteristics. The confidentiality of the participants was maintained.

Statistical Analysis

Data analysis was performed using SPSS software version 26.0; for quantitative variables, the mean ± standard deviation (SD) were calculated. Knowledge, attitudes, and practices were assessed separately using percentages. The relationship between demographic factors (age, sex, and socioeconomic status) and knowledge was assessed using the χ² test. The comparison of scores at different points of time was done using paired t-test. p-value < 0.05 (two-sided) was considered statistically significant.

Results

A total of 209 patients were undergoing HD at the study site during the study period. Of these, 179 patients were enrolled in the study. Thirty patients were excluded from the study, and among them, six were lost to follow-up; hence, 173 were included, with a male predominance (64.7%) (Figure 1). The mean age was 50.5 ± 12.3 years. The mean BMI was 24 ± 4.1 kg/m². Approximately half (47.8%) had formal education (Table 1).

[IMAGE OMITTED. SEE PDF]

Table 1 Demographic profile of the participants.

Demographic characteristics	Total (n = 173), n (%)
Age (years)
0–20	8 (4.6%)
20–40	40 (23.1%)
40–60	72 (41.6%)
60–80	46 (26.6%)
> 80	7 (4.0%)
Gender
Male	112 (64.7%)
Female	61 (35.3%)
BMI (kg/m2)	24 ± 4.1
Socioeconomic status
Upper-class family	4 (2.3%)
Upper-middle-class family	135 (78.0%)
Lower middle-class family	34 (19.7%)
Comorbidities
Diabetes mellitus	24 (13.9%)
Hypertension	75 (43.4%)
Diabetes mellitus and hypertension	59 (34.1%)
Others	15 (8.7%)
Educational status
Uneducated	73 (42.2%)
Educated	100 (57.8%)

Evaluation of Knowledge Involving AVF Self-Care

98.8%, 0.6%, and 0.6% had poor knowledge, adequate knowledge, and good knowledge preoperatively, and 0.6%, 1.1%, and 98.3% had poor knowledge, adequate knowledge, and good knowledge postoperatively. A higher proportion of patients were still unaware of daily thrill verification (12.7%) and exercising with malleable objects (4.0%) (Table 2). The overall knowledge score improved from 0.54 (SD: 1.48) to 11.76 (0.619) at the 6th week (p-value < 0.001).

Table 2 Knowledge about AVF care pre-operatively and postoperatively.

S.N.	Questions	Preoperative	Postoperative	2nd week	4th week	6th week
Yes	No	Yes	No	Yes	No	Yes	No	Yes	No
1	Are you aware of the prevention of weight bearing in the fistula hand?	12 (6.9)	161 (93.1)	172 (99.4)	1 (0.6)	173 (100)	0	173 (100)	0	173 (100)	0
2	Are you aware of exercising with a malleable object?	7 (4.0)	166 (96.0)	166 (96.0)	7 (4.0)	167 (96.5)	6 (3.5)	167 (96.5)	6 (3.5)	163 (94.2)	10 (5.8)
3	Are you aware of the dressing, cleaning, and drying of the fistula?	4 (2.3)	169 (97.7)	172 (99.4)	1 (0.6)	173 (100)	0	173 (100)	0	173 (100)	0
4	Are you aware of using loose bandages or tight dressing over the fistula hand?	1 (0.6)	172 (99.4)	167 (96.5)	6 (3.5)	168 (97.1)	5 (2.9)	170 (98.3)	3 (1.7)	170 (98.3)	3 (1.7)
5	Are you aware of avoiding trauma to the fistula hand?	29 (16.8)	144 (83.2)	170 (98.3)	3 (1.7)	171 (98.8)	2 (1.2)	173 (100)	0	173 (100)	0
6	Are you aware of avoiding excessive weight?	14 (8.1)	159 (91.9)	171 (98.8)	2 (1.2)	170 (98.3)	3 (1.7)	171 (98.8)	2 (1.2)	173 (100)	0
7	Are you aware of the verification of thrill daily?	11 (6.4)	162 (93.6)	151 (87.3)	22 (12.7)	147 (84.9)	26 (15.1)	146 (84.4)	27 (15.6)	146 (84.4)	27 (15.6)
8	Are you aware of avoiding excessive weight loss?	11 (6.4)	162 (93.6)	172 (99.4)	1 (0.6)	173 (100)	0	173 (100)	0	173 (100)	0
9	Are you aware of avoiding blood collection from the fistula hand?	6 (3.5)	167 (96.5)	172 (99.4)	1 (0.6)	172 (99.4)	1 (0.6)	173 (100)	0	173 (100)	0
10	Are you aware of avoiding sleeping on the AVF hand?	2 (1.2)	171 (98.8)	171 (98.8)	2 (1.2)	173 (100)	0	173 (100)	0	173 (100)	0
11	Are you aware of washing with soap and water before hemodialysis?	1 (0.6)	172 (99.4)	172 (99.4)	1 (0.6)	173 (100)	0	173 (100)	0	173 (100)	0
12	Are you aware of avoiding taking blood pressure readings from the fistula hand?	5 (2.9)	168 (97.1)	168 (97.1)	5 (2.9)	169 (97.6)	4 (2.3)	170 (98.3)	3 (1.7)	171 (98.8)	2 (1.2)

