Abstract
Introduction
End-stage kidney disease (ESKD) represents the final stage of chronic kidney disease, profoundly impacting patients and their caregivers through a wide range of physical, psychological, and social challenges. Cultural values and healthcare system disparities often shape these experiences, but comparative cross-cultural perspectives remain limited.
Objective
This study explores the psychosocial experiences and treatment processes of individuals with ESKD and their caregivers in Sri Lanka and Poland, focusing on cultural, systemic, and personal influences on wellbeing.
Methods
An exploratory qualitative design was employed, utilizing semistructured interviews with 27 participants, including 18 individuals undergoing hemodialysis (10 from the Sri Lankan sample and eight from the Polish sample) and nine caregivers (five from the Sri Lankan sample and four from the Polish sample). The interviews were analyzed using conventional qualitative content analysis, identifying thematic similarities and differences across the two cultural contexts.
Results
Three interconnected themes emerged: quality of life, coping strategies, and medical experiences. In Poland, the “Power of (My)Self” reflected individual resilience and personal agency as dominant factors influencing wellbeing. In contrast, the Sri Lankan context was shaped by the “Power of Tradition,” with cultural practices, religious rituals, and communal values playing pivotal roles. Participants in Sri Lanka faced significant resource limitations and infrastructural challenges, while Polish participants benefited from more comprehensive healthcare systems but reported challenges such as depression and emotional isolation.
Conclusion
The findings highlight the profound impact of cultural frameworks and systemic disparities on the lives of individuals with ESKD and their caregivers. While Polish participants emphasized autonomy and self-management, Sri Lankan participants relied heavily on traditional and familial support systems. The proposed conceptual model encapsulates these dynamics, providing a framework for culturally sensitive interventions that address both universal and context-specific needs.
Keywords
Introduction
End-stage kidney disease (ESKD) marks the final stage of chronic kidney disease, with kidney function dropping below 15%. It significantly affects patients’ and caregivers’ quality of life, posing physical, psychological, and social challenges. While hemodialysis prolongs life, it often leads to lifestyle restrictions and emotional burdens (Gerogianni & Babatsikou, 2014a; Tchape et al., 2018).
Globally, ESKD management varies with healthcare resources, cultural beliefs, and economic conditions. High-income countries have advanced care, while low- and middle-income countries (LMICs) struggle with limited access and infrastructure (Thurlow et al., 2021; Crews et al., 2019). In Sri Lanka, a LMIC with strong Buddhist traditions, health and illness are often viewed through karmic beliefs, providing psychological coping mechanisms (Ananda & Ali, 2022). Despite free public healthcare, patients face high out-of-pocket expenses and systemic challenges due to economic crises and resource shortages (Kumar, 2019; Weerakoon et al., 2024). In contrast, Poland's universal healthcare system covers ESKD treatment, including dialysis and transplantation (Rój, 2020; Dębska-Ślizień et al., 2021). However, Polish patients still face psychological difficulties like depression and emotional isolation.
While some research addresses the psychosocial impact of ESKD in specific countries (Ćwiek et al., 2017; Senanayake, 2018), comparative cross-cultural studies are scarce. This study aims to explore and compare the psychosocial experiences of patients with ESKD and caregivers in Sri Lanka and Poland, highlighting how cultural and systemic factors shape their challenges and coping strategies.
Literature Review
Living with ESKD poses significant psychosocial challenges. Patients commonly experience anxiety, depression, social withdrawal, and diminished self-esteem (Finnegan-John & Thomas, 2013; Gerogianni & Babatsikou, 2014b). Caregivers also face substantial pressures, including emotional fatigue, financial hardship, and overwhelming responsibilities (Adejumo et al., 2019; Brunier & McKeever, 1993; Low et al., 2008).
Cultural beliefs strongly influence how individuals interpret illness and choose coping mechanisms. In collectivist contexts like Sri Lanka, religious and spiritual views, particularly Buddhist concepts such as karma and impermanence, shape illness narratives, offering either a source of comfort or passive resignation (Kleinman, 1980; Ananda & Ali, 2022). These beliefs often emphasize shared suffering and communal support.
Despite the growing body of national studies, few have compared how cultural values and healthcare systems together shape the psychosocial experiences of patients with ESKD and their caregivers. This study addresses that gap by exploring lived experiences in both Sri Lanka and Poland, to inform culturally sensitive, context-aware psychosocial interventions.
Methods
Design
This study employed a qualitative design as a part of a mixed-method project on the psychosocial wellbeing of patients with ESKD undergoing hemodialysis and their caregivers in Sri Lanka and Poland. All participants gave written informed consent after receiving detailed study information. Semistructured interviews were conducted in hemodialysis units: in a hospital in Sri Lanka's central province (October 2022) and a hospital in northern Poland (October 2023–May 2024). One Polish caregiver interview was conducted online due to logistical issues. In Sri Lanka, interviews were conducted by the principal investigator, a female experienced qualitative researcher and university lecturer. In Poland, data were collected by a trained female psychology master's student and a female assistant professor, both experienced in qualitative research and chronic illness care. The research team ensured ethical conduct, offering debriefing and psychological support when needed, with a focus on participants’ wellbeing.
