The data presented in this study highlight the day-to-day experiences of individuals with ESKD accessing treatment in the northern part of Ghana and enable suggestions to be made to improve accessibility to ESKD. All but one of the participants had hypertension before developing ESKD. This underscores the central role of hypertension in increasing the global prevalence of CKD and, particularly, as the leading cause of ESKD in sub-Saharan Africa [4, 10,11,12]. It is noteworthy that some participants in this study had their hypertension detected at pharmacy shops where they also purchased antihypertensive medicines, without utilizing the routine care and diagnostic services provided by hypertensive clinics within the country. This resulted in a missed opportunity for the early diagnosis of CKD, as these individuals did not have their kidney function monitored over time to slow or halt the progression of CKD to ESKD. The key findings of the study will now be discussed under the key dimensions of the conceptual framework of access to healthcare [6].

While lack of or inadequate knowledge prevented individuals with symptoms and/or a diagnosis of ESKD from accessing care, it also prevented them from accepting dialysis as a treatment option in the initial stages. Participants mostly denied the diagnosis and delayed the early initiation of treatment, resulting in the late commencement of dialysis, which also contributed to poor prognosis. Perceptions of accessing healthcare in a hospital setting as ‘unmanly’ contributed to delays in diagnosing ESKD among some participants in this study, as such individuals did not have their kidney function monitored over time. Indeed, cultural and religious beliefs as well as the desire for a cure inform the use of herbal medicines [15,16,17,18]. However, the same are also instrumental in accessing biomedical care, especially when other alternatives do not produce the desired outcomes. it is noteworthy that other participants attributed their use of herbal treatments to their inability to pay the cost of dialysis, a key barrier to accessing treatment for ESKD that has already been reported elsewhere [5, 17, 18].

Generally, almost all participants were aware that they had hypertension, diabetes mellitus or both but had no idea it could lead to the development of CKD or ESKD. They only became aware of this after they were diagnosed with ESKD, and haemodialysis when it was mentioned as the existing form of treatment. This lack of awareness of ESKD and haemodialysis increased the tendency of delayed treatment, as many participants were diagnosed late and had to start haemodialysis urgently to preserve their lives. As a consequence, many individuals with ESKD do not get adequate time to plan and prepare for it, resulting in abrupt discontinuation of haemodialysis after a few weeks or months after initiating it. Providing individuals with ESKD with appropriate information is critical to supporting them in addressing their information needs and decision-making about their care. Indeed, C Guha, P Lopez-Vargas, A Ju, T Gutman, NJ Scholes-Robertson, A Baumgart, G Wong, J Craig, T Usherwood and S Reid [13] and JT Hughes, N Freeman, B Beaton, A-M Puruntatemeri, M Hausin, G Tipiloura, P Wood, S Signal, SW Majoni and A Cass [14] report that individuals with CKD feel apprehensive about their prognosis and lack understanding of their condition because they are not provided with adequate information.

A previous report on the number of functioning haemodialysis machines in the study setting was three, but this had increased to six functioning out of a total of eleven haemodialysis machines at the time of data collection for this study [3]. Although this seems to be an improvement, it remains woefully inadequate as the number of people diagnosed with ESKD who require haemodialysis grows to outweigh the number of machines available. The prolonged waiting times caused by the growing number of people with ESKD receiving dialysis services in the facility, along with insufficient functioning haemodialysis machines and frequent breakdowns, are by far the biggest obstacles participants face when trying to access haemodialysis at the facility. Some of the participants were frequently dissuaded from attending dialysis sessions due to waiting times, which usually forced them to turn to the commonly available and less expensive herbal medicines instead of dialysis. This challenge, unfortunately, is a common theme in resource-restricted settings [18].

Participants who resided in the city with the dialysis centre expressed satisfaction with the location of the facility, as some could even walk to the facility for haemodialysis services. However, the majority of our participants travelled to the dialysis centre from remote areas and different regions. This frequently made it difficult for them to arrive at the facility on time for their haemodialysis sessions, and some had to travel a day before their scheduled sessions to avoid delays. This was, undoubtedly, more concerning and stressful for such individuals while adding to the cost of their treatment. Geographical location as a barrier to accessing renal services has been widely reported in resource-constrained settings, and that of Ghana is well documented [3, 5, 18,19,20]. Indeed, it has been shown that individuals who live closer to a healthcare centre have better health outcomes than those who live further away [21]. There are calls for dialysis centres to be established in regions that lack them to improve access [18, 20].

The cost of a haemodialysis session at the time of data collection was GHC300 (USD 25), although there has been a twofold increase, excluding the cost of heparin, which is sold at varied prices in different pharmacy shops. Consequently, families have to contribute money for their kin to stay on dialysis. This continual expenditure ultimately depletes their financial resources, resulting in reduced or missed haemodialysis sessions, which consequently affects their quality of life. Indeed, haemodialysis imposes a substantial financial burden on families and health systems, and the impact is heaviest in resource-constrained settings [22]. Thus, the impact of the cost of treatment on accessing haemodialysis sessions cannot be overemphasized, especially in such a relatively poorer, resource-constrained setting.

Participants had a positive experience with health professionals, notably nurses whom they described as “good and friendly” in providing care to them. Positive experiences with healthcare professionals were linked to receiving support from staff who professionally delivered care and catered to their needs.

One significant strength of this study is the representation of the contextual gap in the literature – it is the first to explore the experiences of individuals with ESKD accessing RRT in northern Ghana. This provides rich, contextual data on seemingly neglected regions in the country in terms of access to RRT. The use of the conceptual framework by Levesque et al. (2013) allowed various facets of access to RRT to be explored in this study and added to the richness of data generated in this study.

In terms of a key limitation of this study, participants had to be receiving haemodialysis to be included in the study. The perspectives of those who had discontinued dialysis would have offered useful insights into factors that led to their withdrawal. However, it was challenging to identify these individuals because they were not followed up, and some were reported to have passed away.

Researchers are central to data collection and analysis in qualitative research, making reflexivity an important aspect of the research process [8]. EAB is a registered nurse and a university lecturer with fourteen years of research experience in the management of ESKD. His interest is in enhancing the quality of life and decision-making experiences of individuals with ESKD. AAI is a registered nurse and a nurse educator. Her active interest in the management of ESKD was piqued during her postgraduate studies in 2021. JKD is a registered nurse, a university lecturer, and a PhD candidate. She has a special interest in using qualitative research methods to address comprehensive health problems in Ghana and beyond. PAA is a registered nurse and a university lecturer. He has a special interest in using qualitative research methods to address comprehensive health problems in Ghana and beyond. All these authors brought their unique perspectives to the design and analysis of data generated in this study.