Journal of Epidemiology and Global Health

Vol. 10(4); December (2020), pp. 344–350

DOI: https://doi.org/10.2991/jegh.k.200716.001; ISSN 2210-6006; eISSN 2210-6014
https://www.atlantis-press.com/journals/jegh

Research Article
Quality of Life of End Stage Renal Disease Patients Undergoing
Dialysis in Southern Part of Kerala, India: Financial Stability
and Inter-dialysis Weight Gain as Key Determinants

Kasi Visweswaran1, Muhammed Shaffi2,3,*, , Philip Mathew4, Minu Abraham2, , Jinbert Lordson1,2,
Premini Rajeev5, Reena Thomas6, Rajeev Aravindakshan6, , Jayadevan G7, Kesavan Rajasekharan Nayar2,
Marthanda Pillai1,2
1
Department of Nephrology, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, Kerala, India
2
Global Institute of Public Health, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, Kerala, India
3
Directorate of Public Health, Ministry of Health, Al Taif, Makkah, Saudi Arabia
4
Department of Community Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
5
College of Nursing, Ananthapuri Hospitals and Research Institute, Thiruvananthapuram, Kerala, India
6
Department of Nephrology, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala, India
7
Department of Nephrology, Shankers Institute of Medical Sciences, Kollam, Kerala, India

ARTICLE INFO ABSTRACT

Article History Background: Quality of Life (QoL) reflects the quality and outcome of healthcare along with key indicators of performance such
Received 06 March 2020 as mortality and morbidity.
Accepted 20 June 2020 Objective: The aim of the study was to measure the QoL among patients with End Stage Renal Disease (ESRD) on maintenance
hemodialysis and to understand various correlates of QoL.
Keywords
Methods: A total of 95 ESRD patients from three dialysis centres in Southern districts of Kerala were interviewed. QoL was measured
Quality of life
WHOQOL-BREF
using vernacular version of World Health Organization Quality Of Life – Brief Version (WHOQOL-BREF) questionnaire.
maintenance hemodialysis Results: The mean age of the patients was 56.2 ± 13 years and 73.7% were males. Mean converted scores for overall QoL was
inter-dialysis weight gain 42.37 ± 21.3 and Health-related QoL (HRQoL) was 43.3 ± 18.3, indicating poor QoL. Males had significantly higher physical
health expenditure domain scores (p < 0.03). Occupation, income and Socio-economic Status (SES) influenced overall HRQoL while better income
and higher SES predicted better scores in psychological and environmental domains.
Conclusion: Patients with better control over inter-dialysis weight gain (≤1600 g) had significantly higher scores. This study
highlights the importance of using QoL tools in assessing the QoL of patients and the factors contributing to it.

© 2020 The Authors. Published by Atlantis Press International B.V.

This is an open access article distributed under the CC BY-NC 4.0 license (http://creativecommons.org/licenses/by-nc/4.0/).

1. INTRODUCTION years [14]. National Family Health Survey data shows that chronic
diseases account to a large proportion of morbidity and highest
End Stage Renal Disease (ESRD) is the result of a progressive wors- utilization rates for both out- and in-patient, services in the state
ening of renal function over a period of months or years [1]. The compared to other states in the country [15].
global burden of ESRD grows at around 7% annually [2] and is a
Diabetes and its complications are draining the economy, impov-
leading cause of death especially in developing countries [3] with
erishing the affected population directly due to out of pocket
limited resources for renal replacement therapy. Over 1 million
expenses incurred and indirectly due to loss of productivity associ-
people die of ESRD annually in these countries [4–7]. Diabetes and
ated with the illness and treatment [16]. The chronic nature of the
hypertension are the leading causes of ESRD [8–11]. Since India
illness has serious impact on the Quality of Life (QoL) of patients
has a huge challenge with the rising burden of these two major
as well as the caretakers [17].
risk factors, it has become an important public health problem in
India [12,13]. The Indian state of Kerala is currently experiencing With the growing recognition of the importance of ‘life quality’
an epidemiological transition and has seen a huge jump in terms besides longevity, there are attempts to use various tools to measure
of per-­capita out-of-pocket spending in health care in the recent QoL related to various health conditions and the factors determin-
ing them. However, there have been only about 24 Indian studies
*
Corresponding author. Present address: School of Public Health, Boston University,
on QoL among ESRD patients till now when a literature review was
Boston, MA USA, Email: [email protected]
Data availability statement: The authors confirm that the data supporting the findings of conducted, using appropriate key words- ‘renal dialysis’, ‘Peritoneal
this study are available within the article. dialysis’, ‘Hemodialysis’, ‘end stage renal disease’ ‘ESRD’ and ‘quality
 K. Visweswaran et al. / Journal of Epidemiology and Global Health 10(4) 344–350 345