Sample
Participants were selected using a purposive sampling approach (Palinkas et al., 2015) aligned with the research objectives outlined by Bulathwatta et al. (2023). The study included 10 individuals with ESKD from Sri Lanka and eight from Poland. Two Polish participants were excluded after initial interviews because they identified as Jehovah's Witnesses rather than Catholics, which did not meet the inclusion criteria. Additionally, five caregivers from Sri Lanka and four from Poland participated. One Polish caregiver was excluded after the initial interview for not meeting the Catholic background criterion.
Inclusion criteria for patients with ESKD required a diagnosis of chronic kidney disease (CKD) stage G5 (ESKD), active hemodialysis treatment, age between 18 and 84 years, and CKD treatment duration exceeding 6 months. Participants were also required to meet specific nationality and religious criteria: Sinhala Buddhist for Sri Lanka and Polish Catholic for Poland. These criteria were established to ensure cultural and religious homogeneity, enabling meaningful cross-cultural comparisons. Although religion was included as a criterion in the study, it was not explicitly stated in the protocol. Comorbidities were not considered for inclusion.
Exclusion criteria included individuals who did not meet the inclusion criteria, declined consent, or lacked the physical or mental capacity to participate. Caregivers were eligible if they were identified by patients with CKD as significant supporters and were at least 18 years old. Caregivers who declined consent or lacked the necessary capacity were excluded.
Data Collection
Two semi-structured interview guides were developed—one for patients with ESKD, one for caregivers—based on literature and study objectives. Each included 27 questions (12 general, 15 open-ended) covering experiences, emotions, relationships, social support, and medical care. Data saturation determined the final sample size for both groups. Interviews (35–60 min) were conducted by experienced researchers, with field notes taken. All interviews were recorded, transcribed verbatim (in Sinhala and Polish), and translated into English. Translations were cross-checked through back-translation and reviewed by independent researchers to ensure cultural and linguistic accuracy. Participants reviewed their transcripts (member checking) to verify accuracy. Researchers practiced reflexivity throughout the process. Triangulation was employed by combining multiple data sources (interviews, field notes, member checks, and translations reviewed by independent researchers) and involving multiple researchers in data analysis to enhance the credibility and trustworthiness of the findings (Nowell et al., 2017). Verified transcripts formed the basis for content analysis.
Data Analysis
An inductive content analysis approach (Joffe et al., 2004; Hsieh & Shannon, 2005) was used to explore interview narratives and identify patterns, meanings, and themes. Open-ended questions enabled a detailed examination of participants’ experiences. Four researchers conducted the analysis: two analyzed the Sinhala data, while three analyzed the Polish data. Researchers independently read transcripts, coded key phrases, and grouped codes into subcategories, categories, and overarching themes. Triangulation ensured reliability by having at least two researchers code each dataset independently (Elo & Kyngäs, 2008). Analytic notes documented coding decisions and reflections, guiding team discussions. Findings were compared, refined, and validated collaboratively to ensure consistency and credibility.
Ethical Considerations
Participants received detailed information about the study's objectives, scope, and procedures beforehand. Participation was voluntary, with the right to withdraw at any time without repercussions. Anonymity was ensured by assigning unique encrypted identifiers, and data access was restricted to the research team.
Ethical approval for the study was obtained from the Ethical Review Committee of the Open University of Sri Lanka, under the application number ER/2022/007 and from the Ethical Review Board of the Institute of Psychology, University of Gdańsk, under inquiry number 03/2023. These measures underscore the study's adherence to ethical research standards, prioritizing participant autonomy, confidentiality, and data security.
Results
Basic demographic information of the participants is presented below. The Sri Lankan sample consisted of eight females (53%) and seven males (47%), with an average age of 48 years. The adjusted Polish sample included nine females (75%) and three males (25%), with an average age of 29 years. Tables 1 and 2 present the demographic details of the Sri Lankan sample, while Tables 3 and 4 outline those of the Polish sample.
Demographic Characteristics of Sri Lankan Participants (Patients).
Demographic Characteristics of the Participants (Sri Lankan Caregivers).
Demographic Characteristics of Polish Participants (Patients).
Demographic Characteristics of the Participants (Polish Caregivers).
Themes, Categories, and Subcategories That Emerged from the Data.
Notably, the “Power of tradition” emerged as a significant influence across all three themes in the Sri Lankan results, reflecting the role of cultural and communal values in shaping participants’ lives. In contrast, the “Power of (my)self” was a predominant influence in the Polish results, emphasizing individual autonomy and self-reliance as key factors shaping their experiences (see Figures 1 and 2).
A model illustrating the mutual relationship among three identified themes and the influence of the power of tradition on them.
A model illustrating the mutual relationship among three identified themes and the influence of the power of (my) self on them.
