Self-determination in health, as a psychological factor influencing observational survival and symptom perception in patients in hemodialysis programs

A multicenter observational study.

Abstract

Introduction: Self-determination in Health (SDH), defined as a patient's inherent ability to make informed and active decisions about their health care, is a modifiable psychological factor that correlates with motivation, proactive behavior, and improved physical health outcomes. In the context of hemodialysis (HD) therapy, SDH promotes functional autonomy and active patient engagement, even in the face of vulnerability; by contrast, its absence is associated with decision delegation and deterioration in health. The study hypothesizes that patients in hemodialysis programs with higher SDH will have a lower perception of symptoms and a longer survival.

Methods: This observational, case-control study was carried out in 14 hemodialysis units in Ecuador from May to June 2025. Patients aged 18 years or older who were enrolled in hemodialysis programs were included. Two groups were formed: one with patients without SDH and the other with patients with SDH. The variables studied included age, duration of hemodialysis treatment, self-determination in health, adherence to treatment, labor integration, physical dependence, acceptance of kidney disease, and scores on "The Dialysis Symptom Index." A 1:1 propensity score matching (PSM) was performed between the groups based on age, sex, and presence of type 2 diabetes mellitus. The means were compared using Student's t-test, while proportions were compared using Chi-squared tests. An observational survival analysis was also conducted, examining the length of stay in the hemodialysis unit up to the date of the survey.

Results: 180 patients without SDH and 184 with SDH were analyzed. Age was similar in both groups (57.9 ± 13.7 years vs. 58.0 ± 11.8 years, P = 0.938). The proportion of men was similar in both groups (51.1% vs. 51.6%; P=0.921). The prevalence of type 2 diabetes mellitus was comparable between the groups (48.3% vs. 47.3%; P=0.841). The group without SDH had a higher rate of physical dependence (53.3%) compared to the group with SDH (25.5%) (P < 0.001). Adherence was greater in the group with SDH (51.6%) than in the group without SDH (36.7%; P < 0.001). Work activity was more common among the group with SDH (38.0%) compared to 12.2% among the group without SDH (12.2%; P < 0.001). The group with SDH showed lower symptom intensity (–25.82%) than the group without SDH (P<0.001). Increased survival was observed in the SDH group, with 29.5 months versus 36.08 months in the non-SDH group (χ2, Log-Rank 7.71, P<0.005).

Conclusions: Patients with SDH exhibited longer survival, significantly higher treatment adherence, and less physical dependence. Additionally, self-determination was associated with a reduction in the severity of perceived symptoms, including pain and psychological symptoms such as worry and sadness, across 18 of the 34 assessed. These findings demonstrate that SDH is not just a psychological concept but also a therapeutic goal that impacts survival. Randomized intervention studies in SDH are necessary.