Stakeholders’ perspectives on barriers and enablers of chronic kidney disease care in Ethiopia: A qualitative study

by Daniel Bekele Ketema, Min Jun, Sradha Kotwal, Workagegnehu Hailu, Martin Gallagher, Rohina Joshi

Background

Chronic kidney disease (CKD) is a growing public health problem in Ethiopia. However, evidence on the health system and contextual factors influencing CKD care remains limited. This study explored the barriers and facilitators to CKD care from the perspectives of healthcare providers and other stakeholders.

Methods

A descriptive qualitative study was conducted using purposive and maximum variation sampling to recruit healthcare providers (including general practitioners, nephrologists/internists, nurse) and non-communicable disease (NCD) officers and program coordinators. Interviews were audio recorded, transcribed, and thematically analysed, underpinned by the Theoretical Domains Framework version 2.

Results

Fifteen participants (six general practitioners, five nephrologists/internists, one nurse, and three NCD program officers and coordinators) were included. About 40% of participants had over six years’ experience. Key barriers to CKD care included patient misconceptions, low patient and healthcare provider awareness, shortage of health workforce, knowledge gaps among junior healthcare providers, limited resources, high out-of-pocket costs, absence of registries for CKD, weak referral systems, inconsistent access to medicines and diagnostics, lack of structured training, and conflict-related disruptions. Facilitators included adherence to guidelines by senior staff, inclusion of CKD into national non-communicable disease strategies, and increased use of media for public health education.

Conclusions

Addressing key barriers and enhancing prioritisation of CKD by clinicians and policymakers is critical. Strengthening workforce capacity, awareness, referral systems, and integration into national strategies offers opportunities to improve CKD care.

A volumetric modulated arc therapy-based dynamic conformal arc technique with limited monitor units (VMAT_liMU) to reduce multileaf collimator interplay effects: A computational phantom study for stage I non-small-cell lung cancer

by Dong Min Jung, Yong Jae Kwon, Yong Wan Cho, Jong Geol Baek, Dong Jae Jang, Yongdo Yun, Seok-Ho Lee, Gahee Son, Hyunjong Yoo, Min Cheol Han, Jin Sung Kim

Volumetric modulated arc therapy (VMAT) for lung cancer involves complex multileaf collimator (MLC) motion, which increases sensitivity to interplay effects with tumour motion. Current dynamic conformal arc methods address this issue but may limit the achievable dose distribution optimisation compared with standard VMAT. This study examined the clinical utility of a VMAT technique with monitor unit limits (VMAT_liMU) to mimic conformal arc delivery and reduce interplay effects while maintaining plan quality. VMAT_liMU was implemented by applying monitor unit limitations during VMAT reoptimisation to minimise MLC encroachment into target volumes. Using mesh-type reference computational phantom CT images, treatment plans were generated for a simulated stage I lung cancer case prescribed to 45 Gy in three fractions. VMAT_liMU, conventional VMAT, VMAT with leaf speed limitations, dynamic conformal arc therapy, and constant dynamic conformal arc therapy were compared. Plans were optimised for multiple isodose line prescriptions (50%, 60%, 70%, 80%, and 90%) to investigate the impact of dose distribution. Evaluation parameters included MLC positional accuracy using area difference ratios, dosimetric indices, gradient metrics, and organ-at-risk doses. VMAT_liMU prevented MLC encroachment into the internal target volume across 60%–90% isodose lines, showing superior MLC accuracy compared with other methods. At the challenging 50% isodose line, VMAT_liMU had 4.5 times less intrusion than VMAT with leaf speed limits. VMAT plans had better dosimetric indices than dynamic conformal arc plans. VMAT_liMU reduced monitor units by 5.1%–19.2% across prescriptions. All plans met the clinical dose constraints, with the aortic arch below tolerance and acceptable lung doses. VMAT_liMU combines VMAT’s dosimetric benefits with the dynamic conformal arcs’s simplicity, minimising MLC encroachment while maintaining plan quality. Reduced monitor units lower low-dose exposure, treatment time, and interplay effects. VMAT_liMU is usable in existing planners with monitor unit limits, offering a practical solution for lung stereotactic body radiation therapy.