Mudasumbwa Gisele

ASSESSMENT OF KNOWLEDGE AND PREVENTION OF CHRONIC
KIDNEY DISEASE AMONG ADULT OUT PATIENTS IN RWANDA

MILITARY HOSPITAL
MUDASUMBWA Gisele
College of Medicine and Health Sciences
School of Nursing and Midwifery
MASTER’S IN NEPHROLOGY NURSING
JUNE 2017
1
ASSESSMENT OF KNOWLEDGE AND PREVENTION OF
CHRONIC KIDNEY DISEASE AMONG ADULT OUT PATIENTS
IN RWANDA MILITARY HOSPITAL
By: MUDASUMBWA Gisele

Student registration number 216341167
A dissertation submitted in fulfillment of the requirements for the degree of

masters in Nephrology Nursing In the College of Medicine and Health
Sciences
Supervisor Name: Dr Lakshmi RAJESWARAN
JUNE 2017
ii
DECLARATION
I, Gisele MUDASUMBWA, hereby declare that this research entitled‖ Assessment of

Knowledge and Prevention of Chronic Kidney Disease among Adult Outpatients in
Rwanda Military Hospital” submitted for partial fulfillment of the requirement for Master
of sciences Degree in NEPHROLOGY NURSING of University of Rwanda, college of
medicine and health sciences is my original work and has not been presented for a degree in
any other University or for any other award. I also declare that a complete list of references is
provided indicating all sources of information quoted or cited.
Signed by Gisele MUDASUMBWA June, 2017
iii
DEDICATION
I wish to dedicate this work to the Lord God almighty who blessed me with knowledge and
gave me ability to conduct this research. In addition, to my beloved husband Jacques T., my
daughter Iria Johannah, my mother, my Sisters and Brothers, my nieces and nephews for
their support and encouragement throughout my study.
iv
ACKNOWLEDGEMENT
First I would like to thank my supervisor Dr Lakshmi RAJESWARAN for her support,
advice and encouragement throughout this study. I am greatly appreciative to her untireless
guidance, dedication and patience that has enabled me to successfully complete this work.
I am greatly indebted to the ministry of health, management of RMH, Intensive care unit
staff for their support and patience during this course and staff of outpatient department for
the support during data collection, and to all out-patients who accepted to participate in this
study. I am also grateful to Mr. Alex T. and Mr. Aimable for their great in-put in content
organization and data analysis respectively.
I am very thankful to my husband Jacques TWAGIRAYEZU, for the support, patience,

tolerance and understanding that have not only enabled me to complete this project, but has
helped me to succeed on all aspects of course. To my daughter Iria, I owe you a lot for your
continuous patience and love despite of my limited time with you.
To my mother Jeanne d‘Arc, my brother Ruphin MUHAYA and beloved sister Cecile, your
prayers encouragement and support has been a great foundation for my achievements. I owe
you so much. Many thanks to my classmates for your time support shared challenges and fun
that kept me going to the end of the course.
Special thanks to Ms Nadege U. and Mrs. Nkurunziza J. I am indebted to the many others not
mentioned who made this study possible.
May God bless you all.
v
ABSTRACT
Background: Chronic Kidney Disease (CKD) has become a major global public health
concern with a large burden for the health care systems and huge costs of treatment,
particularly in the low income countries. The rapid increase of the main risk factors of CKD
such as hypertension (HTN) and diabetes mellitus (DM), together with their associated
lifestyle risk behaviors among the poor populations are expected to result into more critical
health care challenges that developing countries are unable to manage if appropriate
interventions are not put in place. Although clinical approaches are critical for the early
recognition of CKD, increase in patients‘awareness among at risk patients is equally
important for optimal d i s e a s e prevention. However, there is limited information about the
extent to which at risk patients are aware of their vulnerability to CKD in Rwanda.
Objectives: The main objective of the study was to establish the level of knowledge about
CKD and the methods towards its prevention among patients with DM and HTN at Rwanda
Military Hospital Out-patient department.
Methods: Data was obtained from a purposive sample of 120 participants using semi-
structured questionnaire.
Data analysis: Data were obtained and numerically coded, entered and computed in Excel,
using an SPSS Software Version number 20 program. Descriptive analysis was done and data
presented using frequency tables, graphs and diagrams
Results: The results indicated a high awareness among participants about CKD at 91.67%.
However only 42 % were able to associate their condition with vulnerability to CKD. The
results further indicated CKD prevention gaps with majority not following any professional
guidelines in choice of diet and lifestyle modifications not focused on complication
prevention.
Conclusion: The study demonstrates gaps in patient‘s perceived vulnerability and inadequate
competencies for self care and CKD prevention. The findings are critical for improved health
education and promotion for at risk populations.
Key words: Knowledge, Chronic Kidney Disease, Hypertension, Diabetes Mellitus.
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Table of Contents
DECLARATION ........................................................................................................................... iii
DEDICATION ............................................................................................................................... iv
ACKNOWLEDGEMENT .............................................................................................................. v
ABSTRACT ................................................................................................................................... vi
SYMBOLS, AND ABBREVIATIONS/ACRONYMS ................................................................. ix
LIST OF TABLES .......................................................................................................................... x
LIST OF FIGURES ...................................................................................................................... xii
CHAPTER 1 ................................................................................................................................... 1
1.0 Introduction ........................................................................................................................... 1
1.1 Background to the study ........................................................................................................ 1
1.2. Problem Statement ................................................................................................................ 3
1.3 Objectives of the study .......................................................................................................... 4
1.4 Research Questions................................................................................................................ 4
1.5 Significance of the Study....................................................................................................... 4
1.6 Definitions of Key Terms ...................................................................................................... 5
1.7 Sub division of The Project ................................................................................................... 5
1.8 Conceptual Framework.......................................................................................................... 5
1.9 Application of Health Belief Model. ..................................................................................... 8
CHAPTER 2: LITERATURE REVIEW ........................................................................................ 9
2.0 Introduction ........................................................................................................................... 9
2.1 Theoretical literature: ............................................................................................................ 9
2.2 Empirical Literature ............................................................................................................. 10
CHAPTER 3: METHODOLOGY ................................................................................................ 14
3.0 Introduction: ........................................................................................................................ 14
3.1 Research settings ................................................................................................................. 14
3.2 Study design ........................................................................................................................ 15
3.3 Study population and sampling ........................................................................................... 15
3.4 Inclusion criteria .................................................................................................................. 16
3.5 Exclusion criteria ................................................................................................................. 16
3.6 Sample size .......................................................................................................................... 16
3.7 Sampling technique ............................................................................................................. 16
3.8 Instruments .......................................................................................................................... 17
3.9 Data collection procedure .................................................................................................... 17
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3.10 Reliability and validity of the instruments ........................................................................ 18
3.11 Pilot Study ......................................................................................................................... 18
3.12 Data Analysis ..................................................................................................................... 18
3.13 Ethical Consideration ........................................................................................................ 19
3.14 Confidentiality ................................................................................................................... 19
3.15 Anonymity ......................................................................................................................... 19
3.16 Respect for human values. ................................................................................................. 19
3.17 Data dissemination ............................................................................................................ 19
3.18 CONCLUSION ................................................................................................................. 19
CHAPTER 4: DATA ANALYSIS AND INTEPRETATION OF THE RESULTS .................... 20
4.0 Introduction ......................................................................................................................... 20
SECTION II: Knowledge about Chronic Kidney Disease (Perceived susceptibility) .............. 21
CHAPTER 5: DISCUSSIONS ..................................................................................................... 43
5.1. Introduction ........................................................................................................................ 43
5.2. Knowledge of respondents on chronic kidney disease ....................................................... 43
5.3. Respondents Sources of Information and perceived conditions that may lead to
development of chronic kidney disease ..................................................................................... 43
5.4 Respondents perceived factors that can lead to stress ......................................................... 44
5.5. Perception and Reasons why patients consider themselves being at risk of developing
chronic kidney disease ............................................................................................................... 44
5.6. Respondents’ reported Preventive actions and initiatives to remain healthy to reduce
chance of developing CKD........................................................................................................ 45
5.7. Respondents lifestyle adaptations to meet current conditions’ management requirements
and demands .............................................................................................................................. 45
CHAPTER 6: CONCLUSION AND RECOMMANDATIONS .................................................. 48
6.1. Introduction ........................................................................................................................ 48
6.2 Limitations of the study ....................................................................................................... 48
6.3. Recommendations .............................................................................................................. 48
6.4. Conclusion .......................................................................................................................... 49
REFERENCES ............................................................................................................................. 50
APPENDICES .............................................................................................................................. 57
viii
SYMBOLS, AND ABBREVIATIONS/ACRONYMS
CKD: Chronic Kidney Disease
DM: Diabetes Mellitus
GFR: Glomerular Filtration Rate
ML/min: milliliters per minute
RMH: Rwanda Military Hospital
HTN: Hypertension
KDOQI: Kidney Outcomes Quality Initiative
ESRD: End stage renal disease
MSN: Master’s of Science in Nursing
ix
LIST OF TABLES
Table 1: Description of social demographic characteristics of respondents ................................. 20
Table 2: Cross tabulation of Respondent current disease with respect to Age category .............. 22
Table 3: Cross tabulation of Respondent current disease with respect to gender ......................... 23
Table 4: Cross Tabulation of Respondents current disease with respect to Occupation .............. 23
Table 5: Cross Tabulation of Respondents current disease with respect to Education level ........ 24
Table 6: Pearson Chi-Square tests ................................................................................................ 25
Table 7: Knowledge about Chronic kidney disease ...................................................................... 25
Table 8: Cross tabulation of health status and knowledge about chronic disease
causes/Conditions that may leads to develop such disease ........................................................... 26
Table 9: the Causes that may lead a person to developing a chronic kidney disease ................... 27
Table 10: Perception of respondents on risk of developing chronic kidney disease .................... 28
Table 11: Reasons why a patient consider himself at risk of developing chronic kidney disease 29
Table 12: Action that can make you less likely to developing CKD ............................................ 31
Table 13: The Preventive action to reduce chance of developing CKD ....................................... 31
Table 14: Have you ever seen a dietician before? ........................................................................ 34
Table 15: Current diet preferred among diabetic and hypertension outpatients ........................... 35
Table 16: Cross tabulation of current disease and Meals taken .................................................... 35
Table 17: Cross tabulation of Current disease and Use/Eat snack in between meals ................... 36
Table 18: Do you select food? ...................................................................................................... 37
Table 19: Cross tabulation of current disease and frequency of exercise ..................................... 37
Table 20: Cross Tabulation of current disease and Motivation frequency to do exercise/sports . 37
Table 21: Cross Tabulation of current disease and frequency of following exercise program as
per advice from health care professional ...................................................................................... 38
Table 22: Cross tabulation of current disease and habit to forget take drugs (I forget to take my
drugs) ............................................................................................................................................ 38
Table 23: Cross tabulation of current disease and perception on side effect drugs (The drugs I
take must be causing some side effects) ....................................................................................... 39
Table 24: Cross tabulation of current disease and perception on drug consumption (I think I am
taking too many drugs) ................................................................................................................. 39
Table 25: Percentages of respondents with different initiative to maintain good health status and
reduce chance of developing chronic kidney disease. .................................................................. 40
Table 26: Cross tabulation of current disease and smoking experience among ........................... 40
x
Table 27: Cross tabulation of Current disease and alcohol consumption experience among
respondents ................................................................................................................................... 41
xi
LIST OF FIGURES
Figure 1: Distribution of respondents by Health status ................................................................ 21
Figure 2: Distribution of respondent by occupation ..................................................................... 22
Figure 3: Sources of Information on Chronic kidney disease....................................................... 26
Figure 4: Reasons why a patient consider himself at risk of developing chronic kidney disease 30
Figure 5: The Preventive action that you can take to reduce chance of developing CKD ........... 33
Figure 6: Frequency of checking the weight respect to the respondent current disease ............... 34
Figure 7: Cross tabulation of current disease and Meals taken .................................................... 36
Figure 8: Consequences of uncontrolled current disease .............................................................. 41
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xiii
CHAPTER 1:
1.0 Introduction
This chapter discussed the background, problem statement, objectives and significance of the
study, as well as providing the scope of the study.
1.1 Background to the study

