Delphi study on evidence-based CKD prevention strategies for nurses in resource-limited settings: focus on e-learning implementation

Abstract

Background

Interactive e-learning modules are increasingly being used to educate nurses about preventing and detecting chronic kidney disease (CKD). These modules aim to improve knowledge, screening practices, skills, and self-management behaviours. This Delphi study aims to provide a prioritized list of strategies, content, and delivery methods to guide future implementation efforts and improve primary and secondary prevention of conservative CKD care in Syria.

Methods

A second-round Delphi study was performed using the input of 15 CKD clinical content experts (nephrologist-scientist & medical educator) involved in education and clinical practice from March to the end of April 2025. Eligible participants sent an e-mail containing an information sheet and an invitation to participate in the study. Consent is obtained before participants proceed to the survey. In the first round, we identified several potential strategies for CKD prevention education. However, consensus was not reached on all of them. We modified and refined these strategies based on the CKD clinical content experts ' opinions. We asked them to re-evaluate and re-rank these modified strategies in the second round via e-mail. Experts use predefined statements to score the effectiveness of CKD prevention strategies and delivery methods based on existing best practices specified in clinical guidelines, systematic reviews, and research studies. Descriptive statistics such as the median, interquartile range (IQR), and percentage agreement are used to assess consensus. Inferential statistics were used to measure participant agreement using Kendall’s coefficient, and for stability between rounds, the Wilcoxon rank-sum test was used.

Results

We identified (9 primary and 32 secondary strategies) evidence-based CKD prevention strategies to implement within Syria and limited resource areas. Three strategies were deleted as not feasible and related to the Syrian context, and nine strategies were modified based on expert feedback on rationale and suggestions related to culture availability and cost-effectiveness. We added one strategy to replace the Genetic screening strategies with early and regular screening for high-risk populations. Challenges to implementing evidence-based CKD prevention strategies seem to exist in professional, organizational, and external contexts, which should all be considered to increase implementation success within resource-limited areas such as Syria.

Conclusion

Using the Delphi approach to tailor the e-learning module content to the specific needs of nurses, depending on the realities of the Syrian context, by synthesizing clinical work with evidence-based CKD prevention strategies and an obvious need to create a common foundation for nurses’ knowledge of CKD prevention. This study offers actionable strategies to strengthen CKD prevention in resource-limited settings like Syria. Prioritizing cost-effective tools, culturally adapted education, offline modules, Arabic translations, and nurse-friendly protocols is a blueprint for similar conflict-affected regions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-025-04461-0.

Text box 1. Contributions to the literature
• Designing implementation strategies aimed at increasing knowledge and awareness about CKD.
• Develop interactive e-learning modules of CKD prevention strategies based on existing best practices specified in clinical guidelines, systematic reviews, and research studies.
• Exploring modifications and suggestions for interactive e-learning module implementation in Syria can be beneficial through collaborative local and international efforts.
• Further piloting interactive evidence-based CKD prevention strategies adaptive to the Syrian context is required to determine its feasibility and generalizability.

Introduction

Chronic Kidney Disease (CKD) is indeed a significant public health issue in Syria, exacerbated by the ongoing political and economic instability in the region [1]. The studies on refugees indicate a substantial burden of CKD, particularly due to congenital and hereditary conditions, emphasizing the importance of primary and secondary prevention [2]. Addressing modifiable risk factors through effective prevention strategies is crucial for preventing and slowing CKD progression, reducing the physical and psychological burdens, and preventing complications [3, 4].