Evaluation of Attitude Involving AVF Self-Care

The majority of participants had a positive attitude towards AVF self-care preoperatively and postoperatively. 53.8% falsely believed preoperatively that fistula formation could reverse CKD, which decreased to 6.4% at the 6-week follow-up. Motivation for fistula care decreased from 97.1% preoperatively to 78% at the 6-week. Patient's preparedness for fistula care decreased from 94.8% preoperatively to 89.6% at the 6-week follow-up, respectively (Table 3).

Table 3 Attitude about AVF self-care: preoperative, postoperative, and at follow-up.

Attitude about AVF selfcare
		Follow up
S.N.	Question	Preoperative	Postoperative	2nd week	4th week	6th week
Answer	Answer	Answer	Answer	Answer
Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)	Yes, n (%)	No, n (%)
1	Do you think that the fistula care will be beneficial?	168 (97.1)	5 (2.1)	172 (99.4)	1 (0.6)	172 (99.4)	1 (0.6)	172 (99.4)	1 (0.6)	172 (99.4)	1 (0.6)
2	Do you feel motivated for fistula care?	168 (97.1)	5 (2.1)	173 (100)	0 (0.0)	161 (93.1)	12 (6.9)	145 (83.8)	28 (16.2)	135 (78.0)	38 (22.0)
3	Do you feel prepared for fistula care?	164 (94.8)	9 (5.8)	168 (97.1)	5 (2.9)	159 (91.9)	14 (8.1)	156 (90.2)	17 (9.8)	155 (89.6)	18 (10.4)
4	Do you think fistula formation would reverse CKD?	93 (53.8)	80 (46.2)	44 (25.4)	129 (74.6)	26 (15.0)	147 (85)	12 (6.9)	161 (93.1)	11 (6.4)	162 (93.6)

Evaluation of Practice Involving AVF Self-Care

The majority of participants consistently practiced weight-bearing prevention (99.4%), fistula cleaning and drying (99.4%), avoiding sleeping on the AVF hand (98.8%), and avoiding blood collection from the fistula hand (98.8%). Exercise with malleable objects (90.2%) and daily verification of fluid thrill (72.8%) were less frequently practiced (Table 4).

Table 4 Practice on AVF self-care.

AVF self-care
S.N.	Questions	Always practicing	Occasionally practicing	Never practicing
n (%)	n (%)	n (%)
1	Prevent weight bearing in the Fistula hand	172 (99.4)	1(0.6)	0 (0.0)
2	Exercise with malleable objects?	156 (90.2)	15 (8.7)	2 (1.2)
3	Dressing, cleaning, and drying of fistula	172 (99.4)	1 (0.6)	0 (0.0)
4	Use loose bandages or a tight dressing over the fistula hand.	166 (96.0)	5 (2.9)	2 (1.2)
5	Avoid trauma to the fistula hand	170 (98.3)	3 (1.7)	0 (0.0)
6	Avoid excessive weight	167 (96.5)	6 (3.5)	0 (0.0)
7	Verification of thrill daily	126 (72.8)	43 (24.9)	4 (2.3)
8	Avoid excessive weight loss	172 (99.4)	1 (0.6)	0 (0.0)
9	Avoid blood collection from the fistula hand	171 (98.8)	2 (1.2)	0 (0.0)
10	Avoid sleeping on the AVF hand?	171 (98.8)	2 (1.2)	0 (0.0)
11	Wash with soap and water before hemodialysis	172 (99.4)	1 (0.6)	0 (0.0)
12	Avoid taking blood pressure readings from the fistula hand	166 (96.0)	6 (3.5)	1 (0.6)

