Abstract
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Purpose
This study examined the associations between sociodemographic characteristics, knowledge, self-efficacy, social support, comorbidities, and self-care quality among CAPD patients in Central Java, Indonesia.
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Methods
This cross-sectional study included CAPD patients recruited from two tertiary referral hospitals in Central Java (Dr. Kariadi Hospital and Dr. Moewardi Hospital). Data were collected from April to May 2025, with a total sample of 72 patients. The study instruments comprised the Self-care Scale for Peritoneal Dialysis Patients, a knowledge questionnaire, the Duke-UNC Functional Social Support Questionnaire, and the General Self-Efficacy Scale. Data analysis was performed using the chi-square test, Spearman’s rank correlation, and univariate logistic regression.
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Results
Univariate logistic regression analysis demonstrated that the presence of comorbidities was associated with significantly lower odds of good self-care quality (odds ratio [OR], 0.05; 95% confidence interval [CI], 0.01–0.18; p<.001). Higher levels of knowledge (OR, 1.45; 95% CI, 1.19–1.78; p<.001), self-efficacy (OR, 1.27; 95% CI, 1.14–1.42; p<.001), and social support (OR, 1.38; 95% CI, 1.16–1.64; p<.001) were significantly associated with better self-care quality. Sociodemographic factors showed no statistically significant associations with self-care quality (all p>.05).
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Conclusion
Among CAPD patients in Central Java, higher levels of knowledge, self-efficacy, and social support were associated with better self-care quality, whereas the presence of comorbidities was associated with factors hindering optimal self-care. Sociodemographic variables did not demonstrate clear associations with self-care quality, which may be partly attributable to limited statistical power in this sample.
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Key Words: Self care; Peritoneal dialysis; Self efficacy; Social support; Comorbidity
INTRODUCTION
Chronic kidney disease (CKD) is defined as abnormalities of kidney structure or function persisting for more than 3 months, with implications for health, including a glomerular filtration rate of less than 60 mL/min/1.73 m² [
1,
2]. CKD has emerged as a major global health problem, with its prevalence continuing to increase worldwide. Recent estimates indicate that approximately 10% of the global population, corresponding to more than 800 million individuals, are affected by CKD [
3]. In Indonesia, the prevalence of CKD has also risen steadily over time. According to the 2023 Indonesian Health Survey, CKD affects approximately 0.2% of individuals aged over 15 years, representing 638,178 people nationwide. Notably, Central Java ranks third among the 38 provinces, with 88,180 reported cases of CKD [
4].
Management of CKD primarily relies on renal replacement therapies, most notably hemodialysis and continuous ambulatory peritoneal dialysis (CAPD). Hemodialysis involves the use of an external machine to filter blood, whereas CAPD allows patients to independently perform dialysis at home through the instillation of dialysis fluid into the peritoneal cavity. Although CAPD is increasingly adopted in Indonesia as a modality for CKD management, it remains associated with a substantial risk of peritonitis. A systematic review of CAPD data from Southeast Asia (2010–2020) reported a peritonitis proportion of 32% among Indonesian patients, defined as the percentage of patients experiencing at least one episode among 1,456 total cases [
5]. Regional variability has been documented: a local study in Denpasar, Bali, reported a lower proportion of 16.7% (13 of 78 patients), which may reflect differences in sample size and observation duration [
6]. In contrast, major hospitals on Java Island, including those in Jakarta and Bandung, have reported higher proportions ranging from 35% to 40%, suggesting potential regional challenges related to self-care management or access to care [
5]. Importantly, these estimates represent patient proportions rather than incidence rates per patient-year, limiting direct comparisons because of heterogeneity in study design, follow-up periods, and population characteristics. Nevertheless, the consistently high proportions reported on Java, including Central Java, underscore the need for targeted strategies to improve patient self-care and reduce the burden of peritonitis.
Building on these regional challenges, particularly in Central Java, there is a clear need for context-specific research examining factors that support or impede high-quality self-care among CAPD patients. Despite the growing global and national utilization of CAPD, evidence remains limited regarding determinants of self-care quality within specific regional contexts, including Central Java. Many previous studies have examined dialysis populations in aggregate, without adequately distinguishing factors unique to CAPD. In the context of CAPD, self-care refers to a deliberate and routine set of actions performed independently by patients to effectively manage their dialysis treatment. These actions include conducting peritoneal dialysis fluid exchanges under strict aseptic conditions, maintaining appropriate hand hygiene, monitoring for early signs of complications such as peritonitis, and adhering to prescribed treatment regimens designed to minimize infection risk and optimize clinical outcomes.
