End-stage renal disease (ESRD) represents the terminal stage of chronic kidney disease (CKD), where irreversible loss of kidney function necessitates renal replacement therapy, such as dialysis or transplantation, for survival. Globally, CKD is recognized as a growing non-communicable disease burden, contributing significantly to morbidity, mortality, and economic costs. According to the Global Burden of Disease (GBD) study, CKD ranks among the top 20 causes of death worldwide, with an estimated prevalence of nearly 10% in the adult population. Each year, millions of patients progress to ESRD, and in the absence of timely interventions, untreated  ESRD  is   invariably  fatal.  Dialysis  and  kidney transplantation remain the main modalities of treatment, but limited access, high costs, and inadequate awareness continue to challenge effective management, particularly in low- and middle-income countries [1-5].

India carries a disproportionately high burden of CKD and ESRD, driven largely by the rising prevalence of diabetes, hypertension, kidney stones, and post-infectious complications. Estimates suggest that over 200,000 new patients develop ESRD annually in India, yet less than one-third access dialysis due to financial, infrastructural, and awareness-related barriers. Dialysis, especially hemodialysis, is increasingly available in tertiary centers, but peritoneal dialysis and kidney transplantation remain underutilized. The economic implications are immense, as dialysis requires lifelong, recurrent sessions, making it unaffordable for many households. Furthermore, inadequate knowledge about early symptoms, risk factors, treatment options, and preventive strategies contributes to delayed diagnosis and late initiation of renal replacement therapy [6-6].

Punjab, a northern Indian state, faces a unique and alarming scenario with respect to kidney disease. Multiple epidemiological and media reports have pointed toward a higher prevalence of CKD and ESRD in the state, often attributed to the high burden of diabetes, hypertension, pesticide and chemical exposure, lifestyle-related risk factors, and possible environmental contributors such as groundwater contamination. Additionally, tobacco use, alcohol consumption, and low health-seeking behavior exacerbate the progression of kidney-related disorders. Despite the increasing number of patients requiring dialysis across both urban and rural Punjab, community-level awareness regarding ESRD, its risk factors, and treatment modalities remains poorly studied. Misconceptions about dialysis being a cure, limited knowledge about kidney transplantation as a viable alternative, and uncertainty regarding preventive measures continue to widen the gap between disease burden and timely management [10-12].

Awareness and health literacy play a pivotal role in the prevention and control of ESRD. Recognizing risk factors such as diabetes and hypertension, understanding the life-saving role of dialysis, and knowledge about transplantation can empower individuals to seek timely care, adhere to treatment, and adopt preventive strategies. Previous studies from India and other low-resource settings have consistently highlighted poor awareness regarding kidney diseases among the general population [12-15]. However, data specific to Punjab remain scarce, despite its unique socioeconomic, occupational, and environmental risk profile.

The present study was therefore undertaken to assess awareness about ESRD and dialysis among the general public of Punjab. It aimed to evaluate knowledge regarding risk factors, symptoms, dialysis treatment, transplantation, and preventive strategies, while examining the influence of socio-demographic determinants such as age, gender, education, occupation, and residence. By identifying knowledge gaps and vulnerable groups, this study seeks to generate evidence for targeted public health interventions, awareness campaigns, and policy measures to address the growing challenge of ESRD in Punjab.

Study Design and Setting

A descriptive, cross-sectional study was conducted to assess the level of awareness regarding end-stage renal disease (ESRD) and dialysis among the general public of Punjab. Data were collected using a structured, self-administered questionnaire developed on Google Forms. The online survey method was chosen for its wide accessibility, standardized response collection, and feasibility in reaching participants across both rural and urban settings of Punjab.

Study Population and Eligibility Criteria

The study included adults aged 18 years and above, residing in Punjab, from both urban and rural areas. Participants from diverse educational and occupational backgrounds were included to ensure representation. Voluntary informed consent was obtained digitally prior to participation. Exclusion criteria comprised healthcare professionals, medical and paramedical students, individuals with severe cognitive or communication impairments, and duplicate or incomplete responses, to avoid bias.

Sample Size Determination

The sample size was calculated using the single population proportion formula, assuming a 50% prevalence of adequate awareness (due to the absence of state-specific baseline data), with a 95% confidence level and a 5% margin of error. The minimum required sample size was 384, which was rounded up to 400 to account for potential exclusions and non-responses.

