Table 2 Main themes and sub-themes of the study

Finding the true meaning of the behavior of the participants

• Understanding that refusal behavior reflects unacceptance

• Understanding that tantrums are a manifestation of wanting to be cared for

Recognizing and honoring individual psychological states

• Respecting and allowing the state of readiness to emerge

• Respecting the patient’s “no change” phase prior to transitioning to “acceptance”

Culturally sensitive communication in line with patients’ values

• Guiding patient to accept treatment using their beliefs in fate

• Fostering awareness of the effectiveness of dialysis

• Promoting a shift in perspective towards the positive meaning of dialysis

• Leveraging the influence of “relatives”

Customizing care content through cultural transformation strategies

• Explaining information patiently and repeatedly in a more acceptable way

• Reminding patients of information with a relaxed manner and non-blaming words

• Borrowing physician’s authority

Empowerment rather than prohibition

• Not interfering with patients’ coping behavior

• Giving specific responses to concerns