Knowledge and Risk Perception of Kidney Disease among Childbearing Women in Lagos State, Nigeria

a pre-tested, structured questionnaire among 825 we conducted a cross-sectional descriptive study to evaluate self-reported KD knowledge and risk perception among women of childbearing age in urban and semi-urban communities in Lagos State, Nigeria. We employed binary and multinomial logistic regression to assess KD knowledge and risk perception. We used descriptive statistics (mean, frequencies and percentages) to assess socio-demographic factors inuencing knowledge and risk perception of KD risk factors.


Abstract Background
In spite of kidney disease (KD) as one of the eight leading causes of death in women and a chronic public health concern, little is known about women's knowledge and risk perception of KD. We assessed knowledge and perception of KD risk among childbearing women in Lagos State, Nigeria.
Methods Administering a pre-tested, structured questionnaire among 825 women aged 15-49 years, we conducted a cross-sectional descriptive study to evaluate self-reported KD knowledge and risk perception among women of childbearing age in urban and semi-urban communities in Lagos State, Nigeria. We employed binary and multinomial logistic regression to assess KD knowledge and risk perception. We used descriptive statistics (mean, frequencies and percentages) to assess socio-demographic factors in uencing knowledge and risk perception of KD risk factors.

Results
Four hundred and forty-four (53.8%) out of 825 individuals reported being knowledgeable of KD with signi cant proportion found in the younger adults' age group (15-29 years), with mean age of 33.5±11.5 years. High prevalence of self-reported KD risk factors were pica craving, poor diets (junk foods and high in salt), hypertension and urinary tract infection. Multivariate analysis con rmed that the following factors increased the likelihood of knowledge and risk perception of KD: high education, high income and family history of KD. Perception of KD risk at age 40-49 years (OR = 1.22, CI= 1.02-1.63, p = 0.00) and diabetes (OR = 1.40, CI= 1.59-1.18, p = 0.00) were signi cantly perceived as predictors of an increased risk for KD development.

Conclusion
Our study reveals high knowledge of KD but low perception of KD risk factors and its ailments. In view of this, this calls for urgent measures to create sensitization and provide public KD behavioural health interventions as well as easy communication strategies for women to secure better access to pre-and post-natal healthcare services.

Background
Kidney disease (KD) is one of the eight leading causes of death in women worldwide. It causes 600,000 deaths annually and as such KD diagnosis, either acute or chronic is on the rise among women [1,2]. KD is not just an epidemic health problem of increasing incidence and prevalence, but an enormous burden on healthcare system due to the psychological distress that it poses on the patients and their families [3][4][5][6]. It is pertinent to note that women are highly susceptible to kidney diseases (KDs) due to their anatomy which is biologically/physiologically for child-bearing [2].
Women have certain risks for KD such as urinary tract infections (UTIs) and kidney infections (pyelonephritis), which are more common and slightly higher in women than in men -14% women versus 12% in men [7]. This situation has necessitated the need to raise awareness of KD risks and how to lower these risks among women. Risks increase during pregnancy and an autoimmune disorder (systemic lupus erythematosus (SLE) appears mostly during women's reproductive years [8,9]. Women with KD ailments are prone to more problems during pregnancy and birth as a result of other health problems, such as preeclampsia and increased blood pressure. Furthermore, other risk factors such as obesity, increases lifetime risk of end-stage KD [10] and maternal obesity accompanies adverse outcomes in pregnancy, [11,12] including gestational diabetes and preterm births. All of which increase the risk of chronic kidney disease (CKD) in both mother and child.
In Nigeria, medical professional have raised concern over the rising cases of KD and the disease burden among women of child-bearing age [11,12]. Empirical studies have shown that 17,000 new cases of KD are diagnosed annually and about thirty-eight million persons suffer from various stages of the disease [10][11][12]. Women often exhibit KD symptoms at advanced stages, especially when confronted with pregnancy-related complications, such as preeclampsia and other maternal disease. Many of these women already have kidney damage [13][14][15]. This is as a result of not having prior information of their medical histories and risk factors with explicit signs and chronic symptoms [6,2]. The cost of KD treatment and renal replacement therapy in Nigeria is also high, and many patients cannot afford them [16,17]. Unfortunately, treatment of KD is not prioritized by the Nigerian government in the National Health Insurance Scheme (NHIS) [16,17].
Adequate knowledge of KD risk factors will increase risk perception and readiness for lifestyle modi cation and medical screening for early diagnosis. This would prompt early treatment, reduce death and high health care expenses [18][19][20]. In Nigeria, community-based studies on knowledge and risk perception of KD among women in their childbearing age are scanty. Previous studies largely focused on clinical symptoms of KD among women, [10,11,13] neglecting their prior knowledge and risk perception of KD as important factors in early diagnosis and treatments. Consequently, this study focuses on design and promote KD awareness design and promotion towards prevention and screening services, while targeting women of childbearing age using multiple media facilities.
Based on this background, this community-based cross-sectional survey lled an important knowledge gap in the literature by examining knowledge and risk perception of KD development among women in their childbearing age. In year 2018, Lagos State resident nephrologists raised apprehension on increasing cases of KD among women during prenatal period, [11] thus, Lagos State was selected for this study.