Interactive e-learning modules are increasingly used to educate nurses about preventing CKD [5]. These modules offer several advantages, including accessibility, flexibility, and the ability to provide standardized education across diverse geographical locations [6, 7]. Strategies promote the successful and sustainable implementation of healthcare interventions, including e-learning modules, which require a strategic approach that includes a multifaceted method [8], contextual tailoring [9, 10], stakeholder involvement [11, 12], continuous evaluation [13], and ensuring accessibility and usability [14, 15]. Delivery of these implementation strategies typically requires robust technological infrastructure [16, 17], comprehensive training for educators [18], strategic planning [19], blended learning approaches [19], and user-centered design [20]. Conservative CKD care in Syria is hindered by poor awareness of CKD risk factors, due to asymptomatic nature, and inadequate screening practices of high-risk populations. The most feasible and changeable barriers that we found in previous work is a lack of knowledge and awareness about risk factors and early detection among nursing staff in hospitals and community health centers. We found a knowledge gap in the nursing curriculum with diploma degrees underscoring the practical aspects of CKD prevention in Syria [21]. The lessons learned from other countries emphasize how crucial government assistance is to extending practice nurses’ roles in the prevention of chronic illnesses [22, 23]. Nurses are integral to the prevention of CKD [24, 25]. Their roles in screening, patient education, and multidisciplinary care are crucial in mitigating the progression of CKD and improving patient outcomes [26]. Frequent training and education for nurses can further enhance their effectiveness in this critical healthcare area [27].

The Delphi study aims to shape the content and delivery methods of e-learning modules for renal and non-renal nurses working in hospital settings, specifically in departments related to kidney disease, cardiovascular disease, and endocrinology in Syria, ensuring they address this group’s unique challenges and needs [28, 29]. The Delphi method is well-suited for this purpose because it gathers expert consensus through iterative questionnaires, allowing for anonymous and controlled feedback from geographically dispersed experts [30, 31]. e-learning modules, shaped by the Delphi method, can significantly improve the knowledge and skills of nurses in Syria, particularly regarding CKD. However, addressing the infrastructural and workforce challenges is crucial for the successful implementation and sustainability of these educational interventions.

A previous study about an asynchronous web-based e-learning module improved general practice nurses’ knowledge about CKD risk factors and screening practices, although the final scores remained inadequate [5]. Similarly, an internet-based training module for internal medicine residents in the U.S. significantly improved CKD knowledge from pre- to post-test scores [32]. A targeted behavioural-based e-learning intervention aimed at influencing general practice nurses’ intentions to initiate CKD screening showed no significant difference compared to a knowledge-based program. However, changes in attitude and perceived behavioural control were associated with increased intentions to perform kidney health checks [33]. A consensus workshop identified key content areas for CKD e-learning tools, including basic information about CKD, diet requirements, medication management, symptom management, and mental health support [34]. Interactive e-learning, which includes user-influenceable content like quizzes and virtual patients, is generally more effective in increasing learner satisfaction and knowledge than noninteractive e-learning [35]. However, technical barriers can affect the accessibility and usability of these modules in low-resource settings, and technical difficulties and limited experience with interactive e-learning can hinder their effectiveness [35]. Ensuring that the modules are easy to use and accessible is crucial. The Delphi study can help tailor the e-learning modules to address specific barriers faced by healthcare professionals (HCPs) in Syria, such as limited resources and varying baseline knowledge levels [36, 37]. Incorporating feedback from local and international key stakeholders can ensure the modules are relevant and practical [38]—design modules with a straightforward, intuitive interface to enhance user experience and accessibility [39]. Incorporate feedback loops to gather user input and continuously improve the module content and delivery [40].

These CKD prevention modules, developed in collaboration with international and local CKD clinical content experts, can effectively combat CKD in the region by addressing technical barriers and tailoring content to the specific needs of nurses. Therefore, accessing opinions from key stakeholders can be extremely useful to address the barriers to implementing e-learning modules in Syria, such as limited digital literacy, poor internet connectivity, and overburdened HCPs. Implementing specific strategies to overcome these barriers, such as designing modules with a straightforward, intuitive interface and ensuring offline accessibility, can help.

The primary objective of this Delphi study is to tailor the e-learning module content to the specific needs of nurses in the Syrian context, and to address specific barriers faced by implementing evidence-based CKD prevention education programs. These strategies are derived from best practices outlined in clinical guidelines, systematic reviews, and research studies. The study aims to boost the expertise of a nephrologist-scientist and medical educator by incorporating interactive modules that offer innovative learning features. Using e-learning modules, which enhance communication, track progress, and develop essential skills, makes it a valuable tool in modern nursing education. No additional apps or paid licenses are required, ensuring feasibility in low-resource settings such as Google Classroom and the Udemy platform [41, 42]. These modules will encompass engaging elements such as Case studies, infographics, scenario-based questions and Quizzes that respond to the users’ choices, providing a personalized learning experience.