Chronic kidney disease (CKD) is a fundamental public health concern since these patients
are at an increased risk of end-stage renal disease (ESRD). It is a major global health
challenge with a big burden on health care systems, causing both physical and psychological
misery, is closely linked to several cardiovascular diseases, with a considerable morbidity
and mortality outcomes (Khalil, Frazier, Lennie, & Sawaya, 2011; National Kidney
Foundation 2011).
Diabetes mellitus (DM) and hypertension (HTN) are the main risk factors for CKD both in
the developed and developing world. Available studies have established this relationship
based on the risk factors that are shared by two diseases (DM and HTN) like obesity, tobacco
and alcohol use, and h o w t h e y promote vascular changes that r e s u l t i n t o increased
risk for kidney damage (Alramly, Darawad, & Khalil, 2013).
The global increase of patients presenting with CKD and resultant end-stage renal failure
requiring complex renal replacement interventions are likely to reach epidemic proportions
by end of the next decade. For example, CKD, which virtually doubled as a global cause of
death between 1990 and 2010, positioned itself as the 18th top-most universal cause of death
in 2010 ( Lozano, et al;2013), amid increasing treatment costs (McCullough et al. 2010)
It is estimated that by 2030, over 70% of patients with complicated renal disease will be
residents of developing countries (Naicker, 2009; Idem, 2005). This ballpark figure is
frightening due to the fact that the universal cost for dialysis maintenance twice as much
since 1990, while access to renal replacement treatment has remained limited. For example in
2004, only 1·8 million people worldwide were able to access renal replacement therapy, with
less than 5% of that population originating from sub-Saharan Africa (Thomas, et al; 2013;
Grassman, et al; 2005).
1
CKD is a complex disease that has multifaceted etiologies. Changes in population lifestyle
and aging, together with fast urbanization processes, has increasingly led to the recognition
of non-communicable diseases in low and middle income countries as a potential global
disease burden. (United Nations General Assembly, 2011). When lack of exercise, smoking,
poor diet, obesity, alcohol intake work in tandem, can augment a one's risk for kidney disease
by more than 300%, independent of race, sex, and age (National Kidney Foundation 2011).
Available information from surveys carried out in Rwanda continues to indicate a high
prevalence of CKD related main risk factors. For example, results from a recent study
conducted in Rwanda on non-communicable risk factors shows the rate of tobacco use rated
12.9%, a daily consumption of fruit and vegetables at 0.3% and 0.9% respectively, physical
inactivity at 21.4%, harmful alcohol consumption behavior of 23.5% and 41.3% of episodic
and current drinking correspondingly, and a mean body mass index of 22.3%, overweight
a
16.1%, and 2.7% obese (Ministry of Health of Rwanda, 2015) .
Many CKD cases are more likely to be clinically misdiagnosed due to patients‘ lack of
awareness about risk factors for CKD. For example, a study that examined the degree of
CKD diagnosis among 9772 admitted adult patients revealed a 40–70% risk for developing
CKD (Ferris.M, et al;, 2009). As a result, an international need to investigate community
based kidney disease screening and awareness programmes for people at increased risk for
CKD emerged (McCullough et al. 2010).
The benefits of screening at-risk populations for CKD are well documented and available
evidence has shown that screening people especially those with chronic medical conditions
like diabetes mellitus (DM), hypertension (HTN), or those aged 55 years and above offers the
best window of opportunity to detect patients with CKD (Hallan et al; 2006).
The global increase in the prevalence of CKD demands for new global approaches
to CKD from treatment of complicated renal diseases to a much more belligerent
primary and secondary prevention (Nahas et al;2005).
2
1.2. Problem Statement
Chronic Kidney Disease (CKD) has become a major global public health concern with a
large burden for the health care systems and huge costs of treatment, particularly in the low
income countries (Lozano, et al; 2013; McCullough et al. 2010). Current estimates predict
that by 2030, over 70% of patients with complicated renal disease will be residents of
developing countries (Naicker, 2009; Idem, 2005). The rapid increase of the chief risk factors
such as hypertension and diabetes, together with their associated lifestyle risk behaviors
among the poor populations will result into more critical health care challenges that
developing countries are unable to manage (Thomas, et al. 2013). There have been limited
attentions to chronic diseases and CKD in particular largely because of the global health
emphasis on infectious diseases and community‘s lack of awareness (Nugent, Fathima, Feigl
& Chyung, 2011). For example, recent studies have shown that majority of patient at risk of
CKD have inadequate or no knowledge about the disease and or being at risk (Janmohamed
et al. 2013; Van Blijderveen et al. 2013; Vassalotti et al. 2008).
Chronic Kidney Disease (CKD) has become a major global public health concern with a
large burden for the health care systems and huge costs of treatment, particularly in the low
income countries (Lozano, et al; 2013; McCullough et al. 2010). Current estimates predict
that by 2030, over 70% of patients with complicated renal disease will be residents of
developing countries (Naicker, 2009; Idem, 2005). The rapid increase of the chief risk factors
such as hypertension and diabetes, together with their associated lifestyle risk behaviors
among the poor populations will result into more critical health care challenges that
developing countries are unable to manage (Thomas, et al. 2013). There have been limited
attentions to chronic diseases and CKD in particular largely because of the global health
emphasis on infectious diseases and community‘s lack of awareness (Nugent, Fathima, Feigl
& Chyung, 2011). For example, recent studies have shown that majority of patient at risk of
CKD have inadequate or no knowledge about the disease and or being at risk (Janmohamed
et al. 2013; Van Blijderveen et al. 2013; Vassalotti et al. 2008).
While Rwanda has registered considerable improvements in its health status indicators over
the last decade, with great success in the fight against communicable diseases the need to
address the challenges of non-communicable diseases (NCD) remains a high priority on
.
national health agenda (MOH, 2015) The country is still experiences a high prevalence of
NCD risk factors that are closely associated with CKD development. (MOH, 2015).
3
Although clinical approaches are critical for the early recognition of CKD at risk patients like
those suffering from diabetes and hypertension, increase in patients ‘awareness is equally
important if they are to modify their lifestyles towards d i s e a s e prevention. However,
there is limited information about the extent to which at risk patients are aware of their
vulnerability to CKD in Rwanda. This study, therefore, hopes to provide an understanding on
the level of awareness of Rwandan patients with chronic illnesses about chronic kidney
disease and the strategies used to prevent its occurrence.
1.3 Objectives of the study

Main objective
The main objective of the study was to assess the level of knowledge about CKD and the
methods towards prevention among the outpatients at Rwanda Military Hospital.
Specific Objectives
 
 To explore knowledge of outpatients attending Rwandan Military Hospitals about
 CKD

To Asses the understanding regarding prevention of CKD among the outpatients
attending Rwandan Military Hospitals regarding the prevention
1.4 Research Questions


What is the existing level of
knowledge about CKD among outpatients attending
Rwanda Military Hospital?


 attending Rwanda Military Hospital understanding
To what extent do outpatient
the prevention of CKD?
1.5 Significance of the Study
Available research continues to indicate a growing population of patients with CKD in

developing and developed countries. These patients also tend to present late for treatment, a
fact that limits chances to early treatment. In addition CKD is a common disease of among
patients with other chronic ailments like diabetes and hypertension. Results of this study,
carries potential benefits for those involved in the care of patients at risk for CKD, as well as
those responsible for policy formulation and healthcare programming. In this respect,
establishing gaps in people‘s knowledge, about risk factors associated with CKD will help in
designing programmes relevant to population needs.
4
This study possesses a step forward opportunity to assess the degree to which current
practices addresses needs of those at risk for CKD. This can take up healthy behaviors and
modify their lifestyle towards preventing CKD development.
In addition, population data on knowledge on CKD have been noted to be essential to the
understanding of knowledge gaps as well as a basis to formulate community based education
and health promotion programmes.
1.6 Definitions of Key Terms

For the purpose of this study, the following terms have been used and applied as follows.
Knowledge: The information, understanding and skills that one gains through education or
experience (Oxford Advanced Learners Dictionary, 2015).
Knowledge: In this study knowledge is conceptualized as awareness or understanding and

ability to provide an explanation about Chronic Kidney Disease.
Prevention: Action so as to avoid, forestall, or circumvent a happening, conclusion, or

phenomenon, for example disease prevention
(Medicaldictionary.thefreedictionary.com/prevention 2016)
Prevention: In this research prevention is range of health promotion actions that are geared
towards limiting the development of Chronic Kidney Disease.
1.7 Sub division of The Project
This research project was divided in six chapters. Chapter one introduction which containing
the definition of key terms, background, problem statement, objectives (main and specific
objectives), research questions or hypothesis, significance of the study and subdivision of the
project. Chapter two is literature review, Chapter three is the methodology, Chapter four is
the presentation of the results, Chapter five is discussion and Chapter six is the conclusion
and recommendations.
1.8 Conceptual Framework
This study used the health belief model to explain the interrelationship between variables
under study. The Health Belief Model focuses on one‘s perceptions of health problem
threats and associated recommended behavior necessary to prevent or manage the problem
5
at hand. The model emphasize that for a person to adopt recommended behaviors, their
perceived threat of disease should outweigh their perceived barriers to take action
(Raingruber, 2013).
In this conceptual framework the interplay between different variables has been depicted.
This model has been chosen because of its organized method of explaining a range of factors
that shape peoples understanding and ability to cope with heath challenges.
These can be both external and internal influences that occur within and around the patient.
Some are individual while others are from systems around the patient.
One aspect of the conceptual framework explains a system of knowledge, ideas, beliefs,
values and norms and how they influence individuals to deal with their life challenges.
The role of cultural meaning system which comprises of shared cultural schemas that inform
peoples‘ perceptions, beliefs, opinions and views about their world and shape their response
actions as they face both familiar and new challenges. This means that the way the
community understands and acts on a particular problem influences how individuals perceive
themselves susceptible, shapes their perceived severity, perceived threats, perceived barriers,
perceived benefits, and self-efficacy, and thereby motivating their health seeking behavior as
well as ability to continue with care.
The relevance of these cultural schemas with the current study is the provision of
understanding of what informs and motivate patients for example with hypertension and
diabetes about CKD and its prevention. They also help to understand the factors behind the
way people react in case of a health problem or in existence of health risks. For example, a
patient with hypertension stands the risk of developing CKD. However, his reaction is
dependent on how he understands his susceptibility and or how he is aware of the
relationship between hypertension and CKD and the severity of the outcome from this
relationship.
According to Lee (2012) in an event that a patient knowledgeable about a health condition,
for example hypertension, or develops a higher perceived severity of the disease condition,
the intention to have treatment will be more favorable and significant.
The modifying factors depicted in the model are responsible for shaping the way people view
health and its determinants, how they are able to conceptualize information and other factors
to be able to take action at an appropriate time. For example, age of a person may determine
6
the understanding level, while ones level of education can influence how the person analyses
and utilizes the information at hand. On the other hand, a patient‘s age and level of
education, for example can be a barrier to take action. This is especially so when the patient‘s
age or education does not contribute to the generation of correct behavior to take action.
Regarding barriers to taking action on a particular health condition, Walsh (2008) asserted
that barriers to effective treatment can be a result of the individual patient characteristics,
health providers, cues to taking action and the entire health system.
The other aspect of the framework (Cues to action) explains factors that prompt the patient‘s
perceived threat and triggers the decision making processes and a health behavior to continue
with care. These include factors like pain or symptoms and information from relatives/family
members, friends and health care workers or media campaigns.
On the other hand, cues to action directly prompt individuals‘ self efficacy and shape their
decisions involving health behavior and continuity of care (Chou, 2010). Similarly, these
individuals, in turn, update the cultural meaning system through their lived experiences that
accumulate over time.
7
1.9 Application of Health Belief Model.
Individual Modifying factors Likelihood of taking action
Age, sex, ethnicity, Perceived benefit

