Study design and setting

A descriptive qualitative study was conducted to explore the perspectives, experiences, and insights of healthcare providers and other stakeholders regarding the barriers and enablers of CKD management. The study’s major emphasis was on healthcare practitioners working at different healthcare levels, primarily in the Amhara region, including tertiary, secondary, and primary levels of healthcare. The Amhara region was purposefully selected for this study as it is one of the most populous regions in Ethiopia with a high burden of CKD [26]. Reporting of this study was guided by the consolidated criteria for reporting qualitative studies (COREQ) checklist [27] (S1 Appendix).

Participant selection and recruitment

Participants were identified using purposive sampling with maximum variation, supplemented by snowball sampling. Eligible participants were health care providers (general practitioners (GP), nephrologists/internists, and nurses working at the dialysis centre) and non-communicable disease (NCD) program officers and coordinators. We included adults aged 18 years and older, working at least six months in their current role. To confirm a variety of perspectives, diverse recruitment strategies were employed. Initially, we contacted a senior nephrologist (WH) working at tertiary referral centre. We approached participants by sending an invitation letter using personal email and other social media platforms. Diverse participants were approached using a snowball tactic from the primary participants. Potential participants were also invited through department heads with a formal letter. Interested individuals received consent forms and detailed study information by email or preferred channels. The recruitment period was from 15/02/2024 to 20/12/2024. The concept of information power was used to check sample size adequacy, as participants had substantial experience relevant to the study focus [28] (S2 Appendix).

Data collection

Semi structured interviews were conducted on a purposive sample of 15 participants via Zoom, WhatsApp, or telephone, as appropriate. Each interview lasted approximately 35–54 minutes. The semi-structured interview guide was developed based on a review of documents and guidelines on barriers and facilitators to CKD management (S3 Appendix). Due to the impacts of ongoing armed conflict, especially in the Amhara region, all interviews had completed remotely. The war imposed significant security risks, making travel to certain areas unsafe and limiting the feasibility of in-person interviews. Furthermore, the instability in the region disrupted normal operations in many health facilities, making it difficult for participants to allocate time for face-to-face meetings. Thus, online interviews allowed participants to join from their respective locations without compromising safety [29]. It also enabled the inclusion of diverse perspectives across different levels of healthcare settings, which might not have been possible given the current situation. There were, however, challenges associated with conducting interviews online, including unstable internet connections, limited ability to observe non-verbal cues, and potential distractions in participants’ environments [29,30]. To mitigate these challenges, we maintained flexible scheduling and fostered a supportive interview environment.

The interviews were conducted in Amharic language by DK (PhD candidate), who is trained in qualitative methodologies. The participants had no personal or professional relationship with the interviewer, which allowed participants to express their opinions freely. Interviews were audio recorded and transcribed verbatim by research team members. We also collected demographic and practice information, including participant’s age and number of years in current role, to provide aggregate descriptive information on study participants. Further contextual information is provided in context box below (Box 1).

Reflexivity

The lead researcher (DK), an Ethiopian conducting a PhD at UNSW, reflected on how positionality might shape data collection and interpretation. Being Ethiopian facilitated cultural understanding and rapport with participants, enabling open discussion of sensitive topics, including conflict-related service disruptions. Conducting the study from abroad required careful attention to ensure neutral probing and avoid imposing assumptions. All quotations are presented verbatim to preserve participants’ perspectives, and analysis was conducted collaboratively with the research team to minimise individual bias.

Conceptual framework

We used the Theoretical Domains Framework (TDF) version 2 to guide the interviews and describe the enablers and barriers derived from the data. TDF synthesises 128 constructs from 33 behaviour and behavioural change theories clustered into 14 domains [31]. Using TDF to explore barriers and enablers of CKD care provides a structured, theory-driven approach to understanding health care providers’ and stakeholders’ behaviours. TDF integrates multiple behaviour change theories into 14 domains, capturing key influences such as knowledge, skills, social influences, and environmental context and resources (S4 Appendix). By mapping data onto TDF domains, the study can link barriers and enablers to evidence-based behaviour change strategies.

