Knowledge, attitude, and practices toward chronic kidney disease among care providers in Jimma town:cross-sectional study

Background Chronic kidney disease (CKD) is a common and growing health problem that requires adequate Knowledge by health care providers to reduce the progress of the disease. Thus, this study aimed to assess the care provider’s Knowledge, attitude, and practices toward CKD. Method A cross-sectional study conducted among 326 care providers at Jimma University Specialized hospital and three medium to higher clinics found in Jimma Town. Collected data entered into Epi-Data version 3.1 and exported to SPSS version 21 for windows for data analysis. Descriptive statistics and generalized linear modal used to analyze the data. Result The mean age and service year of the participants were 29.68(±4.877) and 4.28(±4.561), respectively. The overall weighted Knowledge, attitude, and practice score of the study participant were 9.0971(8.77, 9.42), 2.53(2.4, 2.65), 10.14(9.94, 10.33) respectively. Over half of the care providers had the awareness to use eGFR to assess kidney function and patient referral to Nephrologists. Also, many care providers knew the five-stage of CKD and the risk factors of CKD, such as diabetes, long-term alcohol consumption, anemia, and cardiovascular disorders, respectively. Care providers had an understanding of late detection, and referral of CKD would increase kidney disease complications. Besides, 275(84.4%) of them are worried about treatment costs related to CKD. Over half of the care providers, 238(73.0%), believed that the Ethiopian ministry of health gave less attention to the problem. Furthermore, 234(71.8%) are interested in studying more on CKD management. Majority 256(78.5%), very likely or likely refer the patient to senior physician and Nephrologist. Conclusion Care providers showed enough Knowledge, a favorable attitude, and practice toward CKD.


Background
Chronic kidney disease (CKD) is a worldwide epidemic health problem of increasing prevalence and costing an enormous burden on healthcare systems [1][2][3]. The global increase in CKD needs a well-organized preventive strategy mainly by detecting the risk factors [4][5][6][7]. According to the American Heart Association (AHA) statement released in 2013, CKD mentioned as a significant risk factor for coronary disease [8][9][10][11][12]. Earlier-stage CKD can also lead to several complications related to anemia and bone mineral metabolism disorders [13]. Despite these known adverse consequences of CKD, the vast majority of the people remain unaware of the disease [14,15]. Kidney disease (KD) can be diagnosed with simple laboratory procedures. However, people's practice toward testing (screening) themselves to know the status of CKD is exceptionally very low.
Further, awareness of CKD remains unacceptably low among care providers [16][17][18][19][20]. Earlier recognition of CKD by nephrologists can slow the progression of the disease [21][22][23][24][25]. However, the late evaluation of CKD patients by nephrologists would increase renal failure [26][27][28][29]. A non-nephrologist mostly sees most patients with CKD seeking treatment in tertiary hospitals. The Nephrologist has relatively sufficient awareness related to CKD diagnosis than non-nephrologist [14,30]. In Ethiopia, because of the poor infrastructure, inadequate laboratory facility, and shortage of human resources in the area, physicians frequently use urine and serum creatinine as a means of CKD diagnosis and its severity. However, serum creatinine may not indeed indicate the different stage of CKD, because creatinine level might increases in the blood after high protein ingestions, intense exercise and after taking some drugs such as Cimetidine, Trimethoprim, Pyrimethamine, Salicylates, Phenacemide, Corticosteroids, and Vitamin D derivatives [31]. Increasing evidence indicates that the CKD burden is growing in developing countries because of increased risk factors such as high blood pressure and diabetes mellitus [32][33][34]. According to the unpublished study, renal disease covers 1.2-6% of adult hospital medical admissions in Ethiopia. Chronic glomerulonephritis, diabetes, and hypertension are the leading causes of chronic kidney disease in Ethiopia.
Additionally, besides the low number of nephrologists in the country, a deficient level of awareness about kidney diseases, risk factors, diagnosis, and management among care providers is believed to be very low. Thus, this study proposed to see the level of care providers' Knowledge, attitude, and practices (KAP) toward CKD. Farther more, the investigators believe that the study will bring change in the area by identifying gaps for future direction and better patient approach regarding CKD management.