Research has demonstrated that effective self-care is crucial for reducing the occurrence of complications, particularly peritonitis, which remains a leading cause of morbidity and technique failure among CAPD patients [
7]. In addition, comorbidities and cognitive impairments may function as factors that challenge optimal self-care, thereby necessitating targeted support to enhance patients’ capabilities and promote better clinical outcomes. Comorbidities are common among patients with CKD and play a crucial role in influencing quality of life as well as the management of dialysis therapy, including CAPD. Patients with multiple comorbidities may therefore benefit from tailored strategies to support consistent self-care practices, which can ultimately lead to improved outcomes in CAPD [
8].
Promoting self-care behaviors is critical, as addressing factors that hinder effective self-care, such as challenges in adherence and consistency, has been shown to improve clinical outcomes and enhance quality of life in dialysis patients. In the context of CAPD, gaps in self-care practices can be addressed to achieve optimal self-care quality, thereby contributing to a lower incidence of peritonitis. Adherence to hygiene protocols, including proper hand washing and correct fluid exchange techniques, has been shown to significantly reduce the risk of infection [
9]. Consequently, strengthening patients’ knowledge, self-efficacy, and social support is essential for preventing complications and safeguarding long-term health.
Previous studies indicate that enhancing knowledge of self-care procedures, particularly aseptic techniques in dialysis, can help overcome barriers to optimal self-care, thereby reducing the frequency of peritonitis and improving health outcomes. Furthermore, a strong understanding of hygiene practices and fluid exchange techniques enhances self-care agency, defined as an individual’s ability to independently meet health needs, consistent with Orem’s Theory, which emphasizes knowledge as a foundational component of self-care [
10]. Strong self-care practices, in turn, reduce technical errors and lower the risk of complications.
Patient confidence also plays a critical role in self-care performance; as complications decrease, self-efficacy increases, leading to greater consistency in daily procedures such as proper hand washing and aseptic fluid exchanges. Increased self-efficacy strengthens patients’ confidence in their ability to perform care procedures correctly. Successful completion of these procedures without complications further reinforces confidence, which subsequently increases motivation, resilience in the face of challenges, and consistency in daily self-care tasks, even in difficult or monotonous situations. As a result, higher self-efficacy directly promotes sustained self-care behaviors, leading to a reduced risk of peritonitis and improved health outcomes [
11].
Moreover, social support provides a sense of security and reduces anxiety, which in turn enhances self-efficacy and engagement in self-care, thereby significantly lowering the risk of peritonitis [
8]. Social support plays a crucial role in strengthening patients’ self-efficacy in managing their health conditions by offering encouragement, emotional assistance, and reinforcement that bolster confidence in performing care procedures effectively [
12]. Consequently, this enhanced self-efficacy contributes to more consistent self-care behaviors and a reduced risk of peritonitis.
Although this study is geographically limited, addressing gaps in local data regarding factors influencing self-care among CKD patients remains essential. The findings are expected to contribute meaningfully not only within the local context but also more broadly, by providing a foundation for personalized interventions aimed at improving quality of life among similar patient populations in other regions. Accordingly, this study aimed to investigate the associations between sociodemographic variables, knowledge, self-efficacy, social support, comorbidities, and self-care quality among CAPD patients in Central Java, Indonesia. The prespecified hypothesis was that these factors would be significantly associated with self-care quality.
METHODS
1. Study Design
This cross-sectional study was conducted among patients undergoing CAPD in Central Java, Indonesia, with the objective of identifying factors associated with the quality of self-care in this population. The study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines.
2. Setting and Samples
This study was conducted at two major referral hospitals in Central Java, namely Dr. Kariadi Hospital and Dr. Moewardi General Hospital, both of which serve as primary referral centers for CAPD patient management. These institutions provide comprehensive CAPD facilities and services and receive patients from multiple districts across the region. The study population consisted of 117 CAPD patients registered at the two hospitals. Given the relatively small population size, a total sampling approach was applied, whereby all patients meeting the inclusion criteria were invited to participate. The inclusion criteria were age between 18 and 65 years, receipt of CAPD therapy for at least three months, not being hospitalized at the time of data collection, ability to operate smartphones and computers, sufficient cognitive capacity to complete digital questionnaires, and provision of written informed consent. The participant selection process proceeded as follows: 117 registered CAPD patients, 109 patients meeting the inclusion criteria, 88 patients providing informed consent, and 72 patients completing the questionnaire fully and validly.