Methods

The Delphi technique can be used to generate insights, particularly in situations where information is limited. It is a methodical approach to gaining consensus among experts [43]. Consensus is attained by completing sequential questionnaires redefined by feedback, culminating in a convergence of opinions and probable consensus [43]. The Delphi approach is helpful because it allows for iteration with controlled feedback and the amalgamation of knowledge from experts. Furthermore, anonymous involvement is essential because it lowers potential halo effects, in which dominant group members give extra credence and are biased [44, 45]. Furthermore, electronic surveys in an e-Delphi design eliminate geographical limits [43]. This could otherwise arise because this is a Syrian study with volunteers from several nations.

Study design

This e-Delphi study is inspired by the Guidance on Conducting and Reporting Delphi Studies (CREDES) and supplemented by recommended criteria for Delphi studies (See Appendix A) [46, 47]. A Two-round Delphi study was performed using the input of 15 CKD clinical content experts involved in the education and clinical practice of CKD prevention. The Delphi method is a structured communication technique used to reach a consensus among experts. Web-based Delphi surveys created in Google forums are advantageous in increasing the feasibility of a broader population within local and international sampling. The first round’s questionnaire was directed by a combination of open and closed questions [48]. Open-ended questions highlighted the obstacles and modifications in implementing CKD prevention strategies, as the CKD clinical content expert (nephrologist-scientist & medical educator) understood. Experts evaluated the effectiveness of CKD preventive content and delivery modalities in closed-ended questions. In the two subsequent rounds of surveys, the experts scored their level of agreement with statements about CKD prevention strategies on a 5-point Likert scale. As part of the process, the CKD clinical content expert panel receives a summary of the replies from the previous questionnaires in the following questionnaire round. This enables respondents to evaluate and revise their responses in the subsequent round [48, 49]. Therefore, the Delphi design is an iterative multi-staged process to combine opinions into a group agreement [50, 51].

Experts were recruited through snowball sampling, starting with key stakeholders in the Syrian Nephrology Society, American Society of Nephrology (ASN), International Society of Nephrology (ISN), European Renal Association (ERA), International Society for Peritoneal Dialysis (ISPD), Malaysian Society of Nephrology, and Philippine Society of Nephrology and Researchers expert in CKD and e-learning. Initial experts recommended additional participants to ensure diversity. Consensus was defined as ≥ 70% of participants rating a strategy as ‘effective’ (4–5 on the Likert scale) or ‘ineffective’ (1–2). Neutral items (score 3) were carried forward for re-evaluation. (See Appendix B)

Study participants and recruitment

Delphi research has no universal standards for determining sample size because it varies depending on the goal of the study, the selected design, and the data collection period [43, 47]. In previous studies, aiming to define strategies, content, and elements in interventions and delivery methods typically reached consensus with responses from 10 to 17 experts in the final round [52–54]. One international expert and two local experts from Arab countries, including specialized CKD clinical content expert members in each of the eight countries, were invited. This ensures a predominance of Arab experts with approximately a 1:2 distribution in the expert panel. A purposive sampling technique was used [55]. As a result, individuals are not chosen randomly, and representativeness is uncertain. Including a heterogeneous sample ensures that diverse opinions are represented [56, 57]. Participants were identified through a combination of methods: Consultation with key nephrologist-scientists and medical educators, and snowball sampling, where identified experts are asked to recommend additional participants.

Preliminary work to inform the e-Delphi design

Pilot test: pre-tested through two phases.

In the first phase, the pilot survey was sent to three researchers and two professors in nursing who published research in CKD prevention in clinical practice. They were asked to review the content and appropriateness of the survey language length, assess the statements’ clarity, relevance, and completeness, and determine if any additional barriers and facilitators needed to be added to the list. In the second phase, they received the final web-based survey to assess the ease of navigation and the changes made following the previous phase. Then, the survey was amended accordingly. Eligible participants sent an e-mail containing an information sheet and an invitation to participate in the study. Consent is obtained before participants proceed to the survey.