Sampling Technique

A purposive-cum-snowball sampling approach was adopted. The survey link was disseminated via social media platforms including WhatsApp, Facebook, and email. Additionally, community volunteers and health workers were engaged to circulate the survey link, particularly targeting rural households. Participants were encouraged to share the link within their networks to expand reach across socio-demographic groups.

Study Tool (Questionnaire Design)

The questionnaire was developed after reviewing relevant literature, kidney disease awareness surveys, and World Health Organization (WHO) guidelines. It was divided into four sections:

• Socio-demographic details: Age, gender, residence (urban/rural), education, occupation, and monthly household income.

• Exposure and risk profile: Family history of kidney disease, known diagnosis of kidney conditions, and awareness of risk factors such as diabetes, hypertension, and kidney stones.

• Knowledge questions: 20 multiple-choice questions covering awareness of ESRD, dialysis, transplantation, complications, lifestyle modifications, and preventive strategies. Each correct response was scored as 1, while incorrect or “don’t know” responses were scored as 0.

• Knowledge score categorization: Total scores (0–20) were categorized as excellent (16–20), good (12–15), fair (8–11), and poor (0–7).

Validation and Pilot Testing

The draft questionnaire underwent expert review by nephrologists, public health specialists, and community medicine professionals to ensure face and content validity. A pilot test involving 30 participants (both rural and urban) was conducted to evaluate clarity, cultural appropriateness, and comprehension. Based on feedback, minor modifications were made. Internal consistency of the tool was found to be good, with a Cronbach’s alpha coefficient of 0.81.

Data Collection Procedure

Participation was voluntary, and only individuals providing informed consent could proceed with the questionnaire. All questions were mandatory, reducing the risk of missing data. On average, respondents completed the survey within 10–12 minutes. Data were automatically recorded in a secure Google Sheet, accessible exclusively to the research team.

Data Analysis

Data were exported into IBM SPSS Statistics version 25 for analysis. Descriptive statistics such as frequency and percentages were used to summarize socio-demographic characteristics, risk profiles, and awareness levels. The Chi-square test (χ²) was employed to assess associations between socio-demographic variables (age, gender, education, occupation, residence) and knowledge levels (excellent, good, fair, poor). A p-value <0.05 was considered statistically significant.

Ethical Considerations

The study adhered to the ethical principles outlined in the Declaration of Helsinki (2013 revision). Participation was anonymous, and no personally identifiable information was collected. Data were used solely for academic and research purposes, ensuring confidentiality.

Out of 400 participants, the largest age group was 30–44 years (31.5%), followed by 45–59 years (27.5%), while 19.0% were elderly (≥60 years) and 22.0% were young adults (18–29 years). Gender distribution showed a slight male predominance (52.5%) compared to females (47.5%). The residence of participants was nearly evenly split, with 49.5% from urban and 50.5% from rural areas, ensuring balanced representation. Educational levels varied, with 38.5% graduates and 21.0% postgraduates, while 10.5% had no formal schooling, reflecting wide diversity in literacy. Occupation-wise, skilled/unskilled workers constituted the largest group (33.0%), followed by homemakers (24.0%) and service professionals (21.5%). Monthly household income distribution revealed that one-third (33.0%) earned below ₹10,000, 31.5% between ₹10,001–25,000, and only 14.0% earned more than ₹50,000. This socio-demographic spread highlights diverse participation, with inclusion across age, gender, socio-economic, and occupational categories (Table 1).

Table 1: Socio-Demographic Characteristics of Participants (n = 400)

Overall, 69.0% of respondents had heard about ESRD or dialysis, while 31.0% remained unaware. A positive family history of kidney disease was reported by 17.0%. Knowledge about risk factors was limited, with diabetes identified by 40.5%, hypertension by 37.0%, and kidney stones by 22.0%, whereas one-third (33.0%) were unaware of any. Sources of information varied, with doctors and health professionals (29.5%) being the leading source, followed by mass media such as TV/radio/newspapers (26.5%) and the internet/social media (23.0%). While 61.0% perceived dialysis as life-saving, 28.0% were unsure and 11.0% disagreed. Awareness of kidney transplantation as an alternative to dialysis was modest, with only 43.0% being aware. These findings indicate partial awareness of dialysis, with gaps in knowledge about risk factors and treatment alternatives (Table 2).

