Assessment of knowledge, attitudes and practices regarding chronic kidney disease in at-risk individuals: A hospital-based cross-sectional study

Gaurav Shekhar Sharma; Hem Lata; Ranjeeta Kumari; Venkatesh S Pai; Sharon Kandari; Farhanul Huda; Prateek Walia; Ravi Kant

doi:10.4103/JME.JME_66_22

ORIGINAL ARTICLE

Year : 2023 | Volume : 4 | Issue : 1 | Page : 7-12

Assessment of knowledge, attitudes and practices regarding chronic kidney disease in at-risk individuals: A hospital-based cross-sectional study

Gaurav Shekhar Sharma¹, Hem Lata², Ranjeeta Kumari³, Venkatesh S Pai⁴, Sharon Kandari¹, Farhanul Huda⁵, Prateek Walia³, Ravi Kant⁴
¹ Department of Nephrology, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
² College of Nursing, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
³ Department of Community and Family Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
⁴ Department of Internal Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
⁵ Department of General Surgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission	03-Jun-2022
Date of Decision	06-Dec-2022
Date of Acceptance	16-Dec-2022
Date of Web Publication	26-Apr-2023

Correspondence Address:
Dr. Ravi Kant
Department of Internal Medicine, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttarakhand
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JME.JME_66_22

Abstract

Background: Chronic kidney disease (CKD) is a global health problem, with a worldwide prevalence of around 9.1 per cent (as of 2017). In India, its prevalence was found to be around 17.2%. There are several risk factors of CKD, out of which the presence of underlying longstanding uncontrolled diabetes mellitus (DM) and hypertension are common. Certain previous studies have tried to assess the level of knowledge, attitudes and practices of such a 'high risk' group for developing CKD but there is a paucity of literature on it. Hence, this study was undertaken to assess these domains in individuals at risk for developing CKD. Patients and Methods: It is an observational cross-sectional study conducted from October 2020 to December 2021 at a tertiary care teaching and referral hospital in India. A total of 215 patients who were at risk of developing CKD, were enrolled and were given a CKD Screening Index questionnaire to fill and scoring was done for all three components-knowledge, attitudes and practices. Results: The mean age was found to be 49.21 ± 13.49 years with a male: female ratio of 1.4:1. Nearly three-a fourth of the patients were having DM while one-fourth of the participants had a previous history of hypertension. The mean scores on the knowledge, attitude and practices scales were found to be 11.80 ± 5.31, 50.18 ± 8.23 and 30.83 ± 7.53 respectively. The study results revealed that the majority of patients had 'low' levels of knowledge scores but 'average' levels of attitude and practice scores. A significant correlation was found amongst knowledge and attitude scores (r = 0.226, P = 0.001), knowledge and practice scores (r = 0.153, P = 0.025) and practice and attitude scores (r = 0.295, P = 0.000) of our patients. Conclusion: There is a need of improving awareness at least amongst the population at risk of getting CKD. Improving knowledge would help in inculcating positive attitudes and healthier practices amongst these, thus delaying the onset of this disease.

Keywords: Attitudes, chronic kidney disease, Chronic Kidney Disease Screening Index, knowledge, practices

How to cite this article:
Sharma GS, Lata H, Kumari R, Pai VS, Kandari S, Huda F, Walia P, Kant R. Assessment of knowledge, attitudes and practices regarding chronic kidney disease in at-risk individuals: A hospital-based cross-sectional study. J Med Evid 2023;4:7-12

How to cite this URL:
Sharma GS, Lata H, Kumari R, Pai VS, Kandari S, Huda F, Walia P, Kant R. Assessment of knowledge, attitudes and practices regarding chronic kidney disease in at-risk individuals: A hospital-based cross-sectional study. J Med Evid [serial online] 2023 [cited 2023 Jun 3];4:7-12. Available from: http://www.journaljme.org/text.asp?2023/4/1/7/374726

Introduction

Chronic kidney disease (CKD) is a global health problem, with a worldwide prevalence of around 9.1 per cent (as of 2017).^[1] In India, its prevalence was found to be around 17.2%.^[2] There are several risk factors of CKD, out of which the presence of underlying longstanding uncontrolled diabetes mellitus (DM) and hypertension are common. DM is considered the most common cause of CKD, worldwide.^[3] The global prevalence of DM was found to be 9.3% (as of 2019). The age-standardised prevalence of DM in ages 20–79 years in 2019, was found to be 8.3% in the whole world and 11.3% in the Southeast Asian region and India is second on the list of countries having maximum diabetics in the world, after China.^[4] These figures indicate that the prevalence of DM and CKD go hand in hand and that both are common public health problems in India.