Trustworthiness of the data

To ensure trustworthiness of the data, criteria of credibility, dependability, confirmability, and transferability were applied throughout the research process [32]. Credibility was enhanced through prolonged engagement with the data, iterative coding using NVivo software. Including a diverse participant across disciplines and healthcare levels enhanced transferability. Dependability was ensured through careful coding of transcripts and documentation of coding frameworks in NVivo to support transparency and consistency (S1 Table). To establish confirmability, data were continuously checked and rechecked throughout the study to address any potential biases.

Data-analysis

Verbatim transcripts of the interviews were reviewed and checked with the audio recordings for accuracy. Transcripts were checked by multiple researchers in the team (DK, RJ, MJ, SK, and WH) who made initial notes and identified potential codes and themes. Transcripts were uploaded to NVivo 14 [33]. We used a deductive strategy guided by the TDF within a reflexive thematic analysis approach to code, interpret, and iteratively refine themes. Transcripts taken from the interview were carefully read and coded independently by two research team members (DK and RJ). An initial coding scheme was created using line-by-line analysis and constant comparison. Transcripts were closely followed to maintain the original meaning of the data. After coding all the transcripts, similar codes were grouped together and rearranged. Transcripts were revisited to ensure all concepts were being captured. Any conflicts in the coding process were resolved through regular discussions until consensus was reached.

Ethical approval and considerations

Ethical approvals were granted by the University of New South Wales (UNSW) Human Research Ethics Committee (HREC) (iRECS5094) and the Amhara Public Health Institute (RERC: NoH/R/T/T/D/07/59). Written informed consent was obtained electronically before participation. Participants were emailed an information sheet and consent form, which they signed and returned prior to the interview.

Demographic characteristics of participants

A total of 15 participants were recruited and included in the analysis: six general practitioners, five nephrologists or internists, one nurse, and one NCD officer and two NCD program coordinators. Among 15 participants, 6 (40%) had been in their current roles for six years or more at the time of interview, and 73% were male. Participants were aged 20–60 years and had between 1 and 15 years of experience in their current roles (S2 Table).

Relevant TDF domains

Thematic analysis identified 8 out of 14 themes aligned with the TDF domains, including environmental context and resources, knowledge and skill, memory, attention and decision processes, beliefs about consequences, emotion and psychological strain, social or professional role and identity, and reinforcement and behavioural regulation (Fig 1).

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Fig 1. Conceptualising barriers and enablers of CKD management using the Theoretical Domain of Framework.

https://doi.org/10.1371/journal.pone.0336781.g001

Barriers to CKD management

Lack of short term nephrological training

Physicians identified the lack of short-term in-service nephrology training as a critical barrier to CKD management, while other participant emphasised the absence of formal dialysis-specific training opportunities.

“Even though we are interested in providing better care, we have not received any training specific to dialysis, so we are not fully confident in the service we provide.” (P09, Nurse).

Domain 2: Environmental context and resources

Environmental context and resources emerged as a key domain influencing CKD management. Participants identified a range of health system barriers to CKD management, including challenges related to workforce, financing, governance, service delivery, health information systems, and access to essential medicines and technologies.

Service delivery and medical products

Participants highlighted several service delivery barriers, particularly regarding medication access and medical equipment availability. One key issue raised was the disruption in the supply of medications and essential medical equipment, which impacts the ability to provide consistent care.

“At the hospital where I currently work, we serve a catchment population of over 10 million people, yet there is not a single dialysis centre. There is no dedicated care unit for CKD, and we do not even have a nephrologist on staff. The government does not prioritise CKD sufficiently, and the number of nephrologists is currently very low.” (P03, Internist).

Health information system

Healthcare providers identified challenges in the availability of CKD data, including a lack of registry for CKD.

“Another important issue is the lack of a data reporting format for CKD that would enable healthcare providers to receive feedback from higher officials. For instance, there are monthly, quarterly, and annual plans for conditions like hypertension and diabetes, and underperformance in these areas requires justification. However, this is not the case for CKD. As a result, healthcare providers tend to overlook CKD” (P10, GP).

