Awareness of Chronic Kidney Disease among Patients Attending Tertiary Care Hospital in Bangladesh

Background: Patients with chronic kidney disease (CKD) are at increased risk of morbidity & mortality. Educational interventions aimed at empower-ing patients are successful in chronic disease management including CKD. Objective: To explore the awareness regarding CKD among patients attending in a tertiary care hospital in Bangladesh. Methodology: This was a descriptive observational study, which includes 100 adult patients attending the department of Medicine in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from January 2013 to June 2013. Data were collected on a pre-tested questionnaire by face-to-face interview to investigate awareness toward: 1) basic knowledge of personal health; 2) perceptions of factors increasing the risk of CKD; 3) knowledge of therapies to slow CKD progression; 4) perceptions of CKD increasing the risk of other medical conditions and 5) Among the participants, 32.8% had knowledge of increasing risk factor of CKD, 30.8% had knowledge of the method of slow progression of CKD, 30.3% had knowledge of conditions for increase risk of CKD and 41.7% respondent had knowledge of treatment of CKD. Conclusion: Most of the study participants had inadequate knowledge of CKD. Lack of CKD screening and educational programs have contributed to the inadequate patient knowledge about the condition.


Introduction
Chronic kidney disease (CKD) is increasingly being recognized as a global public health problem. The declaration of World Kidney Day and its annual observance remained us that CKD is common and harmful for almost all cross section of people [1]. There is some convincing evidence that CKD is treatable [2]. Prevalence of CKD has reached epidemic proportions with a range of 10% -13% population of USA [3], Canada [4], Japan [5], China [6], Taiwan [7], Iran [8], and India [9]. In some countries of Europe, the prevalence of CKD is 8% -10% [10] [11]. Recent data on the prevalence of early stage of CKD in India showed that 15% apparently healthy-looking Indian Central government employees are suffering from kidney disease [9].
As CKD is a silent disease which is treated as one of the leading causes of death worldwide, many developed countries have studied CKD awareness and developed guidelines and educational programs accordingly. Education to improve knowledge on CKD has been documented to play an important role in reducing this particular problem regardless of whether it is primary, secondary or tertiary prevention [12]. Varied risk factors have been reported in the awareness study on chronic kidney disease in different countries.
Bangladesh being a densely populated developing country, its health care budget is only 1.4% of gross national product (GNP) with the priority areas as population control, provision of clean drinking water and eradication of communicable disease. The treatment of non-communicable disease like chronic kidney disease (CKD) has low priority in Bangladesh because of government health policy and high cost of treatment [13]. Development of awareness through screening and educational programs is still in the stage of infancy. The important causes of CKD leading to kidney failure in South Asian region are chronic glomerulonephritis, diabetes and hypertension [13]. In Bangladesh, leading causes of end-stage renal disease (ESRD) are chronic glomerulonephritis (40%), diabetes (34%) and hypertension (15%) [14]. Patients are not aware of the importance of good control of these risk factors. Survey in a few rural, urban, disadvantageous population suggested that 18  Bangladesh [14]. About 30,000 patients are reaching end-stage renal failure every year in this country they need either dialysis or transplantation of kidney [14]. Out of 18% kidney patient, 11% have milder to severe form of kidney failure [14]. Increased CKD awareness over time in different countries and a recent increase in nephrology referrals suggested that these efforts may have some positive impact [15] [16] [17].
It has been observed that physicians other than nephrologists are less likely to recognize CKD and sometimes differ in their clinical evaluation of CKD [18]. A significant number of CKD patients are referred to nephrologists much later than it would have been appropriate [19]. Late evaluation of CKD patients by nephrologists, especially those presenting in end-stage renal disease (ESRD), is associated with suboptimal pre-dialysis care and treatment which ultimately increase mortality [19] [20] [21] [22].
Cancer screening studies have shown that patients with more knowledge and awareness of their diseases are more likely to follow methods that slow progression of the disease [23]. Disease educated patients are more likely to follow proper treatment and cope more successfully with their diagnosis and participate in health care decisions that affect their health [24].
Study on awareness and education of CKD is scarce in Bangladesh. Thus the present study was conducted to explore the awareness regarding CKD among patients attending in a tertiary care hospital in Bangladesh. The study was focused on the relationship between the awareness of CKD with age, occupation and educational status. The information generated out of this study will be useful in implying awareness program for CKD patients. The developed awareness program of the present study is expected to reduce CKD through early adoption of treatment and thereby will contribute to a considerable extent to prevent it from progression towards ESRD. Each of the patient's correct answer was given a score of 1 and therefore the maximum total score was 11. Knowledge scouring was leveled as; no knowledge = 0 score, low knowledge = 1 -5, moderate knowledge = 6 -9 and high knowledge = 9 -11 score. Those who answered 5 or fewer questions correctly were considered to have low knowledge on chronic kidney disease while those who answered 6-8 questions correctly were considered to have moderate knowledge while those who answered 9 -11 questions correctly were considered to have high knowledge on CKD. After editing and coding, the coded data were directly entered into the computer by using SPSS software release for Windows, version 16.0 (SPSS, Inc. Chicago. III). Data cleaning validation and analysis were performed using the SPSS software. Categorical data were presented as frequency,

