Original research•

Exploring rural households’ knowledge and perception of acute kidney injury in the southern region of The Gambia: a mixed-method community-based cross-sectional study design

Abstract

Background The Acute Kidney Injury (AKI) outbreak in The Gambia is a national tragedy attracting international concern, linked to nearly 100 deaths in children. This situation arose due to the use of contaminated medical products by children in the country.

Method We used a mixed-method, cross-sectional study design to assess households’ knowledge and perceptions of AKI in the southern region of The Gambia. A total of 2174 respondents from 123 rural communities were recruited via multistage sampling and were interviewed face-to-face using a questionnaire. Qualitatively, focus group discussions and key informant interviews were conducted. The collected data were analysed as categorical and continuous variables, and thematic areas using SPSS V.26 and NVivo software.

Results The mean age was 36 years (SD±14.17) and 70% of the respondents were women. Most respondents had no formal education (45.6%), lived in extended family households (55%) and 91.6% earned a monthly income of less than GMD5000 (Gambian dalasi) (<US$100). Although 80% of the respondents were aware of the AKI outbreak in The Gambia, 90% showed poor knowledge about the disease. Half of the respondents correctly identified contaminated medical products as the cause of AKI. Interestingly, 97.1% of the participants held a moderate perception of AKI in The Gambia and firmly rejected the notion that the outbreak was politically motivated. The AKI outbreak was viewed as a stern lesson and a wake-up call for the Ministry of Health to take the necessary actions.

Conclusion A significant deficiency in AKI knowledge exists among rural households, even though their perceptions of health services remain positive and unwavering. AKI is viewed as a widespread health concern rather than a political issue. To maintain this view and enhance trust, a national dialogue involving the Ministry of Health and the population is recommended.

What is already known on this topic

  • Acute kidney injury (AKI) remains a significant global public health problem and is ranked as the third leading cause of death in patients with trauma.

What this study adds

  • A significant knowledge deficit exists among rural households regarding AKI, yet their perception of health-seeking behaviour remains positive and resolute.

How this study might affect research, practice or policy

  • The Ministry of Health should intensify awareness creation during outbreaks and maintain positive perceptions of rural households on healthcare services.

Introduction

Acute Kidney Injury (AKI), also known as acute renal failure, signifies a sudden decrease in kidney function.1 This condition might be reversible if detected early and treated promptly with necessary medical interventions. AKI is the third leading cause of death from trauma following patients with haemorrhage and brain injury.2 This multifaceted health issue can manifest in both community and hospital settings, with numerous potential causes, such as infectious agents, toxic substances and surgical procedures.3

AKI is a significant global public health problem, affecting the health and well-being of millions of people across high-income, middle-income and low-income countries. The annual global burden of AKI exceeds 13 million cases, with 85% of these cases occurring in low-income and middle-income countries. The condition reportedly causes up to 1.4 million deaths per year.4 In low-resource settings, AKI accounts for more than 3% of hospital admissions.4 Despite the disparity in the prevalence of AKI between developed and developing countries, evidence suggests a higher incidence in developed nations.5

The WHO issued a medical product alert N°6/2022 on 5 October 2022, identifying four substandard (contaminated) paediatric medical products linked to an AKI outbreak in The Gambia.6 Manufactured by Maiden Pharmaceuticals Limited (Haryana, India), these products include Promethazine Oral Solutions BP, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup.6 This declaration thrust The Gambia into global spotlight concerning AKI outbreak among children.

Before the WHO alert, Epidemiology and Disease Control (EDC) unit of the Ministry of Health (MoH) in The Gambia released a report on AKI in children under the age of 5. According to this report, 32 children developed AKI, with 28 fatalities representing an 87.5% mortality rate.7 An updated report from the EDC, dated 14 October 2022, revealed a cumulative case count of 82 children and a cumulative death rate of 85.4%.8 The update provided preventative measures for the public, including advising against self-medication for children and avoiding certain syrups and all Maiden Pharmaceutical Limited Products.8 The Ministry and Gambia Red Cross Society subsequently recalled over 22 000 bottles of these syrups from the communities.8

This AKI situation is deemed a national tragedy, with various stakeholders, including the government, civil society organisations, child protection agencies, political groups and individuals expressing their concerns. The MoH continues to engage the population via various media outlets such as radio and television. Therefore, we conducted a study to assess knowledge and perceptions of AKI among households in The Gambia. The findings revealed gaps in knowledge and varying perceptions about AKI, thereby highlighting the need to strategise ways of enhancing health-seeking behaviours during this challenging period.