Health workforce

Health workforce limitations were widely noted, with most participants highlighting critical shortages of trained personnel (nephrologists, dieticians, and dialysis nurses).

“There is insufficient government attention to CKD care in general, with a critical shortage of nephrologists and other trained healthcare providers. Nephrologists are primarily confined to teaching referral hospitals, while general hospitals increasingly rely on internists to manage cases due to the lack of specialised personnel.” (P06, GP).

“Once a patient is diagnosed with CKD, the management goes beyond just medications. It involves other aspects like nutritional therapy, counselling, and financial support, as both medications and lab tests can be very expensive. One major challenge is the lack of a dietitian, so nutritional counselling is provided by non-dietitian personnel.” (P05, Nephrologist)

Ongoing armed conflict

Participants noted that ongoing conflict since November 2020 has severely impacted healthcare, leading to medication shortages, supply disruptions, and the turnover of experienced specialists.

“Over the past three years, the ongoing war has significantly affected NCD care. In some cases, we were unable to manage emergencies because resources, including human power and hospital services, were entirely redirected to support fighters and soldiers. Additionally, many patients on follow-up care discontinued their treatment due to road blockages and widespread fear, further exacerbating the situation” (P12, GP).

Leadership and governance

Leadership and governance were identified as key barriers, with participants highlighting the lack of political will, no resource allocation, and low prioritisation of CKD in the national health policy.

“There are no specific government sectors primarily focused on CKD, which reflects a lack of political commitment. We attempted to include CKD in the major non-communicable disease prevention strategic plan, although it has not been fully implemented. Most of the Ministry of Health programmes are donor-driven” (P13, NCD program coordinator).

Domain 3: Emotion and psychological strain

Domains 5 and 6: Reinforcement and behavioural regulation

Participants noted limited engagement in CKD activities due to a lack of structured follow-up, incentives, and accountability mechanisms.

“There are monthly, quarterly, and annual plans for conditions like hypertension and diabetes... however, this is not the case for CKD. As a result, healthcare providers tend to overlook CKD.” (P10, GP). “There is no sponsorship opportunity for this renal program, as a result, due to financial constraints, there is no interest in joining the program.” (P01, Internist)

Domain 7: Memory, attention and decision processes

Participants highlighted challenges related to the cognitive demands of CKD diagnosis and management. Difficulties in retaining and applying clinical guidelines, recognising non-specific symptoms, and making timely decisions about disease staging and treatment planning were frequently noted.

“Another issue is improper staging of CKD using the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, which involve eGFR and albuminuria. There’s also a lack of early planning for kidney replacement therapy, which is a critical problem for CKD patients” (P03, Internist).

Domain 8: Belief about consequences

Healthcare providers highlighted several misconceptions and concerns that influence how CKD is perceived and managed. They noted that many patients fear dialysis will severely impact their quality of life, leading some to refuse treatment altogether. Others believe CKD is an untreatable condition, turning to traditional medicine instead. Additionally, societal and institutional perspectives often focus primarily on dialysis and transplantation, overlooking other pre-dialysis treatments.

“Besides the financial burden, some patients are reluctant to receive dialysis. They feel that lifelong dialysis will impact their family, social life, and economic well-being. In my experience, most patients become unable to continue their regular activities after starting dialysis — not because of the treatment itself, but due to the emotional, financial, and social burdens associated with it.” (P09, Nurse)

Facilitators/enablers to CKD management

Enablers to the management of CKD were categorised into five domains of the TDF domains.

Knowledge and skill of health care providers and patients

Participants identified various facilitators related to knowledge and skills that support CKD management. These include increased access to specialised training (relative to the past), and use of KDIGO guideline by nephrologists. Additionally, they highlighted the importance of ongoing professional development, policy-driven awareness campaigns, and collaborative initiatives to improve CKD care.

“In collaboration with the Ministry of Health, it is good to work on advocacy by posting leaflets, providing education for the community about CKD screening and symptoms, and through different channels like social media and mainstream media” (P05, Nephrologist). “While some programs exist on mainstream media, they are insufficient to meet the need.” (P11, GP)

Environmental context and resources

Participants identified several facilitators under environmental context and resource domain. The inclusion of CKD in the national NCD strategic action plan and ongoing advocacy efforts (leadership and governance) and the relative growing number of nephrologists (though still limited) was highlighted.