Table 2: ESRD/Dialysis Awareness and Risk Profile of Respondents (n = 400)

Knowledge levels across 20 questions revealed variability in understanding. The majority (72.0%) correctly identified the kidney’s main function, while 63.5% and 62.0% recognized diabetes and hypertension, respectively, as key ESRD risk factors. Most participants (70.5%) correctly defined dialysis as artificial blood purification, and 69.0% understood that untreated ESRD can be fatal. However, only 49.0% knew that dialysis becomes essential when kidney function drops below 10–15%. Misconceptions persisted, with just 52.0% knowing the standard frequency of hemodialysis sessions  (three  per  week)  and  43.5%   identifying  low pressure/weakness as common complications. Preventive aspects were better understood, with 62.0% acknowledging ESRD prevention through blood pressure and diabetes control, and 78.0% recognizing the importance of community awareness. Overall, while respondents showed reasonable knowledge in basic areas, detailed aspects of dialysis and dietary restrictions reflected weaker awareness (Table 3). 

Table 3: Knowledge Assessment on ESRD and Dialysis (n = 400)

The overall knowledge distribution revealed that only 17.0% of respondents had excellent knowledge (scores 16–20), and 31.0% achieved good knowledge (12–15). The largest group, 34.5%, fell into the fair knowledge category (8–11), while 17.5% had poor knowledge (0–7). This pattern indicates that while nearly half of participants had good-to-excellent awareness, more than half demonstrated only fair-to-poor understanding, signifying considerable gaps in community-level knowledge about ESRD and dialysis (Table 4).
 

Table 4: Overall Knowledge Score Distribution on ESRD/Dialysis (n = 400)

The association between socio-demographic characteristics and knowledge levels showed significant disparities. Age and gender did not demonstrate significant associations (p>0.05), suggesting comparable awareness across these groups. However, residence (p=0.002) showed urban participants had higher excellent and good knowledge compared to rural counterparts.   Education    was   the    strongest predictor (p<0.001), with postgraduates (28.9% excellent) outperforming those with no formal schooling (5.8% excellent, 41.5% poor). Occupation also influenced awareness (p=0.010), with service professionals having the highest excellent knowledge (26.5%), while homemakers and unskilled workers were more represented in fair and poor categories. These findings highlight educational attainment, occupation, and place of residence as key determinants of awareness, underscoring the need for targeted health education interventions (Table 5).

Table 5: Association Between Knowledge Level and Socio-Demographic Variables (n = 400)

The present study assessed awareness regarding end-stage renal disease (ESRD) and dialysis among the general public of Punjab, with an emphasis on socio-demographic determinants, knowledge of risk factors, treatment options, and preventive strategies. The findings revealed substantial gaps in knowledge, particularly in understanding detailed aspects of dialysis and preventive measures, despite reasonable awareness of basic concepts such as the function of kidneys and the life-saving role of dialysis.

The socio-demographic analysis indicated wide participation across age, gender, residence, educational, and occupational categories, allowing for meaningful insights into variations in awareness. While age and gender did not significantly influence knowledge levels, education and residence emerged as strong determinants, with urban and more educated participants exhibiting higher awareness. These findings align with previous Indian studies, where higher literacy and urban residence were consistently associated with better knowledge of chronic kidney disease (CKD) and ESRD. This suggests that targeted interventions in rural areas and among less-educated populations are urgently needed to bridge the knowledge gap.

In the current study, nearly 69% of participants had heard of ESRD/dialysis, which is higher than reports from certain low-resource regions where awareness has been reported as low as 30–40%. However, only 43% of respondents were aware of kidney transplantation as an alternative treatment, highlighting a considerable deficiency in community knowledge about renal replacement therapy beyond dialysis. Similar patterns have been documented in other Indian states, where misconceptions regarding transplantation, coupled with cultural and financial barriers, have contributed to its underutilization. This reflects the need for stronger public education campaigns that not only emphasize dialysis but also create awareness about transplantation as the most effective long-term solution.

Awareness of risk factors such as diabetes and hypertension was limited to 40.5% and 37.0% of respondents, respectively, while one-third of participants reported no knowledge of any risk factor. This is a particularly concerning finding, given that diabetes and hypertension account for nearly two-thirds of ESRD cases in India. Previous studies from urban centers such as Delhi and Chennai have also noted poor recognition of these risk factors, suggesting that even in regions with higher healthcare access, awareness remains inadequate. In Punjab, where the prevalence of diabetes and hypertension is among the highest in the country, such lack of knowledge could delay preventive care and early detection, thereby contributing to the growing burden of ESRD.