3. Measurements/Instruments
The dependent variable in this study was the quality of self-care among CAPD patients. Independent variables included sociodemographic characteristics (age, sex, education level, marital status, and duration of CAPD therapy), as well as social support, self-care knowledge, comorbidities, and self-efficacy. During the initial exploratory phase, continuous variables such as knowledge, self-efficacy, age, CAPD duration, and social support were dichotomized. However, in the univariate logistic regression analyses, these variables were treated as continuous using their original questionnaire scores, in accordance with methodological recommendations to improve statistical sensitivity and minimize information loss [
13]. All independent variables were specified as predictors of the binary dependent variable, self-care quality (“poor” vs. “good”), and together constituted the primary explanatory variables for the study outcome.
1) Self-care quality
Self-care quality was measured using the Self-care Scale for Peritoneal Dialysis Patients, a 28-item instrument scored on a 4-point Likert scale ranging from 0 (“never”) to 3 (“always”), yielding a total score range of 0–84, with higher scores indicating better self-care [
14]. The instrument has demonstrated excellent content validity (content validity index [CVI], 0.963) and high internal consistency (Cronbach’s α=.93). Although the original scale classifies scores into three categories—poor (<50), moderate (50–66), and good (≥67)—for analytical purposes in this study, the “moderate” category was combined with the “poor” category. This resulted in a binary classification of self-care quality as poor (<67) or good (≥67). In statistical analyses, this variable was coded dichotomously as 1=poor and 2=good. The selection of a cutoff score of 67 was supported by both empirical and methodological considerations. First, this threshold is consistent with prior studies in middle-income countries, where a score ≥67 has similarly been classified as “good” self-care among CAPD patients facing comparable sociocultural barriers [
14]. Second, the cutoff was statistically optimized using receiver operating characteristic (ROC) curve analysis based on the study sample (n=72), which yielded the highest Youden index (0.43), with a sensitivity of 68%, specificity of 75%, and an area under the curve (AUC) of 0.78 (95% confidence interval [CI], 0.71–0.85), indicating strong discriminative power.
Among the 72 participants, 51 (70.8%) were classified as having poor self-care quality, while 21 (29.2%) were classified as having good self-care quality. This distribution is consistent with findings reported in middle-income settings, where sociodemographic and structural barriers frequently contribute to suboptimal self-care practices. Although the distribution of self-care categories was imbalanced, the ROC analysis demonstrated adequate discriminatory ability (AUC=0.78), and the use of the Youden index ensured that the cutoff value remained statistically optimal and not biased by sample distribution. Accordingly, the cutoff score of 67 was not solely based on convention but was empirically validated for the present study context.
2) Self-care knowledge
Self-care knowledge was assessed using a questionnaire developed by the researchers, consisting of 10 items related to CAPD management. Content validity was evaluated using the CVI approach by five CAPD specialists, with all items achieving an item-level CVI (I-CVI) of at least 0.80, indicating adequate content validity. Internal consistency reliability was confirmed with a Cronbach’s α of .857. Each correct response was assigned a score of 10 points, yielding a total possible score range of 0 to 100. Knowledge scores were analyzed as a continuous variable, with higher scores indicating greater self-care knowledge.
3) Social support
Social support was measured using the Duke-UNC Functional Social Support Questionnaire (Duke-UNC-11), an 11-item self-report instrument designed to assess functional social support across affective and confidant domains. The instrument demonstrates strong content validity supported by qualitative and factor-analytic evidence and has shown high internal consistency, with reported Cronbach’s α values ranging from .85 to .92. Participants rated each item on a 5-point Likert scale from 1 (“never”) to 5 (“always”), resulting in a total score range of 11 to 55. Higher scores indicated stronger perceived social support, and scores were treated as continuous variables in the analyses.
4) Self-efficacy
Self-efficacy was assessed using the General Self-Efficacy Scale, a 10-item instrument developed by Schwarzer and Jerusalem [
15]. Content validity was established through expert review, with all items demonstrating an I-CVI ≥0.80. Confirmatory factor analysis supported a unidimensional structure, with acceptable model fit indices (comparative fit index >0.89; goodness-of-fit index >0.90), consistent with previous validation studies [
16]. Items were rated on a 4-point Likert scale ranging from 1 (“not at all true”) to 4 (“exactly true”), producing a total score range of 10 to 40. Higher scores reflected greater perceived self-efficacy, and the variable was analyzed as continuous.