Theme 1: Quality of life
The quality of life for both the Sri Lankan and Polish samples was shaped by four key factors: financial hardship, work life, family life, and everyday life.
Financial Hardship
Financial hardship emerged as a distinct and pervasive concern, influencing multiple aspects of participants’ daily lives, particularly among the Sinhalese sample. Participant 1, a traditional Sinhala medicine practitioner, had to close her clinic due to mounting costs. “I had to pay Rs. 20,000 [$62] in rent for my shop per month, along with electricity bills, which led me to close it. Now, if someone seeks treatment, I provide it at home.” Sinhalese participant 2 was fearful and mentioned that his job is insufficient to cover his medical and travel expenses. As he put it “The current situation in the country is not good, so I fear my job won't be enough. [The patient was emotional]. We anticipate spending more than RS 1500 [approximately $5] on travel expenses for the treatment.” Sinhalese participant 1 also shared that her financial constraints made it difficult to afford the hospital-recommended diet: In her words: “to be honest, affording the diet recommended by the hospital is beyond my means. I simply don't have the financial resources to purchase protein-rich foods like meat, eggs, or milk…”
Sinhalese participant 5 described the financial difficulties she faced during her treatment process. She stated “Now our financial situation is zero. Without spending money, how can I recover myself? I also have to spend money on transportation.”
Polish participants also reported financial strain, especially those who lost jobs due to the demands of treatment. Polish participant 10 explained, “I lost my job, and now I have to rely on a pension; I can’t earn extra. It has had a big impact. It's not that my parents can’t manage financially, but there's a difference between what could have been and what is. We have to support each other financially.” Some Polish participants expressed dissatisfaction with government support. As Polish participant 8 noted: “I think they’re not helping [the government]. As I read on forums, patients, whether post-transplant or with other issues, constantly have to fight to keep their medications on the reimbursement list.”
However, not all experiences were negative. Polish participant 5 described financial stability: “I would describe my financial status as good; I manage well, have two loans, and can afford luxuries and trips, so this disease… I can’t say it doesn’t limit me because I could probably have more, but what I have is great.”
Work Life
Work life changes emerged as a distinct aspect of participants’ experiences, separate from financial hardship. While financial strain was a consistent backdrop, participants specifically described how their ability to engage in work, retain employment, or adjust their careers was directly impacted by ESKD and caregiving duties. For example, participant 5 from the Sinhalese sample resigned from her job due to the disease, and her husband retired to become her full-time caregiver. . As she explained: “I did not retire. I faced many obstacles at once, so I resigned […] He was previously employed at the electricity board and had the option to continue working there until the age of 65. Yet, due to my illness, he felt compelled to resign as well, since there was no one else available to assist me.”
Similarly, Polish participants highlighted disruptions in their professional life. Some transitioned to part-time or remote work due to the physical burden of treatment and time required for dialysis. Polish participant 8 shared: “I obtained permission to work remotely. […] Besides, I work part-time, so I manage my day better and am glad to be back at work, as it keeps my mind occupied.” Meanwhile, many participants mentioned that their financial situation has been severely affected by the treatment and some of them lost their jobs due to the difficulty of managing work alongside dialysis.
Family Life
The family has been recognized as the purpose of living for all the participants in both samples. The statement of “We'll get through this together. We'll adjust our diet, and prioritize your medications, and I'll be here to support you every step of the way. We'll face this challenge as a team…” given by participant 4 from the Sinhalese sample to her husband shows her intimacy with him.
Sinhalese participant 8 explained the impact of his disease on his siblings. “They are very upset and depressed. I was selected for the university as well, which makes them sad as I cannot attend. The only relief is going for a transplant, so they are trying to arrange a transplant.”
Sinhalese participant 13 described the impact on her family when her son was diagnosed with CKD and began dialysis. “Following my son's health crisis, my husband was also diagnosed with high blood pressure.”
Participant 8 from the Polish sample emphasized the crucial role of her partner, who takes on household duties and financially supports the family. “My partner is my biggest supporter. I’m glad he stayed with me [despite the illness], especially since we’re not formally married…” Polish participant 10 explained the nature of her family support: “Our relationship has become closer. I mean with my parents because it hasn’t changed with my brother. My relationship with my parents has strengthened a lot. […] I live with my parents.”
Polish participant 1 explained her dependency on the family: “I am now so weak that without the help of my husband and son, I can’t do anything. Sometimes I just cry because I want to do something…”
Everyday Life
Participants from both samples discussed their everyday lives in terms of the diet they are required to follow, their financial situation, and their isolation.
Participant 1 from the Sinhalese sample shared that her financial constraints made it difficult to afford the diet recommended by the hospital. In her words: “to be honest, affording the diet recommended by the hospital is beyond my means. I simply don't have the financial resources to purchase protein-rich foods like meat, eggs, or milk…”
Sinhalese participant 5 described the financial difficulties she faced during her treatment process. She stated: “Now our financial situation is zero. Without spending money, how can I recover myself? I also have to spend money on transportation.”