personality, socioeconomic of improve the
factors and Knowledge quality of life,
about CKD. reduced morbidity
and mortality.
Perceived Perceived threat of CKD

susceptibility and
Perceived barrier
severity- Diabetes
- Knowledge,
mellitus, Hypertension, attitude, perception
CKD, Obesity, Alcohol Cues to action - Different sources and lack of
and Smoking. of information about CKD and its information and
prevention (Radio and TV family support.
programs, health education and
promotion from health
professionals).
Exercise, diet, medications, regular

screening and Family support.
Adopted from Chou, 2010
8
CHAPTER 2: LITERATURE REVIEW
2.0 Introduction
This chapter focuses on the literature that underpins the significance of the current study. It
has been examined both the theoretical and empirical evidence relevant to the current
proposed study.
2.1 Theoretical literature:
The search engines such as Hinary, Google chrome; Pubmed has been accessed to find out
the relevant information on CKD. In this literature review various studies have been used
from 1990s up to date. The studies conducted from 2000 up to date were included under
literature review
Chronic kidney disease (CKD) is a term that describes all kinds of renal dysfunction, from
damaged and at risk through the severely chronic kidney failure. Chronic kidney disease
(CKD) is an age-related renal dysfunction that quite often is accelerated in patients with
diabetes, hypertension, primary renal disorders, and obesity (Gansevoort et al., 2013).
Decreased renal function is a predictor of hospitalization (Gansevoort et al., 2013; Go AS, et
al., 2004), cognitive dysfunction (Etgen, 2012) and poor quality of life (Perlman, et al,. 2005;
Chin, et al., 2008) The healthcare burden is highest in early stages due to increased
prevalence, affecting around 35% of those over 70 years (O'Callaghan, Shine, & Lasserson,
2011).
CKD is defined based on a range of kidney damage indicators from imaging or proteinuria
and decreased renal function (KDOQI, 2002; NICE, 2008). Kidney Outcomes Quality
Initiative (KDOQI) and National Institute for Health Excellence (KDOQI, 2002; NICE,
2008) recommends use of serum creatinine concentration to estimate GFR (eGFR) and
transforming it using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)
equation (Levey AS, et al., 2009). CKD-EPI has been used as a more accurate predictor of
clinical risk (Matsushita K, et al., 2012 CKD placed under five stages according to Kidney
Outcomes Quality Initiative (KDOQI) (KDOQI, 2002) protocols.
9
The largest stage of CKD, with over 90% of cases, has been estimated from a UK
retrospective lab audit study to be CKD stage 3 with 84% stage 3a (GFR of 45 to 59
2 2
ml/min/173m ) and 16% stage 3b GFR of 30 to 44 ml/min/173m (Lusignan, et al., 2012).
Whatever the underlying etiology, once the loss of nephrons and reduction of functional renal
mass reaches a certain point; the remaining nephrons begin a process of irreversible sclerosis
that leads to a progressive decline in the GFR.
The different stages of CKD form a continuum. The following stages of CKD have been ( De
Lusignan S, et al., 2012).
2
 1: Kidney injury with normal or increased GFR (>90 mL/min/1.73 m )

2
 2: Mild reduction in GFR (60-89 mL/min/1.73 m )

2
 3a: Moderate reduction in GFR (45-59 mL/min/1.73 m )

2
 3b: Moderate reduction in GFR (30-44 mL/min/1.73 m )

2
 4: Severe reduction in GFR (15-29 mL/min/1.73 m )

2
 5: Kidney failure (GFR <15 mL/min/1.73 m or dialysis)
2.2 Empirical Literature

Chronic kidney disease (CKD) is a major global health challenge with a big burden on health
care systems, causing both physical and psychological misery, is closely linked to several
cardiovascular diseases, with a considerable morbidity and mortality outcomes (Khalil,
Frazier, Lennie, & Sawaya, 2011; National Kidney Foundation 2011).
Quite often, CKD has been noted as a silent disease. In many patients with CKD the rate of
morbidity and mortality has been high (Levey, et al, 2007; Tonelli.et al, 2006). In 2010, CKD
emerged the 18th among global causes of deaths (Lozano et al. 2013). Hypertension and
Diabetes are the two main risk factors (Levey & Coresh, 2012) that are associated with the
development of CKD. This is because the two diseases share risk factors like obesity,
tobacco and alcohol use, and h o w t h e y promote vascular changes that r e s u l t i n t o
increased risk for kidney damage (Alramly et al. 2013). The prevalence of adult hypertension
has been globally estimated at 26%, with majority 66% of the cases residing in the
developing world (Ibrahim & Damasceno 2012). Correspondingly, the global estimated
prevalence of diabetes has been noted at 6.4% with a prediction that by 2030 this figure will
have reached 7.7% (Shaw et al. 2010).
10
CKD is a complex disease that has multifaceted etiologies. Changes in population lifestyle
and aging, together with fast urbanization processes, has increasingly led to the recognition
of non-communicable diseases in low and middle income countries as a potential global
disease burden. (United Nations General Assembly, 2011).
In a study to estimate the prevalence of CKD among diabetic patients in Tanzania showed
that 83.7% of the participants had CKD, and none knew they had the disease (Janmohamed
et al. 2013). Similar findings were found in a Netherlands based study where the highest
incidence of CKD of 25 000 per 100 000 person was noted among participants with diabetes
(Van Blijderveen et al. 2013). Low level of awareness was too indicated in this study.
Additionally, many other studies have shown that knowledge of CKD is reasonably low in all
populations. For example, in one American study less than 3% of the participants gave
kidney disease as a critical health problem, as opposed to 55 and 61 percent naming diabetes
and hypertension respectively (Waterman, et al., 2008). As well, less than half of the
participants in this study could explain what kidney disease mean, while a limited number
could relate diabetes and hypertension with CKD development, or perceived them as being at
risk. In a similar study among Australian diabetic patients, revealed a much more limited
knowledge level of CKD risk factors with barely 3% and 9% naming hypertension and,
diabetes as risk factors for CKD respectively (White SL, et al 2008.). Nevertheless,
population data on knowledge on CKD have been noted to be essential to the understanding
of knowledge gaps as well as a basis to formulate community based education and health
promotion programmes (Chow et al., 2014).
Because of CKD initial asymptomatic presentation, early disease detection is difficult. In

patients where CKD has remained undiagnosed or treated, it may progressively result into to
End Stage Renal Disease (ESRD)( Plantinga, Tuot, Powe, 2010). There have been increasing
cost burden associated with management of CKD over the past decade (Mahdavi-Mazdeh.,
2010), with exceedingly high impact on developing countries where resources are limited.
This is why prevention of CKD has been recommended as the most effective health policy
for cost reduction in these countries (Barsoum, 2006; Mahdavi-Mazdeh, 2010).
Several studies have demonstrated the relationship between patient‘s awareness about CKD
and its associated risk factors and their potential readiness to engage in life style
modifications and other health-promotion behaviors (Chow, et al, 2012; Wright-Nunes, et al.
2012). Therefore, improved population knowledge about CKD and its risk factors remains a
11
critical prevention approach especially among vulnerable populations. Available evidence
continues to indicate that when patients with CKD presents late for treatment, the clinical
outcomes tend to be poor (Chan, et al. 2007).
Late presentation, on the other hand could be associated with limited understanding of the
factors responsible for the development of CKD as well consequences of late presentation.
This similar reason could account for the observed late referral trends among patients who
start dialysis where approximately 15–80% of patients report late for treatment (Schwenger,
et al, 2003; Kessler, et al, 2003). This is despite of the availability of guidelines for effective
management and referral of patients with CKD, or those that are potentially on risk (Nephrol.
Dial. Transplant, 2002).
The ability to follow self-care recommendations is an essential element of the CKD

prevention plan. This approach highlights patients‘ role in developing care plans and self-
monitor their health issues (Huisman et al.2009).
Studies have established this relationship between diabetes mellitus and
h ypertension as main global risk factors for CKD based on the two diseases shared risk
factors like obesity, tobacco and alcohol use, and h o w t h e y promote vascular changes that
r e s u l t i n t o increased risk for kidney damage (Alramly, Darawad, & Khalil, 2013). The
global increase of patients presenting with CKD and end-stage renal failure requiring
complex renal replacement interventions. For example, CKD, which virtually doubled as a
global cause of death between 1990 and 2010, positioned itself as the 18th top-most universal
cause of death in 2010 ( Lozano, et al;2013), and increasing treatment costs (McCullough et
al. 2010).
Current estimates predict that by 2030, over 70% of patients with complicated renal disease
will be residents of developing countries (Naicker, 2009; Idem, 2005). This ballpark figure is
frightening due to the fact that the universal cost for dialysis maintenance twice as much
since 1990, while access to renal replacement treatment has remained limited. For example in
2004, only 1·8 million people worldwide were able to access renal replacement therapy, with
less than 5% of that population originating from sub-Saharan Africa (Thomas, et al; 2013;
Grassman, et al; 2005).
Lack of awareness about risk factors for CKD among patients has been implicated to underlie
misdiagnosis in several settings. For example, in a study that examined the degree of CKD
12
diagnosis among 9772 admitted adult patients revealed a 40–70% risk for developing CKD
(Ferris.M, et al;, 2009).
Available evidence has continued to show that screening people especially those with chronic
medical conditions like diabetes mellitus (DM), hypertension (HTN), or those aged 55 years
and above offers the best window of opportunity to detect patients with CKD (Hallan et al;
2006).
There is a global increase in the prevalence of CKD w h i c h demands for new global
approaches to CKD from treatment of complicated renal diseases to a much more belligerent
primary and secondary prevention (Nahas et al;2005).In a conclusion, the chapter two
combined different theoretical review (assessment of knowledge about CKD among
outpatients and prevention of CKD). In addition to that many authors have shown that there
is a relationship between patient‘s awareness about CKD and its risk factors. Regarding to
the empirical literature, many studies conducted in both developed and developing countries
have revealed that knowledge of CKD is reasonably low in all populations. While findings of
these studies are supportive and relevant to the objectives and scope of the current study, they
were carried out on specific populations, a fact that can limit generalizabity of the results.
13
CHAPTER 3: METHODOLOGY
3.0 Introduction:
The methods used in carrying out this proposed study have been described here. The research
setting, study design, sampling methods, data collection, management and analysis had been
explained. As well, detailed ethical considerations for this study were offered.
3.1 Research settings