Methods and materials

Study design and setting

A mixed-method, cross-sectional study design was employed to assess the households’ knowledge and perception of AKI in the southern region of The Gambia. Our study incorporates both quantitative and qualitative data. To identify the communities most affected by AKI, we used the most recent situation report from the EDC detailing the distribution of AKI cases by districts.

The Gambia is among the smallest countries in West Africa; it has an estimated population of about 2 million, a land size of 11 000 km2 and the country is divided into two equal halves (North and South) by the river Gambia.9 The country is further divided into eight local government administrative areas (LGAs), and this study was conducted in four LGAs: Brikama, Mansakonko, Janjanbureh and Basse.

The study participants included community residents who had lived for more than 6 months preceding the study, attained age 18 years and above, and consented to participate. Non-residents and guests were excluded from the study. The outcome variable of the study was knowledge and perception of AKI in The Gambia. The explanatory variables included sociodemographic variables such as age, gender, ethnicity, education level, occupation and income.

Data collection

Data were collected via a combination of face-to-face interviews using structured questionnaires, focus group discussions (FGD) and key informant interviews (KII). The structured questionnaire served as a means for gathering quantitative data, encompassing socio-demographic variables such as age, gender, marital status, educational level, family type, monthly income, number of children less than 5 years, occupation, sources of drinking water and experience flooding in the last rainy season. The knowledge section included knowledge about AKI, sources of information, signs and symptoms, knowledge on AKI health seeking, diagnosis, treatment and transmission. The perception part included the existence of AKI in The Gambia, causes of AKI, treatment of AKI by traditional medicines, linkage of AKI to weak drug regulations, perception of healthcare service satisfaction and whether AKI was politically motivated.

The structured questionnaire was adopted from studies conducted in sub-Saharan Africa10–15 and standardised to the local context of AKI injury in The Gambia. The structured questionnaires were pretested among Gambia College students at the Brikama campus to ensure reliability and validity. We then ran a reliability test and calibrated the tool to have a Cronbach alpha score of 0.82, which is above the usual threshold of 0.70. The structured questionnaires were deployed on the KoboToolbox, which is a common Open Data Kits (ODK) for researchers in developing countries.

In the qualitative phase, we conducted twelve FGDs with specific cohorts; including three cohorts of teachers and traditional healers, two cohorts of students, traditional communicators and healthcare workers, respectively. Each FGD cohort was homogenous, with specific characteristics depicting their involvement in the discussion. Similarly, we conducted eight KIIs with three healthcare administrators, three community leaders (Alkalos) and two youth leaders. These discussions and interviews were centred around their understanding of AKI, the impact of the outbreak on healthcare service delivery and strategies for preventing and controlling such outbreaks in the country.

The entire data collection was carried out by 200 students from the School of Public Health at Gambia College from 5 January to 20 January 2023. The students had 2 days of training on the data collection tools and the interview techniques including translation of key terms into three local languages, namely Mandinka, Fula and Wolof to avoid ambiguity. Before the data collection, consultative meetings were held in December 2022 with regional authorities such as Regional Governors, Local Government Authorities, District Chiefs, and Village Alkalos to inform and seek their consent for the study.

The students used Android phones equipped with the KoboToolbox application, a platform for data gathering. The questionnaires were entered into the KoboToolbox application, thus creating a user-friendly interface for data collection. The questions were deployed in the ODK application, and compulsory questions were marked, which if not answered, the interviewer could not proceed to the next question. An additional unique feature of the application was its ability to capture the geo-coordinates of the communities in different districts, offering additional insights into the study areas. For FGD and KII, voice recorders were used to capture detailed information. This comprehensive approach to data collection allowed us to gain in-depth insights into the community’s knowledge and perceptions of AKI.