of life’. Among all these, there was only one study done in Kerala words used among six patients. Two independent experts reviewed
using the WHOQOL-BREF tool. the suggestions and incorporated into the translation. After this,
the tool was applied on another six patients to validate the clarity
This study was therefore undertaken, with the following objectives:
and appropriateness and then finalized.
1. To measure the overall QoL, Health-related Quality of Life
The questionnaire demonstrated good internal consistency with
(HRQoL) and domain specific QoL among ESRD patients.
Cronbach’s alpha of 0.84 and Guttmann’s split half reliability of
2. To understand the key socio-demographic factors, illness and 0.9. The internal consistencies in the four domains of WHOQOL-
treatment-related factors affecting the QoL. BREF were as follows: Physical = 0.73, psychological = 0.65,
social = 0.47 and environmental = 0.72.

2. MATERIALS AND METHODS

2.3. Definitions Used
We conducted a descriptive cross-sectional survey among patients
from three dialysis centers– one each from Thiruvananthapuram, Compliance to dialysis was defined as not missing any dialysis
Kollam and Pathanamthitta districts in southern part of Kerala session in the last 2 months preceding the data collection day.
state. The first center is a tertiary care hospital; second hospital is a Compliance to Inter-Dialysis Weight Gain (IDWG) was defined as
secondary care center while the third is a teaching hospital attached not gaining more than 3 kg weight between two dialysis sessions
to medical college. We collected the data using a patient interview in the last 2 months preceding the data collection day. The cut-
schedule and a translated version of World Health Organization off of 3 kg was based on previous literature [22,23]. Out of pocket
Quality Of Life – Brief Version (WHOQOL-BREF) tool. expenses in this study, was defined as the direct cost to the patient
and was calculated as the sum of all deductibles, coinsurance, and
copayments for covered services plus all costs for services that are
not covered and included transport cost as reported, but did not
2.1. Sample
include opportunity cost.
All patients aged 18 or above, undergoing hemodialysis in the first
shift in these centers during the data collection period were enrolled
in the study. Patients of non-Kerala origin, those who had a failed 2.4. Ethical Consideration
transplant and those who had apparent cerebrovascular disease
or serious intellectual impairment were excluded from the study. Prior to the commencement of the study, approval was obtained
Data was collected by trained health workers, over 1-month period from the Institutional Ethics Committees. We got the approval to
per centerspread across 6-months in all three centers. All patients use the translated WHOQOL-BREF tools from the researchers.
attending the dialysis unit during the data collection period were Informed consent was obtained from all participants, who were
enrolled for the study, following the inclusion and exclusion criteria. assured full privacy and confidentiality when answering the survey
questions.

