Development and Validation of a Cross-Cultural Knowledge, Attitudes, and Practices Survey Instrument for Chronic Kidney Disease in a Swahili-Speaking Population

<div><p>Introduction</p><p>Non-communicable diseases are a growing global burden, and structured surveys can identify critical gaps to address this epidemic. In sub-Saharan Africa, there are very few well-tested survey instruments measuring population attributes related to non-communicable diseases. To meet this need, we have developed and validated the first instrument evaluating knowledge, attitudes and practices pertaining to chronic kidney disease in a Swahili-speaking population.</p><p>Methods and Results</p><p>Between December 2013 and June 2014, we conducted a four-stage, mixed-methods study among adults from the general population of northern Tanzania. In stage 1, the survey instrument was constructed in English by a group of cross-cultural experts from multiple disciplines and through content analysis of focus group discussions to ensure local significance. Following translation, in stage 2, we piloted the survey through cognitive and structured interviews, and in stage 3, in order to obtain initial evidence of reliability and construct validity, we recruited and then administered the instrument to a random sample of 606 adults. In stage 4, we conducted analyses to establish test-retest reliability and known-groups validity which was informed by thematic analysis of the qualitative data in stages 1 and 2. The final version consisted of 25 items divided into three conceptual domains: knowledge, attitudes and practices. Each item demonstrated excellent test-retest reliability with established content and construct validity.</p><p>Conclusions</p><p>We have developed a reliable and valid cross-cultural survey instrument designed to measure knowledge, attitudes and practices of chronic kidney disease in a Swahili-speaking population of Northern Tanzania. This instrument may be valuable for addressing gaps in non-communicable diseases care by understanding preferences regarding healthcare, formulating educational initiatives, and directing development of chronic disease management programs that incorporate chronic kidney disease across sub-Saharan Africa.</p></div

The Epidemiology of Chronic Kidney Disease in Northern Tanzania: A Population-Based Survey

<div><p>Background</p><p>In sub-Saharan Africa, kidney failure has a high morbidity and mortality. Despite this, population-based estimates of prevalence, potential etiologies, and awareness are not available.</p><p>Methods</p><p>Between January and June 2014, we conducted a household survey of randomly-selected adults in Northern Tanzania. To estimate prevalence we screened for CKD, which was defined as an estimated glomerular filtration rate ≤ 60 ml/min/1.73m2 and/or persistent albuminuria. We also screened for human immunodeficiency virus (HIV), diabetes, hypertension, obesity, and lifestyle practices including alcohol, tobacco, and traditional medicine use. Awareness was defined as a self-reported disease history and subsequently testing positive. We used population-based age- and gender-weights in estimating prevalence, and we used generalized linear models to explore potential risk factors associated with CKD, including living in an urban environment.</p><p>Results</p><p>We enrolled 481 adults from 346 households with a median age of 45 years. The community-based prevalence of CKD was 7.0% (95% CI 3.8-12.3), and awareness was low at 10.5% (4.7-22.0). The urban prevalence of CKD was 15.2% (9.6-23.3) while the rural prevalence was 2.0% (0.5-6.9). Half of the cases of CKD (49.1%) were not associated with any of the measured risk factors of hypertension, diabetes, or HIV. Living in an urban environment had the strongest crude (5.40; 95% CI 2.05-14.2) and adjusted prevalence risk ratio (4.80; 1.70-13.6) for CKD, and the majority (79%) of this increased risk was not explained by demographics, traditional medicine use, socioeconomic status, or co-morbid non-communicable diseases (NCDs).</p><p>Conclusions</p><p>We observed a high burden of CKD in Northern Tanzania that was associated with low awareness. Although demographic, lifestyle practices including traditional medicine use, socioeconomic factors, and NCDs accounted for some of the excess CKD risk observed with urban residence, much of the increased urban prevalence remained unexplained and will further study as demographic shifts reshape sub-Saharan Africa.</p></div

Mean score for knowledge domain by known-groups.

<p>*Reference group for p-value</p><p>Mean score for knowledge domain by known-groups.</p

Inclusion criteria for survey items.

<p>Inclusion criteria for survey items.</p

Demographic and social characteristics of the survey respondents.

<p>*Other Tribal Ethnicities represented in our groups include Maasai, Luguru, Kilindi, Kurya, Mziguwa, Mnyisanzu, Rangi, Jita, Nyambo and Kaguru</p><p># Includes housewives and students</p><p>† Professional includes any salaried position (e.g. nurse, teacher, government employee, etc.) and retired persons</p><p>††For comparison of urban and rural</p><p>Demographic and social characteristics of the survey respondents.</p

Forest plot.

<p>The crude and fully-adjusted (model 4) prevalence risk ratios for CKD by each variable relative to the reference group for each variable.</p

Venn diagram.

<p>The proportion of CKD associated with HIV, hypertension, and diabetes.</p

Action Cycle Outlining the Iterative Process for Developing and Piloting the Cross-Cultural Survey Instrument.

<p>Action Cycle Outlining the Iterative Process for Developing and Piloting the Cross-Cultural Survey Instrument.</p

a-c, Polychoric correlation matrices for the three domains of knowledge, attitudes, and practices based on results of the 606 adults who completed the piloted survey instrument.

<p>*The response scale consisted of <i>Yes</i>, <i>No</i>, <i>Do not know</i> and <i>Unsure</i> with <i>Do not know</i> and <i>Unsure</i> coded as one response.</p><p>†The response scale consisted of <i>Yes</i> and <i>No</i></p><p>‡The response scale consisted of <i>Very Unlikely</i>, <i>Unlikely</i>, <i>Likely</i> and <i>Very Likely</i></p><p>††Item 26 was removed from the final version of the instrument</p><p>a-c, Polychoric correlation matrices for the three domains of knowledge, attitudes, and practices based on results of the 606 adults who completed the piloted survey instrument.</p

Characteristics of the Survey Sample.

<p>§ Other tribal ethnicities represented in our groups include Luguru, Kilindi, Kurya, Mziguwa, Mnyisanzu, Rangi, Jita, Nyambo, and Kaguru</p><p># Includes housewives and students</p><p>† Professional includes any salaried position (e.g. nurse, teacher, government employee, etc.) and retired persons</p><p>* Heart Disease includes coronary disease, heart failure, or structural diseases</p><p>Characteristics of the Survey Sample.</p