Sampling and sample size

We employed a multistage sampling technique to select communities, households and individuals for the interviews. The process was initiated by randomly selecting communities within each LGA boundary proportionate to the effect of AKI outbreak in the Lower River Region—25 communities, West Coast Region—23 communities, Central River Region—35 communities and Upper River Region—40 communities as in figure 1.

Figure 1
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Figure 1

The map is adapted from the Ministry of Health’s Epidemiology and Disease Control Acute Kidney Injury updates prepared on 14 October 2022. AKI, acute kidney injury.

Additionally, proportionate sampling was used to determine the necessary sample size per community based on the population of each community. At the community level, households were selected randomly using a taxpayer’s list provided by the Alkalo of the local villages. A random number table was generated on the basis of four digits, and selection was done using a blind guess to point to a number. The next three digits were also selected until the required household sample was met. Finally, a simple random sampling method was used to select the respondents from each household. To be eligible for participation, respondents had to be residents of the selected household for at least 6 months and 18 years or older. However, guests and individuals who were sick were excluded from this study.

The estimated minimum sample size was calculated using the Epi Info software V.7.0. Using The Gambia’s projected population of approximately 2 million, we used a 95% CI, a design effect of 0.05 and a precision of 99.9%. This estimation led to a sample size of 2000 respondents from selected households in AKI-affected districts across enumeration areas. With incomplete records and a non-response rate of 8.7%, we then recruited and interviewed 2174 respondents.

Statistical analysis

Before data analysis, the questionnaires were checked for completeness, entry errors and missingness by data collectors and supervisors during data collection. The data was then exported to Microsoft Excel for further checking and cleaning and imported to the Statistical Package for Social Sciences (SPSS) for analysis. Data were analysed using the IBM statistical package SPSS V.26.0.

Quantitative data were analysed and displayed as frequencies and percentages for categorical variables, whereas continuous variables were summarised using mean and range. To identify statistical associations, we employed bivariate analysis and multivariable logistic regression; thus, the significance level was set at p valve<0.05.

Qualitative data were analysed using NVivo software V.14. The authors translated and transcribed the original recorded versions of the discussions in local languages into English, leveraging their fluency in different local languages. The translated responses were then grouped into thematic areas for further analysis.

In this study, the AKI outbreak in The Gambia refers to an abrupt decrease in kidney function, which encompasses both injury (structural damage) and impairment (loss of function), affecting Gambia children alleged to be associated with the consumption of contaminated paediatric syrup. Respondents’ knowledge was assessed based on a set of nine questions. Part of the question items on knowledge was if they had ‘heard of the current AKI outbreak among children in The Gambia’. Responses were aggregated and classified into good, average and poor knowledge categories. Each response was dichotomised, with a ‘yes’ response scored as 1 and a ‘no’ response scored as 0. Composite knowledge scores were then calculated and grouped into poor, fair and good knowledge categories, corresponding to the 33rd, 66th and 99th percentiles. The respondents’ perception was evaluated using a 12-question Likert scale, ranging from 1 to 5 points; ‘strongly agree’ was scored as 5, ‘agree’ as 4, ‘undecided’ as 3, ‘disagree’ as 2 and ‘strongly disagree’ as 1. Perceptions were categorised into low, medium and high groups, corresponding to the 33rd, 66th and 99th percentiles, respectively.

Patient and public involvement

Consultative meetings were held at regional government levels (governors’ office, regional health directorates and regional education directorates) to inform and obtain consent for the study to be conducted in their respective regions.

Results

This study was conducted across 123 communities in four regions of The Gambia’s South Bank: Lower River, West Coast, Central River and Upper River Region. A total of 2174 respondents from these communities, located in the selected LGA, participated in the study. As indicated in table 1, the average age of the respondents was 36.41 years, with a SD of ±14.17. The age group of 31–43 years represented 26.2% of the study participants. Women accounted for over 70% of the participants (n=1535), and 82.6% (n=1795) of the respondents were married.