In many aspects, the level of practice corresponded with the level of knowledge. For example, only 87.3% of individuals were aware of the importance of daily AVF thrill checks, and correspondingly, only 72.8% practiced this aspect of self-care.

On analysis of age, gender, and socioeconomic status, the “Male” gender and “Upper” socioeconomic status had significantly higher knowledge acquisition postoperatively (Table 5).

Table 5 Knowledge about AVF care: preoperative and postoperative.

Preoperative	Postoperative
Variables	Knowledge		Knowledge
Poor, n (%)	Adequate, n (%)	Good, n (%)	p value	Poor, n (%)	Adequate, n (%)	Good, n (%)	p value
Gender	Male	111(99)	1 (0.9)	0	0.228	0	0	112(100.0)	0.042*
Female	60 (98)	0	1 (1.6)	1 (1.7)	2 (3.3)	58 (95.0)
Socio economic status	Upper	3 (75)	0	1 (25.0)	0.082	0	0	4 (100.0)	0.041*
Upper middle	134 (99)	1 (0.7)	0	0	0	135 (100.0)
Lower middle	34 (100)	0	0	1 (3.0)	2(5.9)	31 (91.1)
Total		171 (98.8)	1 (0.6)	1 (0.6)		1 (0.6)	2 (1.1)	170 (98.3)

Discussion

Prior studies have explored the KAP regarding AVF self-care at a point of time [15–18]. Our study is the first of its kind to assess the KAP over a period of time. We observed that most of our patients had poor preoperative knowledge of AVF self-care, although half of them had some form of formal education [15, 20].

The knowledge score improved in all domains during follow-up except for awareness of exercising with malleable objects and daily verification of thrill. We believe that the improvement in knowledge in our setting may be attributed to the increased interaction between patients and healthcare providers during dialysis sessions or treatment. However, this scenario may not be applicable in remote healthcare facilities, where the availability of skilled staff or healthcare providers may not be guaranteed at all times. In such settings, alternative strategies, like Telemedicine and Remote Consultation, Community Health workers, and Peer Support Groups, can be employed. Failure of improvement in daily thrill checks, exercising with a malleable object, may suggest that healthcare providers and dialysis centers emphasize visible and immediate AVF care (e.g., avoiding trauma, cleaning, and dressing) more than preventive and proactive measures. It also may suggest that patients might not fully understand the importance of daily thrill checks as an early detection tool for AVF dysfunction.

Despite poor knowledge, preoperative attitude toward fistula care was positive, with almost all participants acknowledging its benefits. However, motivation decreased over time, which is concerning since ESKD patients require long-term adherence to AVF maintenance strategies. The burden of chronic illness, along with treatment fatigue, may lead to complacency, increasing the likelihood of AVF complications and repeated hospitalizations [15]. To counteract declining motivation, Regular Reinforcement Sessions, motivational interviewing and goal-setting, peer support, and family involvement can be employed. Initially, approximately half of the patients believed that fistula formation could reverse CKD, which decreased substantially at the 6-week follow-up, suggesting that the hospital interaction can remove false attitudes. Still, 6.4% at the end of 6 weeks believed the fistula could lead to a cure. This reflects not only a failure in effectively conveying medical information but also potential barriers related to health literacy, as half of the study population was uneducated.

The level of practice was found to correspond with the level of knowledge, similar to that in previous studies [18]. The practice with the lowest compliance was the daily AVF thrill checkup (72.8%), which can be explained by the population's limited knowledge about the importance of this checkup (87.3%). Other factors, such as forgetfulness and decreased self-motivation may contribute to its lower practice. It is recommended that this crucial aspect of care have regular assessment, emphasized during patient education on AVF self-care. Demonstrating the method of checking the AVF thrill can also enhance patients' self-confidence in performing this task.