2.2. Tools
2.5. Statistical Analysis
A pre-tested interview schedule was used to collect demographic and
Data was entered in Epidata version 3.1 (EpiData Association,
selected clinical parameters. The demographic parameters were age,
Denmark) [24]. Statistical analysis was performed using R Statistical
gender, education, occupation, monthly income and family history of
software version 3.2.4 (R Core team, Austria) [25]. Mean and stan-
end state renal diseases. We used the 2014 version of Kuppuswamy’s
dard deviation were calculated to summarize the QoL scores for each
scale [18] to assess the Socio-economic Status (SES) and grouped
domain, across the three centers. One-way ANOVA and Student’s
them to upper, middle and lower socio-­economic groups. We gath-
t-test were used to assess the relationship of scores with categorical
ered the history and duration of diabetes, hypertension and dyslipid-
variables. A p-value <0.05 was considered statistically significant.
emia, and the duration since being diagnosed as renal failure.
Information on HRQoL was collected by interviewer administered
WHOQOL-BREF questionnaire [19–21], which is an abbreviated 3. RESULTS
version of the WHOQOL-100 tool. The tool was developed by the
WHO for QoL assessment. It consists of 26 questions covering 24 This paper reports the findings from 95 patients. The mean age of
facets and provides a profile of scores on four dimensions of QoL: the patients was 56.2 ± 13 years, 73.7% were males and 55.8% were
physical health, psychological, social relationships and the environ- un-employed (Table 1). Hypertension was reported by 85% patients,
ment. In addition, the tool has two global scores- one of overall QOL 62.1% had diabetes mellitus and 23.4% had dyslipidemia. The mean
and another one on the overall satisfaction with health (HRQoL). duration of hypertension was 9 years while that of diabetes was
The raw scores were transformed to a 0–100 scale to enable compari- 16.5 years, indicating that a good proportion of the patients might
sons to be made between domains composed of unequal numbers of have developed hypertension secondary to nephropathy. Around
items. Higher scores reflect better QoL of the individuals. 13% patients had a family history of ESRD that required dialysis.
We used the Malayalam translated version of the WHOQOL-BREF On an average, it has been 3 years since the patients in the study
[21]. We tested the appropriateness, understandability and clarity of were diagnosed to have nephropathy (range: 1–40 years) and 2 years
346 K. Visweswaran et al. / Journal of Epidemiology and Global Health 10(4) 344–350