Study settings
Data for our study was collected from three senatorial districts in Lagos State, located in south western region of Nigeria. Lagos State comprises of twenty Local Government Areas (LGAs), grouped into three zones known as senatorial districts: Lagos Central, Lagos West and Lagos East [21]. The Lagos Central senatorial district has ve urban LGAs (Lagos Island, Lagos Mainland, Surulere, Apapa and Eti-Osa) and Lagos West senatorial district has ten urban LGAS (Agege, Ifako-Ijaiye, Alimosho, Badagry, Ojo, Ajeromi/Ifelodun, Amuwo-Odo n, Oshodi/Isolo, Ikeja and Mushin), as well as Lagos East senatorial district which consists of 5 semi-urban LGAs (Shomolu, Kosofe, Epe, Ibeju-Lekki and Ikorodu) [21]. Urban communities are centred in Lagos Central and Lagos West while semi-urban communities are found within Lagos East senatorial district. Lagos State, also called the world's next 'mega-city' due to its increasing urban population growth and economic development, has an estimated population growth of 25 million with increasing poverty rate. The Oxford Poverty and Human Development Initiative (OPHI) in 2019 reported that 20% of Lagos population are vulnerable to poverty, as well as the intensity of economic deprivation in Lagos State stands at 41.1%, living below the national poverty line of 69% [22]. Lagos State health system exhibit medical diversity in Nigeria, which harmonize public, private and tradomedical facilities [23]. Though, Lagos State Monitoring and Accreditation Agency for healthcare facilities reported that state government are putting in place policies that will bring quality healthcare to all residents of Lagos State. Still, the public healthcare facilities are not well stocked, not well managed and have short staff shortages as well as many of the facilities are run down [23]. Women do not have access to adequate healthcare, as a lot of public hospitals are substandard and private hospitals are unaffordable [23]. The public healthcare provides services at the primary, secondary and tertiary levels and women receives ante-and post-natal care from both primary and secondary healthcare.