Table 1
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Socio-demography characteristics of respondents

With respect to education, nearly half of the respondents (45.6%, n=990) had not received formal education. More than half of the respondents (55%, n=1195) lived in extended family setups with up to two children under 5 years of age in approximately 57% of the households. The majority of respondents (90%) reported a monthly income ranging from GMD100 (Gambian dalasi) to GMD5000, with an average monthly income of GMD2203.25 and a SD of GMD2814.86. Farming was identified as the predominant occupation of the participants. Less than 18% of respondents access their drinking water from pipe-borne water provided by the National Water and Electricity Company (NAWEC). Over 42% of the respondents reported experiencing flooding in the previous rainy season, with slightly more than 10% asserting that the flooding affected their drinking water supply.

Figure 2 below provides insight into the family history of non-communicable diseases as reported by the study participants. The data revealed that over half of the respondents (51.5%) acknowledged the prevalence of hypertension in their family members.

Figure 2
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Figure 2

Pie chart showing the reported family history of non-communicable diseases.

Figure 3 shows respondents’ knowledge of kidney function. More than 67% of the respondents reported that they did not know the functions of the kidneys and 21.4% reported that the kidneys produce urine.

Figure 3
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Figure 3

shows respondents’ knowledge of kidney function.

Knowledge of AKI

From the data in table 2, it is evident that over 80% of the respondents in our study had heard about the AKI outbreak among children in The Gambia. A significant proportion (47.4%) reported having heard of this condition from radio broadcasts. Most respondents recognised the primary symptoms of AKI, such as fever, inability to pass urine and diarrhoea, with proportions of 13.2%, 8.6% and 8.6%, respectively.

Table 2
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Showing knowledge of acute kidney injury (AKI) among children in the Gambia

Furthermore, 97.7% of the respondents indicated that the diagnosis and management of AKI could be sought at health facilities. However, only a minority (3%) reported that traditional healers could address AKI. Almost half (48.6%) of those surveyed attributed the cause of AKI in children in The Gambia to contaminated syrup, aligning with findings about an outbreak traced to a single Indian manufacturer’s syrup-based paediatric medication. Meanwhile, more than three-quarters of the respondents (78.9%) were aware that AKI was not a contagious disease. Additionally, 12% of the respondents stated that they knew about an AKI case personally. Based on the composite score of knowledge, our study revealed a significant knowledge gap about AKI: 9 out of 10 respondents had limited knowledge about the disease. This highlights the need for more widespread education and awareness campaigns on AKI.

Perception of respondents on acute kidney injury

Respondents’ perceptions regarding AKI are summarised in table 3. Nearly a quarter (24.7%) of the respondents strongly agreed with the statement ‘AKI does not exist in The Gambia’. When queried about the causes of AKI, 35.3% and 35.8% of the respondents agreed that the condition could be attributed to contaminated paediatric syrup and contaminated drinking water, respectively. Approximately 30% of the respondents were uncertain when asked if traditional medicine could be a potential cause of AKI. The issue of confidence in the local health system was also touched on, with 24.7% of respondents reporting a loss of confidence due to the prevalence of AKI in The Gambia. In contrast, 28.7% of the respondents disagreed with the statement, ‘We are not satisfied with our family members continuing to receive routine immunization because of AKI.’ Regarding political motivation, more than a quarter of the respondents strongly disagreed that AKI in The Gambia was politically driven. On analysing the responses, it was concluded that 97.1% of the study participants had a medium level of perception of AKI.

Table 3
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Perception of respondents on acute kidney injury

Table 4 presents the results of multivariate logistic regression analyses predicting the knowledge of AKI among the respondents. Several variables were found to be significant predictors. In the age category of 44–56 years, there was an increased likelihood of possessing knowledge about AKI compared with the 18–30 age group, with an adjusted OR (aOR=1.840, 95% CI: 1.019 to 3.322). Education level has also emerged as a key predictor. Respondents with tertiary education were found to have increased odds of having AKI knowledge by a factor of 5 (aOR=5.297, 95% CI: 1.893 to 14.822) compared with those with no formal education. In terms of occupation, farmers had a more than twofold increase in the odds of AKI knowledge (aOR=2.257, 95% CI: 1.382 to 3.686) compared with unemployed respondents. Conversely, extended family members demonstrated a slightly reduced likelihood of AKI knowledge (aOR=0.920, 95% CI: 0.736 to 1.149) compared with single parents.