to since they were classified as renal failure (range: 1–28 years). Table 3 | QoL scores across centres and domains
About 80% of the patients were on regular hemodialysis for more
than 6 months (median 16 months, range: 0.5–131 months). 74.7% Centre 1 Centre 2 Centre 3
Domains (n = 24) (n = 34) (n = 37) p
of patients reported that someone in the household had to accom-
pany them for dialysis. Out of pocket monthly expenses ranged Mean ± SD Mean ± SD Mean ± SD
from INR2000 to INR50000 (with a median value of US$296. Item
Physical 47.7 ± 16 39.4 ± 12 43.2 ± 8.7 0.041
wise break-up of expenses is given in Table 2. Please note that some
Psychological 53.4 ± 18.4 42 ± 13.6 43.6 ± 11.5 0.009
patients had out-of-pocket expenses only on medicines, since the Social 53.8 ± 24.9 43 ± 18.2 46.2 ± 12.5 0.087
cost of injectable, dialysis and transportation were covered under Environmental 63.3 ± 15.8 41.5 ± 10.9 48.5 ± 12 <0.001
the government-supported.
Out of 95 patients, 44 had two dialysis per week, 43 had three dial- were as follows: physical, 43 ± 12.4 (median 38, range 13–81); psy-
ysis per week while eight had one dialysis per week. Almost all chological, 45.5 ± 14.8 (median 44, range 19–81); social, 47 ± 18.6
(98.9%) patients had full compliance to the dialysis schedules and (median 50, range 0–94); and environmental, 49.7 ± 15.2 (median
82.5% had full compliance to IDWG target. The median IDWG was 50, range 19–88). Table 3 compares the values between the cen-
1600 g (range: 0–4500 g). ters. Except for Social domain, the three centers differed in terms
The mean converted scores for overall QoL was 42.37 ± 21.3 of mean values of QoL scores.
(median 50, range 0–100) and the mean converted scores for Occupation, income and SES influenced overall HRQoL signifi-
HRQoL was 43.3 ± 18.3 (median 50, range 0–100), both indicating cantly. Patients with better Income and higher SES had better
poor QoL. The mean converted scores for the individual domains scores in psychological and environmental domains. Males had
better scores in physical domain, while higher education groups
Table 1 | Socio-demographic profile of the patients (N = 95) had better scores in physical and environmental domains (Table 4).
Overall HRQoL was poor among patients who were not diabetic
Characteristics N (%) probably due to early onset of disease and prolonged duration
of dialysis. This is also reflected in poor scores with increase in
Sex
Male 70 (73.7) number of months on dialysis. Table 5 summarizes the scores on
Female 25 (26.3) all four domains and HRQoL with respect to various disease and
Type of family
dialysis-related factors. Inter-dialysis weight gain was found to
Nuclear 78 (83.9) significantly impact overall HRQoL and all the four domains.
Joint family 15 (16.1)
Just as people with better income had better scores, people who
Marital status were spending more money had better QoL across all the four
Married 88 (92.6) domains, but not overall HRQoL. People who were not dependent
Unmarried 5 (5.3)
on others to accompany them for dialysis had better scores, though
Widowed 2 (2.1)
the difference was not statistically significant.
Education
7 years or less of formal schooling 16 (18)
8–12 years of formal schooling 43 (48.3)
Graduates and above 30 (33.7) 4. DISCUSSION
Occupation
Unemployed 53 (55.8) Kidney disease is one of the growing causes of disability and death
Skilled/semi-skilled 29 (30.5) worldwide [26]. Increasing prevalence of diabetes and hypertension
Professionals 13 (13.7) account for the high incidence of Chronic Kidney Disease (CKD)
Income per month (INR; US$ within brackets) [27]. Many of the cardiovascular death occur in the background of
≤5386 (<90) 29 (30.9) CKD [28]. ESRD is a recognized public health problem worldwide
5387–13,494 (90–225) 21 (22.3) [29] and the increasing prevalence of ESRD parallels the increasing
13,495–36,016 (225–600) 23 (24.5) prevalence of Type 2 Diabetes Mellitus and Hypertension with total
≥36,017 (>600) 21 (22.3) number of people with diabetes projected to rise from 336 million
Socio-economic status in 2012 to 522 million in 2030 [30], with diabetic nephropathy
Upper socio-economic group 3 (3.4) emerging as the second highest cause of ESRD in South Asia [31].
Middle socio-economic group 44 (49.4)
Lower socio-economic group 42 (47.2) Although successful renal transplantation with a well-matched
kidney is the ideal solution, it is not easily attainable. The option
between hemodialysis and peritoneal dialysis is biased toward hemo-
Table 2 | Reported expenses in the last month dialysis worldwide except in few pockets where chronic ambulatory
peritoneal dialysis is preferred over hemodialysis [32]. Initiation of
Variables Median (range) in INR hemodialysis at the optimal time and delivery of adequate dialysis
Oral medications 4000 (500–14400) and other supports offer a relatively good QoL [33]. In developing
Injectable 3800 (0–18000) economies, limited availability of insurance cover and other logis-
Dialysis 6600 (0–28800) tic supports result in poorer QoL in spite of adequate dialysis [34].
Transportation 1440 (0–9600) In this connection, compliance of the patients to dietary, fluid and
2018 rate, unadjusted for inflation. potassium restrictions are important [35]. Most patients/relatives
 K. Visweswaran et al. / Journal of Epidemiology and Global Health 10(4) 344–350 347