Rwanda is sovereign state in central and east Africa and one of the smallest countries on the
African mainland. Located a few degrees south of the Equator, Rwanda is bordered by
Uganda in the north, Tanzania in the east, Burundi in the south and the Democratic Republic
of Congo in the west.
The country has a health care system that is decentralized on multi-tiered system. It is
composed of the following tiers and associated packages of health services: 18 dispensaries
(primary health care, outpatient, referral), 16 prison dispensaries, 34 health posts (outreach
activities – immunizations, antenatal care, family planning), 430+ health centers (prevention,
primary health care, inpatient, maternity), 39 district hospitals (inpatient and outpatient) and
4 national referral hospitals (specialized inpatient and outpatient).
The 4 referral hospitals are: Centre Hospitalier Universitaire de Kigali (CHUK), Centre
Hospitalier Universitaire de Butare (CHUB), King Faisal Hospital (KFH) and Rwanda
Military Hospital. The quality of healthcare in Rwanda has historically been very low, both
[
before and immediately after the 1994 genocide. In 1998, more than one in five children died
before their fifth birthday. President Kagame has made healthcare one of the priorities for the
.
Vision 2020 development programme Boosting spending on health care to 6.5% of the
.
country's gross domestic product in 2013 compared with 1.9% in 1996.In recent years
Rwanda has seen improvement on a number of key health indicators (MOH, 2016):
 Between 2005 and 2013, life expectancy increased from 55.2 to 64.0

.
 Under 5 mortality decreased from 106.4 to 52.0 per 1,000 live births 

 Incidence of tuberculosis has dropped from 101 to 69 per 100,000 people.
This current study has been conducted in Rwanda Military Hospital in the out-patient
department. The hospital is located in Kicukiro district about 1km from Rwanda international
14
Airport, and 15km from Kigali city center. It is one of the 5 national referral hospitals. It was
built in 1968; the hospital was mainly to cater for military personnel. Although the hospital
currently serves a large number of non-military populations. The setting has been selected
because of high patient population from and beyond its catchment area.
3.2 Study design
The study design was expected to outline the critical approaches to be used answering the
research questions at hand (Polit & Beck 2010). It is imperative that the most suitable design
be chosen to achieve aims of the study (Parahoo 2006).
The proponents of quantitative methods research argues that variables in human phenomena
can only be studied objectively (Parahoo 2006). It is to this effect that quantitative approach
has been selected as the most apposite research method for this particular study. Quantitative
research approaches use a controlled design that organizes the research question first and
detail the method of data collection and analysis to be employed (Robson 2007).
Additionally, a cross-sectional descriptive design, as LoBiondo-Wood & Haber (2006)
describes has been used in this study.
3.3 Study population and sampling
The population for this study was adult patients diagnosed with hypertension and or diabetes
attending an out-patient clinic at Rwanda Military Hospital in Rwanda. A population
according to Parahoo (2006) is ―the total number of units from which data can potentially
be collected‖. Delimitation of the population to a homogenous level group has been achieved
through inclusion and exclusion criteria. It is from the ensuing group that the target
population was formed, the set of patients about which the proposed generalizations was
made (Haber 2010).
15
3.4 Inclusion criteria
 An adult patient attending an out-patient clinic with a confirmed diagnosis of
hypertension and or Diabetes.
3.5 Exclusion criteria

 Pediatric patients

 Patients with ailments other than hypertension and or Diabetes
3.6 Sample size

Proponents of quantitative approaches to research urge that sample size calculation should be
undertaken at the level of study designing (Proctor et al. 2010). Other scholars suggest that
selection of such a large sample to represent the entire target population (Polit & Beck,
2010). It's against this reasoning that a sample of participants was selected for this study.
Nevertheless, selection of study participants was based on considerations of the nature of

patients attending the clinic where some of the patients had been attending over time and
would only attend occasionally, with others on predictable visits. Other considerations were
the need to ensure that only those who meet the study criteria are included. For example only
those with consistent and complete data and have been on treatment were selected.
3.7 Sampling technique
Sampling is basically a process by which the researcher chooses a fraction of the target
population, as the representative study population. Working with samples rather than with
large populations offers a more cost-effective and practical strategy in research (Polit & Beck
2010).
Patients were purposively selected on the basis of their diagnosis and eligibility i.e meeting study
inclusion criteria. First, the researcher identified potential participants from registry and
appointment records. Given the varying numbers of patients attending the clinic, the researcher
adapted self on the clinic schedules to be able to meet those identified patients. About the
population the researcher used all participants meeting the inclusion criteria which mean patients
with HTN and DM. The sample was composed of 12O patients.
Patients were contacted during their visit to the clinic. Where patients selected were not easily
accessible in the clinic (those who visited the clinic occasionally) the researcher had to follow
16
them up using the community health workers‘linkages. This was an ongoing process where a list
of all contacted was made. Within a one month period of the planned data collection, a total of
120 participants were generated. This is approximately 40% of the overall monthly clinic visit.
3.8 Instruments
Quantitative data are collected for the purposes of categorizing and describing behaviors
attributes, and population activities (Parahoo, 2006). However, systematic, objective, and
repeatable methods should be used to collect data. According Robson (2007), collection of
data should be through simple mechanisms that allow answers to the research question to be
obtained and with necessary data collected.
Being aware of these guiding principles the instrument selected for data collection for this study
is a questionnaire. The questionnaire was developed based on the tenets of the Health Belief
Model and literature review. The tool was developed in English and translated in Kinyarwanda
to cater for those who do not understand English. In addition to that for those who cannot read
and write, their responses had been written by the researcher as well.
3.9 Data collection procedure
After getting ethical clearance from IRB and permission from Rwanda Military Hospital the
researcher approached the unit manager of outpatient’s department for self- introduction and give
information about the research. For collecting data, the researcher used self-administered
questionnaires among 120 outpatients. The instrument was designed to assess knowledge and
prevention of CKD among outpatients. Participants have got all information related to the topic
and were ensured that their contribution is voluntary and confidential in order to get their
consent. Each participant completed their questionnaire individually with researcher assistance
when needed. The filled-in questionnaires were given to researcher.
17
3.10 Reliability and validity of the instruments
Validity
Questionnaire validity has been defined as the extent to which the research tool measures
what it is intended to measure (Polit & Beck, 2010). The instrument should address all
features of the problem being studied. Two aspects validity have been continually reported in
the literature. These are content validity and face validity (Parahoo 2006).
Face validity essentially examines whether the concept being tested are being measured in
the questionnaire (LoBiondo-Wood & Haber 2010). This will be achieved through having
other people to test-run the tool to check whether the questions are clear, relevant, and not
ambiguous (Jones & Rattray, 2010).
A content validity test on the other hand, ensures that only asked questions are relevant and
enough, thus covering all study areas being studied (Parahoo 2006).
Reliability
Reliability of a research instrument refers to its ability to generate the same results when used
under the same conditions. However, reliability is not easy to achieve particularly when it
involves people as study subjects (Robson 2007). In quantitative research, reliability basically
focuses on consistency and stability (Polit & Beck 2010). Using the test-retest method a stability
test was performed on a small population (Polit & Beck, 2010). To do this, a pilot study has been
done and the results generally indicated that the tool was clear to the participants and has a
potential of generating the desired responses.
3.11 Pilot Study
Piloting in research is an important stage in the design of the study tool. It allows evaluation
of the instrument before actual data collection begins (Parahoo 2006). A small sample of
subjects of 21patients with hypertension and diabetes that have been attending outpatient
clinic was used for the pilot study.
3.12 Data Analysis
Data was numerically coded and captured in Excel, using an SPSS Software Version number
20 programmes. A descriptive analysis of data has been used.
18
3.13 Ethical Consideration
Permission to carry out the study has been requested from the University Rwanda, School of
Nursing and to the College of Medicine and Health Sciences Research committee. Also the
researcher obtained permission from Rwanda Military Hospital management to be able to
access the study setting.
In addition, participants were approached, explained about the study and study objectives, as
well as the role they are expected to play if they consent to participate. Participants were
given as much time to consider their participation as possible.
3.14 Confidentiality
Data was saved electronically and secured with password and only the researcher was having
accessibility to the information. All the participants were given a code number.
3.15 Anonymity
The anonymity has been insured (participants names were not appeared in the
questionnaires).
Each participant was given a code number.
3.16 Respect for human values.

Participants were treated with respect and requested for a valid consent to participate.
3.17 Data dissemination

The research process was complete after data collection, analysis and management. Therefore the
research findings are to be used to the community and to myself as for academic purpose. The
copies of this report will be given to the University of Rwanda, to my supervisor for her record
keeping. The report findings will also be given to the health organizations includes Rwanda
Military Hospital where study were conducted and to CMHS library for helping future students
in their research. Finally the findings will be published in nursing journals.
3.18 CONCLUSION
In this chapter, different elements are identified. It includes a research settings where a
research is conducted, it also concern a study design which summarize the different methods
and techniques used to acquire more information. In addition, it also contains a study
population, sampling techniques, data collection and data analysis instruments.
19
CHAPTER 4: DATA ANALYSIS AND INTEPRETATION OF THE
RESULTS
4.0 Introduction
The present study assessed the knowledge and prevention of chronic kidney disease among
adult diabetes and hypertension outpatients in Rwanda Military Hospital using frequency
tables and cross tabulation to show the incidence of factors of chronic kidney diseases among
patients, respectively with preventive measures. By using cross tabulation, this study
revealed perceptions, leading factors, and preventive measures taken to reduce risk of getting
chronic kidney disease. Finally socioeconomic and demographic characteristics of
outpatients are explored through descriptive statistics. The study sampled 120 respondents
from which 66.67% have hypertension, and only 11.67% have diabetes while the remaining
proportion has both conditions.
Table 1: Description of social demographic characteristics of respondents
Variables Categories Frequency Percentage