5) Sociodemographic and clinical variables
Sociodemographic and clinical variables included age, sex, education level, marital status, duration of CAPD therapy, and comorbidities. For analytical purposes, variables were classified as categorical or continuous. Categorical variables included education level, sex, marital status, and comorbidities, while continuous variables included age (in years), knowledge scores (0–100), and CAPD duration (in months). Categorical variables were coded as follows: sex (1=male, 2=female); education level (1=primary, 2=secondary, 3=higher education); marital status (1=single, 2=married/divorced/widowed); and comorbidities (1=present, 2=absent).
4. Data Collection/Procedure
Data were collected using an online questionnaire distributed via Google Forms to patients residing in Central Java Province, Indonesia. Participants were patients receiving care at Dr. Moewardi Hospital in Surakarta and Dr. Kariadi Hospital in Semarang, both of which serve as recognized CAPD referral centers in Central Java. Patients who met the inclusion criteria and voluntarily consented to participate were recruited as study respondents. Following completion of data collection, responses were compiled, cleaned, and prepared for statistical analysis to generate the study findings.
5. Ethical Considerations
This publication reports variables derived from a dissertation study that received ethical approval from the Ethics Committee of Dr. Moewardi Hospital on March 11, 2025, under approval number 508/III/HERC/2025. Data collection was conducted between April and May 2025. Written informed consent was obtained from all participants prior to study enrollment, and the confidentiality of participant data was strictly maintained throughout the research process. During the recruitment phase, all eligible patients were actively and non-discriminatively informed about the study objectives, procedures, potential benefits, and possible risks. Each individual was provided with an equal opportunity to make a voluntary decision regarding participation, free from coercion or undue influence. This process ensured that participation was based on full understanding and autonomy, thereby minimizing potential selection bias. A total sampling approach was employed to include all eligible patients from the registered population. Importantly, patients who declined participation experienced no reduction in the quality of medical care they received. The study was conducted in strict accordance with the ethical principles of the Declaration of Helsinki, ensuring protection of participants’ rights, dignity, and well-being.
6. Data Analysis
Data were analyzed using IBM SPSS ver. 26.0 (IBM Corp., Armonk, NY, USA). To assess associations among variables, two analytical approaches were applied based on variable type and whether statistical assumptions were met. For categorical variables, including education level, sex, and comorbidities, Pearson’s chi-square test was initially used to examine associations with the dependent variable, provided that no expected cell frequency was less than five. However, because several cells in the contingency tables, particularly those involving marital status, had expected frequencies below five, Fisher’s exact test was used as an alternative, in accordance with established statistical guidelines and reviewer recommendations.
For continuous variables, including age, duration of CAPD therapy, knowledge level, self-efficacy, and social support, associations with the dependent variable (self-care quality, dichotomized as poor versus good) were evaluated using Spearman’s rank correlation. This nonparametric method was selected because it does not require the assumption of normality and is appropriate for data that are ordinal, non-normally distributed, or influenced by outliers.
Given the relatively small sample size (n=72) and the inclusion of nine predictor variables, the events-per-variable ratio was substantially below the recommended minimum threshold of 10. This limitation increased the risk of overfitting, unstable coefficient estimates, and inflated standard errors. Accordingly, univariate logistic regression analyses were performed to examine the independent effect of each predictor on the likelihood of achieving good self-care quality. Results are presented as odds ratios (ORs) with corresponding 95% CIs, reflecting the magnitude and direction of associations.
RESULTS
1. General and Clinical Characteristics of Study Participants
The general and clinical characteristics of the study participants, as shown in
Table 1, are presented to provide demographic and social context for patients undergoing CAPD. Key variables included age, sex, educational level, and other sociodemographic characteristics. This information was considered essential for characterizing the study population, examining relationships between independent variables and self-care quality, and assessing the representativeness of the sample.
Table 1 presents the demographic and clinical characteristics of the 72 patients undergoing CAPD in this study. The mean age of participants was 41.64±11.67 years, with 48 (66.7%) males and 24 (33.3%) females. With respect to educational attainment, seven participants (9.7%) had primary education, 23 (31.9%) had secondary education, and 42 (58.3%) had completed higher education. Regarding marital status, 17 participants (23.6%) were single, while 55 (76.4%) were married, widowed, or divorced. Comorbidities were present in 49 participants (68.1%) and absent in 23 (31.9%). The mean duration of CAPD therapy was 43.28±47.56 months. The mean knowledge score was 63.06±13.28, the mean self-efficacy score was 21.90±9.09, and the mean social support score was 27.94±10.91. With respect to self-care quality, 51 participants (70.8%) were classified as having poor self-care, while 21 (29.2%) demonstrated good self-care.