Data collection

Data were obtained during March and April 2025. The questionnaire for each round was filled out electronically and saved anonymously in Google Forms. The CKD clinical content experts panel had four weeks to answer the surveys. Non-responders received e-mail reminders twice over the four weeks. The estimated time consumption for each questionnaire was 20–30 min. Participants were asked to rate each statement on a five-point Likert scale, from 1 (Very ineffective) to 5 (Highly effective). Statements were derived from existing best practices outlined in clinical guidelines, systematic reviews, and research studies. Participants also had the option to provide additional comments or suggest new statements. This was followed by participants’ demographics, which included age, gender, qualification, nationality, country of practice, years of experience, and expertise with e-learning modules. The round opened for 4 weeks, and reminder e-mails were sent to non-responders after two weeks to increase the response rate. Items scored between 4 and 5 (most effective) by ≥ 70% were considered and excluded from the second round. Items scored between 1 and 2 (ineffective) by ≥ 70% were excluded from the second round. Only items that scored 3 (neutral) were included in the second-round survey for re-rating. Additional items suggested by participants in the free-text field were reviewed and carried forward to the second round. Statements that did not reach consensus in the first round were re-rated by participants. The same five-point Likert scale was used. Participants have the opportunity to suggest additional strategies.

Data analysis

Quantitative data was examined using the IPM SPSS27 version and assessed in three areas: consensus, agreement, and stability, utilizing descriptive and inferential statistics. The inclusion of assertions in the next set of surveys was evaluated based on a predetermined degree of consensus, stability, and agreement (See Table 1). Consensus refers to the extent to which the expert panel members agree. Descriptive statistics described the score distribution (percentages-median) and compute the interquartile range (IQR). Statements were grouped and rated according to their significance scores [58]. The Likert scale was considered an ordinal scale [59]. The consensus was statistically summarized for central trends and dispersion using a previous median and interquartile range (IQR) criteria. Furthermore, for each statement, the proportion of agreement with replies rated effective/very effective was utilized to assess consensus. Statements that do not gain consensus according to previously stated criteria are eliminated before the subsequent questionnaire round. Table 1 displays each round’s criteria for statistical consensus, agreement, and stability measures [46, 47]. Kendall’s coefficient of concordance, where 0 represents no agreement and 1 represents a complete agreement, is used to assess agreement across experts across assertions. The Wilcoxon rank-sum test was used to evaluate response stability over questionnaire rounds. P-values < 0.05 indicate statistical significance in all analyses. We discovered a statistically substantial degree of agreement among the judges, as demonstrated by a p-value of 0.001. Kendall’s W-value of 0.483 indicates reasonable agreement. The findings suggest that eight techniques differ considerably, whereas two (“BMI and waist circumference on kidney health and low-protein diets and sodium restriction”) do not. The principal investigator conducted analyses between the qualitative data rounds. For the qualitative data, the investigator conduct content analysis inspired by the analytic steps of Graneheim and Lundman [60]. A content analysis was applicable for systematically analyzing written content [61]. This analytic approach is sufficient to identify content areas and to combine or collapse similar statements from a CKD clinical content expert panel into new statements for the following questionnaire round [43, 60]. Initially, the answers to open-ended questions were read several times. The analyses were then carried out in an iterative procedure that includes numerous steps: (1) Detection of content areas that emerged with little data interpretation, (2) Division of content areas to meaning units based on related content and context, (3) Coding meaning units, (4) Interpretation of codes based on similarities and differences, and division of codes to tentative categories to be formulated into themes [60, 62]. It might be further upon in the future questionnaire cycle. The qualitative research uncovered numerous professional, organizational, and external barriers. Addressing these issues is critical to properly implementing and distributing the content. We removed three statements and added new ones based on the experts’ feedback.

Table 1.

