Maintenance hemodialysis adherence in Somalia: a multicenter study of barriers and facilitators

Maintenance hemodialysis (MHD) is a life-sustaining treatment for end-stage kidney disease, but missed or shortened treatments remain associated with adverse outcomes. In resource-limited settings, financial and health-system constraints may complicate long-term treatment engagement. Evidence from Somalia is limited. To assess adherence to scheduled MHD sessions and identify sociodemographic, economic, healthcare-system, access, and patient/therapy-related factors associated with missed sessions among adult patients in Mogadishu, Somalia. A multicenter, facility-based analytical cross-sectional study was conducted from January to May 2026 at three tertiary dialysis centers in Mogadishu. All eligible adults receiving MHD for at least 3 months during the study period were invited using a consecutive census approach. Of 385 active MHD patients identified, 252 met eligibility criteria, consented, and completed the study questionnaire. The primary outcome was missing more than two scheduled dialysis sessions in the preceding month. Quantitative barrier domains and a single open-ended challenge question were assessed. Multivariable modified Poisson regression with robust standard errors estimated adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs). The 252 participants had a mean age of 50.8 ± 17.7 years; 50.8% were female and 54.8% were unemployed. Forty-six participants (18.3%, 95% CI 14.0-23.5) reported missing more than two sessions in the preceding month, while 157 (62.3%) reported difficulty remaining for the full 4-hour session. The most frequently reported single biggest challenge was dialysis treatment cost (71/252, 28.2%). Thirty-one participants (12.3%) reported no major challenge; this was classified as a self-reported absence of barriers rather than a confirmed intrinsic facilitator. In the adjusted model, missed sessions were more prevalent among employed patients (aPR 2.79, 95% CI 1.08–7.22), retired patients (aPR 2.30, 95% CI 1.22–4.34), and students (aPR 4.68, 95% CI 1.82–12.03) than among unemployed patients. Patients living 5–10 km (aPR 0.47, 95% CI 0.24–0.92) or > 10 km (aPR 0.38, 95% CI 0.17–0.85) from the center had fewer reported missed sessions than those living < 5 km away. Healthcare-system barrier score showed a positive but non-significant adjusted association (aPR 1.62, 95% CI 0.96–2.74). In this cohort of maintenance dialysis patients in Mogadishu, missed sessions and treatment difficulties were common, with treatment cost the most frequently reported challenge. Improving dialysis adherence will likely require coordinated financial, psychosocial, access, and health-system interventions. Because the study included only patients who had remained on MHD for at least 3 months, the findings should not be interpreted as national estimates or as evidence of causality.