Sinhalese participant 9 mentioned that she is losing social contact with friends due to this disease. She stated: “I can't hang out with friends because they're either busy with work or have moved away. Additionally, some people avoid me because of my sickness…”
Participant 1, from the Polish sample, described her challenges with dietary restrictions: “It's not easy; we’re supposed to follow a diet that restricts almost everything. Drink as little as possible – I had a huge problem with this because of diabetes… and I still drink too much.”
For some patients in the Polish sample, the disease has not significantly impacted their financial situation. Polish participant 2 stated: “You can't say that this kidney disease has had such a significant impact because we live at the same level as we did before I got sick…”
Many patients regardless of their gender and age, experience social isolation, avoid social interactions, refrain from sharing their health status outside the family, and watch relationships often diminish. Polish participant 2 described her experience of isolation: “I definitely miss contact with people, like with friends, over small, trivial things. Not anything particular, just to… Since I’m feeling bad, I sometimes just want to hear about something, like someone chatting…”
Coping Strategies
The coping strategies of both samples included both adaptive and maladaptive approaches.
Adaptive Coping Strategies
In both the Sinhalese and Polish samples, adaptive coping strategies were used to manage the challenges of ESKD. These strategies included maintaining family harmony, engaging in social support networks, managing finances, and participating in religious or cultural practices.
Family harmony, meeting friends, managing finances, and following religious rituals were identified as most common adaptive coping mechanisms in the Sinhalese sample. As Sinhalese participant 8 stated: “my family's food pattern has completely changed due to my disease. They've shifted to eating more fruits and using less oil in cooking. They make sure that any food they bring home is good for me…”
Sinhalese participant 4 explained the support he receives from his friends, saying: “I frequently meet with my friends and talk to them. They have been a great help to me, even in my search for a kidne.y.
Sinhalese participant 7 stated that the government's support manages the disease: “I receive Rs 5,000 [about $15] per month from the government. Additionally, my friends are also helping me.”
Sinhalese participant 6 expressed gratitude for her recovery and vowed to visit spiritual places to fulfill promises made to God. She said: “I've experienced immense benefits through cultural rituals. My daughter prayed for my health at the Temple of the Tooth, and I recovered…”
Sinhalese participant 2 was trying to understand the psychological and physical aspects of the disease condition through the core Buddhist belief of “letting go.” He expressed: “The solution is to practice letting go. Then we do not have problems.”
Positive thinking, acceptance of the illness, setting goals (such as a kidney transplant), finding solace in learning about their illness, and engaging in distraction techniques through hobbies were common adaptive coping strategies among the Polish sample. As Polish participant 1 mentioned: “I try to change my thinking and focus on positive things, pushing away thoughts that make me feel trapped. It's intense. […] I push away thoughts about feeling unwell by turning on the TV or engaging with my pets, so I can distract myself.”
For some patients, the crisis served as a catalyst for personal growth, inspiring them to seek and acquire new knowledge. Polish participant 2 mentioned, “Since being diagnosed with diabetes, I’ve been in this medical world. Then I chose my studies and work in this area, so I find it easier to understand what doctors are telling me.”
A few patients maintained a supportive group and engaged in enjoyable activities. Polish participant 1 mentioned: “Right now, we have this group; we’ve become more outgoing with a few women. We bake cakes, bring them, share them with the nurses…”
Polish participant 3 explained her positive hopes regarding the possible transplant: “My goal now is to get a transplant, go through the tests, get the certificates I need, and persist in pursuing that goal.”
Polish participant 7 mentioned the support he receives from his friends: “That's exactly it, I stick more with my friends than with my family, so we've been through a lot together, and one friend even offered—well, most of them, every other one, said they would give me a kidney if they could. And one of them got so involved that he personally checked everything to find out what he needed to do.”
Most patients see themselves as believers but do not actively practice or associate with the Catholic Church. Polish participant 1 explained: “I mean, I believe in God and that He exists. […] I don’t believe in priests, don’t believe in earthly beings, as I think we’re all sinful.” Some patients described their disease as “superstitions” or esoteric experiences. Polish participant 2 explained, “I have certain superstitions, like carrying a chimney sweep's button, which I bring with me to exams or important events.”
Polish participant 4 admitted: “Although I don’t go to church, deep down I believe in God and usually pray when I have moments of doubt, moments of despair, when I don’t understand why so many bad things are happening around me, why I still don’t have my health. Faith and prayer help me; they make me feel more spiritual and stronger.”
Maladaptive Coping Strategies
Helplessness, hopelessness, withdrawal, and mistrust were identified in both samples and are presented here as maladaptive coping strategies. These behaviors or emotional states appeared to reduce individuals’ ability to actively manage the challenges of ESKD and were often linked to passivity, emotional distress, or isolation. While such responses are understandable given the burden of the illness, we grouped them separately due to their recurring presence and impact on participants’ overall wellbeing.
