Examining multilevel socioenvironmental factors associated with pursuit of kidney transplant among predominantly African American end stage renal disease patients undergoing dialysis Open Access

Abstract

Kidney transplant is the recommended treatment for many people with end stage renal disease (ESRD). Kidney transplant recipients experience increased life expectancy, reduced hospitalization, and improved quality of life, compared to those who remain on dialysis. Still, low kidney transplantation rates are observed among ESRD patients in the U.S. African American (AA) patients are disproportionately impacted as they are 3 times more likely to advance to ESRD than white patients, but have 30% lower transplantation rates (United States Renal Data System, 2018). Racial disparities in transplantation may be explained in part by socioeconomic status (SES) inequalities. This dissertation conducted two studies to elucidate multi-level social and environmental factors associated with kidney transplant pursuit among predominantly AA ESRD patients receiving dialysis care from Atlanta, Emory-operated dialysis clinics, in order to promote equitable access to kidney transplant.

Our quantitative study examined associations between neighborhood-level SES characteristics of dialysis patients’ (n=1118) physical, social, and service environments and kidney transplant wait-listing, using sequential cox proportional regression modeling. Secondary patient data was obtained from dialysis clinic electronic medical records and the United States Renal Data System. Patients’ home neighborhood characteristics were collected using census-tract data from the 2011-2016 American Community Survey. In our qualitative study, we completed semi-structured interviews with AA hemodialysis patients (n=22) to assess how dialysis patients’ social network functions (i.e. social influence, social undermining, social companionship, and social support) and experiences with SES declines while on dialysis influence kidney transplant pursuit.

Quantitative results showed increased exposure to SES disadvantages within patients’ physical and social environments were associated with reduced waitlisting rates. Qualitative interview findings revealed that local family and successful transplant recipients provided important social influence, encouraging transplant. Family and other dialysis patients were resources for companionship and emotional social support but often limited in providing financial or informational social support for transplant pursuit. Most patients (59%) experienced declines in SES while on dialysis, which impeded transplant pursuit. Future efforts to promote equitable access to transplant should consider strategies that address neighborhood disadvantages, diversify social networks and strengthen SES for AA dialysis patients.

Table of Contents

Table of Contents

Chapter One - Introduction. 1

I.    Background. 1

A.      The burden of end stage renal disease in the United States. 1

B.      Treatment options for patients with ESRD.. 2

C.      Kidney transplantation rates remain low and unevenly distributed across populations. 5

II.  Literature Review.. 7

A.      Racial inequities in African American ESRD patients’ pathway to kidney transplant. 7

B.      Multilevel socioeconomic disadvantages associated with African American ESRD patients’ reduced access to transplantation rates 8

C.      Increasing African American ESRD patients’ access to kidney transplant 17

III. Theoretical Approach. 18

IV. Significance and Aims of Research. 29

V.  References. 33

Chapter Two - Neighborhood Socioeconomic Features and Waitlisting. 42

A quantitative study examining associations between neighborhood socioeconomic disadvantage and access to kidney transplant among predominantly African American dialysis patients. 42

I.    Introduction. 42

II.  Methods. 46

III. Data Analysis. 51

IV. Results. 54

V.  Discussion. 57

VI. References. 65

Chapter Three - Social Network Functions and Kidney Transplant Pursuit 70

A qualitative study exploring African American dialysis patients’ social network functions associated with pursuit of kidney transplant in Atlanta, Georgia. 70

I.    Introduction. 70

II.  Methods. 74

III. Data Analysis. 77

IV. Results. 78

V.  Discussion. 96

VI. References. 105

Chapter Four - Socioeconomic Decline and Kidney Transplant Pursuit 111

A Qualitative study examining African American end-stage renal disease patients’ experiences with socioeconomic decline while on dialysis and its associations with pursuit of kidney transplant 111

I.    Introduction. 111

II.  Methods. 115

III. Data Analysis. 117

IV. Results. 118

V.  Discussion. 133

VI. References. 140

Conclusion. 145

I.    Main findings. 145

II.  Evaluation of Research. 150

III. Implications for Public Health Research and Practice. 153

IV. Conclusion. 156

V.  References. 157

References. 160

About this Dissertation

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• Permission granted by the author to include this thesis or dissertation in this repository. All rights reserved by the author. Please contact the author for information regarding the reproduction and use of this thesis or dissertation.

School	Laney Graduate School
Department	Behavioral Sciences and Health Education
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Public Health
Keyword	Kidney Disease Chronic Disease Kidney Transplant Health Equity
Committee Chair / Thesis Advisor	Kimberly Jacob Arriola, Emory University
Committee Members	Cam Escoffery, Emory University Janice Lea, Emory University Rachel Patzer, Emory University

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