What are the barriers to self-care of CKD?

Lack of knowledge among patients, insufficient communication between doctors and patients, and lack of motivation are stumbling blocks to self-care of chronic kidney disease (CKD) in Singapore, while trust for doctors and family support can turn the tide around, a local study finds.

“Singapore is ranked first in the world for diabetes-induced ESKD* and has the fourth highest prevalence of ESKD in the world,” said the researchers led by Dr Tazeen Jafar from Duke-NUS Medical School, Singapore. “[However,] treatment adherence in CKD patients tends to be poor due to a lack of awareness of CKD and low overall health literacy.”

“[Hence,] understanding CKD management and its challenges from the patients’ perspective will be vital in developing patient-centred interventions which will improve patients’ behaviour with respect to treatment adherence, thereby leading to better patient outcomes,” they added.

For the qualitative study, 20 patients (mean age 67.8 years, 70 percent male) with CKD not requiring dialysis and who had diabetes in a public primary care clinic were interviewed one-to-one using a semi-structured question guide. [BMJ Open 2020; doi:10.1136/bmjopen-2020-041788]

Lack of knowledge and awareness of the disease on the patient’s part, coupled with a lack of communication between the doctors and patients, were impediments to empowering the patients for self-management.

In particular, there was a lack of explanation of CKD when patients received their diagnosis. This was further compounded by reluctance of patients to ask questions about their condition, despite their desire to know more.

Based on the interviews, patients expressed being overloaded with all kinds of information on CKD — leading to some of them feeling confused on what information to follow. Instead of generic advice, patients would prefer personalized information that is specific to them.

Specifically, clear recommendations on diet would equip patients to better self-management. “Clear dietary guidelines that cover the local food options should be provided by the polyclinics and communicated to patients with CKD,” suggested Jafar and co-authors.

Another barrier to CKD care was patient’s attitude towards self-management. From the interviews, the researchers found that many patients had a passive attitude and did not want to take responsibility/ownership of their condition.

Another factor leading to a lack of motivation was fatalistic thinking — leading to feeling of helplessness. Such patients did not believe in the benefits of self-management or face difficulty incorporating active management into their routine.

“Addressing these barriers could potentially decelerate the progression of CKD to ESKD among patients, reduce healthcare expenditure on renal replacement therapy and bolster the current standard of care by empowering patients’ self-management skills,” the researchers said.

On the other hand, family support was cited as a major facilitator of self-care.

In addition, patient’s trust for doctors also promote patients to actively take charge of their condition. The patients reported feeling more motivated to follow their doctors’ advice.

“A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD,” said Jafar and co-authors.

“Strategies should also focus on increasing patient engagement and optimizing family support by involving family members in patients’ care,” they added.

*ESKD: end-stage kidney disease