Hypertension is another common risk factor for CKD. Based on the definition of Hypertension prevailing in the year 2010, around 31% of adults, had hypertension all over the world. It was found that compared with men who had systolic blood pressure (SBP) <120 mmHg and diastolic blood pressure (DBP) <80 mmHg, off any type of antihypertensive medications, the relative risk of CKD 5D, for men with hypertension who had a SBP more than 210 mmHg or DBP more than 120 mmHg was 22.1 (P < 0.001).^[5]

Other factors which predispose an individual to a higher risk of CKD include coronary artery disease (CAD), male sex, advancing age, prolonged exposure to analgesics and other nephrotoxic agents, smoking, hyperuricemia, genetic pre-disposition, past history of an episode of acute kidney injury (AKI) etc.^[3] Knowledge about these risk factors, especially among high-risk individuals, is expected to delay the onset of disease. Certain previous studies have tried to assess the level of knowledge, attitudes and practices of such a 'high risk' group for developing CKD but there is a paucity of literature on it.^[6],[7],[8] In fact, no such Indian study could be found during the literature search. There is a need for such study to determine knowledge, attitudes and practices in the Indian scenario to guide future interventions for the reduction of CKD burden in the population.

Hence, this study was undertaken to assess knowledge, attitudes and practices of individuals at risk for developing CKD using CKD Screening Index,^[9] a validated assessment tool [Appendix 1]. The objectives of the study were to estimate the level of these three domains in individuals at risk for developing CKD, to determine correlation amongst all these domains and to determine the association between these domains and certain risk factors of CKD.

Methods

Study design and duration

It is an observational cross-sectional study conducted from October 2020 to December 2021.

Study area

The study was conducted in outpatient department (OPD) as well as the in-patient department (IPD) areas of departments of Nephrology, Internal Medicine, Pulmonary Medicine and General Surgery at a tertiary care teaching and referral hospital in India.

Study population

Patients fulfilling the following inclusion criteria were enrolled in this study - Age more than or equal to 18 years and 'at risk' of developing CKD, by having any of these risk factors-past history of DM, past history of hypertension, past history of an episode of AKI, past history of CAD, past history of chronic analgesic intake, personal history of smoking and family history of CKD. Those aged <18 years and known cases of CKD, were excluded from the study.

Sample size

Assuming the mean knowledge score as 19.27 with a SD of 2.6 from a previous study, attitude score of 59 ± 6.1 and practice score of 31 ± 5.1, the sample size was calculated using the following formula for a 95% confidence level and a Margin of error (E) of 1: n = (Z_α/2σ/E)².

Where n = sample size, Z = Z statistic for a level of confidence (for 95% CI, Z = 1.96), σ = Standard deviation, E = Margin of error.

Hence sample size = 25.96 ≈ 26 for knowledge score, 143 for attitude score and 100 for practice scores. Taking the maximum of these we had used a sample size of 143. Since the sampling was not done randomly, we multiplied it with a design effect of 1.5 to obtain a sample size of 215.

Sampling technique

An equal number of patients were enrolled from each department consecutively (ensured by from the entries made in the IPD/ward admission register) till the completion of sample size.

Ethical approval

Approval was obtained from Institute Ethical Committee (IEC) via letter no-AIIMS/IEC/20/684, dated - 03 October 2020.

Study tool

The patients enrolled were asked to fill the CKD Screening Index questionnaire^[9] by the investigator, any time during admission. The questionnaire was validated for translation into the local language (Hindi) by reverse translation into the original language (English). The scoring was done for all three components-knowledge, attitudes and practices. Knowledge was measured on a dichotomous scale. From a list of 24 items, patients were asked to mark the response that suited them best. The final score was obtained out of 24. Attitudes and practices were measured using 5 and 4-point Likert-type scales, respectively. The attitudes scale had 15 items which would record patients' attitudes towards their aptitude to identify symptoms and initiate suitable help-seeking conduct in themselves or someone else with CKD symptoms. Scores ranged from 15 to 75. The practices scale had 12 items that would record patients' healthy practices towards protection from having CKD. Scores ranged from 12 to 48. Patients were categorised as Low/Average/High scorers based on the cut-off scores of <50%, 50 to 75% and greater than 75% respectively of the total score.

Statistical analysis

All the data was entered in an excel spreadsheet and checked for error and it was analysed using IBM SPSS Statistics version 23.0 (IBM Corp., Armonk, NY USA). Descriptive statistics have been presented as mean scores, standard deviations and frequencies to describe the demographic characteristics of the participants along with study variables. Amongst Inferential statistics, Pearson correlation was used to find out correlation amongst all these three parameters and a two-tailed independent t-test was applied to see the association of scores of these parameters with risk factors of CKD.