2. Associations between Independent Variables and Self-Care Quality
Table 2 illustrates the associations between various independent variables and self-care quality.
Table 2 presents the results of chi-square and Fisher’s exact tests examining associations between independent variables and quality of self-care among 72 participants. For education level, among participants with primary or secondary education (n=30), 22 (73.3%) had poor self-care and 8 (26.7%) had good self-care (
p=.518). Among participants with higher education (n=42), 29 (69.0%) had poor self-care and 13 (31.0%) had good self-care. For sex, among male participants (n=48), 35 (72.9%) had poor self-care and 13 (27.1%) had good self-care (
p=.582), whereas among female participants (n=24), 16 (66.7%) had poor self-care and 8 (33.3%) had good self-care. With respect to marital status, 13 single participants (76.5%) had poor self-care and 4 (23.5%) had good self-care (
p=.762, Fisher’s exact test), while among married, widowed, or divorced participants (n=55), 38 (69.1%) had poor self-care and 17 (30.9%) had good self-care. In contrast, comorbidities showed a statistically significant association with self-care quality. Among participants with comorbidities present (n=49), 44 (89.8%) had poor self-care and 5 (10.2%) had good self-care (
p<.001). Among those without comorbidities (n=23), 7 (30.4%) had poor self-care and 16 (69.6%) had good self-care. The results of the Spearman’s rank correlation test between the independent variables and self-care quality are presented in
Table 3.
Table 3 presents the results of Spearman’s rank correlation analyses examining associations between selected variables and quality of self-care among the 72 participants. The correlation coefficient between knowledge level and self-care quality was .80 (
p<.001). Self-efficacy was also strongly correlated with self-care quality (r=.68,
p<.001), as was social support (r=.69,
p<.001). In contrast, age showed a weak and non-significant correlation with self-care quality (r=.10,
p=.450), and duration of CAPD therapy was not correlated with self-care quality (r=.05,
p=.890).
3. Univariate Logistic Regression Analysis on Self-Care Quality
This section presents the results of univariate logistic regression analyses examining associations between individual predictors and self-care quality among patients undergoing CAPD. The univariate analyses indicated that several psychosocial and clinical factors were significantly associated with self-care quality.
Univariate logistic regression analysis showed that for each one-point increase in score, the odds of being classified in the “good” self-care quality category increased by 45% for knowledge (OR, 1.45; 95% CI, 1.19–1.78; p<.001), 27% for self-efficacy (OR, 1.27; 95% CI, 1.14–1.42; p<.001), and 38% for social support (OR, 1.38; 95% CI, 1.16–1.64; p<.001). Conversely, the presence of comorbidities was associated with substantially lower odds of good self-care quality (OR, 0.05; 95% CI, 0.01–0.18; p<.001). For age, the OR was 1.03 per additional year (95% CI, 0.99–1.08; p=.174). For education level, the OR was 1.67 for primary education (95% CI, 0.33–8.57; p=.537) and 0.62 for secondary education (95% CI, 0.19–2.03; p=.430), both relative to higher education. Male sex, compared with female sex, was not significantly associated with self-care quality (OR, 0.74; 95% CI, 0.26–2.15; p=.583). Similarly, single marital status compared with married status showed no significant association (OR, 0.31; 95% CI, 0.03–2.94; p=.306). Duration of CAPD therapy was also not significantly associated with self-care quality, with an OR of 0.99 per additional month (95% CI, 0.98–1.01; p=.295).
DISCUSSION
The univariate logistic regression analysis presented in
Table 4 indicates that comorbidities function as barriers to self-care quality among CAPD patients, whereas knowledge, self-efficacy, and social support emerge as supportive factors. These findings underscore the urgency of nursing interventions that target modifiable determinants, particularly by strengthening knowledge and social support, to mitigate the negative impact of comorbidities and enhance patient autonomy overall. In Indonesia, where access to peritoneal dialysis remains constrained by limitations in facilities and specialized expertise [
17], such strategies may serve as a key approach for optimizing CAPD management at the community level.