Table 4
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Multiple logistic regression showing predictors of AKI knowledge among respondents

The qualitative of AKI focus group discussion and key informant interviews

Opinion about AKI in The Gambia

Participants expressed their opinions about the outbreak of AKI as unfortunate and associated with either intrinsic or extrinsic factors:

….AKI came about as intrinsic factors such as the prevailing self-medication practices, poor periodic screening habits and late hospital consultations etc. Extrinsic factors include, poor licensing and certification, lack of healthcare auditing, poor infrastructure and lack of medication as well as limited medicalized support………

opinions about the deaths of children under the age of 5 due to AKI, students’ group have described the death of children under the age of 5 as

…… a tragedy that will forever be remembered in the history of the Ministry of Health. We know that children are vulnerable to many adverse circumstances, but this situation is beyond our imagination. Children are the future leaders; hence, they should be supported and protected……

The impact of the under 5 mortalities

The expressions of parents, teachers and healthcare workers deduced that:

…… it is unimaginable to lose your adorable child; the trauma is heart-wrenching, painful, and thought-provoking. We were all affected and shared the sorrow with our fellow citizens and the situation has exposed the shortcomings of our health care system. This is a bitter lesson for everyone to learn………

factors leading to AKI in your community and country at large

Participants expressed that……. The Ministry of Health has been twisting the narrative about AKI and to some extent, we are confused about the factors leading to AKI. They initially told us that AKI was caused by contaminated syrups, and they recalled almost all syrups in our communities. They also told us that flooding was the cause of this, and at another time, they said it was an unknown cause. We are still in a dilemma as to the cause of the disease………

Prevention of AKI

Participants recommended that AKI……… This unfortunate incident could have been prevented if the state put up stringent regulations about testing all medicines, provided laboratories and monitored and supervised health services. We are calling on the state to hold people complicit and responsible in this situation……

Discussion

The recent outbreak of AKI in The Gambia, which tragically claimed the lives of almost 90 children, has drawn the attention and concern of both the national and broader international community. Suspicions have arisen that the outbreak is connected to importing and selling contaminated paediatric syrups, placing The Gambia’s MoH under scrutiny. To mitigate public fear and concern, a study was conducted among rural inhabitants to gauge their understanding and perception of AKI outbreak. Notably, this study is the first conducted among the general population since the outbreak commenced.

The study surveyed over 2100 individuals across 123 communities in four regions, probing their knowledge and understanding of the AKI outbreak in The Gambia. The findings revealed that nearly 70% of the respondents were women, and 47% were farmers. Furthermore, an overwhelming majority (91.6%) had a monthly income of less than GMD5000.00. These align with the World Bank Poverty and Gender Assessment 2022, indicating a natural poverty rate exceeding 50%.16 Interestingly, our study found fewer than 20% of rural residents obtained drinking water from NAWEC. This suggests that their drinking water may not have undergone any form of treatment before consumption. The Gambia Bureau of Statistics' 2018 Multi-Indicator Cluster Survey report corroborates this finding, showing that approximately 19% of rural dwellers source their drinking water from tube wells or boreholes.17

The Ministry had previously linked the AKI outbreak to contamination of drinking water due to flooding, our study revealed that nearly 43% of the respondents were impacted by flooding, and only 11% reported that the flooding affected their drinking water supply. However, our study could not verify the exact cause of this outbreak.