Knowledge levels did not vary significantly by age group preoperatively or during follow-up. However, previous studies have reported that the majority of individuals who adhered to maximum precautionary measures were within the age range of 40–60 years [3]. However, postoperative knowledge correlated with higher socioeconomic status and male sex, suggesting a need for frequent and thorough counseling, especially among females from lower-class families.

Our research has limitations. This was a single-center study, limiting the generalizability of the results. We did not assess the correlation of knowledge with the duration of dialysis or document the interaction the patients had with the health care providers during the follow-up that could have an impact on their KAP during the postoperative period and at follow-ups. To address this, future studies should incorporate standardized tools to measure patient education exposure, such as structured questionnaires or provider logs, to quantify the impact of healthcare interactions on AVF self-care.

Conclusion

The majority of the patients undergoing HD planned for AVF in a tertiary care setting in Nepal exhibited a favorable attitude towards fistula care, but their knowledge was poor. Knowledge improved during subsequent follow-ups; however, motivation for self-care decreased over time. Patients' practices generally aligned with knowledge scores. Future research should assess the effectiveness of structured education programs using standardized protocols and tools to determine their long-term impact on AVF care adherence and outcomes.

Author Contributions

Santosh Dev: conceptualization, methodology, data curation, investigation, validation, supervision, formal analysis, visualization, writing – original draft, writing – review and editing, resources, and software. Prajjwol Luitel: data curation, formal analysis, writing – original draft, writing – review and editing, and investigation. Birendra Sah: data curation, formal analysis, writing – original draft, writing – review and editing, and investigation. Bivek Kumar Yadav: data curation, formal analysis, writing – original draft, writing – review and editing, and investigation. Barsha Dev: writing – review and editing, writing – original draft, and formal analysis. Ishwor Thapaliya: data curation, formal analysis, writing – original draft, writing – review and editing, and investigation. Kajan Raj Shrestha: supervision and visualization. Uttam Krishna Shrestha: visualization and supervision.

Acknowledgments

The authors have nothing to report.

Ethics Statement

Ethical clearance and permission letters were obtained from the Institutional Ethical Committee of Institute of Medicine. Before enrollment, patients provided informed consent. To maintain confidentiality, patient information was safeguarded. The study protocol conforms to the ethical guidelines of the Declaration of Helsinki 2013.

Consent

Written consent was obtained from all patients for publication and any accompanying images, a copy of which is available for review by the Editor-in-Chief of this journal on request.

Conflicts of Interest

The authors declare no conflicts of interest. All authors have read and approved the final version of the manuscript. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Data Availability Statement

The data sets used during this study are available from the corresponding author upon reasonable request.

Transparency Statement

The lead authors Prajjwol Luitel and Birendra Sah affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

References

J. S. Thurlow, M. Joshi, G. Yan, et al., “Global Epidemiology of End‐Stage Kidney Disease and Disparities in Kidney Replacement Therapy,” American Journal of Nephrology 52, no. 2 (July 2021): 98–107, https://doi.org/10.1159/000514550.

M. Ghimire, S. Vaidya, and H. P. Upadhyay, “Prevalence of Newly Diagnosed End‐Stage Renal Disease Patients in a Tertiary Hospital of Central Nepal, Chitwan: A Descriptive Cross‐Sectional Study,” Journal of Nepal Medical Association 59, no. 233 (2021): 61–64.

Q. T. A. Iqbal, A. Shareef, A. Afzal, and S. Ashraf, “Arteriovenous Fistula Care: Knowledge, Attitude and Practice in ESRD Patients on Hemodialysis,” Professional Medical Journal 25, no. 09 (2018): 1426–1431.

A. K. Bello, I. G. Okpechi, M. A. Osman, et al., “Epidemiology of Haemodialysis Outcomes,” Nature Reviews Nephrology 18, no. 5 (2022): 378–395.

R. K. Mandal, R. Pande, K. K. Yadav, and K. Goit, “Clinical Profile of End Stage Renal Disease Patients Undergoing Hemodialysis in a Tertiary Care Hospital of Nepal,” Journal of Advances in Internal Medicine 12, no. 1 (2023): 8–11, https://nepjol.info/index.php/JAIM/article/view/56678.