Methodology
percentage and continuous variable were expressed as mean ± SD (standard deviation

Results
A total of one hundred (100) participants were included in this study. Of them, forty (40) were male and sixty (60) were female, among females most of them were housewives and male to female ratio was 1:1.5. Almost one third (32.0%) respondents were in 3 rd decade. Majority (43.0%) patients came from lowermiddle-income family. In all age groups, the majority (60%) respondents had low knowledge of CKD.
About the association between knowledge score with different age group, it was observed that majority patients (60%) had low knowledge score which was 9.0% in ≤20 years age group, 21  High knowledge score was found 5 (12.5%) in male patients and 6 (10.0%) in female patients respectively. The mean knowledge score was found 6.5 ± 6.7 in male patients and 6.0 ± 5.9 in female patients. The mean score difference was not statistically significant (p > 0.05) between two groups ( Table 2).
This study reveals that 82.0% of the participants believe that renal transplantation is the treatment of choice in CKD, 22.0% knows about dialysis is a treatment option of CKD, and as 21.0% believe that CKD can be treated by drugs (Table 8). Table 9 shows that 32.8% respondents believe that there are some factors that increase the risk of CKD, 30.8% know the issues that slow down the progression of CKD, 30.3% are aware of the conditions for increase of CKD, and 41.7% have knowledge about treatment of CKD. Table 6. Participants believe that factor increases risk of CKD (n = 100).

Discussion
This descriptive observational study was carried out with an aim to determine About the association between knowledge score with different age group it was observed that majority of the study patients (60%) had low knowledge score which was 9.0% in ≤20 years age group, 21.0% in 21 -30 years age group, 16.0% in 31 -40 years age group, 10.0% in 41 -50 years age group and 4.0% in >50 years age group patients. The mean knowledge score differences were not statistically significant (p = 0.240) among knowledge scores with different age groups in this current study. Leng C.W., et al. [25] showed majority of the respondents answered 3 to 5 questions correctly giving a mean score of 3.44 ± 1.53 and a median score of 3; Eighty (5.6%) respondents had no knowledge of kidney disease; Of these 80 respondents, most of them were > 40 years old (72.1%). Tan A.U., et al. [26] reported that only younger age was independent predictors of overall knowledge score. The current study is consistent with these above studies.
In this present study, it was observed that majority (31.0%) respondents were passed primary education level followed by 29.0% passed college & University level, 23.0% passed high school and 16.0% respondents had no education level.
Tan A.U., et al. [26] reported that nearly all participants (96%) in their study had at least completed high school education. In another study, Leng C.W., et al. [25] observed that 40.7% and 37.6% had secondary level and above secondary level of education respectively. Erick W. [27] obtained that 70% of the participants had acquired formal education of less than high school level. This low level of education could account for the inadequate patient's knowledge. Studies documented that a high correlation between educational attainment and health outcomes, as educated patients are more likely to allow proper treatment and cope more successfully with their diagnosis and participate in health care decisions that affect their outcome.
In this present study, it was observed that 31.0% respondents mention that they believe diabetes increases the risk of CKD, 32.0% hypertension, 12.0% fam-  [28]. Most of the participants believed that a family history of chronic kidney disease increases the risk for CKD but a previous study in the United States by Tan A.U., et al. [26] showed that although most chronic kidney disease patients had a family history of chronic renal failure, they did not believe that it predisposed to chronic kidney disease. Tan A.U., et al. [26] 22.5% and 20.0% in male and female respectively and high knowledge score was found 5 (12.5%) in male patients and 6 (10.0%) in female patients. The mean knowledge score was found 6.5 ± 6.7 in male patients and 6.0 ± 5.9 in female patients. The mean score difference was almost similar between male and female participants. This result differs from the findings of Turner S. et al. [29], who had observed that younger and female participants had greater knowledge and awareness of CKD.
Regarding the associations between knowledge score and educational status, it was observed in this current study that low knowledge score was found in 10.0% respondents who had no institutional education, in 17.0% had primary educa- To summarize, the current study found that majority (60%) of the participant tion. This could be due to inadequate mass media involvement.

Conclusion
This study was undertaken to explore the awareness regarding CKD among the patients attending in a tertiary care hospital. Most of the respondents were in 3 rd decade and female predominant and they were mostly housewife. Majority of the study participants had inadequate knowledge of CKD. Lack of CKD screening and educational programs have contributed to the inadequate patient knowledge about the condition.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this paper.

Limitations of Study
It was a single centre study with relatively small sample size.