Helplessness and hopelessness identified in the Sinhalese sample are considered maladaptive coping strategies. Most of them feel helpless and hopeless particularly those facing challenges related to caregiving responsibilities or finding suitable organ donors. Sinhalese participant 3 explained that he feels helpless as he does not have children, and no one is there to look after his wife if something happens to him. “It's hard, and sometimes the helplessness is overwhelming, but we have to keep going.” Similarly, Sinhalese participant 2 expressed a sense of limitation and reliance on close kin for life-saving support, stating: “I believe that if I find a donor, it should ideally be a family member, as external individuals may not be as inclined to donate.” While not overtly emotional, this belief may reflect a sense of constrained possibility and reduced perceived support, which could contribute to feelings of hopelessness.
Some individuals in the Polish sample exhibit mistrust of healthcare providers, experience depression, withdraw from relationships, struggle with hopelessness, and thoughts of suicide. According to Polish participant 8: “I want to be able to have some control, which isn’t always a good trait. It caused me to refuse anaesthesia for a procedure that usually requires sedation, as I insisted on watching what they were doing…”
Some patients are isolated from others as a result of depression, loss of purpose, and feelings of uselessness and boredom. Polish participant 2 stated: “When I feel bad, or something terrible happens, I cut myself off from distant people. I don’t want to involve them…”
Some individuals are reluctant to discuss their illness, which can be considered a passive coping response and may hinder emotional expression. Polish participant 4 said, “I have friends who, as I mentioned, don’t know about my illness, so they can’t support me because they don’t understand what's wrong with me…”
Some patients are focusing excessively on suffering, leading to despair and abandoning efforts to improve wellbeing. Polish participant 2 expressed: “Honestly, I’ve thought about suicide a few times [voice breaks], knowing that not much is left for me…”
Medical Experience
The medical experience of both the sample includes the knowledge of the disease, self-management and attitudes toward the treatment process.
Knowledge and Self-Management
Most of the Sinhalese individuals did not fully understand the nature of the disease. Sinhalese participant 7 acknowledged feeling confused about the disease due to the conflicting information he had received. He said: “I'm not sure what this disease exactly is. Some say the kidneys are melting; others say they're shrinking.”
Sinhalese participant 3, who was unaware of the effects of dialysis, questioned its impact, stating: “I don't even know what dialysis is, even though I'm undergoing it. Does dialysis make people weak?”
Some patients were dissatisfied with the information provided by doctors. Sinhalese participant 1 expressed frustration over doctors’ reluctance to offer details beyond prescribing medication. She said: “Doctors aren't open to answering our questions. They seem unwilling to engage beyond just medication…”
Unlike the Sinhalese, Polish individuals generally appreciate the high quality of medical care and individualized attention from healthcare professionals. Polish participant 2 remarked, “Every time, the doctors have taken a highly individual approach, showing care and concern,” emphasizing the importance of tailored care.
Similarly, Polish patient 4 added, “Honestly, I feel safe here. Sure, the building is now renovated, but even before, in the old building, the sense of security from the staff mattered more to me,” highlighting how the supportive environment created by the staff fosters a sense of safety and trust among patients.
Polish participant 2 explained, “My kidneys don’t remove toxins, don’t filter, don’t work, which is why I’m on dialysis.”
Some Polish patients demonstrate a strong curiosity to deepen their understanding of their condition and are motivated to pursue knowledge that supports self-management. For instance, Polish Participant 2 shared, “Since being diagnosed with diabetes, I’ve been in this medical world. Then I chose my studies and work in this area, so I find it easier to understand what doctors are telling me.”
This highlights how gaining knowledge about their illness can empower patients, enabling them to better comprehend medical advice and actively participate in managing their health.
Many patients with diverse educational backgrounds actively engage in their treatment by consulting doctors and verifying information on social media forums. Polish participant 8 explained: “even though I was also doing my doctorate, but in a different field, I’m passionate about these things, so I read scientific articles, dig around, and try to organize things in my mind…”
Treatment
The Sinhalese sample expressed satisfaction with dialysis but highlighted inadequate infrastructure. Sinhalese participant 11 described his father's postdialysis routine, stating: “there is a dialysis shift from 7 p.m. to 12 a.m. Patients coming for that shift, especially those traveling from distant places, cannot leave immediately and have to stay overnight. We often end up sleeping on chairs or even on the floor.”
Some patients highlighted difficulties caused by medication shortages. Sinhalese participant 9 elaborated, stating: “We often can't find basic medicines here. Sometimes, we even have to provide the hospital with supplies like plasters because they run short. It's really tough.”
Compared to the treatment facilities of Sinhalese, Polish individuals are generally more satisfied with the available services. Polish individuals are not traveling long distances for dialysis. They typically come from nearby areas. For those from farther away, receiving treatment in Gdańsk as a personal choice with satisfaction. Polish participant 5 said: “I’m from Gdynia, so I’m closest to the station in Gdynia, but I would never want to go there. Here… Here, I feel safe.”