Sampling
Data was collected from a household survey of 1850 households conducted in September-November 2018. It was a baseline survey for an upcoming kidney health interventions. This purpose of the survey was to sensitize the public about kidney risk factors and its ailments as well as referring persons with kidney symptoms within the communities in the senatorial districts where the interventions and health facilities was presumed to be initiated. The justi cations for purposive sampling were determined by the urgent needs of the upcoming health intervention and sensitization programmes for women in their reproductive age, especially those with high risk factors. Multi-stage, strati ed and equal sampling techniques were applied to identify the households to be included in the survey. A mixture of random and purposive selection techniques were applied at each stage of sampling (Fig. 1). First, three senatorial districts by urban and semi-urban strati cation were purposively selected in the survey: Lagos West and Lagos Central (urban) as well as Lagos East (semi-urban). These three senatorial districts were selected as Lagos State Ministry of Health have proposed health intervention coverage scheme within the communities in these senatorial districts for easier dissemination of health information on kidney and its risk factors among women population. The three senatorial districts has twenty local government areas (LGAs): Agege, Ajeromi Ifelodun, Alimosho, Amuwo Odo n, Apapa, Badagry, Kosofe, Mushin, Oshodi Isolo, Ojo, Ikorodu, Surulere, Ifako-Ijaye, Shomolu, Lagos Mainland, Ikeja, Eti-osa, Lagos Island, Epe, and Ibeju Lekki. Second, the 2006 National Population Census gures did not include wards in the LGAs; however, the 1991 National Population Census contained the number of wards (246) in the 20 LGAs. Within the 20 LGAs in the three senatorial districts, 113 wards/constituency were randomly selected from 246 wards according to urban and semi-urban strati cation. Third, in each ward, we randomly selected 24 wards out of 113 wards at 40% by proportional allocation techniques [24], as health community workers are positioned in those selected wards by Lagos State Ministry of Health for the health intervention projects.
Fourteen communities were randomly selected from the 24 wards as they ts the criteria of being urban and semi-urban. Ten urban communities were randomly selected from Lagos West and Lagos Central senatorial districts (Okekoto, Keke, Alapere, Awodi-ora, Oko-oba, Agbarawu-Obadina, Oju-oto, Epetedo, Iwaya, and Igbobi) while four semi-urban communities were randomly selected from Lagos East senatorial district (Etita, Erodo, Ilara and Ijede) [21]. Fourth, the estimated number of households in the selected ten urban and four semi-urban communities in Lagos State population census gures was 119,452 using the projection formula [25].
where E = 2006 population; GR = Growth rate of 3.2%; n = number of years (1991 to 2018). While the sampling frame for this study was obtained by factoring in the 2016 projected population of the selected communities by the average household size of 6.5 [21], which gave a total of 18,377 including male and female population. The pre-census list was used to determine 1850 households containing childbearing women in the selected urban and semi-urban areas to avoid bias as well as to ensure equal chance of selection. A maximum of two respondents were recruited from each household obtained from a complete list of the 2006 enumeration areas (EAs) of the selected communities. Finally, a total of 850 childbearing women and resident in Lagos State for at least 5 years and aged between 15 and 49 years were purposively and equally selected from the sampled households. Besides, the purposive sampling technique was adopted from studies that have used this technique in selection of respondents and kidney diseases [26][27][28].

Data Collection
A pre-test structured questionnaire was deployed to collect information on socio-demographic factors, as well as knowledge and risk perceptions of KD as well as its risk factors. The initial draft of the knowledge and risk perception of KD questionnaire was generated through literature review of existing public [28][29][30] and related modi ed version of questionnaires [31][32]. The questionnaire was reviewed for content and face validity by medical sociologists (n = 2), demographers (n = 3), nephrologists (n = 3), and public health practitioners (n = 2). Internal consistency of the instrument was veri ed by the use of Cronbach's alpha (α) and was evaluated only between the risk perception questions, which had a uniform pattern of responses, based on the Likert scale as well as the instrument's heterogeneity of responses [33,34]. The higher the α coe cient, the more consistent is the questionnaire items in measuring the variables under study [33,35]. The Cronbach α was set at 0.5 for this current study.
The questionnaire instrument comprises 4 sections: the rst section included the socio-demographic status and the second section consists of self-reporting of medical/biomedical factors such as personal and family health history. The third section involves the lifestyle factors, which were documented among study respondents. The fourth section included the history of nephrotoxic medications intake (herbal supplement and herbal drink ingestion) which was assessed through self-reporting by the study respondents as well as anthropometric measurements (weight and obesity) were self-reported with clinical proof.
Research assistants were trained for data collection in August 2018 and data was collected in the randomly selected ten urban and four semi-urban communities across the three senatorial districts of Lagos state. Copies of the questionnaire were administered both in English and in the major local language in the selected study community (the Yoruba ethnic group). Permission to carry out the study in the selected communities was received from opinion and community (Baale) leaders. Data were collected on site during house-to-house visits that were conducted between 7am and 12 pm or at the nearest community public ground when respondents did not live far away from this facility as agreed upon by the study respondents. Data was collected from 850 respondents, and 825 questionnaires were included in the nal sample as they were completely lled as well as having adequate data for analysis. The University of Ibadan Social Sciences and Humanities Research Ethics Committee (SSHEC), Nigeria (UI/ SSHEC/14/0003), approved the study.