Building on this, the findings of the present study demonstrate a strong association between comorbidities and self-care quality. Consistent with previous literature, comorbidities have been repeatedly identified as a major barrier to effective self-care, primarily due to increased complexity in simultaneously managing pharmacological regimens, nutritional requirements, and symptom control across multiple conditions [
18]. This mechanism is further supported by evidence showing that individuals with multiple comorbidities have a reduced capacity to sustain optimal self-care behaviors. These observations align with Orem’s Nursing: Concepts of Practice, which posits that while multiple chronic conditions increase self-care demands, successful fulfillment of these demands depends heavily on self-efficacy and the availability of adequate systemic support [
10]. Moreover, patients with comorbidities consistently report lower quality of life, particularly in physical and social functioning domains, compared with patients without comorbidities [
18].
The clinical implications for nursing practice are substantial, as nurses must assume central roles as coordinators of integrated educational programs that extend beyond technical instruction in peritoneal dialysis procedures. Such programs should actively promote self-efficacy, strengthen patients’ understanding of interconnected chronic conditions, and systematically assess readiness for independent self-care management [
19]. A holistic and integrated management approach that encompasses comprehensive comorbidity care is essential for achieving optimal outcomes, as emphasized by prior work advocating specialized self-care measurement tools for peritoneal dialysis populations [
11,
14]. Accordingly, evidence-based training programs that prioritize patient autonomy and complication prevention are particularly critical for populations with high comorbidity burdens [
20]. This highlights the necessity of implementing structured, evidence-driven strategies to address the complex demands imposed by multiple chronic conditions.
The findings further reveal a significant positive relationship between patient knowledge and self-care quality in CAPD, with each one-unit increase in knowledge corresponding to a measurable improvement in outcomes. This reinforces the central role of patient education in empowering individuals to manage their treatment effectively. Structured educational programs have consistently been shown to improve adherence and self-care behaviors in dialysis populations [
21]. According to Orem [
10], knowledge constitutes the foundational basis for meeting self-care needs, and when combined with self-efficacy, it substantially strengthens patient autonomy.
The primary mechanisms underlying this relationship include improved understanding of sterile techniques and fluid management. In addition, early recognition of complications and consistency in home dialysis routines represent critical components of effective self-care. Evidence from skill-based training programs indicates that targeted educational interventions can significantly reduce the risk of peritonitis [
22], while simultaneously reinforcing patients’ sense of responsibility for their own care. Within the Indonesian context, comprehensive CAPD training programs have been associated with increased patient independence and reduced complication rates [
20].
In clinical practice, healthcare providers should lead integrated care models that account for patients’ cognitive, emotional, and practical readiness for self-care. Evidence-based strategies, including readiness assessments and autonomy-focused training in peritoneal dialysis management, offer scalable models for proactive CKD care. These approaches have been shown not only to improve survival outcomes but also to enhance overall quality of life. Recent narrative reviews further emphasize the importance of individualized pre-training assessments, while underscoring that structured educational interventions remain essential for achieving optimal self-care outcomes among peritoneal dialysis patients [
23].
Self-efficacy demonstrated a significant positive association with self-care quality among patients undergoing CAPD. Specifically, each one-unit increase in self-efficacy scores was associated with a corresponding improvement in self-care outcomes. These results reaffirm self-efficacy as a major predictor of self-care behavior within this patient population.
These findings are consistent with Orem’s self-care theory [
10], which emphasizes patient confidence as a fundamental component in the management of chronic diseases such as CKD. By strengthening self-efficacy through targeted nursing interventions, including skills training, emotional support, and personalized education, patients may become more autonomous in performing self-care activities, improve adherence to CAPD protocols, and substantially reduce the risk of complications such as peritonitis.
Recent evidence suggests that self-efficacy functions as a key mediator between knowledge and self-care among patients with early-stage CKD [
24]. This finding creates opportunities for nurses to design responsive interventions that tailor educational content to patients’ levels of self-confidence. A systematic review by Riski et al. [
25] further confirms that self-efficacy–based interventions are particularly effective in addressing sex differences and the complexity associated with comorbid conditions among peritoneal dialysis patients.
Ultimately, evidence-based nursing programs that prioritize the development of self-efficacy represent a critical factor in improving long-term prognosis, reducing morbidity, and enhancing quality of life among patients with CKD. These findings are consistent with epidemiological data [
3], which demonstrate that the effectiveness of dialysis therapy is closely linked to patient behavior and the quality of self-care practices adopted.
Social support also demonstrated a significant positive association with self-care quality among patients undergoing CAPD, such that each one-unit increase on the social support scale corresponded to improved self-care quality. This finding highlights the critical role of strong social networks in promoting adherence and sustained engagement in CAPD self-care. These results are consistent with Orem’s self-care theory, which posits that external support systems enhance patients’ capacity to meet self-care demands despite the burdens imposed by CKD, including emotional stress and the complexity of daily treatment routines, thereby reducing isolation and supporting long-term independence.