Results

Sociodemographic characteristics

A total of 215 patients' data was collected with mean age 49.21 ± 13.49 years with a male: female ratio of 1.4:1. It was observed that more than half (63.3%) of participants were OPD patients. Nearly three-fourths of patients (70.2%) were having DM while one-fourth of participants had a previous history of hypertension whereas only 16% were having a previous history of both DM and hypertension. Among these patients, only 2.3% were having a family history of CKD [Table 1].

Table 1: Sociodemographic characteristics of patients at risk of developing chronic kidney disease (n=215)

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Level of knowledge, attitude and practices

The mean scores on knowledge, attitude and practices scales were found to be 11.80 ± 5.31, 50.18 ± 8.23 and 30.83 ± 7.53 respectively. About half of the patients (50.7%) were having a 'low' level of knowledge whereas only 1/10^th (10.7%) had a 'high' level of knowledge regarding the risk of CKD. Nearly 1/3^rd (70.7%) patients were having an 'average' level of attitude towards the risk of CKD and nearly half (56.3%) were performing 'average' in practices in response to their disease condition [Table 2].

Table 2: Patient's knowledge, attitude and practice scores regarding the risk of chronic kidney disease (n=215)

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Correlation between patient's knowledge, attitude and practice scores

Further, the study evaluated the correlation amongst knowledge, attitude and practice scores of patients regarding CKD. The Pearson correlation showed that there exists a weak positive correlation amongst knowledge, attitude and practice scores, which was significant at P < 0.05. A significant correlation was found amongst knowledge and attitude scores (r = 0.226, P = 0.001), knowledge and practice scores (r = 0.153, P = 0.025) and practice and attitude scores (r = 0.295, P = 0.000) of our patients [Table 3].

Table 3: Correlation between knowledge, attitude and practice scores of patients at risk of developing chronic kidney disease

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Association between selected socio-demographic variables and knowledge, attitude and practice scores regarding the risk of chronic kidney disease

A significant association was found between the previous history of DM and a patient's knowledge scores (t = 2.098, P = 0.037) at a P < 0.05 level of significance [Table 4]. However, no significant association was found between other variables and their knowledge scores. A significant association was there between past history of DM (t = 3.83, P = 0.000), past history of hypertension (t = −3.74, P < 0.000), past history of analgesic abuse (t = −2.23, P = 0.02) and family history of CKD (t = −2.22, P = 0.02) with attitude scores, at P < 0.05 level of significance [Table 5]. There was a significant association between past history of hypertension (t = −2.49, P = 0.01) and past history of CAD with practice scores (t = −2.16, P = 0.03) at P < 0.05 level of significance [Table 6].

Table 4: Association between past history of diabetes mellitus and knowledge scores regarding the risk of developing chronic kidney disease

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Table 5: Association between selected demographic variable and attitude scores regarding the risk of developing chronic kidney disease

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Table 6: Association between selected demographic variables and practice scores regarding the risk of developing chronic kidney disease

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Discussion

Our study revealed that the majority of patients had 'low' levels of knowledge scores but 'average' levels of attitude and practice scores. Our participants had a mean knowledge score of 11.80 ± 5.31. Overall 'poor' knowledge levels found in our study were also found in previous studies by Yusoff et al.,^[7] Gheewala et al.^[10] and Danguilan et al.^[11] This overall 'low' level of knowledge could be associated with patients' 'poor' socio-economic, 'lower' educational backgrounds and could also be associated with their 'poor' education and counselling done by their primary care physicians.^{[7],[10],[11]} On the contrary, a similar cross-sectional study by Khalil and Abdalrahim found that most of the patients had knowledge about CKD (mean score was 19.27 ± 2.6), but half of them had incorrect information related to its clinical features. They had also noted that most of them were unaware of the significance of discovering health-related issues at the initial stages.^[6] Another study by Sa'adeh et al., which had used another tool for assessment had found that amongst hypertensive patients, the median knowledge score for different variables was ranging between 17 and 20 out of a maximum score of 30.^[8]

We had found in our study that the mean score for attitude was 50.18 ± 8.23. The majority (70.7%) of our patients were 'average' scorers. Similar findings were obtained by certain previous studies. Khalil and Abdalrahim had found a mean score of 59 ± 6.1, higher than what we have found. Another study by Yussof et al. had revealed that the majority (68.9%) of their participants had good attitude scores.^[7] Saadeh et al. had found that amongst hypertensive patients, the median attitude score for different variables was ranging between 67-69 out of a maximum of 90.^[8]