Table 4 | QoL scores and socio-demographic factors

Physical Psychological Social Environmental HRQoL

Age groups
24–45 42.8 ± 11.9 45.3 ± 15.2 48.5 ± 16.8 45.4 ± 11.2 36.8 ± 21.4
46–64 41.2 ± 10.5 46.5 ± 13.9 48.8 ± 16.0 49.3 ± 15.7 44.6 ± 19
65 above 44.9 ± 15.9 42.6 ± 15.2 42.7 ± 22.4 51.6 ± 15.5 44.9 ± 14.6
p 0.514 0.554 0.376 0.421 0.285
Sex
Male 44.3 ± 13.2 45.1 ± 20.2 45.8 ± 20.2 50 ± 15.6 43.2 ± 18.7
Female 39.1 ± 8.7 50.5 ± 13 48.9 ± 14.1 48.9 ± 14.1 43.6 ± 17
p 0.030 0.632 0.189 0.744 0.919
Type of family
Nuclear 42.6 ± 12.1 44.6 ± 15.1 46.6 ± 18 48.9 ± 15.4 43.7 ± 18.7
Joint 42.6 ± 13.6 49.2 ± 14.2 48.6 ± 23.1 53.1 ± 14.5 40.8 ± 17.9
p 0.997 0.273 0.753 0.325 0.573
Marital status
Married 42.4 ± 11.8 45.2 ± 15.1 47 ± 18.5 49.7 ± 15.4 43 ± 18.6
Unmarried 46.6 ± 12.8 45.2 ± 6.5 41.2 ± 20.1 47.8 ± 10.4 42.6 ± 16.9
Widowed 59.5 ± 30.4 59.5 ± 13.4 62.5 ± 17.6 56.5 ± 17.6 56.5 ± 9.1
p 0.126 0.411 0.397 0.791 0.595
Education
7 years or less of formal schooling 34 ± 10.6 39.1 ± 14.6 37.8 ± 16.2 41.6 ± 12.8 38.4 ± 17.9
8–12 years of formal schooling 44.1 ± 12.7 47.1 ± 14.4 48.9 ± 18.8 51.3 ± 14.4 43.7 ± 18.5
Graduates and above 45.9 ± 11.6 47.5 ± 15.1 49 ± 19.5 53.2 ± 16.2 45.6 ± 19
p 0.005 0.135 0.101 0.036 0.458
Occupation
Unemployed 41.5 ± 13 43.4 ± 15.9 44.1 ± 20.9 47 ± 15.6 37.9 ± 19.3
Skilled/semi-skilled 45.9 ± 11.6 49.5 ± 12.5 53 ± 12.6 52.7 ± 12.1 49.6 ± 12.2
Professionals 44 ± 10.8 45.3 ± 14.4 45.6 ± 18.1 54 ± 18.1 51.5 ± 19.3
p 0.238 0.208 0.111 0.145 0.004
Income per month-INR (US$)
≤5386 (<90) 38.8 ± 11 40.7 ± 10.9 44.8 ± 16.8 41.3 ± 12.9 32 ± 19.6
5387–13,494 (90–225) 43 ± 11.5 45.9 ± 16.4 49.1 ± 16.7 51.7 ± 12.2 45.3 ± 15.4
13,495–36,016 (225–600) 42.7 ± 6.8 41.6 ± 10.5 42 ± 14.1 46.1 ± 9.5 46.9 ± 13.1
≥36,017 (>600) 47.1 ± 15.9 54.7 ± 17.7 52 ± 25 62.6 ± 16.8 52.5 ± 17.9
p 0.112 0.004 0.283 <0.001 <0.001
Socio-economic status
Upper and Middle group 44.6 ± 11.7 49.7 ± 15.6 48.6 ± 20.6 54.5 ± 15.3 51 ± 17.6
Lower group 40.1 ± 11.8 40.8 ± 12.1 44.3 ± 16.2 44.3 ± 13.5 38.9 ± 18.2
p 0.076 0.003 0.280 0.001 0.003
Bold italicized p-values indicates significance.