Criteria for statistical measurements of consensus, agreement, and stability

	Statistics	Round 1	Round 2
Consensus	Median Interquartile range (IQR) Percentage agreement	≥ 3 ≤ 1.5 ≥ 70%	≥ 3 ≤ 1.5 ≥ 70%
Agreement	Kendall’s coefficient of concordance (W)	P < 0.05	P < 0.05
Stability	Wilcoxon rank-sum test	NA	P < 0.05

Results

Expert panel (Participants)

A total of 50 participants were identified by their publications about CKD and e-learning experts, including the corresponding authors and many members in GlomCon (“Glomerular Disease Study and Trial Consortium”) groups —all experts in CKD and education training for HCPs in kidney diseases. Out of 50 invited, 15 (30%) participants responded to the invitation. One participant did not complete the survey in the second round. Fifteen of them participated in both rounds. Most study participants had over 15 years of experience and a doctorate. Table 2 summarizes participants’ characteristics.

Table 2.

Participants characteristics

Participants Characteristics (N = 15)	N(%)*
Familiarity with CKD Prevention
Very Familiar (1.0)	12 (80%)
Familiar (0.8)	3(20%)
Primary Field of Expertise
General Nephrology	10(66.7%)
Pediatric Nephrology	2(13.3%)
Hypertension Management	1(6.7%)
Transplant Nephrology	2(13.3%)
Experts work as (Multiple options)
Clinician	8(53.3%)
Specialist	2(13.3%)
Educator	2(13.3%)
Researcher	4(26.7%)
Age(years)
30–40	3(20%)
40–50	5(33.3%)
> 50	7(46.7%)
Sex
Male	9(60%)
Female	6(40%)
Years of Experience in Clinical Practice
< 10 years	3(20%)
10–15 years	3(20%)
> 15 years	9(60%)
Qualification
Doctorate	8(53.3%)
Master’s	7(46.7%)
Workplace Setting
Hospital	10(66.7%)
Private Practice	3(20%)
University/Research Institution:	2(13.3%)
Geographic Location
Urban	10(66.7%)
Rural	5(33.3%)
International or local experts
Syria	6(40%)
Outside Syria	9(60%)
Nationality
	Saudi Arabia: 2(13.33%)
	USA: 2(13.33%)
	Malaysia: 1(6.67%)
	Philippine: 1(6.67%)
	India: 1(6.67%)
	Iraq: 1(6.67%)
	Lebanon: 1(6.67%)
Professional Affiliations and Certifications: (Multiple-Choice Questions)
The Syrian Society of Nephrology.	2(13.33%)
The Philippine Society of Nephrology	1(6.67%)
The American Society of Nephrology (ASN)	2(13.33%)
The International Society of Nephrology (ISN)	10(66.67%)
The American Board of Internal Medicine (ABIM).	1(6.67%)
The Middle East Society of Organ Transplantation MESOT	2(13.33%)
Board Certification in Nephrology, Hypertension Management)	3(20%)
Participate in online educational modules?
Always	3(20%)
Often	5(33.33%)
Sometimes	6(40%)
Rarely	1(6.67%)
Challenges in CKD Prevention Education: Multiple-Choice Questions
Lack of Time	10(66.67%)
Technical issues and frequent interruptions of electric supply	8(53.33%)
Limited Internet Access:	9(60%)
Language Barriers:	3(20%)
Lack of Materials in Local Language	3(20%)
Lack of interest	1(6.67%)
Geographically isolated rural area	1(6.67%)
Additional features would you like in CKD modules?
Offline access options	5(33.33%)
Multilingual support (e.g., Arabic)	3(20%)
Practical case studies	2(13.33%)
Culturally relevant content	2(13.33%)
Community-based training programs	1(6.67%)
Display panels/screens for kidney failure	1(6.67%)
Government-supported training	1(6.67%)
Multidisciplinary team support	1(6.67%)
How likely are you to recommend interactive CKD modules to colleagues?
5 (Very likely)	15(100%)

Note: Fifteen of a CKD Clinical Content Expert panel participated in both rounds. One participant did not complete the survey in the second round

First-round outcomes

In the first round, 41 strategies were evaluated. Three strategies—Genetic screening (71.43% rated ineffective) because of the logistics of funding a genetic study and screening a massive population unavailable in Syria. Bariatric surgery (78.57% ineffective) because of high costs and systemic resource limitations (e.g., lack of specialized surgical infrastructure, funding, and trained personnel) is legal for specific patients and not recommended in Syria. APOL1 Genetic Variants in African Americans unrelated to the Syrian context —were excluded due to infeasibility in Syria’s resource-limited context. Ten strategies underwent modifications based on expert feedback, such as replacing seafood-derived omega-3 with plant-based alternatives and simplifying CKD-EPI equation training for nurses. (See Table 3)

Table 3.