“The presence of a strategic plan for CKD, along with a revised health policy that encourages decentralised services, which is crucial for early screening and management of CKD.” (P13, national-level NCD program lead). “Screening and treatment have also started at the lower levels of the healthcare system (health centres), which is important for preventing CKD. This ensures that patients can access treatment closer to their home.” (P10, GP)

“One opportunity I recall is a new initiative called the Public-Private Partnership Dialysis Centre, which provided dialysis services for both AKI and CKD patients. This initiative improved the availability of consumable supplies and allowed a greater number of patients to access the services.” (P04, Nephrologist)

Social/professional role and identity

Participants highlighted the increasing recognition of nephrology as a vital specialty within the healthcare system, while also pointing to structural barriers in professional pathways.

“A system should be introduced to allow general practitioners to join nephrology programmes directly, rather than first specialising as internists. The current pathway, requiring GPs to become internists before subspecialising in nephrology, is time-consuming” (P10, GP)

Beliefs about consequences

Participants underscored the value of expanding laboratory services, particularly creatinine testing in primary care, and highlighted the benefits of early detection and staging for improved CKD management.

“Early detection and staging based on KDIGO guidelines lead to better management.” (P04, Nephrologist)

Behavioural regulation and reinforcement

Participants emphasised that improving outcomes requires deliberate efforts to promote adherence through system-level interventions.

“Promoting adherence to treatment through advocacy, education, and policy changes is critical to improving outcomes” (P04, Nephrologist)

The summary of themes with illustrative quotes for facilitators and barriers to CKD management is presented in Table 1 and Table 2 respectively.

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Table 1. Summary of themes and illustrative quotes for barriers to CKD management.

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Table 2. Summary of themes and illustrative quotes for facilitators to CKD management.

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Health system-related barriers

The lack of service delivery for the prevention and control of CKD at the primary health care level, which is often the first point of contact for communities, is similar to other low-resource settings [34,35]. Participants described that healthcare providers at this level, including general practitioners, frequently lack adequate knowledge and training in CKD screening, diagnosis, and management. This is compounded by a lack of clinical guidelines and limited opportunities for professional development. In contrast, nephrologists and internists reported using KDIGO guidelines, which they found beneficial for guiding evidence-based and consistent care [25]. Similar to our study findings, research from other LMICs have also described gaps in provider knowledge and challenges in delivering CKD care at the primary level [23,36,37]. Participants in this study underscored the importance of targeted sustainable educational initiatives, including those delivered during medical residency and through workplace-based training, as critical strategies to strengthen CKD management competencies at the primary care level.

Another recurrent barrier was the critical shortage of specialised workforce for kidney care, including nephrologists, dietitians, and dialysis nurses. For instance, respondents noted that there were only two nephrologists available in the entire Amhara region. This aligns with national data showing that Ethiopia has an extremely limited nephrology workforce, with a ratio of 0.26 nephrologists per million population [15]. Added upon this shortage, most of these nephrologists are based in major cities, leaving many regions without nephrologists. Our findings are further supported by the Global Kidney Health Atlas report, which highlights stark disparities in nephrology workforces globally, with 80-fold more nephrologists in high- vs. low-income countries [35,38]. In addition, participants noted that most nurses staffing dialysis units lack formal training; they often receive only informal, hands-on training and tend to move onto other rotations rather than specialising in dialysis care. This lack of structured training contributes to substandard care, as similarly noted in global perspective on dialysis services in Ethiopia [15].