fail to accept the concept of ‘opt out of dialysis’ when the condition We have found that patients with ESRD due to causes other than
has deteriorated beyond a stage of very poor QoL and dialysis helps diabetes are having poorer QoL than their counterparts with dia-
only to prolong the life and associated sufferings. betes. This can be explained by the earlier onset of non-diabetic
causes. The dialysis vintage in non-diabetic ESRD patients was
We undertook this study to access the overall QoL, HRQoL and
35.35 months where as in diabetics, it was 18.09 months. However,
scoring in individual domains on a scale of 0–100 using WHOQOL-
non-diabetic ESRD patients on maintenance hemodialysis had
BREF tool. Any score <50 is considered ‘poor’. Our findings are in
poor QoL scores compared to diabetic possibly because of the dif-
line with other studies highlighting SES, occupation and income as
ference in dialysis vintage. Patient compliance to diet, fluid and
key determinants of QoL [36,37]. Even though dialysis adequacy
potassium restrictions and associated ischemic heart disease are
is an important immediate factor which affects QoL, other factors
important determinants of QoL and occurrence of sudden death.
are also important. The overall QoL, HRQoL and scores in indi-
Fluid restriction is advised so as to restrict inter-dialysis weight
vidual domains were all below 50 on a scale of 0–100. SES, espe-
gain (IDWG) to <3 kg. Patient compliance to fluid restriction can
cially income and occupation were key determinants of QoL. Both
be assessed by IDWG. One of the important observations in our
sexes had the same quality in most domains studied. However, the
study was poorer QoL scores in patients with higher IDWG. This
males had better QoL in physical domains. These finding are in line
evidence opens up an opportunity for the health care worker to
with those reported in recent studies elsewhere including reviews
highlight the IDWG while counselling the patient.
[36,37]. Dialysis adequacy, even though an important immediate
factor which affects the QoL, is determined by many other factors In this study, the monthly median out of pocket expenditure for
as this study results show. hemodialysis in 2018 was US$ 296. This is much less compared
348 K. Visweswaran et al. / Journal of Epidemiology and Global Health 10(4) 344–350