Age of Respondent Between 20-25 Years 4 3,33
Between 26-31 Years 1 0,83
50 Years or above 55 45,83
Gender of Respondent Male 42 35
Female 78 65
Marital Status Single 15 12,5
Married 61 50,83
Divorced 33 27,5
Widowed 11 9,17
Education Level No education/Illiterates 13 10,83
Primary level 69 68,33
Secondary 24 20
Tertiary/University 14 11,67
Current Disease of Respondent Diabetes 14 11,67
High Blood pressure/HTN 80 66,67
Diabetes and Hypertension(DM&H 26 21,67
Occupation Status Public Servant/Employed 10 8,33
Self employed 47 39,17
Unemployed 63 52,5
Total Sample size/Valid cases 120 100
Source: Primary data
20
Table 4.1 shows the frequencies and percentages of social and demographic characteristics
of respondents participated in this study. Female were almost double of male respondents,
65% of respondents were female. Among which 45.83% of patients surveyed were aged 50
years or above. The survey interviewed patients of different marital status, however a half
(50.83%) of all respondents are married and widower and single patients are less
interviewed groups 9.17 % and 12.5 % respectively. A big proportion (68.33%) of
respondents have at least attended primary school, while only 10.83% that is 13
respondents out 120 have not attended primary school. The High blood
pressure is most common disease among sampled patient, where about 80 respondents which
is 66.67% have Hypertension.
SECTION II: Knowledge about Chronic Kidney Disease (Perceived susceptibility)
Figure 1: Distribution of respondents by Health status
Figure 4.1 indicates that hypertension is most common disease among sampled participants,
where about 80 respondents which are 66.67% have hypertension. Only 12% of participants
were suffering with diabetes and hypertension.
21
Figure 2: Distribution of respondent by occupation
The figure 4.2 shows that only 8.33% of respondents are public servants and more
than a half 52.50% are not employed
Table 2: Cross tabulation of Respondent current disease with respect to Age category
Age of respondent
Current Disease 20-31 Years 32-43 Years 44-49 Years 50 Years or above Total
Diabete 21.43% 0% 42.86% 35.71% 100
Hypertension 2.50% 30% 27.50% 40% 100
Diabete and Hypertension 0% 7.69% 23.08% 69.23% 100
Overall Percentage 4.16% 21.66 28.33% 45.83% 100
Table 4.2 shows that a larger number of patients interviewed are in older age. About
45.85% of all respondents have 50 years or above. In addition to that, more than half
(69.23%) patients who suffer from both diabetes and hypertension are more than 49
years. hypertension is less frequent among young people, only 2.5% of hypertension
patients are between 20 and 31 years. It is very clear that diabetes and hypertension is
associated with age, the most (more than 70%) of patients are 44 years and above.
22
Table 3: Cross tabulation of Respondent current disease with respect to gender
Gender of Respondent
Current Disease Male Female Total
Diabete 28.57% 71.43% 100
Hypertension 37.50% 62.50% 100
Diabete and Hypertension 30.77% 69.23% 100
Total 35% 65% 100
Table 4.3, shows the association between gender, diabetes and hypertension. The three
diseases are less frequent among men than among women; two in three interviewed patients
were female. About 71.43% of diabetes patients interviewed were females, 62.5% of
hypertension patients were female.
Table 4: Cross Tabulation of Respondents current disease with respect to Occupation
Occupation status
Current disease Employed Self_Employed Not Employed Total
Diabete 7.14% 14.29% 78.57% 100
Hypertension 8.75% 42.50% 48.75% 100
Diabete and Hypertension 7.69% 42.31% 50.00% 100
Overall percentage 8.33% 39.17% 52.50% 100
Table 4.4, shows the association between employment status and current disease of
respondent.
The results reveal that most patients currently are not employed. This results support the idea
that inactivity/immobility can be one of the leading factors of diabetes and hypertension.
A majority, of diabetes patients (78.57%) are currently not employed, and for all three
diseases, patients with an employment are less than 10 percent; 7.14%, 8.75%, and 7.69%
Patients suffer from diabetes, hypertension, and both diabetes and hypertension
respectively among patients with an employment..
23
Table 5: Cross Tabulation of Respondents current disease with respect to Education level
Education level
Current disease No education Primary level Secondary Tertiary Total
Diabete 7.14% 64.29% 28.57% 0% 100
Hypertension 11.25% 57.50% 18.75% 12.50% 100
Diabete and Hypertension 11.54% 53.85% 19.23% 15.38% 100
Total 10.83% 57.50% 20% 11.67% 100
The study shows the association between education level and current disease of
patients, it is revealed that education doesn‘t clearly associate with diabetes and
hypertension according to the results in table 4.5. A larger number, 57.5% of all
respondents attend primary school, while 10.83% have not attended any school. The
results from table 4.5 showed that no diabetic patient has university level education,
but 15.38% of diabetic and hypertension patients have a university level education.
Thus, diabetes and hypertension is present from all people either illiterates or more
educated persons.
4.2 Results from bivariate analysis (Chi-square test)
The researcher wanted to see the independency between social economic and
demographic characteristics of respondents which would influence the knowledge
about chronic kidney disease among outpatients diabetic and hypertension at Kanombe
military hospital is summarized in table 4.2.1. The results indicate that there is no
association between knowledge about chronic kidney disease and the following socio
economic and demographic variables: Age of respondent, Gender, Marital status,
Education level, and Occupation.
24
Table 6: Pearson Chi-Square tests
Socio economic And demographic  2 -Values df p-value

variables
Age of respondent 4.754 5 .447
Gender of respondent .120 1 .729
Marital Status of the respondent 3.949 3 .267
Occupation of the respondent 1.028 2 .598
Education level of the respondent 5.079 3 .166
By using primary data collected at Rwanda military hospital among diabetic, and
hypertension patients, at 5% level of significance none of demographic characteristic variable
is significant (p-values>0.05).
4.3: Objective one: Knowledge of outpatient on chronic kidney disease (Perceived

susceptibility)
In this study, the researcher wanted to know how many respondents know about chronic
kidney disease. Patients of diabetes and hypertension should be aware of chronic kidney
disease.
Table 7: Knowledge about Chronic kidney disease
Have you ever heard of Chronic

Kidney Disease ? Number of Respondent Percentage
Yes 110 91.67
No 10 8.33
Total 120 100
However, the results in table 4.7 shows 8.33% of respondents said that they don‘t know
anything about chronic kidney disease, while the majority of respondents 91.67% have heard
about the disease.
25
Figure 3: Sources of Information on Chronic kidney disease
The results of figure 3 revealed that the main source of kidney disease information is
provided by health service providers (39.17%), followed by information provided by friends
and neighbors. The internet was seen as the least source providing kidney disease
information, where only 5.83% of respondents obtained information using internet.
Table 8: Cross tabulation of health status and knowledge about chronic disease
causes/Conditions that may leads to develop such disease
Know Factors Don't know Factors

Current disease leading to CKD leading to CKD Total
Diabete 64.29 35.71 100
Hypertension 88.75 11.25 100
Diabete and Hypertension 84.62 15.38 100
Overall percentage 85 15 100
CKD: Chronic kidney disease
Although 91.67% of respondents revealed that they know chronic kidney diseases, not all of
them know factors causing kidney diseases. Table 4.9 shows that 15% of all respondents
have no information about factors that may lead a person to develop chronic kidney disease.
26
About one third (35.71%) of respondents suffering from diabetes are not aware of causes of
kidney disease.
Table 9: the Causes that may lead a person to developing a chronic kidney disease
Condition that may lead a person to develop CKD Percentage

Delay to urinate when in need 0,36%
Due Ineffective functioning of Kidney 0,36%
Due to hepatitis C 0,36%
HIV 0,36%
Ineffective circulation of blood 0,36%
nature of job 0,36%
Unbalanced diet 0,36%
Uncontrolled weight 0,36%
Chronic urinary tract infection 0,72%
Excessive Prostitution 0,72%
Heart diseases 0,72%
Ineffective medication of current disease 0,72%
Side effects of drugs consumed 0,72%
Accident 1,45%
Contaminated by dirty objects/Lack of hygiene 1,45%
Diabetes 2,17%
Hypertension 2,54%
Don't know 6,52%
Lack of Physical exercise 6,52%
Long period of body immobility 8,70%
Consumption of a lot of oil, Salt or Sugar 9,78%
Hard works demanding a lot of physical enery & Stress 10,14%
Consumption of a lot of tobacco & alcohol 14,86%
Do not drink enough water 29,35%
Total 100%
Table 4.9 present the conditions that may lead a person to develop a chronic kidney
disease. The first listed condition was consumption of high level of alcohol and tobacco
with 14.86% of all responses. However, respondents provided different conditions
according to their knowledge, not all of them provided right answers. It noted that more
than a half of responses given were wrong.
The most common wrong information among patients were not to drink or drinking little
quantity of water which represent 29.35 % of all respondents. Among other conditions
provided by respondents are listed in descending order in table 4.9, where consumption of
high quantity of salt, oil, sugar and uncontrolled diet, and no practices of physical
exercises are the second and the third condition with 9.78% and 6.52 % respectively.
27
The remaining conditions include presence of current disease (diabetes, and hypertension),
consequences of consumed drugs, heart diseases, ineffective circulation of blood, and
inefficiency functioning of kidney.
Table 10: Perception of respondents on risk of developing chronic kidney disease
Being at Risk of CKD Number of respondent Percentage

Yes 113 94.17
No 7 5.83
Total 120 100
Table 4.10 shows how respondents think of being attacked by chronic kidney disease. Only
5.83% of all respondents think that they are not at risk of developing a chronic kidney
disease (CKD).
28
Table 11: Reasons why a patient consider himself at risk of developing chronic kidney
disease
Reason to be at risk of developing CKD Percentage

Due to life conditions changes 0.38%
Liver disease 0.38%
Problem of hepatitis 0.38%
Body contact with contaminated persons 0.77%
Contaminated by dirty objects/Lack of hygiene 0.77%
Diabetes & Hypertension 0.77%
Side effects of drugs consumed or consumption a lot of drugs 0.77%
Excessive Prostitution 0.77%
Delay in medication/Ineffective medication of current disease 0.77%
Heart diseases 1.15%
Nature of job 1.15%
Unbalanced diet/Incomplete diet 1.15%
Not consider him/herself being at risk of develop CKD 2.69%
Diabetes 3.85%
Lack of Physical exercise/ No practice of physical exercise 6.54%
Consumption of a lot of tobacco & alcohol 6.92%
Consumption of a lot of oil, Salt or Sugar 7.31%
Long period of body immobility/Long time seating 7.69%
Hypertension 8.46%
Hard works demanding a lot of physical energy & Stress 8.85%
Accident/ It comes just like an accident no specific Reason 15.77%
Do not drink enough water/low level consumption of water 22.69%
Total 100%
The table 4.11 shows that more than a half of reported reasons as to why patients think
they were at risk of developing chronic kidney disease were wrong. One out of five
respondent, 22.69% said that do not drink water could be the main reason to be affected
by chronic kidney disease. However, these responses are wrong. 8.45% % of responses
indicate that hypertension disease as major reason patients feel at risk of chronic disease.
Diabetes, consumption of high salt, oil, sugar, and uncontrolled diet, consumption of a lot
of alcohol and tobacco have been listed among other reasons of being at risk for
developing chronic kidney disease.
The majority of respondents reported wrong reasons about leading factors of chronic kidney
disease. Most of them said that that lack of or insufficient water in the body, immobility of
body, no practices of physical exercises, unknown cause of the disease, and nature of
job/long seating time at job, high complicated job (hard works and stress) were the major
29
reasons for respondents to think that he/she was at risk of developing chronic kidney disease.
In addition to that, a small number of wrong reasons reported were: presence of other
diseases (e.g: Liver disease, problem of hepatitis), contaminated by others by contact,
ineffective medication, and violation of doctor‘s advice
Figure 4: Reasons why a patient consider himself at risk of developing chronic kidney
disease
30
4.4: Objective two: assessment of knowledge about preventive measures among
outpatient at Rwanda Military Hospital
The second objective of this research was to assess the understanding regarding
prevention of CKD among outpatients attending Rwandan military hospitals. The results
in table 4.13 show the results of preventive actions according to the patients.
Table 12: Action that can make you less likely to developing CKD
Know measure to prevent CKD Number of respondent Percentage