Descriptive analysis of CKD prevention strategies statements included in the first and second a round

Second-round outcomes

The second Delphi round successfully refined 10 strategies to address Syria’s challenges. By prioritizing cultural relevance, cost-effectiveness, and simplified protocols, these strategies are now actionable within low-resource settings. The unanimous consensus (100% on seven strategies) underscores their feasibility and alignment with expert priorities. (See Table 4)

Table 4.

Modified strategies and key improvements

Identification of strategies

We anticipated identifying evidence-based CKD strategies suitable for implementation in Syria. These strategies were categorized into primary and secondary prevention. (See Table 5).

Table 5.

CKD prevention strategies: Delphi consensus outcomes

Barriers and suggestions

The study identified key barriers and suggestions for the implementation of these strategies. These factors are expected to exist in professional, organizational, and external contexts. (See Figs. 1 and 2)

Fig. 1.

Barriers to implement CKD prevention content

Fig. 2.

Barriers to implementing e-learning delivery method

Discussion

Significance

The Delphi Method was employed to determine the best evidence and practices for providing Syrian nurses with CKD prevention education programs. Implementing interactive e-learning modules for evidence-based CKD prevention strategies in resource-constrained settings takes careful preparation and consideration of local requirements, accessibility, and sustainability. This method has been demonstrated to enhance healthcare practitioners’ knowledge and skills [5, 40]. Tailor the content to the target audience’s unique requirements and environment. Involving local and international experts in planning can help achieve this [63, 64]. Modify already-effective platforms to suit the local environment, as demonstrated by the My DESMOND platform’s adaptation for CKD management [64]. Using asynchronous e-learning modules to provide practice nurses with flexibility is especially useful in environments with limited resources where nurses may have different schedules [5, 33]. To enhance learning and knowledge application in practice, including feedback and support methods like facilitated meetings or local learning collaboratives (LLCs) [65]. Refining evidence-based CKD prevention strategies required combining global experience with contextualization unique to Syria. For example, in order to accommodate Syria’s restricted access to seafood, the cost of seafood and cultural dietary customs, international experts suggested plant-based omega-3 equivalents (such as flaxseeds and walnuts) as alternatives to marine-derived supplies. Similarly, Syria’s resource limitations are addressed by substituting affordable methods like blood pressure monitoring, urine dipsticks, and serum creatinine-based eGFR for genetic screening. These modifications preserve diagnostic rigor while guaranteeing scalability in low-resource environments. For instance, using the current infrastructure to prioritize ultrasonography for diseases like ADPKD (since genetic testing is not yet available) helps reduce the number of undiagnosed cases associated with consanguineous marriages, which are a high-risk factor in Syria. These results are consistent with e-learning adaptations in other contexts with limited resources. If issues with infrastructure, support, and content are resolved, e-learning can be very helpful in environments with limited resources. Strategic planning, strong policy backing, and adaptive learning technology to accommodate learners’ varied requirements are frequently necessary for successful implementations [66–68].

For example, in studies in conflict zones like Yemen [69] and South Sudan [70, 71], prioritizing localized information and offline-accessible modules is crucial to overcoming low digital literacy and unstable internet. Ensuring educational resources are culturally relevant and appropriate for the local context is essential. This improves the content’s appropriateness and relevancy, increasing its effectiveness in areas affected by conflict [72]. The shift from genetic to radiological screening mirrors approaches in sub-Saharan Africa, where ultrasound replaced costly molecular diagnostics for CKD surveillance [73, 74]. However, this study uniquely addresses Syria’s distinct challenges, such as environmental toxin exposure [75] and consanguinity-driven genetic risks, through targeted screening of high-risk groups (e.g., elderly populations in bombed areas and children with congenital anomalies) [1, 76, 77].