Study design and study setting
A cross-sectional study was conducted at Jimma University Specialized Hospital (JUSH) and three leading higher private clinics, Jimma town, Ethiopia from February 25, 2018, to June 21, 2018. The University hospital is the only specialized referral hospital in the Southwestern part of Ethiopia, serving approximately 12 million inhabitants.

Sample size and sampling method
The sample size was determined based on the single population proportion formula using Z2 × p × q/d2 with the assumption of the prevalence of 50% for Knowledge, attitudes, and practices (KAP) of chronic kidney disease, a 95% confidence interval and a margin error of 5%. Finally, adding a 10% non-response rate, the total sample size was 422. Study subjects recruited using a nonprobability purposive sampling method.

Inclusion and exclusion criteria
The study covered a wide variety of care provider professionals found in the internal medicine wards, Pediatrics wards, gynecology and obstetrics ward, surgery ward, and many others. General practitioner, resident doctors, specialist doctors, and other health sciences professionals were eligible for the study. Then, consenting professionals received questions on Knowledge, attitude, and practice on chronic kidney diseases.

Method of data collection
We developed a questionnaire after an extensive literature review to include items assessing Knowledge, attitudes, and practices (KAP) on CKD. Experts in the area evaluated issues difficultly and discrimination in the survey. We did the pre-test among volunteer health care providers to figure out problems in the questionnaire. The data collectors and supervisors discussed the study thoroughly among themselves before data collection. Cronbach's alpha (> 0.62) used to examine internal consistency and reliability. The questionnaire divided into two sections with the first section comprising the socio-demographic future, service year, and type of area (specialty) that the health care providers are currently working. The later section contains KAP questions to assess professional KAP of chronic kidney disease. The final version administered as part of this study consisted of 25 items divided into three conceptual domains: Knowledge, attitudes, and practices for kidney disease. We designed the knowledge domain to test the understanding of care providers on the etiologies, diagnosis, and treatment of kidney disease as well as the normal function of the kidneys. Fourteen questions in a fourpoint response scale ("Yes", "No," "Do Not Know," "Unsure") prepared to assess Knowledge. Similarly, four questions with a five-point categorical response scale ("Strongly Agree", "Agree", "Not sure", "Disagree", "Strongly disagree") prepared to measure care provides attitudes. Finally, the practice domain comprised seven items with a four-point Likert-scale ("Very Unlikely", "Unlikely", "Likely", "Very Likely") to evaluate care providers' practice.

Statistical analysis
Data analysis performed using the International Business Machines Corporation-Statistical Package for Social Sciences program version 21 (IBM-SPSS Statistics 21). Results of the continuous variables expressed as means ± Standard Deviation (SD), whereas frequencies (percentages) used to display the result of categorical variables. The normality of the continuous data viewed by using the Kolmogorov-Smirnov test and the data distribution was normal. Generalized linear model used to analyze Knowledge score and crude associations. A dummy coding of 0 and 1 used to enter the nominal independent variables into the regression model. The possible presence of multicollinearity between independent variables was explored based on the variance inflation factor (VIF). Internal consistency of all types of questions and their subscales assessed using Cronbach's alpha. All P values considered significant at < 0.05. For the knowledge domain, we calculated a composite score (range: 0-14). To do so, we first scored each item as correct (1) or incorrect (0) with the responses 'Do Not Know' and 'Unsure' treated as incorrect. We then obtained the sum of the 14 scored items. For the attitudes domain, each item scored as "Strongly agree" (1), 'Agree' (1) or 'Not sure' (0), 'Disagree' (0), and 'Strongly disagree' (0). For the practices domain, each item scored as 'Very unlikely' (1), 'Unlikely' (1), 'Likely' (0), or 'Very likely' (0). The study participants who scored 70% and above in the overall weighted mean score considered as having adequate Knowledge, positive attitude and good practices.

Ethical considerations
The Ethical Review Board of Jimma University approved the study with the reference number IHRPGD/3019/ 2019. All ethical requirements stringently ensured to keep participants confidentiality.

Participant characteristics
A total of 326 health care professionals involved and the majority of the participants were Male 227(69.6%) and general practitioners 96(29.4%). The mean age and service year of the participants were 29.68(±4.877) and 4.28(±4.561), respectively (Table 1).