This interpretation is reinforced by existing literature. A qualitative study by Fox et al. [
12] highlights how family and peer networks within the peritoneal dialysis experience alleviate psychological stress and strengthen adherence to daily routines, which in turn reduces the risk of peritonitis through shared accountability. In addition, a systematic review by Riski et al. [
25] identifies social support as a primary predictor of self-care behavior among CKD patients, underscoring its critical role in addressing comorbidities and sex disparities that frequently exacerbate inconsistencies in the peritoneal dialysis population. This mechanism likely operates through a buffering process, whereby community involvement enhances motivation and problem-solving capacity, as evidenced by a cross-sectional analysis of preventive self-care factors among peritoneal dialysis patients that links family support to improved technique mastery and quality of life [
11].
In clinical nursing practice, these findings support the implementation of integrated interventions, such as family training programs grounded in peritoneal dialysis education frameworks described by Jaelani et al. [
20]. These interventions aim to prevent complications by establishing a robust supportive environment, thereby contributing to improved health outcomes, as summarized in the CKD epidemiology review by Kovesdy [
3]. This holistic approach may be particularly effective in resource-limited settings such as Indonesia, where national health surveys indicate a rising prevalence of CKD [
4].
Demographic variables, including age, sex, education level, duration of CAPD therapy, and marital status, showed no statistically significant associations with self-care quality. The absence of significant relationships may be attributable to sample homogeneity and limited variability, which could reduce statistical power and obscure more subtle effects [
26]. Therefore, these null findings should not be interpreted as evidence of no association in broader populations, but rather as a caution against overgeneralization and an indication of the need for larger and more diverse samples to detect nuanced influences.
While these associations provide a foundation for targeted interventions, several study limitations must be acknowledged to appropriately contextualize the findings. The cross-sectional design precludes causal inference, as it captures associations at a single time point rather than directional or temporal effects. Thus, the observed relationships should be interpreted as correlational rather than causal.
Furthermore, the relatively small sample size (n=72) limits the precision and generalizability of the findings. Although the 95% CIs for key predictors such as knowledge (1.19–1.78), self-efficacy (1.14–1.42), and social support (1.16–1.64) are relatively narrow, indicating reasonable precision, the CIs for other variables (e.g., primary education, 0.33–8.57; marital status, 0.03–2.94; age, 0.99–1.08) are wide, reflecting substantial uncertainty and exploratory associations. As a result, multivariable analyses to adjust for potential confounders such as age or treatment duration were not feasible, which limits the robustness of the observed effects.
The use of an online survey method, while practical, may have introduced selection bias by excluding patients without reliable digital access, who are more likely to be older or have lower educational attainment. This limitation may restrict the generalizability of the findings and reduce the ability to evaluate potential non-response bias.
Future research should employ longitudinal study designs, inclusive recruitment strategies, and a priori power calculations, assuming an OR of approximately 2.5 to achieve at least 80% statistical power. Such approaches would strengthen causal inference and ensure that self-care enhancement strategies can be evaluated and applied across more diverse patient populations.
CONCLUSION
In this sample of CAPD patients in Central Java, higher levels of knowledge, self-efficacy, and social support were associated with improved self-care quality, whereas comorbidities were associated with barriers to optimal self-care. Sociodemographic variables, including age, sex, education, marital status, and treatment duration, showed no clear associations with self-care quality, potentially due to limited statistical power to detect moderate effects. These findings underscore the need for interventions that target knowledge enhancement, psychosocial support, and comorbidity management to improve self-care among this population.
To translate these findings into practice, clinical recommendations include targeted patient education using brief digital videos and visual aids focused on infection detection, aseptic techniques, and comorbidity management. Delivering content in simple, accessible language may enhance health literacy and adherence, while strengthening peer- and family-based social support systems can further reinforce sustained self-care behaviors.
For future research, larger longitudinal studies incorporating multivariable analyses are recommended to control for key confounders such as self-efficacy and comorbidities. The use of hybrid data collection approaches, combining online surveys with in-person interviews, may reduce selection bias and improve the generalizability of findings within Indonesian populations with CAPD.
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CONFLICTS OF INTEREST
The authors declared no conflict of interest.