The emphasis on Arabic-language materials and simplified terms (e.g., “protein in the urine” instead of “albuminuria”) bridges literacy gaps among nurses [78, 79], while culturally tailored dietary guides (e.g., modifying kibbeh with lentils) enhance adherence to low-protein diets. Such modifications reflect a pragmatic balance between global best practices and localized feasibility [80]. Bariatric surgery offers a promising intervention for preventing CKD in patients with obesity. The potential benefits of improved renal function and reduced CKD progression are significant [81, 82]. Still, the local experts in Syria didn’t consider this option and prefer to work on modifying lifestyle for multiple reasons, such as resource availability, cost, and patient management, which is crucial for successful implementation in these settings. Further studies and tailored guidelines are needed to optimize the use of bariatric surgery for CKD prevention in low-income countries [83–85]. The experts also exclude APOL1 genetic variants, particularly the G1 and G2 alleles, which are strongly associated with an increased risk of CKD, especially among individuals of African ancestry, not the Syrian population [86].

These modules can significantly improve primary and secondary CKD prevention by early detection and slow the CKD progression to stages 3–4 in resource-limited settings by leveraging evidence-based content, customizing to local contexts, ensuring usability, and fostering collaboration.

Limitations

Because a recent Syrian study [21] revealed substantial CKD-prevention knowledge deficits among renal nurses in clinical settings, we excluded them from the Delphi consensus panel to prevent anchoring the recommendations on outdated practice. We included two nursing professors in the pilot test before the survey. Consequently, front-line renal nurses’ perspectives were not directly represented when shaping either the content or delivery methods of the CKD-prevention e-learning modules.

Clinical implications

This study emerged from clinical work with evidence-based CKD prevention strategies and an obvious need to create a common foundation for nurses’ knowledge of CKD prevention. The work will be conducted in hospital settings in Syria, specifically in departments related to kidney disease, cardiovascular disease, and endocrinology. All the participants in this study contribute to developing interactive CKD prevention modules. From the rationale and suggestions, it is possible to tailor the content and delivery method to fit the Syrian context to measure efficacy from the clinical implementation of evidence-based CKD prevention. Clinically, developing CKD prevention education modules will positively impact the unification of CKD prevention strategies in Arab countries and further develop CKD care to adapt CKD prevention strategies to fit the Syrian context. This e-Delphi study focuses on CKD prevention strategies tailored to the Syrian environment; however, CKD prevention education could probably be used in a broader context in general headache care.

Conclusion

This study provides actionable strategies to improve CKD prevention with limited resources by combining global experience with Syrian regional realities. A model for similar conflict-affected areas can be created by prioritizing nurse-friendly practices, culturally appropriate education, and affordable instruments. In order to maintain these interventions, future work should increase stakeholder engagement, validate ideas through pilot implementation, and promote continuous education and follow-up.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Conceptualization K.W., C.W.; methodology C.W. and F.A.; validation K.W., C.W., F.A.; formal analysis F.A. and C.W.; data curation F.A. and W.K.; writing—original draft preparation K.W., C.W. and F.A.; writing—review and editing. C. W., K.W., F.A., L.L., Q.Y. and W.K.; visualization C.W. and K.W.; supervision K.W. and C.W.; project administration C.W. and F.A. All authors have read and agreed to the published version of the manuscript.

Funding

No funds, grants, or other support were received.

Data availability

All data in this study are available upon request by contacting the corresponding authors.

Declarations

Ethics approval and consent to participate

Before participating in the study, all the subjects provided informed consent. The Ethics Committee of Shandong University approved the protocol (No. 2023-R-091). They were informed that their participation was entirely voluntary and that they could withdraw from the study at any time. Anonymized and confidential information was collected. All participants provided written informed consent. We offered our e-mail address and phone number so they could contact us if they had any unresolved difficulties. All the procedures were performed following the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.