Knowledge
The overall weighted Knowledge, attitude, and practice score of the participant on CKD were 9.0971(8.77, 9.42), 2.53(2.4, 2.65), and 10.14(9.94, 10.33). Male participants had higher mean Knowledge (9.54(9.17, 9.91)) than females. Residents 10.1(9.49, 10.65) had a higher knowledge score than other professionals. Also, male sex 0.875(0.204, 1.547) residents 1.84(0.979, 2.694) and specialist 1.72(0.802, 2.646) showed significant liner associations with the crude knowledge score of chronic kidney disease. The majority of the respondents, 191 (58.6%) knew that eGFR (estimated Glomerular Filtration Rate) is a better way to assess the severity of kidney disease. Also, 180(55.2%) of the participants had a knowledge that eGFR helped in referral to a nephrologist (Q2). The highest proportion of the study participants, 202(62.0%), do not think an age-related reduction of eGFR with no kidney disease leads to low eGFR as far as serum creatinine is in the normal range (Q3). Farther more, the majority of the participants also declared that they did not know about the standard treatment protocol and the Modification of Diet in Renal Disease (MDRD) formula to asses kidney function in patients (Q4). Almost all care providers, 298(91.4%), had the understanding that diabetes and hypertension are possible risk factors of CKD. Furthermore, they knew that long-term alcohol consumption and anemia are the potential risk factors of CKD (Table 2).

Attitude
The majority of the study participants, 275(84.4%), agreed that they worry about treatment cost for CKD (Q1). To the same extent, 219(67.2%) of participants also believed that CKD is a significant public health problem in Ethiopia (Q2), and 238(73.0%) of the participants disagree that the ministry of health is working hard in the prevention of the disease (Q3). Furthermore, 234(71.8%) participants agreed that they need more education on CKD and eGFR (Q4) ( Table 3).

Practices
The majority of the participants 256(78.5%), Very likely or likely refer patients with CKD to senior physician and

Discussion
This study has assessed the care providers' Knowledge, attitude, and practices toward chronic kidney disease in Jimma town, Jimma Ethiopia. Overall, study participants involved in this study had enough Knowledge, favorable opinion, and practice toward CKD. Participants knew the essential functions of the kidney, risk factors, and diagnosis of CKD. Renal diseases requires a compressive management of glomerular filtration rate, and need to monitor our blood glucose and blood pressure level quite regularly. The Modification of Diet in Renal Disease (MDRD) is a multicenter clinical trial study designed to assess acceptance, safety, and efficacy of restricted protein and phosphorus diets in patients with   [44].
In the current study, care providers showed a keen interest in learning about eGFR and kidney disease. Besides, the majority of the study participants felt that kidney problem in Ethiopia is a public health problem that the minister of health gave less attention to the prevention and treatment of CKD. The reason might be a lack of human resources and infrastructure. Resources is one of the vital element to decrease the spread of diseases and improve health services for patients. Kidney disease is now a health problem that kills a thousand individuals without seeing doctors [45]. To mitigate the problem, the ministry of health needs to make a tremendous effort on the health infrastructure and capacity building in the area. As far as practice parameters are concerned, we identified that the majority of the study participants very likely or likely refer patients to Nephrologists. Furthermore, care providers confirm that they had no regular or periodic meeting to discuss kidney disease. However, they often had a talk with their patients about kidney diseases and preventive measures.

Limitations
We understand that the current study might suffer from the usual "egg or chicken" dilemma, as the cross-sectional design did not allow for a conclusion about the direction of casualty between the response variable (KAP) and predictor variables. The second limitation of the study may be study subject selection bias and recall bias.

Conclusion
The overall weighted knowledge score of the participant on CKD was 9.0971 (8.77, 9.42), which is above a moderate level. Care providers should update themselves on the current advancement of sciences related to CKD treatment and management. Clinical departments should prepare regular meetings to discuss issues associated with CKD. Furthermore, patient referral to the appropriate care unite should be encouraged. The ministry of health should give adequate attention to the prevention work, as many care providers agreed that CKD is a public health problem in Ethiopia. Thus, health ministry and other concerned bodies should update the status of CKD in the country and should get the attention it deserves on treatment and prevention options. Care providers should also update themselves on the current advancement of sciences related to CKD treatment and management. Clinical departments also should prepare regular meetings to discuss issues associated with CKD.
Additional file 1. Data collection tool.