Table 5 | QoL scores and factors related to disease and dialysis

Variable Physical Psychological Social Environmental HRQoL

Diabetes
No 43.9 ± 15.3 47.8 ± 15.8 49 ± 19.9 47.2 ± 14.2 36.9 ± 20.6
Yes 42.4 ± 10.3 44.1 ± 14.2 45.8 ± 17.8 51.3 ± 15.6 47.2 ± 15.7
p 0.615 0.250 0.440 0.196 0.012
Dyslipidemia
No 42.4 ± 13 45 ± 14.9 47.5 ± 19.1 49.5 ± 15.6 42.3 ± 19.3
Yes 44.5 ± 10.3 46 ± 14.3 44.9 ± 17.6 49.5 ± 13.6 46.2 ± 15
p 0.451 0.781 0.607 0.451 0.33
Hypertension
No 51.1 ± 13.8 51.4 ± 15.7 53.5 ± 21.1 53.6 ± 16.7 55.5 ± 18.7
Yes 41.6 ± 11.6 44.5 ± 14.6 45.9 ± 18 49.1 ± 14.9 41.2 ± 17.5
p 0.026 0.142 0.224 0.392 0.016
Family history of ESRD
No 43.1 ± 12.9 46.1 ± 14.6 46.2 ± 19.1 49.3 ± 14.4 41.5 ± 17.8
Yes 41.4 ± 9 42.5 ± 17.3 50.5 ± 15.8 52.4 ± 19.7 52.3 ± 19
p 0.569 0.506 0.407 0.608 0.085
Number of dialysis per week
1 33.7 ± 13.6 38.5 ± 19.4 46.1 ± 27.8 44.7 ± 16.6 39.2 ± 19.3
2 44.6 ± 11.9 48 ± 14.7 46.6 ± 18.8 50.5 ± 14.5 45.1 ± 16
3 42.5 ± 12.1 43.9 ± 13.9 47.1 ± 16.5 49.3 ± 15.7 41.1 ± 20.4
p 0.068 0.171 0.988 0.607 0.501
Number of months on dialysis
≤16 43.5 ± 12.4 45.8 ± 15.8 48.9 ± 20.6 52.2 ± 16.4 48.1 ± 17.2
>17 42.1 ± 12.7 45.4 ± 14.2 45.4 ± 18.1 48.9 ± 13.9 38.2 ± 19.9
p 0.611 0.885 0.416 0.319 0.019
Duration of diabetes (years)
≤15 41.9 ± 8.3 46.3 ± 16.1 48.1 ± 18.4 55.3 ± 17 49.1 ± 15
>16 46.3 ± 10.7 46.8 ± 12.6 49.9 ± 15.2 55.7 ± 13.5 53.6 ± 9.4
p 0.153 0.908 0.734 0.925 0.243
Duration of hypertension (years)
≤6 42.7 ± 9.4 45.4 ± 17.1 51 ± 20.7 54.1 ± 15.9 48.1 ± 18.2
>7 45.5 ± 14 48 ± 13.5 44.2 ± 16.2 54.6 ± 14.2 47.8 ± 9.9
p 0.429 0.562 0.214 0.899 0.944
Number of months since nephropathy diagnosis
≤36 39 ± 8.7 42.3 ± 15.3 42.8 ± 20.6 43.3 ± 12.9 40 ± 18.3
>37 45.9 ± 15.9 48.2 ± 15.1 49.7 ± 18 55.2 ± 16.5 41 ± 20
p 0.031 0.102 0.125 0.001 0.821
Number of months since diagnosed as kidney failure
≤24 42.4 ± 11.6 44.6 ± 15.6 47.4 ± 19.7 48.1 ± 16.7 44.1 ± 18.4
>25 44.2 ± 13.8 45.8 ± 14 47.8 ± 16.7 52.3 ± 13.1 42.6 ± 19.1
p 0.519 0.706 0.915 0.188 0.697
Average inter-dialysis weight gain (g)
≤1600 44.3 ± 11.5 46 ± 14.9 50.5 ± 16.8 52.1 ± 15.5 47.4 ± 15.7
>1601 40.9 ± 13.5 45.1 ± 15.4 42.4 ± 20 47.2 ± 14.5 37.9 ± 20.6
p 0.207 0.789 0.041 0.13 0.018
Coming alone for dialysis
No 42.1 ± 12 45 ± 15.5 46.5 ± 20.4 48.6 ± 14.8 41.5 ± 18.3
Yes 45.5 ± 14.6 48.4 ± 14.7 49.1 ± 15.1 54.7 ± 16.9 45.6 ± 20.6
p 0.335 0.361 0.524 0.143 0.418
Do any household members have to
take leave to accompany
No 43.8 ± 14 46.4 ± 15.7 47.4 ± 19.6 52 ± 15.4 42.5 ± 20.2
Yes 41.3 ± 9.7 44.6 ± 14.6 45.5 ± 17.9 45.8 ± 15.6 42.5 ± 16.1
p 0.357 0.604 0.657 0.098 0.997
Monthly average expenses
≤12,740 38.9 ± 9.5 40.5 ± 11.1 41.3 ± 14.9 43.3 ± 11.6 40.6 ± 14.2
>12,741 46.8 ± 13.9 50.5 ± 16.8 51.8 ± 20.4 55.8 ± 15.8 45.2 ± 21.4
p 0.001 0.001 0.005 <0.001 0.220
Bold italicized p-values indicates significance.
 K. Visweswaran et al. / Journal of Epidemiology and Global Health 10(4) 344–350 349

to the expenses reported by Umesh Khanna in private hospitals RT, RA and JG data curation. JL and PR project administration.
across India in 2005 (US$ 358, at 2018 rate, after adjusted for infla- MP and KRN supervision of the project. All authors reviewed and
tion) [38]. Similarly, in a study, which compared the cost in various edited the manuscript.
Asian countries, Li and Chow [39] reported a higher figure of US$
331 for India (as of 2018, adjusted for inflation). A private tertiary
care teaching institution in central Kerala (2012) reported a higher FUNDING
cost of US$ 806 (2018 rate) per month [40], while a public sector
hospital (2017) reported an expenditure of US$ 544 (2018 rate) per The authors received no financial support for the research, author-
month [41]. ship, and/or publication of this article.
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