Silent struggles: exploring the lived experiences of patients undergoing hemodialysis in a fragile health system following the COVID-19 pandemic and war in tigray: a hermeneutic phenomenological qualitative study

Individuals with end-stage kidney disease (ESKD) who require hemodialysis in low-resource settings and conflict-affected areas encounter significant physical, emotional, and financial difficulties. In Tigray, northern Ethiopia, the combined impact of war and the COVID-19 pandemic has greatly disrupted healthcare services, including access to life-sustaining hemodialysis services. However, there is limited understanding of the lived experiences of patients undergoing hemodialysis in unstable environments. This study aimed to explore the lived experiences of patients undergoing long-term hemodialysis in a weakened healthcare system after war and the COVID-19 pandemic in Tigray, Ethiopia. A hermeneutic phenomenological qualitative study was conducted at Ayder Comprehensive Specialized Hospital in Mekelle, Tigray, from February 14 to March 15, 2026. Twenty-one adult patients on maintenance hemodialysis were purposively selected using a maximum variation sampling technique. Data were gathered using a semi-structured interview guide conducted in Tigrigna and analyzed using a hermeneutic phenomenological approach with Atlas.ti version 25. Themes and subthemes were identified through repetitive coding and interpretation of the participants’ stories. Four key themes and eight sub-themes emerged from the analysis. The first theme, living with the burden of hemodialysis, showed ongoing physical pain, exhaustion, dependency, lower productivity, and uncertainty about survival and the possibility of a transplant. The second theme, hemodialysis within a fragile health system, showed problems such as limited access to hemodialysis services, shortages of medicines and supplies, difficulty in transportation, and heavy financial costs, which led families to sell possessions and use other coping mechanisms. The third theme, humanized care and provider support, described supportive relationships with healthcare professionals, trust, respectful communication, and emotional support, even in the face of scarce resources. The fourth theme, emotional distress and psychosocial resilience, revealed experiences of hopelessness, anxiety, social isolation, and fear of death, along with resilience built through faith, family support, and hope for transplantation. Patients with end-stage kidney disease receiving hemodialysis in the post-conflict setting of the Tigray region experience multifaceted challenges that are exacerbated by weakened healthcare systems, financial hardships, and disruptions in essential healthcare services. Addressing these challenges requires strengthening the hemodialysis infrastructure, providing comprehensive psychosocial support, and establishing financial protection mechanisms. Such interventions are crucial for improving survival outcomes and enhancing the quality of life of ESKD patients living in conflict-affected settings.