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AUTHORSHIP
Study conception and design acquisition - MSASN; data collection - MSASN; data analysis - YW; the interpretation of the results - ETP; drafting and critical revision of the manuscript - RS; and final approval - RS.
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Funding
None.
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ACKNOWLEDGEMENT
This manuscript is partially derived from the doctoral dissertation of the Muhamad Syamsul Arif Setiyo Negoro, conducted within the Doctoral Program in Public Health at the Faculty of Medicine, State University of Semarang. The dissertation provided several core variables that serve as the foundation for this study. This article presents a more concise and refined version of the original dissertation and is adapted to meet the standards of scientific publication.
The author would like to thank all those who have provided support and assistance during this research process.
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DATA AVAILABILITY STATEMENT
Based on the characteristics of the study and the data utilized, no new data were generated or analyzed in this research; therefore, the data sharing statement is not applicable to this article. This manuscript reports the analysis of previously collected data as part of my doctoral dissertation project. The dataset is neither publicly available nor deposited in any data repository.
Table 1.General and Clinical Characteristics of Study Participants (N=72)
|
Variables |
Categories |
M±SD or n (%) |
|
Age (year) |
- |
41.64±11.67 |
|
Sex |
Male |
48 (66.7) |
|
Female |
24 (33.3) |
|
Education level |
Primary |
7 (9.7) |
|
Secondary |
23 (31.9) |
|
Higher education |
42 (58.3) |
|
Marital status |
Single |
17 (23.6) |
|
Married/widowed/divorced |
55 (76.4) |
|
Duration of CAPD (month) |
- |
43.28±47.56 |
|
Comorbidities |
Absent |
23 (31.9) |
|
Present |
49 (68.1) |
|
Quality of self-care |
Poor |
51 (70.8) |
|
Good |
21 (29.2) |
|
Knowledge |
- |
63.06±13.28 |
|
Self-efficacy |
- |
21.90±9.09 |
|
Social support |
- |
27.94±10.91 |
Table 2.Associations between Independent Variables and Quality of Self-Care (N=72)
|
Variables |
Categories |
Poor group of quality of self-care |
Good group of quality of self-care |
χ2
|
p
|
|
n (%) |
|
Education level |
Primary & secondary |
22 (73.3) |
8 (26.7) |
1.31 |
.518 |
|
Higher education |
29 (69.0) |
13 (31.0) |
|
Sex |
Male |
35 (72.9) |
13 (27.1) |
0.30 |
.582 |
|
Female |
16 (66.7) |
8 (33.3) |
|
Marital status |
Single |
13 (76.5) |
4 (23.5) |
- |
.762†
|
|
Married/widowed/divorced |
38 (69.1) |
17 (30.9) |
|
Comorbidities |
Present |
44 (89.8) |
5 (10.2) |
26.60 |
<.001*
|
|
Absent |
7 (30.4) |
16 (69.6) |
Table 3.Associations with Quality of Self-Care (N=72)
|
Independent variable |
M±SD |
r |
p
|
|
Age (year) |
41.64±11.67 |
.10 |
.450 |
|
Duration of CAPD (month) |
43.28±47.56 |
.05 |
.890 |
|
Knowledge level |
63.06±13.28 |
.80 |
<.001*
|
|
Self-efficacy |
21.90±9.09 |
.68 |
<.001*
|
|
Social support |
27.94±10.91 |
.69 |
<.001*
|
Table 4.Univariate Logistic Regression Analysis for Self-Care Quality (N=72)
|
Predictor |
Level reference/unit |
OR (95% CI) |
p
|
|
Age |
Years |
1.03 (0.99–1.08) |
.174 |
|
Education |
Primary (ref: higher education) |
1.67 (0.33–8.57) |
.537 |
|
Secondary (ref: higher education) |
0.62 (0.19–2.03) |
.430 |
|
Sex |
Male (ref: female) |
0.74 (0.26–2.15) |
.583 |
|
Duration of CAPD |
Month |
0.99 (0.98–1.01) |
.295 |
|
Marital Status |
Single (ref: married) |
0.31 (0.03–2.94) |
.306 |
|
Comorbidities |
Present (ref: absent) |
0.05 (0.01–0.18) |
<.001*
|
|
Level of knowledge |
Score (per 1-point increase on the scale) |
1.45 (1.19–1.78) |
<.001*
|
|
Self-efficacy |
Score (per 1-point increase on the scale) |
1.27 (1.14–1.42) |
<.001*
|
|
Social support |
Score (per 1-point increase on the scale) |
1.38 (1.16–1.64) |
<.001*
|
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