Polish participant 6 stated, “Compared to other facilities, I rate them very highly here; it's a well-qualified team,” reflecting confidence in the expertise of the medical staff.
According to Polish participant 4, nurses are friendly and often provide a source of support. “The nurses are always so welcoming and helpful.”
According to Polish patients, the medical staff generally respond to questions and approach each patient individually. Polish patient 2 stated: “Every time, the doctors have taken a highly individual approach, showing care and concern.”
Discussion
This study offers a unique cross-cultural comparison of the psychosocial experiences and treatment processes of individuals with ESKD and their caregivers in Sri Lanka and Poland. The findings identified three core themes—quality of life, coping strategies, and medical experiences—each deeply influenced by the cultural, economic, and healthcare contexts specific to each country.
Quality of Life
Participants from both countries reported a diminished quality of life as a result of the physical, psychological, and financial burdens associated with ESKD. In Poland, some participants were able to maintain financial stability due to systemic healthcare support, whereas Sri Lankan participants universally faced significant economic hardships. These findings are consistent with previous studies emphasizing the critical role of resource availability in managing chronic illnesses (Senanayake, 2018; Ziętalewicz & Bargiel-Matusiewicz, 2024).
Despite these differences, family support emerged as a universal factor in fostering resilience, highlighting the pivotal role of familial networks in coping with chronic disease.
Coping Strategies
Coping strategies varied significantly between the two cultural contexts. Polish participants predominantly employed adaptive strategies such as autonomy, goal-setting, and cognitive reframing, reflecting the individualistic cultural orientation characteristic of Western societies. In contrast, Sri Lankan participants relied on communal support, religious rituals, and adherence to traditional values, consistent with the collectivist societal norms typical of Eastern cultures. These findings align with existing literature on cultural influences on coping, which underscores the emphasis on individual agency in Western cultures versus communal interdependence in Eastern contexts (Maguire et al., 2021; Fischer & Grønning, 2021).
Notably, maladaptive strategies, including feelings of helplessness and depression, were observed in both groups. This shared experience highlights the universal need for targeted psychosocial interventions to support individuals with ESKD and their caregivers.
Medical Experiences
The medical experiences of participants reflected systemic disparities between the two contexts. Polish participants reported satisfaction with the quality and accessibility of healthcare services, benefiting from structured and individualized care within a well-established healthcare system. In contrast, Sri Lankan participants encountered significant infrastructural challenges, including long travel distances and limited resources. These findings are consistent with previous research highlighting the essential role of systemic support in managing chronic illnesses (Boonstra et al., 2022).
Addressing these disparities requires the development of culturally adaptive strategies that consider local resource constraints while prioritizing the specific needs of patients and caregivers.
Cross-Cultural Insights
The conceptual model proposed in this study encapsulates the dynamic interplay between cultural frameworks, coping strategies, and medical experiences. The “Power of (My)Self” framework identified in the Polish context underscores the importance of resilience and autonomy, while the “Power of Tradition” observed in Sri Lanka emphasizes the role of communal and religious influences. These frameworks provide a foundation for designing culturally tailored interventions that respect and integrate cultural values while addressing the universal challenges associated with ESKD.
Previous research aligns with these findings in distinct ways. For example, Eloia et al. (2021) highlighted the significance of religious coping and spirituality in CKD, which resonates with the “Power of Tradition” framework seen in the Sri Lankan context. Similarly, Siqueira et al. (2019) emphasized the role of religiosity and a sense of coherence in improving survival quality among patients with CKD—an aspect closely related to resilience, reinforcing the “Power of (My)Self” framework in the Polish context.
Together, these studies demonstrate how cultural, spiritual, and psychological factors shape coping mechanisms and influence the wellbeing of individuals living with CKD.
Study Strengths
This study's cross-cultural design compares the experiences of patients with ESKD and caregivers in Sri Lanka and Poland, revealing both universal challenges and culturally specific factors. Its comprehensive scope examines multiple life dimensions—quality of life, coping, and medical experiences—offering a holistic understanding of ESKD's impact on patients and families. Including caregivers alongside patients is a key strength, highlighting the reciprocal influence of chronic illness within family systems. The qualitative methodology, using semistructured interviews, allows for in-depth exploration of lived experiences, while methodological rigor (triangulation and reflexivity) enhances the credibility of findings, despite the common limitation of recall bias.
A strong focus on cultural sensitivity ensures findings are relevant and respectful of participants’ contexts, promoting culturally informed healthcare practices. The study also provides practical recommendations for improving patient education, psychosocial support, and addressing healthcare disparities, particularly in underserved settings like Sri Lanka.
Finally, the research lays a foundation for future mixed-method studies, contributing to global discussions on health equity and culturally sensitive care. Its innovative design, methodological rigor, and practical focus offer valuable insights for improving ESKD management across diverse populations.
