Physical exercise is a safe and beneficial intervention for individuals on hemodialysis, improving cardiovascular health, physical function, and quality of life.1–3 However, despite these benefits, exercise participation remains low and is poorly integrated into kidney care routines.4,5 In this context, investigating perceived benefits and barriers to exercise has emerged as a crucial factor for improving adherence among these individuals.6 Delgado and Johansen demonstrated that, despite the numerous documented benefits, 92% of individuals with End-Stage Kidney Disease (ESKD) reported encountering at least one barrier to exercise participation.7 Commonly reported barriers include tiredness, muscle fatigue in the lower limbs, and body pain.8–10

Questionnaires are recognized as cost-effective tools that provide an objective means of gathering information from large samples.11 In a systematic review conducted by our research group, we observed that the assessment of perceived benefits and barriers to exercise has largely relied on a single instrument: the "Dialysis Patient-Perceived Exercise Benefits and Barriers Scale" (DPEBBS), which is considered reliable, valid, and structurally adequate.12 The DPEBBS has been used in five studies, showing positive results in 6 out of 9 psychometric properties. However, it has been validated for use only for English, Chinese,13 and Turkish speaking patients,14 which may contribute to its limited application in research studies.12 Moreover, the DPEBBS has yet to be translated, culturally adapted, and validated for other languages, including Brazilian Portuguese.

Given the burden of ESKD,5 this study is essential to address an existing gap by providing a validated tool that accurately assesses exercise perceptions among Brazilian Portuguese-speaking hemodialysis patients. Therefore, the aim of this study was to translate, culturally adapt, and assess the measurement properties of the DPEBBS in people with hemodialysis in Brazil.

The development of the DPEBBS-BP addresses a critical gap in understanding the benefits and barriers to physical exercise among individuals on hemodialysis in Brazil. Prior to this adaptation, there was a lack of culturally relevant tools specifically designed for this population, which limited the ability to accurately assess and address their exercise-related needs and challenges. Evaluating the measurement properties and clinical viability of instruments is essential to avoid the use of measures with low quality and little applicability.30 In this context, the main results of this study demonstrate that the DPEBBS-BP is a valid and reliable instrument for evaluating these factors in the Brazilian setting.

The confirmatory factor analysis supported a robust seven-factor structure, accounting for a significant portion of the variance, indicating that the translated instrument effectively captures the intended constructs. The DPEBBS-BP demonstrated strong internal consistency and test-retest reliability, confirming its stability over time. Additionally, the moderate correlations between the DPEBBS-BP barrier scores and established measures of functional capacity highlight its relevance in assessing key aspects of participants' experiences with exercise. During the adaptation process, all 24 original items of the scale were retained, while 6 new items were added to better reflect cultural and contextual factors. Furthermore, 9 items were revised to enhance clarity and comprehension based on feedback from both experts and the target population. As a result, the final version of the DPEBBS-BP consists of 30 items - 15 addressing perceived benefits and 15 addressing perceived barriers to exercise. The authors recommend evaluating these domains separately to facilitate a more nuanced interpretation of the results. The successful adaptation of the DPEBBS-BP offers a valuable tool for clinical practice and research, enabling healthcare professionals to better understand exercise perceptions among Brazilian individuals undergoing hemodialysis. This, in turn, can inform more targeted interventions and support strategies to improve patient adherence and outcomes.

In addition to our study, the DPEBBS has been validated by only two other research teams: one for the English and Chinese versions and the other for the Turkish version. 13,14 Our confirmatory factor analysis revealed a seven-factor solution that accounts for 59% of the variance, closely aligning with Zheng's six-factor solution (57% variance) and Tas and Akyol's five-factor solution (58% variance). While our analysis introduced two new factors - “Benefits related to willingness to exercise and self-care perception” and “Benefits related to psychological health” - the findings remain consistent with those reported by Zheng et al. and Tas and Akyol in terms of reliability. For a better view of comparisons between studies, see Supplemental Appendix 6. These studies demonstrate that, despite variations in factor structures and measurement properties, culturally specific adaptations like the DPEBBS-BP are crucial for addressing the unique needs of Brazilian individuals on hemodialysis.

To our knowledge, this study is the first to examine the correlations between benefit and barrier scores and variables such as socioeconomic status, functional capacity, and quality of life. While a previous study utilized the DPEBBS to assess the perception of benefits and barriers in relation to quality of life, using the KDQOL questionnaire, it focused solely on quality of life and found a significant correlation with DPEBBS scores (r = 0.55, p < 0.001).8 In contrast, our study is pioneering in its exploration of how benefit and barrier scores relate to functional capacity. We found that participants with greater functional capacity, as measured by the DASI questionnaire and the functional capacity domain of the SF-36, reported fewer barriers to exercise. This suggests that individuals with higher functional capacity are better able to overcome perceived barriers.

This study also represents the first effort to calculate the SEM and the MDC for the DPEBBS-BP scale. The values presented provide a reference point for future research studies that will help to identify the lowest score needed to detect change between two assessments. In our analysis, we found that the average benefit and barrier scores related to age and self-reported physical activity exceeded the SEM value for benefits, and age and socioeconomic status differences between the upper and middle classes surpassed the SEM for barriers. These findings reflect statistical significance and also highlight clinically relevant differences, underscoring the practical utility of the DPEBBS-BP in assessing meaningful changes in the perceptions of individuals with ESKD over time.

Participants in this study reported higher scores for benefits compared to barriers, reflecting a greater awareness of the advantages of exercise. Items related to daily life and physical function received the highest scores. In contrast, items related to disease symptoms and potential adverse effects of exercise received the highest scores for barriers. These challenges should be addressed through educational interventions that encourage exercise, promoting a more active and healthy lifestyle for people with chronic kidney disease.4,31,32

The findings of this study have some important implications for both clinical practice and future research. The validation of the DPEBBS-BP for Brazilian individuals on hemodialysis provides a robust tool to assess perceptions of benefits and barriers to exercise. Despite being an individual response, it was observed that older individuals, women, those with fewer years of formal education, and those with lower socioeconomic status perceived more barriers. This may be a guide for some actions regarding individuals on hemodialysis treatment. By identifying specific benefits and barriers related to daily living, physical function, and psychological health, health professionals can develop targeted educational and motivational strategies to address the unique challenges faced by this population. Furthermore, the correlation of barrier scores with functional capacity highlights the need for comprehensive support systems that address physiological factors that affect individual participation. Future research should explore changes in perceptions, test interventions and expand the application of the DPEBBS-BP.

This study successfully validated the DPEBBS-BP, providing a reliable and culturally relevant instrument to assess perceptions of exercise among Brazilian people with hemodialysis. The results demonstrated a strong alignment with previous studies while also highlighting unique factors specific to this population, such as benefits related to willingness to exercise and psychological health. Additionally, the correlations identified between barrier scores, functional capacity offer valuable insights for healthcare professionals to develop more comprehensive, patient-centered care plans.

This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sectors.

This study was carried out in accordance with the principles of the Declaration of Helsinki. The approval was granted by the Ethics and Research Committee on Human Beings (CEPSH) of the Federal University of Santa Catarina (UFSC), under approval number 65,560,222.8.0000.0121.

Informed consent was obtained from all individual participants included in the study.

Marcieli A. Martins: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Gabriela L.M. Ghisi: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. Marvery P. Duarte: Investigation, Resources. Jacqueline F.S. Monteiro: Investigation, Resources. Heitor S. Ribeiro: Investigation, Resources, Writing – review & editing. Danielle S.R. Vieira: Data curation, Formal analysis, Writing – review & editing. Daiana C. Bundchen: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.