The mean score of practices of our patients was calculated as 30.83 ± 7.53. While the majority (56.3%) of our participants scored 'average' on the practice scale, the study conducted by Yusoff et al. had found that the majority (88.3%) of its patients had 'good' practices towards the risk of CKD.^[7] A previous study done by Sa'adeh et al. had demonstrated that amongst hypertensive patients, the median practice score for different variables was ranging between 37 and 42 out of a maximum of 48.^[6],[8]

A significant correlation [Table 3] was found amongst knowledge and attitude scores, knowledge and practice scores and practice and attitude scores of our patients. There was a weak positive correlation which was significant at P < 0.05 level. Similar findings were observed in previous studies by Sa'adeh et al. and by Sabouhi et al.^[8],[12] This implies that as knowledge of a patient regarding CKD improves, his attitude towards the disease also changes in a positive direction and subsequently he/she develops more healthy practices towards his/her risk of getting CKD. This also indicates that just by improving the patient's knowledge, by education and repetitive counselling etc., his attitude and practices towards his risk of getting CKD, can all be improved. Thus, proper education of patients who are at risk of getting CKD, by their treating physicians and specialised nurses is required at regular intervals. A concept of 'integrated speciality clinics' where specialists of relevant branches together provide services to patients at the same time, can be implemented. Public education by interactive sessions can be tried. This also highlights the need for specialised nursing personnel and dieticians in such clinics.

We had detected a significant association (P < 0.03) between the past history of DM and the patient's knowledge scores. A similar observation was achieved in a previous study by Gheewala et al.^[10] This can be due to patient seriousness towards their disease condition and healthcare counselling to provide some basic knowledge regarding CKD. On the contrary, a study by Khalil and Abdalrahim had found that the family history rather than the past history of DM along with the family history of hypertension and patients education level, were significantly associated with participant's knowledge scores.^[6] A previous study by Yusoff et al. had revealed that variables like gender, education level, employment status and monthly family income had a significant association with patients' knowledge level.^[7] Another study by Sa'adeh et al. had found that factors significantly associated with higher knowledge scores of patients were age <65 years and high education level.^[8]

In this study, a significant association was found between past history of DM, past history of hypertension, past history of chronic analgesic abuse and family history of CKD with attitude scores. On the other hand, a previous study by Khalil and Abdalrahim had found that family history of Hypertension, history of ischemic heart disease and gender were significantly associated with participants' attitude scores.^[6] In the study by Yusoff et al., a significant association was found between participants' gender, marital status and occupation with their attitude level.^[7] Another previous study by Sa'adeh et al. had found that age <65 years, high-income status and high knowledge scores were significantly associated with higher attitude scores.^[8]

We had observed a significant association between past history of hypertension and past history of CAD with practice scores. However, a prior study by Khalil and Abdalrahim had shown that family history of hypertension, along with age, gender and monthly income had a significant association with practice scores of patients. They had also observed that patients' education status and income were having significant association with poor knowledge and unhealthy practices.^[6] In a previous study by Yusoff et al., it was found that a significant association existed between marital status and practices.^[7] A different finding was observed by Sa'adeh et al., they found that male sex and body mass index within normal limits, were significantly associated with higher practice scores.^[8]

To summarise, the majority of our patients scored 'low' on the knowledge scale but scored 'average' on attitude and practice scales. A significant correlation was found amongst knowledge and attitude scores, knowledge and practice scores and practice and attitude scores of our patients. Thus, a patient having more knowledge about CKD would have a better attitude towards it and further would have more favourable and healthier practices towards the prevention of CKD.

Strengths and limitations

To the best of our knowledge, there is no such published previous Indian study, probably making it the first of its kind in this country. Secondly, it has used a previously validated questionnaire-CKD Screening Index, making the results more reliable.^[9]

Limitations of the study include exclusion of both very sick patients (who were not in a position of understanding the questionnaire at a point in time) as well as of at-risk general population (as the study was hospital-based). Secondly, the assessment tool had used closed-ended questions, restricting the capacity to explicate the underlying reasons for certain consequences.

Conclusions and Recommendations

The knowledge on the risk of getting CKD was found to be poor amongst the at-risk population, which implies a need for improving public awareness in this field, by educating them. This should be done by their treating physicians and specialised nurses through proper and repeated counselling sessions, to make them understand the nature of this disease and make them more compliant with ongoing treatment and ensure their regular follow-up. Imparting public awareness is also important and can be done by specialists at various levels, with the support of government or non-government organisations. Improving knowledge would further improve attitudes and improving attitudes would further improve the practices of individuals at risk of developing CKD, thus helping them in inculcating positive attitudes and healthier practices in delaying the onset of CKD. Finally, larger-scale research is needed in this regard including multiple Indian centres, for its better understanding of our population.

Acknowledgement

To Mr. Abhishek, Research Associate and resident doctors from various departments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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