This study's strengths lie in its cross-cultural design, comparing the experiences of patients with ESKD and caregivers in Sri Lanka and Poland. It reveals universal challenges while highlighting culturally specific factors, offering insights that are both globally significant and contextually relevant. The study also demonstrates methodological rigor through reflexivity, triangulation, and credibility-enhancing strategies, which strengthen the trustworthiness of its findings.
Another strength lies in the study's comprehensive scope, which examines multiple dimensions of life affected by ESKD, including quality of life, coping strategies, and medical experiences. By addressing such a wide range of psychosocial factors, the research offers a holistic understanding of the impact of ESKD on patients and their caregivers, emphasizing the interconnected influences of personal, familial, and systemic factors.
The inclusion of caregivers alongside patients is particularly noteworthy. This dual focus enables the study to explore the interrelated dynamics of chronic illness management within family systems, illuminating the reciprocal impact of ESKD on both patients and their support networks. By integrating caregivers’ perspectives, the research underscores their critical role in patient wellbeing and enriches the overall analysis.
The study's qualitative methodology is another significant strength. The use of semistructured interviews facilitates an in-depth exploration of participants’ lived experiences, capturing the complexity and nuance of their psychosocial and medical realities. This approach yields insights often overlooked in quantitative research, offering a detailed and personal perspective on the challenges faced by individuals living with ESKD. Furthermore, the application of rigorous triangulation methods, with data independently coded by multiple researchers, enhances the credibility and reliability of the findings. While rich in depth, this method may also be subject to recall bias—a common limitation in retrospective qualitative interviews.
A strong emphasis on cultural sensitivity further distinguishes this research. By tailoring the study design and interpreting results within the cultural and religious contexts of the participants, the researchers ensure that the findings are both relevant and respectful of participants’ worldviews. This cultural sensitivity not only strengthens the applicability of the study's conclusions but also underscores the importance of contextually informed healthcare practices.
In addition, the study generates practical implications for healthcare providers and policymakers. It identifies actionable recommendations, such as enhancing patient education, expanding psychosocial support services, and addressing systemic disparities in healthcare access. By focusing on underserved populations, particularly in Sri Lanka, the research highlights systemic inequalities and advocates for targeted improvements in healthcare infrastructure and resources.
Finally, the study establishes a strong foundation for future research. Its findings can inform larger-scale, mixed-methods studies that further examine the interplay between cultural, systemic, and psychosocial factors in chronic disease management. Its contribution to the global discourse on health equity and culturally sensitive care is particularly significant, emphasizing the need for inclusive healthcare strategies that cater to diverse patient populations.
The study's innovative design, rigor, cultural inclusivity, and practical focus offer valuable insights into ESKD, enhancing academic knowledge and guiding improvements in patient and caregiver wellbeing across cultures and healthcare settings.
Study Limitations
This study encountered several limitations that should be considered when interpreting its findings.
First, although the sample size may seem limited, it aligns with qualitative research priorities, which focus on depth rather than generalizability. Data saturation was monitored during collection and deemed achieved when no new codes or themes emerged, based on ongoing comparisons and team discussions confirming the richness of the data.
Second, the study focused exclusively on two specific cultural groups: Sinhalese Buddhists and Polish Catholics. While this cultural specificity allows for a rich exploration of the interplay between cultural, religious, and systemic factors, it may limit the applicability of the findings to other ethnic or cultural groups. These specific contexts should be carefully considered when interpreting the results and applying them to broader populations.
The data were collected through semistructured interviews, which effectively captured detailed experiences but were prone to recall bias, as participants reflected on different stages of their illness. This highlights the importance of incorporating complementary methods, such as longitudinal or mixed-method approaches, in future studies to enhance accuracy and validate these findings.
Implications for Practice
This study highlights the importance of developing culturally sensitive interventions that align with the unique values and coping mechanisms of patients and caregivers. In contexts such as Sri Lanka, where traditional practices and communal support systems are deeply embedded, integrating cultural resources into healthcare delivery can significantly enhance patient engagement and outcomes. For example, organizing short retreats for patients and caregivers focused on relaxation, mindfulness, and spiritual healing could provide emotional relief and foster resilience. Similarly, establishing social clubs where patients and caregivers can connect, share experiences, and support one another would cultivate a sense of community and mutual understanding, further bolstering coping mechanisms and overall wellbeing.
These findings are relevant to nursing practice, as nurses are often at the frontline of chronic illness management and long-term patient care. Through culturally competent care, nurses can bridge the gap between medical treatment and psychosocial support, ensuring that patients receive care that respects their beliefs and coping mechanisms. Strengthening both nursing education and clinical practice to include psychosocial and cultural dimensions, particularly in contexts like Sri Lanka, where such integration may be limited, can better equip nurses to deliver holistic, patient-centred care. Improving access to healthcare and psychological support is vital for patients with ESKD in resource-limited settings. Healthcare policymakers should prioritize addressing systemic disparities, including logistical barriers and infrastructure gaps, to ensure equitable care.