Yes 99 82.5
No 21 17.5
Total 120 100
In order to assess the knowledge about preventive actions, researcher investigated the
knowledge of outpatients on the preventive measure about chronic kidney disease.
Table 4.12 shows knowledge about the measure to prevent chronic kidney disease. About
17.5% of all respondents do not have any knowledge about prevention of chronic kidney
disease (CKD).
Table 13: The Preventive action to reduce chance of developing CKD
Preventive Measures Percentage

Avoid A lot of consumption of meat 0.33%
Avoid Tight clothes 0.33%
Follow health advice on Radio or TV 0.33%
Measures can be taken when it happen to get CKD 0.33%
Reduce level of kidney disease 0.33%
Take a lot of medicine 0.33%
Take medicine effectively 0.33%
Avoid Prostitution 0.66%
Follow doctors and Health professionals' advice 0.66%
Avoid dirty objects/Improvement of hygiene 0.99%
Do regular health check up 1.64%
Take a balanced and controlled diet, avoid pepper 1.97%
Early treatments and effective medication of current disease 2.63%
Reduce Long period of body immobility/Long time seating 3.29%
Reduce hard works demanding a lot of physical energy & Stress, look time of rest 4.93%
Do not know any preventive measure 6.91%
Avoid Consumption of a lot of tobacco & alcohol 11.84%
Avoid A lot of salt, oil and Sugar 12.83%
To do regular Physical exercise/sports 19.41%
To drink enough water/ consumption of much of water 29.93%
Total 100%
31
The table 4.13 shows that more than one third given measures to prevent against
chronic kidney disease was wrong. Around a third (29.93 %) of responses said that
drink enough water is a preventive measure however, this is wrong. 19.41% of
respondent said that practices of regular physical exercise could be the measure to
prevent chronic kidney disease, while regular health checkup has 1.64% of all
responses.
Among other listed preventive measures as shown in the table 4.13 include avoiding
high quantity of salt, oil, and sugar; avoid consumption of a lot of alcohol and
tobacco, effective medication of diabetes, and hypertension , avoid obesity and have
a particular diet including fruits, avoiding a lot of meats and pepper.
The majority of respondents who reported wrong preventive measures, most of them think
that consumption of a lot of water on daily basis and avoiding very energy demanding works
can be the major preventive measure to combat against chronic kidney disease. In addition to
that, a small number of responses about preventive measure were; to respect doctor‘s
instruction, and follow advices from Radio, and TV, and to avoid prostitution.
32
Figure 5: The Preventive action that you can take to reduce chance of developing CKD
33
SECTION III: PREVENTION OF CHRONIC KIDNEY DISEASE
4.5: Behavior of outpatients and practices of preventive measures of chronic kidney

diseases (Cues to action)
Table 14: Have you ever seen a dietician before?
Current disease Yes No Total

Diabete 14.29 85.71 100
Hypertension 28.75 71.25 100
Diabete and Hypertension 30.77 69.23 100
Overall percentage 27.5 72.5 100
In general, Table 4.14 indicates that only 27.5% have consulted a dietician for counseling,
and health regulation and control. It is very clear that the majority for all type of disease
patients did not consult the dietician. Only 14.29%, 28.75%, and 30.77% of respondents who
suffer from diabetes, hypertension, and both diabetes and hypertension respectively have
consulted the dietician while the remaining did not.
Figure 6: Frequency of checking the weight respect to the respondent current disease
34
Figure 6 indicates respondents’ frequency of checking weight. The results
showed that 45% of all respondents do weight checks one time per month.
Diabetic patients have a high number of people who never checked for their
weight. Among respondents who suffer from diabetes 14.29 % have never
checked their weight, while 10% among respondents who suffer from
hypertension have never checked their weight.
Table 15: Current diet preferred among diabetic and hypertension outpatients
Current disease Food without Salt Food without oil Food without Sugar
Yes No Yes No Yes No
Diabete 35.71% 64.29% 35.71% 64.29% 71.43% 28.57%
Hypertension 62.50% 37.50% 41.25% 58.75% 27.50% 72.50%
Hypertension and Diabete 80.77% 19.23% 69.23% 30.77% 76.92% 23.08%
Total 63.33% 36.67% 46.67% 53.33% 43.33% 56.67%
The table 15 shows that the most spoken type of diet among all patients was food without
salt which has 63.33% of all respondents and the least spoken type of diet was drinks
without sugar which has 43.33% of all response. Diabetic patients are with high
percentages among other to food without salt and food without oil both two type of diet at
64.29%.
Table 16: Cross tabulation of current disease and Meals taken

1-2 meals 3 meals 4 meals
Current Disease per day per day per day Total
Diabete 92.86 7.14 0 100
Hypertension 76.25 22.5 1.25 100
Diabete and Hypertension 57.69 38.46 3.85 100
Total 74.17 24.17 1.67 100
The research wanted to analyses the meals status among patients, and the results in table
16 show that many people (74.17%) take between one and two meals per day while only
1.678% of all respondents take 4 meals per day. Respectively to the current health status of
respondents, none diabetic take 4 meals while 92.86% of all diabetic patients take between
one and two meals per day.
35
Figure 7: Cross tabulation of current disease and Meals taken
Table 17: Cross tabulation of Current disease and Use/Eat snack in between meals
I have a snack I generally snack I often nibble
Current disease when I need it during the evening between meals Never
Diabete 7.14 14.29 28.57 50
Hypertension 17.5 15 60 7.5
Diabete and hypertension
Hypertension 7.69 11.54 69.23 11.54
Total 14.17 14.17 58.33 13.33
Table 17 indicates the frequencies of snacking between the meals among patients
respective to their current disease. In general, 58.33% of all respondents reported that they
took snacks often between the meals, while 13.33% said that they never took snacks.
Based on current disease, we have seen that 69.23% of patients who suffer both diabetes
and hypertension took snacks often between meals. Moreover, in all categories diabetic
patients took less snacks than other patients (hypertension, or patients suffer both diabetes
and hypertension).
36
Table 18: Do you select food?
Select food Number of respondents Percentage

Yes 103 85.83
No 17 14.17
Total 120 100
Table 18 shows the preferences of patients about selecting diet.
Table 19: Cross tabulation of current disease and frequency of exercise
>3 times 2-3 times Once

Current disease Many time a week a week a week Rarely Never
Diabete 7.14 0 21.43 7.14 28.57 35.71
Hypertension 3.75 6.25 18.75 26.25 32.5 12.5
Diabete and
Hypertension 7.69 7.69 23.08 15.38 30.77 15.38
Total 5 5.83 20 21.67 31.67 15.83
The results in table 19, show the cross tabulation of current disease of respondent and
frequency that patients do physical exercise as measure to prevent chronic kidney disease.
Less number of patients, only 5% do physical exercise many times a week, and 5.83% do
exercise more than three times per week. A big number 35.71% of diabetic patients never
do physical exercise, while hypertension patients has the lowest number of people who
never did physical exercise among three type of diseases which is 12.5 % of all
hypertension patients.
Table 20: Cross Tabulation of current disease and Motivation frequency to do

exercise/sports
Current disease Always Often Sometimes Never No sport

Diabete 35.71 14.29 7.14 7.14 35.71
Hypertension 48.75 26.25 8.75 3.75 12.5
Diabete and
Hypertension 57.69 7.69 11.54 7.69 15.38
Total 49.17 20.83 9.17 5 15.83
Source:Primary data
Table 20 indicates motivation of patients to practices physical exercise respectively

to the current disease. The results shows that 15.85% of all respondents participated
in the study reported that they did not do physical exercise or sport, while 5% said
37
that they never felt motivated to do sports even if they did sports. The patients who
suffered both hypertension and diabetes were the highest proportion at 57.69% of
people who always felt motivated to do sport, and a high number of people who
never felt motivated to do sport which is 7.69%.
Table 21: Cross Tabulation of current disease and frequency of following exercise program
as per advice from health care professional
Current disease Always Often Sometimes Never No sport

Diabete 35.71 0 7.14 21.43 35.71
Hypertension 51.25 21.25 6.25 8.75 12.5
Diabete and
Hypertension 57.69 11.54 3.85 11.54 15.38
Total 50.83 16.67 5.83 10.83 15.83
The results in table 21 indicate that 50.83% of all respondents do always follow
exercise program as per advice from health care professionals. Based on current
disease of respondents, diabetics have lowest percentage 35.71% of patients who
always followed their exercise program as per advice from health care professionals.
Table 22: Cross tabulation of current disease and habit to forget take drugs (I forget to
take my drugs)
Always Often Sometimes Never

Diabete 0 0 21.43 78.57
Hypertension 1.25 1.25 7.5 90
Diabete and
Hypertension 3.85 0 11.54 84.62
Total 1.67 0.83 10 87.5
The results from table 22 show the frequency of habits to forget taking drugs among
patients respectively to the current disease they have. In general, 87.5 % said that they
never forgot to take drugs, and 10% of all respondents did sometimes forget to take
drugs. One out of five diabetic patient said that he/she sometimes forgot to take drugs
and hypertension patients had the highest percentage of 90% who never forgot to take
drugs.
38
Table 23: Cross tabulation of current disease and perception on side effect drugs (The
drugs I take must be causing some side effects)

Diabetes 0 7.14 35.71 57.14
Hypertension 1.25 5 27.5 66.25
Diabetes and
Hypertension 7.69 11.54 23.08 57.69
Total 2.5 6.67 27.5 63.33
Table 23 indicates the perceptions of patients about consequences of drugs taken. The
results show that 63.33% of all respondents thought that drugs consumed do not have
side effects on the health while only 2.5 % thought that drugs consumed must have
had some side effects on them. The results in table 4.25 also show perceptions about
drugs side effect based on current disease, 35.71% of diabetic patients who sometimes
thought that drugs consumed could have had some side effects on them.
Table 24: Cross tabulation of current disease and perception on drug consumption (I think
I am taking too many drugs)

Diabetes 7.14 7.14 21.43 64.29
Hypertension 5 7.5 7.5 80
Diabetes and
Hypertension 11.54 11.54 23.08 53.85
Total 6.67 8.33 12.5 72.5
The table 24 indicates perceptions about quantity of drugs taken by patients based on
their current disease. In general, majority 72.5% they never thought that they took too
many drugs, and only 12.5% sometimes thought that they took too many drugs while
6.67% of all respondents always thought that they took too many drugs. Based on each
disease, 11.54% of all patients who suffer both diabetes and hypertension always
thought that they took too many drugs.
39
Table 25: Percentages of respondents with different initiative to maintain good health
status and reduce chance of developing chronic kidney disease.
Variables Categories Number of respondents Percentage