L. M. Yeh, S. Y. H. Chiu, and P. C. Lai, “The Impact of Vascular Access Types on Hemodialysis Patient Long‐Term Survival,” Scientific Reports 9, no. 1 (2019): 10708.

P. Ravani, S. C. Palmer, M. J. Oliver, et al., “Associations Between Hemodialysis Access Type and Clinical Outcomes: A Systematic Review,” Journal of the American Society of Nephrology 24, no. 3 (February 2013): 465–473.

W. Metcalfe, I. H. Khan, G. J. Prescott, K. Simpson, and A. M. Macleod, “Hospitalization in the First Year of Renal Replacement Therapy for End‐Stage Renal Disease,” QJM: An International Journal of Medicine 96, no. 12 (December 2003): 899–909, https://doi.org/10.1093/qjmed/hcg155.

K. B. Karki, J. Maskey, M. Giri, et al., “Assessment of Chronic Kidney Disease Support Program of Government of Nepal, 2016,” (Nepal Health Research Council, Kathmandu, Nepal, 2017).

V. Kumar and V. Jha, “End‐Stage Renal Disease Care in South Asia: Demographics, Economics, and Opportunities,” Clinical Nephrology 86, no. 13 (2016): 23–26.

V. Natti Krishna, B. Tiwary, M. N. Nayak, N. Patel, P. Gandhi, and P. Majumdar, “Knowledge of Arteriovenous Fistula Care in Patients With End‐Stage Kidney Disease in South Asian Countries: A Systematic Review and Meta‐Analysis,” Chronic illness 20, no. 1 (2023): 23–36.

L. Liu, Y. P. Liu, J. Wang, L. W. An, and J. M. Jiao, “Use of a Knowledge‐Attitude‐Behaviour Education Programme for Chinese Adults Undergoing Maintenance Haemodialysis: Randomized Controlled Trial,” Journal of International Medical Research 44, no. 3 (2016): 557–568.

A. Hamadah, “Attitudes and Perceived Barriers Toward Arteriovenous Fistula Creation and Use in Hemodialysis Patients in Jordan,” Saudi Journal of Kidney Diseases and Transplantation 30, no. 4 (2019): 905–912.

S. Cuschieri, “The STROBE Guidelines,” Saudi Journal of Anaesthesia 13, no. S1 (2019): S31–S34.

N. Rashid, M. Aamer, U. Malik, N. Arif, M. W. Akram, and A. Irshad, “Arteriovenous Fistula (AVF) Self‐Care: A Study at a Tertiary Care Hospital in Lahore, Pakistan,” Annals of King Edward Medical University 24 (April 2018): 706–712.

P. Shrestha, S. Bhujel, and S. Shah, “Knowledge Regarding Arteriovenous Fistula Among Hemodialysis Patients in a Hospital of Rupandehi,” Journal of Universal College of Medical Sciences 7, no. 2 (2019): 30–33.

N. Ozen, N. Tosun, F. I. Cinar, et al., “Investigation of the Knowledge and Attitudes of Patients Who Are Undergoing Hemodialysis Treatment Regarding Their Arteriovenous Fistula,” Journal of Vascular Access 18, no. 1 (2016): 64–68.

W. D. M. G. Amarasinghe, K. M. B. Pabodha, M. H. W. M. N. Wijayapala, E. M. K. G. H. B. K. Ekanayaka, J. M. M. U. Jayasinghe, and D. U. S. Ratnapala, “Assessment of Knowledge, Attitudes and Practices (KAP) on Arterio‐Venous Fistula (AVF) Care Among End Stage Renal Disease (ESRD) Patients on Hemodialysis‐Study in Uva Province, Sri Lanka,” Sri Lanka Journal of Surgery 40, no. 3 (2022): 06–10.

M. Radhakrishnan and S. B. Nagaraja, “Modified Kuppuswamy Socioeconomic Scale 2023: Stratification and Updates,” International Journal of Community Medicine and Public Health 10 (October 2023): 4415–4418.

N. R. C. Pessoa and F. M. P. Linhares, “Hemodialysis Patients With Arteriovenous Fistula: Knowledge, Attitude and Practice,” Escola Anna Nery—Revista de Enfermagem 19, no. 1 (2015): 73–79.