De nition of Terms
The de nition of terms used in this study were adapted from previous studies. For instance, self-reported history of hypertension with clinical proof was de ned as past medical history of hypertension, and/or the use of antihypertensive medication in the past three months prior to the study [36]. Obesity, measured by a body mass index, BMI ≥ 30 kg/m 2 [37], was also self-reported with clinical proof. KD Family history was self-reported with clinical proof; as it relates to having one or more family members with KD, dialysis, kidney transplant, or inherited disease (polycystic kidney disease) [38]. Diabetes was obtained from selfreported history, with the clinical proof use of insulin or an oral hypoglycemic agent [39]. Physical inactivity was de ned as less than 30 minutes of moderate activity per week or less than 20 minutes of vigorous activity three times per week, or the equivalent [40]. Personal history of pica craving in pregnancy was de ned as craving of substances with little or no nutritional value [41]. Kidney stone was self-reported, with clinical proof as a condition with clumps of mineral (calcium salts) in the kidney or lower down in the urinary tract [42]. Self-reported history of urinary tract infection (UTI) with clinical proof was de ned as an infection that affects the lower urinary tract [43].

Demographics
While the mean age of the respondents was 33.5 ± 11.5 years; the mean age in the urban communities was 30.2 ± 10.9 and that of the semi-urban communities was 43.7 ± 6.3 years (range 15-49 years). Most participants were less than 30 years old. Compared to semi-urban population, respondents from urban communities were younger and more educated, and had higher income in indicated in Table 1.  Similarly, ndings revealed that urban respondents had better knowledge of lifestyles risk factors than their semi-urban counterparts. Lifestyles risk factors such as poor diet high in salt (p < 0.00), alcohol (p < 0.00), poor nutrition during pregnancy (p < 0.03), and herbal drink ingestion (p < 0.00) were acknowledged in more than 50% of the urban respondents. Urban respondents compared to their semi-urban counterparts revealed that persons with medical/ biomedical factors such as diabetes (p < 0.00), family history of KD (p < 0.00), and hypertension (p < 0.00) are at risk of having KD [ Table 2]. As regards signs and symptoms, both urban and semi-urban respondents mentioned bloody/frothy urine (p < 0.02) and body swelling (p < 0.01) as possible signs and symptoms of having KD ailments [ Table 2]. Generally, 53.8% of the respondents had good knowledge of KD as against 46.2% of them with poor knowledge of KD [ Fig. 1].
Prevalence of self-reported risk-inducing factors among participants  Perception of kidney disease as well as its risk factors among participants Table 4 shows  Table 4].  Figure 3 shows an overall risk perception of the respondents in relation to KD development. Overall, a majority of women had low risk perception towards having KD as well as its related ailments (61.3%) as indicated in Fig. 3.