Have a particular diet ? Yes 76 63.33
No 44 36.67
Total 120 100
Do Exercises/Sport Yes 101 84.17
No 19 15.83
Total 120 100
Improve life style Yes 105 87.5
No 15 12.5
Total 120 100
Try to reduce stress level Yes 113 94.17
No 7 5.83
Total 120 100
Successful controlled life style Yes 113 94.17
No 7 5.83
Total 120 100
Table 25 shows percentages of people who have adopted some preventive measure to control
their health and reduce the chance to have chronic kidney disease as these three diseases were
among the leading factors of chronic kidney disease when health was not controlled. It shows the
percentages of respondents who had a particular diet, who selected food, did physical exercise,
tried to improve life style, tried to reduce stress level, and those who had successfully maintained
their health status at a controlled level.
Table 26: Cross tabulation of current disease and smoking experience among
10 cigarette or Smoke less than 10 Used to smoke but

more per day cigarette per day not smoke today Never smoked
Diabete 0% 0% 28.57% 71.43%
Hypertension 1.25% 1.25% 20% 77.50%
Diabete and
Hypertension 0% 0% 19.23% 80.77%
Total 0.83% 0.83% 20.83% 77.50%
The results of table 26 shows that a majority (77.5%) of all patients have never
smoked cigarette, while 20.835 used to smoke but did not smoke on that day. On the
other side, the table show smoking experience of patients according to the current
disease. Only hypertension patients currently smoked; 1.25% smoked a lot (10 and
above cigarettes) while patients who suffered both hypertension and diabetes were
19.23% of patients who smoke on that day
40
Table 27: Cross tabulation of Current disease and alcohol consumption experience among
respondents
Current disease Drink but not every day Used to drink Never drank
Diabete 7.14 42.86 50
Hypertension 11.25 35 53.75
Diabete and
Hypertension 3.85 34.62 61.54
Total 9.17 35.83 55
The results of table 27 shows that a majority of all patients (55%) have never drank alcohol,
while 35.83 used to drink but not drink on that day. On the other side, the table show
drinking experience of patients according to the current diseases. 11.25% of all hypertension
patients did drink alcohol while only 3.85% of patients who suffered both diseases did drink
alcohol but not every day.
Figure 8: Consequences of uncontrolled current disease
Figure 8 shows that the most spoken consequence of unsuccessful treatments of current
disease was high cost of health services with 70.0% of all respondents, moreover other
consequences were also above 50% for all respondents. All three consequences can happy to
more than a half once the current diseases are not well treated.
41
Conclusion
In this chapter, data analysis and interpretation of results were presented by using frequency
tables and cross tabulation to show the incidence of factors of CKD among patients and
preventive measures. The study sampled 120 respondents from which 66.67% have
hypertension, and only 11.67% have diabetes while the remaining proportion has both
conditions. A descriptive statistics of social demographic characteristics of respondents was
presented and showed high number of females (65%) who participated in the study. The
majority in the study reported wrong reasons about leading factors of chronic kidney disease
and about 17.5% of all respondents do not have any knowledge about prevention of CKD.
42
CHAPTER 5: DISCUSSIONS
5.1. Introduction
This chapter discusses the main findings of the study. The discussion largely relied on the
results of the study that were found to provide significant meaning and relevance to the
objectives. In addition, relevant literature was used to make analysis and conclusions where
applicable. The study focused on finding out patients‘ knowledge and prevention of CKD. This
chapter is therefore limited to these aspects.
5.2. Knowledge of respondents on chronic kidney disease
Regarding respondents knowledge about CKD, (table 4.7) the results indicated that majority
(91.67%) were aware of the condition. The results have significant practical implications. For
example, patient‘s awareness of their conditions and potential complications helps in
facilitating their involvement in health promotion activities as well as adhering to treatment
recommendations. The findings of this study are comparable to previous CKD knowledge
surveys that observed the significance of knowledge by patients of diabetes, hypertension in
preventing complications of their conditions (Oluyombo et al 2016).
5.3. Respondents Sources of Information and perceived conditions that may lead to
development of chronic kidney disease
According to the results (table 4.8) majority (60.83%) respondents received information from
other sources other than from health care provider. These finding provides a negative signal
to the effectiveness of the health education provided to clients. It indicates a gap in either the
emphasis put on CKD, or shallowness of the information provided by the health care
providers. The problem here is that when patients get information from non-health related
sources, they are likely to get wrong information or right information wrongly that may
increase their risk for complications including CKD. For example, when respondents were
asked about causes of CKD, (Table table 4.10) majority (57.42%) of the respondents were
not able to acknowledge their conditions as risk factors to CKD. Several studies have
demonstrated the relationship between patients awareness about CKD and its associated risk
factors and their potential readiness to engage in life style modifications and other health-
promotion behaviors (Chow , et al, 2012; Wright-Nunes et al. 2012). These findings are of
43
practical importance since available evidence continues to indicate that when patients with
CKD presents late for treatment, the clinical outcomes tend to be poor (Chan , e t al. 2007).
Therefore improved population knowledge about CKD and its risk factors remains a critical
prevention approach especially among vulnerable populations like those with HT & DM.
Limited understanding of the factors responsible for the development of CKD could be an
element of poor source of information.
5.4 Respondents perceived factors that can lead to stress
Stress is one of the factors that negatively influence the progress and management of DM and
HTN (Bruce et al., 2010). The ability of the patient to participate in those activities that are
less stressful and or to avoid and prevent such factors that can put him or her on stress
requires that the patient be aware of these factors. The study results (Figure 4.11) have shown
that respondents are aware of factors are likely to be stressful to them. These findings are of
practical significance since the patients are more likely to avoid them being aware of how
stress can impact on their current condition (Chow WL, et al, 2012; Wright-Nunes JA, et al.
2012). The strategies used by respondents to avoid such situations were not investigated by
the current study
5.5. Perception and Reasons why patients consider themselves being at risk of developing
chronic kidney disease
Findings of this study (table 4.11) shows that majority (94.17%) respondents perceived
themselves being at risk of developing CKD, even when only few were able to indicate their
current health condition among the leading conditions that can lead them to developing CKD
(figure 4.4). This could be due to poor or inadequate information about the relationship
between their condition and CKD. The resultant of this situation is the influence it has on HT
and DM patients‘ attitude and practices that are geared to keep them safe from developing
CKD as a complication of their conditions.
The findings are similar to Chow et al, 2014 conclusions of how understanding of knowledge
gaps among HT and DM patients about their potential risk are essential to the development
of approaches to improve patients‘ involvement in preventive strategies. The author
recommended need for new practical clinical and community based education and health
promotion program to facilitate patients‘ awareness and self care practices. The findings
44
therefore points to the need for improved health education and promotion strategies both at
study site and its catchment areas.
5.6. Respondents’ reported Preventive actions and initiatives to remain healthy to reduce
chance of developing CKD
Study results (table 4.13) and (table 4.14) shows that majority reported actions that are
positive to CKD risk reduction. However on specific and individual actions, respondents
indicate only one action even when there was an option for indicating more than one.
Preventive actions that have been noted to reduce the chance of developing CKD involve
strategies that improve patients‘ lifestyles and behavior changes and are complementary in
nature (Chow, et al, 2012; Wright-Nunes, et al. 2012). When these are viewed in the context
of holistic care, where no single action can achieve maximum patient outcome, the results
provides an understanding of the prevailing gaps in self care competences to prevent
development of CKD given their limited participation. On the other hand a good number of
respondents indicated actions that are not health promoting.
These findings further demonstrate respondents‘ possible limited knowledge about their
condition and their role in promoting their health including prevention of CKD. This could
also be an indication of gaps in health care practices with regards to patients‘ health
education and health promotion. This kind of situation poses a big risk to the patient for
developing CKD since majority seems unaware of the potential risk their conditions hold to
develop CKD as well as their limited participation in activities to prevent its occurrence.
Available information from similar studies indicate that patients are more likely to adopt
positive healthy lifestyle only if they are able to relate their conditions and associated
complications(Clarke, Yates, Smith, & Chilcot, 2016)
5.7. Respondents lifestyle adaptations to meet current conditions’ management

requirements and demands
Regarding patients involvement in different lifestyles, the result shows that patients with both
HT and DM (table 4.21) were more likely to participate exercise as a measure to live healthy
than those with DM or HT alone. This is probably due to the patient‘s experience of several
symptoms from the two conditions at the same time. However, the results show no
45
significant associations between patient‘s condition and habits to forget taking drugs and or
any negative attitude towards drugs (tables 4.24 and 4.25).
Regarding patients visiting a dietician (table 4.15), majority (72.5%) have never visited a
dietician. The results show minor influence of patients‘ conditions on the practice.
This practice holds dangerous implications since diet is fundamental to the management of
both DM and HTN. This also indicates that patients‘ choices of food/diet do not follow any
professional recommendations. Given the dietary requirements for patients of DM and HTN
the current patients‘ practices are suboptimal for adequate management of these conditions.
In addition, the practice signals gaps in information and potential risks for complications and
subsequent CKD development since wrong dietary choices can result into negative outcomes
due to uncontrolled glucose levels and or other dietary influences on HTN.
Additionally, results of the study have shown that respondents were knowledgeable about
food relevant to their condition (table 4.17). This is a positive finding that can build upon to
enhance positive living among patients with HTN and DM. Nevertheless, this finding leaves
a question of the extent to which the diet meets the requirements of individual patients since
majority are not recommended by dietician. This once again provides an understanding of the
possible practical gaps in managing these patients since treatment with drugs alone may not
be adequate with inappropriate dietary supply. This may also be an indicative of the gaps
within the health care system particularly with regards to health education and promotion all
of which leaves patients of DM and HTN at risk of complications resulting from poor self
care and subsequent development of CKD.
With regards to patients habit of regular medical checkup, the results shows that majority
(Table 4.16) of the patients check their weight once a month and moderately few more than
once a month. While this is a positive practice, the nature of their conditions requires much
more regular check up and particularly their weight.
This practice is probably due to inadequate understanding of the importance of regular
medical checkups as well as limited understanding of the association between weight and
their current condition.
Regarding alcohol consumption and smoking, these are the known factors associated with
diabetes and hypertension. Patients with diabetes and hypertension are also likely to have
their condition worse if they continue to consume alcohol and to smoke (Levey & Coresh ,
2012).
46
The study result (Table28 and 29) indicate that majority (77.5%) and (55%) have never
consumed alcohol nor smoked before respectively. However a sizable number of respondents
indicated that have ever consumed alcohol (35%) and smoked (20%). The reasons for
stopping are beyond the scope of this study. However, the results are indicative of a positive
practice.
To sum up the discussion above, it has been observed that the results of this study and the
findings from previous authors seem to be similar and comparable though there is some little
contradiction among them. Furthermore the discussion was on the results of the study that
were found to provide significant meaning and relevance to the objectives of this research.
47
CHAPTER 6: CONCLUSION AND RECOMMANDATIONS
6.1. Introduction
This general conclusion includes problem statement, Summary of the main points or
findings, Strengths and weakness of the study (limitations of the study), recommendation and
perspectives for the further researchers.
6.2 Limitations of the study
It is important to note the limitations and weaknesses of this study. There are some
limitations that future researchers should consider when applying the findings. One of the
limitations of this study was the pre-existing data on CKD in Rwanda. In addition, the author
acknowledges limitation in terms of sample size. This limitation may compromise the
generalizability of these results. However, RMH being a national referral hospital, the results
provides an informative picture of a big population since participants are from a wider
community and diverse background.
Despite the limitations, the author believes that the findings from this study are important.
Focus group discussions could be used for future research in order to obtain more
information.
6.3. Recommendations
Based on the findings of this study, the author recommends that:
Patient: HTN and DM patients‘knowledge and self-care skills be targeted as a mechanism