In cultures that emphasize individual strength and autonomy, such as Poland, fostering resilience and self-reliance is essential. Tailored mental health interventions, patient education on adaptive coping strategies, and structured support groups can play a pivotal role in enhancing psychological wellbeing and empowering patients to navigate the challenges of ESKD more effectively.
A multidisciplinary, collaborative care approach is essential for addressing the complex medical and psychosocial needs of patients with ESKD and their caregivers. Prioritizing patient-centred care and integrating physical, psychological, and cultural aspects ensures responsive and supportive healthcare that empowers patients and caregivers.
Conclusions
This study explored the psychosocial experiences and treatment processes of individuals with ESKD in two distinct cultural contexts—Eastern (Sri Lanka) and Western (Poland). As the first study to compare these cultural perspectives in relation to the psychosocial wellbeing of patients and their families, it uncovered significant influences on quality of life, coping strategies, and medical experiences.
A key finding was the contrasting frameworks shaping participants’ wellbeing. Among Sinhalese participants, the power of tradition, rooted in communal values and cultural practices, emerged as a central factor influencing their experiences. In contrast, Polish participants emphasized the power of (my)self, characterized by autonomy and self-determination. These divergent paradigms underscore the profound interplay between cultural norms and individual coping strategies in managing chronic illness.
The findings contribute to the development of a conceptual model that integrates these cultural dynamics, offering a robust framework for designing culturally sensitive healthcare interventions. By incorporating these insights into clinical practice, healthcare providers can enhance patient and caregiver wellbeing while addressing systemic disparities across diverse cultural and healthcare settings.
Supplemental Material
sj-pdf-1-son-10.1177_23779608251360594 - Supplemental material for Contrasting Cultures, Shared Struggles: A Qualitative Analysis of the Experiences of End-Stage Kidney Disease Patients and Their Caregivers in Poland and Sri Lanka
Supplemental material, sj-pdf-1-son-10.1177_23779608251360594 for Contrasting Cultures, Shared Struggles: A Qualitative Analysis of the Experiences of End-Stage Kidney Disease Patients and Their Caregivers in Poland and Sri Lanka by Darshika Thejani Bulathwatta, Agata Rudnik, Judyta Borchet, Sonia Zelechowska, Małgorzata Treppner, Jakub Ruszkowski, Agnieszka Zakrzewska, Alicja M. Dębska-Ślizien, Bogdan Biedunkiewicz, Leszek Tylicki and Mariola Bidzan in SAGE Open Nursing
Supplemental Material
sj-docx-2-son-10.1177_23779608251360594 - Supplemental material for Contrasting Cultures, Shared Struggles: A Qualitative Analysis of the Experiences of End-Stage Kidney Disease Patients and Their Caregivers in Poland and Sri Lanka
Supplemental material, sj-docx-2-son-10.1177_23779608251360594 for Contrasting Cultures, Shared Struggles: A Qualitative Analysis of the Experiences of End-Stage Kidney Disease Patients and Their Caregivers in Poland and Sri Lanka by Darshika Thejani Bulathwatta, Agata Rudnik, Judyta Borchet, Sonia Zelechowska, Małgorzata Treppner, Jakub Ruszkowski, Agnieszka Zakrzewska, Alicja M. Dębska-Ślizien, Bogdan Biedunkiewicz, Leszek Tylicki and Mariola Bidzan in SAGE Open Nursing
Footnotes
Acknowledgments
We would like to extend our gratitude to the Director of Teaching Hospital Kandy, Sri Lanka, and Dr. Nishantha Nanayakkara, Consultant Nephrologist at Teaching Hospital Kandy, Sri Lanka, for granting us access to the Hemodialysis Unit for data collection. Finally, we are profoundly grateful to all the participants who took part in this research and generously shared their experiences.
ORCID iDs
Ethical Considerations
The study received ethical approval from the Ethical Review Committee of the Open University of Sri Lanka, under the application number ER/2022/007 and from the Ethical Review Board of the Institute of Psychology, University of Gdańsk, under inquiry number 03/2023.
Author Contributions
DB was involved in study conceptualization, data curation, study design, data collection, qualitative analysis, and manuscript drafting; AR in study conceptualization, data curation, study design, qualitative analysis, manuscript drafting, and revision; JB, AZ, ADŚ, BB, and LT in data collection; SZ in data collection and qualitative analysis; MT in qualitative analysis; JR in data collection and manuscript revision; MB in study conceptualization and design, data collection, manuscript revision, supervision, and mentorship. All authors contributed to the article and approved the submitted version.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The data that support the findings of this study are available upon request from the corresponding author.
Supplemental Material
Supplemental material for this article is available online.
Patient Consent Statement
Informed consent was obtained from all participants included in the study. The participants were briefed about the nature of the research, its purpose, procedures, potential risks, and benefits. They were informed about their voluntary participation and the confidentiality of their identity.
Permission to Reproduce Material From Other Sources
Permission was obtained to reproduce any copyrighted material from other sources used in this article.
Clinical Trial Registration
This study is not a clinical trial, and thus, registration is not applicable.
References
Supplementary Material
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