Selected Issues And Discussion
The results of this study showed an inadequate knowledge of the link between risk factors and KD as well as low perception of KD risk among women aged 15-49 years in Lagos State, Nigeria. The major self-reported lifestyle risk factors were misuse of analgesic, regular intake of herbal supplement and herbal ingestion. The medical/biomedical risk factors reported by the respondents were diabetes, hypertension, kidney stones and urinary tract infection. This is similar to the ndings in other global population-based studies [49][50][51][52] and Nigerian studies [11,12] of the same reported lifestyle and medical/biomedical risk factors conducted among female population in their reproductive age. Several studies has documented that chronic diseases such as hypertension, diabetes and urinary tract infection are the leading causes of KD among women during pregnancy [37,43]. However, other clinical studies have reported genetic causes as one of the medical/biomedical risk factors, that increases the chances of KD risk among women in their childbearing years or in pregnancy condition [53,54].
In addition, more than half of the studied respondents were not certain that misuse of prescribed medicine and analgesic could adversely affect the kidneys. Similarly, majority of the respondents have con dence that herbal supplements and herbal drinks are better remedies for chronic ailments such as diabetes and hypertension. Clinical studies in Nigeria have documented that herbal supplement and drink ingestion is a major causes of acute kidney injury, which has over the years increased CKD morbidity and mortality of individuals [55][56][57]. Health information on the adverse effect of the use of herbs in treatment of chronic ailments should be tailored to towards individuals who are involved in such practices especially in grassroots' communities. This will further enlighten them and make them to adopt good health seeking behaviour and take on healthy lifestyles.
Increased knowledge and awareness of KD risk were found among educated younger adult women (15-29 years) more than their counterparts with low education. Limited literacy encourages misconception, 'denial of medical reality' of chronic ailments, delayed diagnosis, poor lifestyle modi cations, increased morbidity and mortality in end-stage renal disease [58,18]. Adequate knowledge and awareness of health tips will encourage one adopting lifestyle modi cations and better management of risk factors [17,19].
Therefore, early identi cation and treatment of KD will reduce the rate of progression as well as burden of the disease complications, therefore enhancing the quality of life of women. Studies have shown that poor medical/biomedical knowledge of KD risk factors is much higher among the age cohort of 40-49 years in Nigeria [4,59] and in the female gender in an African-American population in their childbearing years in the United States of America [60][61]. Women in this age cohort (40-49 years) should be targeted for regular and comprehensive health education.
The study ndings also revealed that risk factors were more predominant among respondents with better KD knowledge and its contribution to kidney ailments. This may be assumed from 'denial of medical reality' that they are not susceptible to any chronic ailments. This could stem from their indifferent attitude of upbringing, cultural and religious beliefs of not allied with life-threatening diseases [62]. Most individuals do not want to come to terms with chronic ailments even if their lifestyles are pointing to health risks [62][63]. Therefore, knowledge and risk perception is becoming an increasingly important feature of health promotion of the prevention of chronic diseases such as KD [64][65]. Although, previous studies [66,67], have suggested a divergence between how individuals with KD risk factors perceive and understand their risk as well as the risk information provided to them by health workers. Appropriate health literacy and in-depth understanding of the risks associated with living unhealthy lifestyles will in uence and signi cantly stimulate positive responsiveness to have different assertiveness towards KD risk [65].
The respondents showed poor perception of KD risk factors. The most identi ed risk causes were lifestyle risk factors. About 61.3% of the respondents had low perception of not being susceptible to KD risk even though their self-reported risk factors pointed to KD risk. Women's poor perception could be linked to poor attitude towards KD risks: that is, it is not likely for them to have KD ailments despite their lifestyles. As a result of this, they may not take any KD cautionary measures leading to KD prevention. Hence, risk perception may be a strong motivating factor for behavioural change, particularly in 'high risk' individuals with prevalent risk factors to ensure perceived control over their actions and embrace behaviour modi cations [68].
Women who exhibited low risk KD perception could have arisen from the fact that they lacked con dence with regard to health information to understand KD lifestyle and its risk factors, which are a great concern to health stakeholders and professionals [69]. Women seem to believe that they are invincible and invulnerable to any disease development, which habitually leads to poor perception as they are susceptible to KD development [70]. That is, they often underestimate the risks associated with their behaviour (lifestyle and medical/biomedical risk factors). Health literacy interventions aimed at changing misconception and improving attitudes enhance better-adopted approaches in dealing with chronic illness.
Age (15-29 years), high level of education, high income and medical/biomedical risk factors (hypertension, diabetes and family history of KD) were associated with increased level of knowledge of KD. Similarly, age (40-49 years), and medical/biomedical risk factors (hypertension and diabetes) were independently associated with greater odds of respondents' KD risk perception. This is similar to the report of other studies [3,4]. Emphasis should, therefore, be placed on health educational intervention programmes that will be geared toward improving women's responsiveness and understanding towards KD as well as its risk factors. This will also assist to educate young and middle-aged women (≥ 30 years) on the various risk factors and the increased tendency towards developing KD on account of biological changes that are usually associated with increasing age of women during childbearing period.
Regular health check-ups are known to be effective in detecting and treating chronic diseases at an early stage. The ndings of this study showed that women were less likely to perceive the usefulness of regular health assessments as an effective KD preventive measure due to low perception of the association between risk factors and kidney ailments. This indication requires the need to increase efforts to reach out to women to educate them on the bene ts of regular medical check-ups and screening. In addition, some myths contribute to KD neglect in women. One of such is the persistent interpretation of health issues related to women through their reproductive capacity. As a result of this, misperception often occurs in risk factors associated with males, with KD perceived as disease of men. Diagnosed KD women are always identi ed among women with lifestyle choices residents in high-income countries [2,71]. In view of this, targeted policy programmes and health interventions among women should be highlighted and considered to meet the speci c needs and context of women in relation to non-communicable diseases, such as KD.