With respect to knowledge assessment, while a majority correctly identified the kidneys’ function and the fatality of untreated ESRD, misconceptions persisted in several areas. Less than half of the participants were aware that dialysis is initiated when kidney function falls below 10–15%, and only half knew the correct frequency of hemodialysis sessions. Moreover, awareness about dietary and fluid restrictions, infection risks, and common complications of dialysis was suboptimal. These knowledge deficits mirror the findings of earlier Indian and international studies, where awareness about treatment details was consistently lower than awareness about the general concept of kidney disease. Such gaps could lead to non-adherence to treatment, inappropriate health-seeking behavior, and ultimately, poorer outcomes in patients requiring dialysis.

The distribution of knowledge scores further underscores the urgent need for public health interventions. Only 17% of respondents demonstrated excellent knowledge, while more than half fell into fair or poor categories. This imbalance is indicative of superficial awareness within the community — individuals may have heard of dialysis or ESRD, but lack comprehensive understanding of its causes, management, and prevention. Importantly, education was the most significant predictor of knowledge, with postgraduates far outperforming those without formal schooling. This finding emphasizes the role of health literacy in shaping awareness, reinforcing the argument for community-level health education programs tailored to low-literacy populations.

The role of information sources is also notable. Doctors and health professionals were the primary source of knowledge for only 29.5% of participants, while a substantial proportion relied on mass media, family, or social networks. This reliance on non-medical sources increases the risk of misinformation and perpetuation of myths. Strengthening physician-patient communication, integrating kidney health education into primary care, and leveraging digital media responsibly could help disseminate accurate information. Additionally, community-based interventions, such as health camps and school-based awareness programs, may be particularly effective in rural Punjab, where dependence on non-medical sources is likely higher.

An important public health implication of this study is the recognition of disparities between urban and rural populations. Urban residents had significantly higher levels of excellent and good knowledge compared to rural counterparts. This urban-rural divide has been well-documented in other non-communicable diseases, including hypertension and diabetes, and reflects inequities in access to health services, health information, and social determinants of health. In Punjab, where rural communities face unique occupational and environmental exposures — such as pesticide use and groundwater contamination — targeted awareness programs are critical to prevent the progression of kidney disease in high-risk populations.

Taken together, the findings highlight the dual challenge of ESRD management in Punjab: while the disease burden continues to rise due to lifestyle and environmental risk factors, awareness about its causes, treatment, and prevention remains inadequate. Without immediate measures to improve health literacy, promote screening for diabetes and hypertension, and educate the public about treatment options, the state may face a worsening crisis of ESRD with significant social and economic implications [12,14,15].

Strengths and Limitations

The strength of this study lies in its large and diverse sample size of 400 participants, representing both urban and rural populations across Punjab, with varied educational, occupational, and socio-economic backgrounds. The use of a structured, validated, and pilot-tested questionnaire enhanced the reliability of the findings, while the online Google Form ensured uniformity and completeness of responses. The study also offers valuable region-specific evidence on awareness levels of ESRD and dialysis, an area with limited prior data. However, some limitations must be acknowledged. The purposive-cum-snowball sampling technique may have introduced selection bias, favoring individuals with internet access and basic digital literacy, which could underrepresent marginalized rural populations with limited connectivity. The cross-sectional design restricts causal inference, and self-reported responses may be subject to recall and social desirability bias. Furthermore, exclusion of healthcare professionals and students, though necessary to avoid bias, limits comparisons with medically informed groups. Despite these limitations, the study provides critical insights into community awareness and highlights urgent gaps requiring public health attention.

This study demonstrates that awareness of ESRD and dialysis among the general public of Punjab is moderate, with significant gaps in knowledge regarding risk factors, dialysis protocols, dietary restrictions, complications, and kidney transplantation as a long-term alternative. Education, occupation, and residence were key determinants of awareness, with rural and less-educated populations particularly disadvantaged. These findings emphasize the need for targeted community-based health education, integration of kidney health into primary care programs, and the use of mass media and digital platforms for disseminating accurate information. Strengthening awareness about early detection, risk factor management, and treatment options can empower individuals to seek timely care, reduce the burden of ESRD, and ultimately improve health outcomes in Punjab.

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