Participants in our study described dialysis care as largely inaccessible and unaffordable. This reflects the severe shortage of dialysis infrastructure in Ethiopia, where a 2021 survey reported only 35 haemodialysis units nationwide, two-thirds of which are located in Addis Ababa, home to just 4.3% of the population [15]. Many regions lack any dialysis services, and where they do exist, patients often face high out-of-pocket costs. Reported charges for a dialysis session in private facilities typically range from approximately USD 42–55 (prior to currency devaluation) [15,39]. Taken together, these findings underscore that dialysis costs are prohibitively high relative to average household income, leaving most patients reliant on private providers and facing catastrophic out-of-pocket expenditure. These barriers mirror broader challenges reported across sub-Saharan Africa, where dialysis infrastructure is scarce, utilities like water and electricity are unreliable, and financial and geographic barriers remain high [40]. Studies from the broader African context also emphasise the difficulty of expanding dialysis within limited healthcare budgets and competing health priorities [41,42].

The participant noted that although CKD is included in Ethiopia’s NCD strategic action plan [43], its implementation is slow and poorly coordinated. Building on this, participants identified systemic barriers that continue to hinder progress, including limited political commitment, inadequate financing, and weak health information systems, marked by poor documentation, limited digital infrastructure, lack of CKD-specific registries, and scarcity of locally relevant data. These findings align with challenges documented in other LMICs, where NCDs like CKD often remain under-prioritised in national health agendas [38,44], and poor health information systems [13,36,37]. This may contribute to late diagnoses, fragmented service delivery, and an overall lack of structured programmes to address the growing burden of kidney disease [38].

Patient level barriers

Limited awareness and poor understanding of CKD, misconceptions about the disease, and inadequate adherence to treatment recommendations were the main patient level barriers identified. As clearly highlighted by the respondents, CKD is often perceived as a punishment for past actions, often attributing the disease to divine retribution. This leads to poor health seeking behaviour for the patients. Furthermore, previous studies documented that patients often prefer traditional medicine, due to cultural beliefs, mistrust of conventional treatments, or financial problems [45,46]. Health literacy, including awareness about disease progression and risk factors, is a central part of contemporary medicine [47,48]. Our findings highlight that targeted strategies to improve awareness and understanding of CKD may support better management and treatment outcomes.

Contextual challenges

Study participants described how contextual issues, particularly the ongoing armed conflict in Ethiopia, have severely impacted the provision of CKD care. As described, the conflict had disturbed routine health services, especially in the affected regions, through the destruction of health facilities, displacement of healthcare workers, and insecurity that limits access to both patients and providers. Prior studies indicated that loss of infrastructure and staff displacement disrupt the continuity of care [49–51]. As some participants shared, patients were left without access to regular follow-up, medication, even basic health information. This was seen in chronic conditions like CKD, which require ongoing monitoring and consistent treatment [52,53]. Patients in these settings were faced difficulty to maintain regular contact with healthcare providers which place them increased risk of disease progression [54,55]. Most importantly, there is no structured approach to managing NCDs in Ethiopia during crises. These contextual challenges are consistent with previous findings highlighting how conflict settings weaken healthcare systems to handle chronic conditions [52].

Participants’ insights on strengthening CKD management

Study participants underlined several actionable suggestions to improve CKD care in Ethiopia. Inclusion of CKD in the national NCD prevention strategies was recommended as a major step toward prevention and long-term care. The participant advocated for dedicated nephrology units and decentralised CKD services to improve access across healthcare levels. Participants also called for government subsidies for dialysis service and improved access to essential medications. However, these efforts need strong political will, continual investment in the health workforce, and robust health information systems to support implementation and track the disease progress.

Strengths and limitations of the study

Including participants from diverse healthcare levels and professional backgrounds provided a broad perspective that enriched the findings. However, the study also has limitations. The small sample size, impacted by the ongoing armed conflict, may limit the generalisability of the findings. Additionally, the use of online interviews, though necessary due to the conflict, may have introduced selection bias related to internet access, and differences in communication dynamics compared to in-person interviews. Perspectives from dietitians, pharmacists, patients and other health cadres were not captured and should be explored in future research. Similarly, the study did not capture perspectives from all regions of Ethiopia, which may limit the breadth of regional representation; this remains an important area for future research to strengthen the generalisability of findings across the country. Finally, member checking was not conducted, which we acknowledge as a limitation, though trustworthiness was ensured through established qualitative rigor criteria.