Conclusion
KD knowledge and its risk factors among women of childbearing age is quite high in Nigeria. Many of the respondents among the young and middle age cohorts had low risk perception towards KD development, with more prevalent lifestyle and medical/biomedical risk factors, which has severe health implications. Despite the respondents' knowledge on kidney disease and its risk factors, it could be deduced that respondents do not have appropriate information on the adverse effects of risk factors on kidney organ. It is pertinent to infer that respondents do not perceived that they are prone to KD and its associated ailments. Therefore, it is imperative that women should be provided an adequate knowledge and clari cation that being a female has higher chances of being at KD risk as a result of their anatomy. This recommendation could be achieved through sensitization, timely diagnosis and proper follow-up of women during public enlightenment programmes. In order to pose a positive impact on KD reduction among generations of women, KD advocacy programmes should be implemented across all levels of government. Furthermore, health demographers, sociologist as well as community health workers should strategize and design health intervention programmes that will assist and accommodate 'high risk' childbearing women in KD-related health facilities with chronic ailments. Women in the grassroots' communities should be targeted for KD screening programme and other chronic ailments as they do not have full access to health facilities in their various communities. Nigerian government should also intensify to provide a public KD health policy that supports behavioural interventions for women population in regard to their overall health.

Policy Recommendations, Study Limitations And Future Research Ideas
Knowledge of kidney risk was quite high among younger adult women aged 15-29 years and with their self-reported lifestyle risk factors, their perception towards kidney disease risk was low generally among the respondents. Younger women's predisposition to KD were 22% greater than young (19%) and middleaged women (13%). Most clinical studies only provided a gender-speci c prevalence of CKD, which was greater in females. Based on the outcome of this study, we recommend that women's health should be made a priority in health policies in order to improve a well-structured health programmes that will address the health needs of women, especially in the areas of non-communicable diseases. Urgent attention needs to be paid to preventive measures and intervention to slow women's involvement in unhealthy lifestyles.
Community health workers should be motivated to carry out awareness health programmes to discuss lifestyle and biomedical factors that predispose women to KD development during childbearing age.
Screening programmes and treatment facilities should be provided during awareness talks, especially in communities with high-risk populations for KD. Women who are diagnosed with KD before or during pregnancy should be given special medical attention and government should make a special medical insurance that will carter for such women with KD needs. Most of all, women in grassroots' communities should be targeted for KD related and other preventive health programmes.
This study had several strengths and limitations. The strength of our study, however, was a combination of multi-stage, strati ed and equal sampling method, and to a large extent a good coverage of urban and semi-urban communities where the study was carried out. The sample of the respondents who participated in the survey is large and allows for a robust analysis of the research problem. The study found a connection between KD knowledge and its risk perception among women of childbearing age from Lagos State of Nigeria. Based on the authors' knowledge, this study is the rst non-clinical study of its kind to address women-related KD as a topical, which has a re ective effect in urging women to know their medical history before prenatal periods.
One of the few shortcomings of this study is the adoption of cross-sectional research design which seems to provide a limited view of respondents' risk factors over time. In other words, the study did not include medical diagnosis of the diseases while detailed self-reporting was adopted. for those diagnosed with other common chronic diseases. The knowledge and risk perception issues that the researchers looked at were based on social matters and were measured with psychological scale of measurements [5,17,21,24]. The KD knowledge and its risk factors were self-reported, thereby making the concern of recall bias of importance. The determination of lifestyle and medical/biomedical risk factors did not involve the length of time they had such risk factors and such information was got during the research. In view of the cross-sectional nature of this study, we suggest that longitudinal studies on the causation between KD knowledge and its ailment progression should be considered in future health and demography surveillances sites or surveys.
Although the knowledge and medically scienti c analysis of the causes of KD within a population has signi cantly been improved in the recent times, the speci c opportunities for future research focus on key awareness disparities which occur in the developing countries, particularly in Africa. In spite of the fact that women are highly susceptible to KD development as a result of their biological and physiological make-up for child bearing, as well as addressing the knowledge and perception gaps among KD victims, women in their childbearing age remain one of the most crucial research areas that is continually being neglected. Research intervention and policy frameworks should be provided to stimulate thought and interests for future research among KD research community and health demographers. Consequently, this will improve the understanding of speci c KD policy interventions that will maximize health bene ts and minimize risks among women populations.  Level of perception of KD risk among participants