for CKD prevention. This should entail patients‘involvement at all stages of care with
appropriate health education and promotion. New practical clinical and community based
education and health promotion program to facilitate patients‘awareness and self care
practices such regular check up of HT & DM, weight, and lifestyle modifications by health
care providers are essential. Limited understanding of the factors responsible for the
development of CKD could be an element of poor source of information. Public as well as
patients in particular with CKD should be well informed about CKD prevention and its risk
factors.
48
Nursing practice: Nurses should be responsible for planning and designing intervention
program to provide information that will help people at risk of CKD. Study results indicated
serious gaps in patients‘ information and self care skills. For example, majority of
respondents received information from other sources other than their health care provider.
These provide a negative signal to the effectiveness of the health education and promotion
provided to clients. Healthcare providers particularly nurses who are not only frontline health
providers but are also always in contact with patients, especially those at risk of CKD need to
be aware of the patients information and self care needs for better care planning and priority
setting.
Nursing Education: Inability to provide optimal information and other health promotional
support by nurses and other healthcare providers could be an element of limited knowledge
about the patients‘condition and skills to deliver to the patients. This calls for special
attention to education needs of nurses to ensure their continuous up-to-date knowledge for
optimum patient care. This may be in form of nursing curriculum transformations and
continuous professional development programs.
Nursing Research: There is evidence of limited information about CKD and its risk factors
in Rwanda. This impacts both on population awareness as well as evidence based practice.
More research is needed on how much nurses understand CKD and its associated factors and
the current practices. The extent to which the current nursing curriculum emphasizes such
conditions needs to be investigated.
6.4. Conclusion
In conclusion, the study demonstrates gaps in patients‘knowledge about their conditions

particularly how they are at risk of developing CKD. It further shows inadequate
competences for self care especially those that are fundamental to CKD prevention. Finally,
the study findings have a practical implication for needed improvements in patients care with
regards to health education and promotion at all levels of care about patients‘current
condition as well as potential risks to CKD. More research is needed about knowledge and
prevention of CKD in at risk patients and health providers.
49
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56
APPENDICES
ANNEX I: QUESTIONNAIRE
CONSENT FORM
Dear respondent,
My name is MUDASUMBWA Gisele, I am a Rwandan postgraduate student enrolled in the

Nephrology (Masters) program at the CMHS /UR. I am conducting a research as part of
requirements for a M.Sc. Degree in Nephrology.
The title of my study is‖ Assessment of Knowledge and Prevention of Chronic Kidney
Disease among Adult Outpatients in Rwanda Military Hospital‖.
I kindly request for participation by completing this questionnaire. Your participation is

voluntarily and any information given will be kept confidential. No names will be written on
the questionnaire.
If you have any questions, contact me on the following address:
MUDASUMBWA Gisele MSCN
Email: bebegisele@yahoo.fr
+250788586687/07836355688
57
QUESTIONNAIRE
SECTION I: Demographic Data and background characteristics
Instruction: Please select one response by using a tick [X] near your choice. Give a written
response where spaces are provided. Do not write your name on the questionnaire.
1. What is your Age?
1. 20-25yrs 2. 26-31 3. 32-37 4.38 -43 5. 44-49 6. 50 and above.
2. What is your gender?
1. Male…… 2. Female……
3. What your marital status?
1. Single ………..2. Married …………. 3.Divorced……….
4.Widowed…………
4. What is your Socio-economic status?
Employed ………. Self- employed………..unemployed………

5. What is your level of education?
1. No education 2. Primary …….3. High school (A2)…………4. University
SECTION II: Knowledge about CKD (Perceived susceptibility)
1. Known health
status Diabetic
Hypertensive
Diabetic and hypertensive
2. Have you ever heard about CKD?

Yes………. No………
3. Circle all the sources of information given below
58
i. Radio ii. Television iii. Newspaper iv. Internet v. Friends, vi.
Health service providers
4. Have you heard of anyone suffering from chronic Kidney disease (CKD)?
Yes …….. b. No ……..
5. Can you name some of the conditions that may lead to a person developing CKD
a. Yes ……. b. No ………
6. If yes in question 5, give at least three conditions you know.
i. …………………………………
ii. ……………………………
iii. ……………………………..
7. Do you consider yourself being at risk of developing CKD?
Yes …….. No ……
8. If question 7 is Yes give reasons why do you consider yourself at risk of CKD
………………………………………………………………………………….
9. Do you know of any actions you take that can make you less likely to develop
CKD
Yes …. No ……
10. If yes to question 9 yes, mention at least four actions
1…………………………………….
2…………………………………….
3……………………………………
4………………………………………
11. Has a doctor, nurse or another professional talked to you about the consequence
of your
Current disease? Yes…….. No ……..,
59
SECTION III: Prevention of CKD ( Cues to action)
1. Have you ever seen a dietician before? Yes …….. No………
2. How often do you check your weight?
i. Once a month
ii. Twice a month
iii. Once a quarter
iv. Rarely
v. Never
3. Are you currently on any particular diet? Yes…….. No………….
4. If yes, which of these is your diet?
i.Food without salt (salt free) yes no
ii.Food without oil (oil free) yes no
iii.Food without sugar (sugar free) yes no
5. How many meals do you eat a day?

A B C
I often eat a 1-2 meals per
3 meals per day fourth meal day
6. Do you eat snack in between
No / I have a I generally I often nibble
snack when I have snack between meals
need it during the
No I haven‘t snack. evening
7. Do you select the food you eat Yes No
8. If yes, what could be the basis to select the type of food? ……………………………………..
9. Do you exercise regularly? Yes …….. No ……..
10. How often do you do exercise?

A B C D
> 3 times a 2-3 times a
Most of the time week week 1 time a week Rarely
60
11. Do you usually feel motivated to exercise?

12. Do you follow your exercise program as per the advice from the health care professionals on
the basis of your cardiovascular condition?
13. Do you try to improve your lifestyle in your everyday life?
Yes…… No…….
If ye, give reason…………………………………………………….
If no, give reason…………………………………………………….
14. Do you try to reduce your stress level in your everyday life?
Yes……. No………
15. According to you what are the contributing factors that increase stress
-Social problem
-Economic problem
-Illness or Health problem
16. Which of the following statements apply to you
A B C D
Always (1) Often (2) Sometimes(3) Never (4)
I forget to take my drugs

The drugs I take must be
causing some side effects
I think I am taking too
many drugs
17. How would you describe your smoking experience at present?
I smoke 10 or I smoke but I don‘t
I smoke more than 10 less cigarettes not every day smoke but I
I never smoked
cigarettes every day every day used to
18. How would you describe your alcohol consumption experience at present?
I drink but not I don‘t drink I never
I drink alcohol every day every day but I used to drank.
61
19. Regarding your current health status and life style do you consider yourself
successful in maintaining your current condition under control? Yes…… No…….
20. In an event that your current condition gets out of control to develop CKD,
what do you think would be the challenges in your life?
-Long term treatment -High cost of treatment
-Immobility -Death.
62
ANNEX II: PROJECT ACTIVITY PLAN
PERIOD (months)
2016 2017
Activity Personnel 11 12 1 2 3 4 5 6 7 8 9 10 11 12
Proposal and 1
tools
development &
Ethical
Clearance
Recruit and train 1
assistants
Pilot Study 2
Recruit 2
participants
Data collection 3
Data analysis 2
Report writing 2
Dissemination of
findings
63
ANNEX III: PROJECT BUDGET
Item Number Unit Cost Rwfr Total Rwfr
Project Personnel
1 0 0
Principal Investigator,
Research Assistant, 4 250000 1000000
Statistician 1 500000 500000
SUBTOTAL 1 1300000
Equipment, supplies and services
Laptop computer 1 300000 300000

Printer 1 150000 150000
Papers 10 5000 50000
Printing (ink etc) 25000 25000
Other writing materials (Note Books, 15000
pens, markers, flipcharts etc) 15000
SUBTOTAL 2 540000
Travel
Local Travel@25000rwfr/per day 750000 75000
SUBTOTAL 3
Report writing and Dissemination 300000 300000
GRAND TOTAL 2415000
64
Declaration
65

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ASSESSMENT OF KNOWLEDGE AND PREVENTION OF CHRONIC

KIDNEY DISEASE AMONG ADULT OUT PATIENTS IN RWANDA

College of Medicine and Health Sciences

School of Nursing and Midwifery

MASTER’S IN NEPHROLOGY NURSING

By: MUDASUMBWA Gisele

A dissertation submitted in fulfillment of the requirements for the degree of

Supervisor Name: Dr Lakshmi RAJESWARAN

I, Gisele MUDASUMBWA, hereby declare that this research entitled‖ Assessment of

Signed by Gisele MUDASUMBWA June, 2017

I am very thankful to my husband Jacques TWAGIRAYEZU, for the support, patience,

May God bless you all.

Key words: Knowledge, Chronic Kidney Disease, Hypertension, Diabetes Mellitus.

CKD: Chronic Kidney Disease

DM: Diabetes Mellitus

GFR: Glomerular Filtration Rate

ML/min: milliliters per minute

RMH: Rwanda Military Hospital

KDOQI: Kidney Outcomes Quality Initiative

ESRD: End stage renal disease

MSN: Master’s of Science in Nursing

1.1 Background to the study

1.3 Objectives of the study

1.4 Research Questions

Available research continues to indicate a growing population of patients with CKD in

1.6 Definitions of Key Terms

Knowledge: In this study knowledge is conceptualized as awareness or understanding and

Prevention: Action so as to avoid, forestall, or circumvent a happening, conclusion, or

1.7 Sub division of The Project

1.8 Conceptual Framework

Individual Modifying factors Likelihood of taking action

Age, sex, ethnicity, Perceived benefit

Perceived Perceived threat of CKD

Exercise, diet, medications, regular

Adopted from Chou, 2010

2.1 Theoretical literature:

2.2 Empirical Literature

Because of CKD initial asymptomatic presentation, early disease detection is difficult. In

The ability to follow self-care recommendations is an essential element of the CKD

Studies have established this relationship between diabetes mellitus and

3.1 Research settings

3.2 Study design

3.3 Study population and sampling

3.5 Exclusion criteria

3.6 Sample size

Nevertheless, selection of study participants was based on considerations of the nature of

3.7 Sampling technique

3.9 Data collection procedure

3.11 Pilot Study

3.12 Data Analysis

3.16 Respect for human values.

3.17 Data dissemination

Variables Categories Frequency Percentage

SECTION II: Knowledge about Chronic Kidney Disease (Perceived susceptibility)

Figure 1: Distribution of respondents by Health status

Source: Primary data

Table 4: Cross Tabulation of Respondents current disease with respect to Occupation

4.2 Results from bivariate analysis (Chi-square test)

Socio economic And demographic  2 -Values df p-value

4.3: Objective one: Knowledge of outpatient on chronic kidney disease (Perceived

Have you ever heard of Chronic

Know Factors Don't know Factors