Our study found that over half of the participants reported family history of hypertension. However, if this figure is ascertained then it is nearly twice as high as the national prevalence of hypertension in The Gambia, which is 29% according to a study conducted by Cham et al on the burden of hypertension in the country.18 Unfortunately, our findings also suggest a significant lack of knowledge about kidney function, with almost 70% of the respondents being unable to explain the function of the kidney. This gap in understanding may contribute to the overall knowledge of AKI. Furthermore, we noted that fewer than a quarter of the participants correctly identified up to three signs and symptoms of AKI, indicating a substantial lack of awareness about the disease. The MoH has reported six major signs and symptoms of AKI: fever, vomiting, little or no urine, cough, runny nose and diarrhoea. Despite this knowledge gap about the disease, the health-seeking behaviour of the respondents appeared to be positive and proactive, with many inclined to seek immediate care at the nearest health facility when faced with health concerns. The Gambia’s policy of providing access to a healthcare worker within every 5 km radius has undoubtedly facilitated this trend, particularly among rural residents.19

Our research also revealed that nearly half (48.6%) of the study participants reported that the AKI outbreak among Gambian children was due to contaminated paediatric syrup. This finding aligns with the WHO’s medical product alert on substandard paediatric syrup4 and research by Bastani et al, which indicated that AKI in The Gambia was likely linked to contaminated medications.10 Nevertheless, this understanding conflicts with some reports from MoH, which at some point suggested that flooding was the cause of AKI. Similarly, more than 46% of the respondents indicated that the cause of AKI in The Gambia remains unknown. This uncertainty is likely due to the MoH’s failure to definitively identify the cause of the disease, which has tragically claimed the lives of more than 90 children in the country.

Our study uncovered a significant knowledge gap concerning AKI among rural households, even though their perception remains unclear. Over a quarter (33.3%) of the respondents believed that the incidence of AKI in the country could be attributed to poor drug regulation. Meanwhile, 24% and 28.7% of the respondents denied that AKI had caused them to lose confidence in the health system or that their family members would discontinue routine immunisation due to AKI, respectively. These findings underscore the importance of rural households in healthcare services, likely because they do not have many alternatives. Intriguingly, over half of the respondents dismissed the notion that the country’s AKI situation was politically motivated. The outbreak coincided with the country’s political and election seasons, but the deaths of children from AKI were seen as an unfortunate reality rather than a piece of political propaganda. Our study revealed a moderate perception of approximately 97%, indicating that the AKI outbreak did not severely affect rural households view of the country’s healthcare services. The knowledge of AKI among our respondents correlated statistically with respondent age, education level, occupation and family type.

Limitations and strengths

AKI is known to be caused by various factors, but infectious and non-infectious causes are notable. However, the MoH has blamed the current AKI outbreak on three different causes: contaminated paediatric syrup, contamination of drinking water supply by flooding or AKI of unknown causes. This has limited this study to expand and consider other causes of AKI.

Transcribing certain phrases from the local language into English may lead to slight alterations. One primary limitation of the study is gender disparity, largely due to the study’s timing. During the time the study was conducted, a significant portion of the male population had finished their agricultural duties and migrated to urban areas for employment. Information bias could be introduced during the interviews, as respondents might either under- or over-report their circumstances.

On a positive note, the study possesses numerous strengths. These include a well-developed study methodology, triangulation approach (incorporating both qualitative and quantitative aspects), a substantial sample size and a variety of socio-cultural contexts. The study’s findings can be generalised to all rural inhabitants, as their socio-cultural backgrounds align closely with those in the country’s northern region.

Conclusion

Despite widespread international and national concerns regarding the outbreak of AKI among children in The Gambia, our study confirmed limited knowledge about the disease among respondents. Interestingly, 80% indicated awareness of AKI in The Gambia, but 90% displayed a poor general understanding of the disease. Therefore, it is critical for the MoH and its partners to intensify awareness campaigns, particularly targeting rural communities during such outbreaks. Effective engagement can be achieved through community outreaches, reproductive clinics, mass media, open field days and traditional communicators. Notably, almost half of our respondents associated the AKI outbreak with contaminated syrup, although some uncertainty persists as the exact cause remains under investigation by the ministry. The survey also revealed a moderate perception of AKI, with respondents suggesting that the outbreak had little to no effect on their health-seeking behaviours and acceptance of services such as routine immunisation. AKI is perceived not as a political issue but as a significant concern affecting everyone. Consequently, MoH and its partners should strive to maintain this perception among rural dwellers. National dialogue is recommended to establish trust between MoH and the population.

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