Population-level barriers to home hemodialysis implementation: a public health systems analysis of adoption readiness, health equity, and policy implications in China

Background Home hemodialysis (HHD) can improve clinical outcomes and reduce system costs, yet utilization remains negligible in mainland China. This study quantified population-level willingness to adopt HHD and identified multilevel determinants with direct relevance to service delivery, equity, and implementation. Methods A cross-sectional survey was conducted at a tertiary dialysis center in Huzhou, China (February 2022–November 2025) among consecutive adults receiving thrice-weekly in-center hemodialysis for ≥3 months. The primary outcome was high HHD adoption intent (Likert 4–5). Multivariable logistic regression, with bootstrap validation, estimated independent associations across sociodemographic, clinical, psychosocial, infrastructural, economic, and health-system engagement domains. Results Of 2,847 participants (72% response rate), 717 (25.2%) reported high adoption intent. High-intent patients were younger (54.8 ± 13.7 vs. 59.6 ± 14.3 years), more often male (61.6% vs. 54.3%),