Education interventions
Education interventions for patients with CKD vary in terms of their methodology, intervention type and outcomes. Some studies have used education tools such as worksheets to teach patients about CKD. The one-page worksheet proved effective in that patients who took part in the study had an improved their knowledge about their diagnosis, their kidney function and eGFR compared to controls [57]. Another study involved a multidisciplinary team for the care of pre-dialysis patients. The program was beneficial but it required: early patient referral to the nephrology centre, adequate resources for staff and infrastructure, and available resources for patients with ESKD [58].
Patients and health-care providers continuously access health information online. Not all information is reliable therefore it is important that patients are directed to the right sources. These sources are generally associated with a Professional Nephrology association or consumer organisations that have links to professional organisations. Some of these include the National Kidney Disease Education Program (NKDEP), The National Kidney Foundation, Kidney Health Australia, National Kidney Federation, The Kidney Foundation of Canada and Pró Renal from Brasil. Their website addresses can be found in Table 2.1. These organisations provide evidence-based patient information and resources along with a platform for patients to communicate with others.
The future of education interventions will most likely involve face-to-face interaction between patient and health-care provider combined with information technology (IT) [59]. The current high internet and mobile phone use means that patients have the technology to access information, however the target patient population and the type of technology used should be considered. In the iNephro study it was identified that users of the ‘Medication Plan’ smart phone application were predominantly middle-aged, well-educated and relatively healthy males [59]. The target population for CKD is generally people over the age of 50 who may also have other comorbidities such as diabetes, hypertension or CVD. The application and health programs need to be user friendly and preferably interactive to enable patient feedback.
Other IT delivery methods include Telehealth interventions such as the delivery of telephone-based educational materials and prompts via landline and video-conferencing of clinical visits. Interactive voice response system (IVRS) applications are easy to use, can be accessed from any phone and may therefore appeal more to an older patient group. Personal health record (PHR) for use by patients to communicate with their health care provider are becoming more widely used, but the
personal health records (ePHR) identified that patients with internet access and post-secondary education were more likely to indicate their intentions to use an ePHR. They indicated ePHR would facilitate greater involvement in their own care and improve access to lab results and health information. Privacy concerns were reported but they were not associated with intent to use an ePHR [60].
Educators
Teaching should take place in either a primary, secondary or combined health-care setting. This would allow key stakeholders to provide adequate patient care and education and a greater access to resources for patients. Educators should include primary care physicians, nephrologists, nurses and allied health care professionals including pharmacist, nutritionist, psychologist, social worker and physiotherapist. Education should begin once the patient has surpassed the initial diagnosis stage so they are more receptive to the information given. It should also be frequent as there is a vast amount of information to be acquired [39]. A study on patient priorities has shown that patients identified the hospital consultant as the most useful resource followed by the dietitian, renal community nurse and renal unit nurse. The General Practitioner, self-help groups / patient associations, pharmacists, family and friends were seldom used as sources of information. Participants valued face to face education interaction the most, on their own and with their family [35].
In order for education to be standardised and taught in a diverse setting, National Standards for CKD education will need to be developed. These standards could be based on the diabetes self-management education standards which focuses on: programme structure - key stakeholders, participants, providers, curriculum, resources; the process of education, assessment and the outcomes including quality improvement measures [61].
Patients and carers
It is apparent that patients are not satisfied with the amount of education being given as their information needs have not been met. Patients’ awareness about CKD, its management, and knowledge about preventing its progression is also limited [62]. This issue has been ongoing for decades and is not isolated to the CKD community but within general patient education [63].
Possibly the main barriers to the implementation of patient education interventions is the lack of coordination of services, inadequate preparation of physicians, nurses and educators and lack of interest from administration [63].Coordinating education programs with other established institutions such as the Diabetes Association and the Heart Foundation may be an effective way of delivering information to CKD patients.
2.7.1 Other future strategies for CKD
The World Health Organization (WHO) has developed a non-communicable diseases action plan to be implemented from 2013 to 2020. This focuses on reducing four modifiable risk factors, namely tobacco use, unhealthy diet, physical inactivity and harmful use of alcohol. There are nine target areas to be addressed by 2025 which include: reducing premature death of CVD, cancer, diabetes or chronic respiratory diseases by 25% in those aged between 30 to 70; reduce harmful alcohol intake by 10%; reduce prevalence of physical inactivity by 10%, salt intake by 30%, tobacco use by 30%, the prevalence of high blood pressure by 25%, stop the rise in diabetes and obesity, increase availability of preventive therapy for heart attacks and strokes for 50% of people, and an 80%
availability of affordable technology and medicine to treat non-communicable diseases. It is estimated that the cost of implementing the Global Action Plan will be $11 billion per year, while the estimated loss of productivity and health care cost without taking action will be $7 trillion over
the next 20 years. By taking action against the four risk factors, the resulting reduction in CVD, cancer, diabetes and chronic respiratory diseases [64] will directly affect the incidence of CKD.
CKD promotion needs to be escalated in the national agenda so that changes to the Australian health care system can be implemented. General practitioners will have a key role to play in the early detection of the disease and in coordinating continuity of care. Healthcare education needs to incorporate learning outcomes that include symptom control and quality of life matters [65].
Research that focuses on the prevention of CKD and the reduction of symptoms should be included in the research priority list [66].