A cross‐sectional study on the ability of physicians to hypertension management in China's Sichuan Tibetan rural area

Abstract This study aimed to investigate the hypertension management abilities of rural physicians in a high‐altitude Tibetan area. A cross‐sectional survey was conducted in the Ganzi Tibetan Autonomous Prefecture, China, in October 2020. Information about healthcare resources in local medical institutions, along with the knowledge, attitudes, practices, and training status of primary care physicians, was collected. Limited resources were observed in terms of equipment, drugs, and personnel in the 18 township hospitals included. A total of 132 physicians participated in this survey. The scores for hypertension‐related knowledge, attitudes toward hypertension management, routine practice ability, priority given to hypertension, and confidence in performing certain tasks were 32.60%, 67.40%, 18.90%, 65.15%, and 35.60%, respectively. The most concerning issues lay in the ignorance of the healthy lifestyle, undervaluation of cardiovascular risks, and lack of confidence in optimally performing management activities. Only 9.85% of the physicians received more than 24 days of training per year; 28.79% preferred a longer training time. While training was generally provided in conference sessions (63.64% of current training programs), physicians preferred remote education (55.30%), and on‐site guidance (46.21%) from professionals. The current training was centered around clinical skills (61.36%) and was identified as a major training requirement by the physicians surveyed (80.30%). This survey suggests that the medical resources may not be effective, with deficiencies present in the knowledge and practices of primary care physicians in the Sichuan Tibetan area. Hypertension education and skill‐development courses based on the specific issues identified should be provided to these physicians in the future.


INTRODUCTION
Hypertension is the main risk factor for cardiovascular and cerebrovascular diseases and all-cause deaths worldwide. 1,2 There are around 245 million hypertensive patients in China, which is a heavy burden on families and society. 3 Primary care health institutions (community health service centers, community health service stations, township hospitals, and village clinics) are the main battlefield of hypertension management in China; thus, the level of hypertension management in these institutions directly affects the trend of cardiovascular and cerebrovascular disease development. 4 In 2009, a national policy called Essential Public Health Services (EPHS) was launched in China. 5 Chronic disease screening and management were provided free of charge to residents by grassroots health institutions. 6 Studies have shown that the national EPHS program helped improve the quality of hypertension treatment situation. 7,8 Some studies reported a greater improvement in hypertension management in rural and poorer regions than in urban areas 9,10 ; however, others indicated that the urban areas achieved better hypertension management, 11,12 suggesting that the urban-rural disparities in the management of hypertension may have persisted.
However, there remains an obvious gap in the economic and medical resources in rural areas with different geographical locations. The per capita gross domestic product (GDP) of the second-largest Tibetan residential region in China, the Ganzi Tibetan Autonomous Prefecture, which has an average altitude of 3500 m and a population of 1.6 million people, is less than half of the national per capita GDP. 13,14 The economic and medical resources here lags far behind that of other rural areas. The quality of hypertension management in this region is lower than in urban communities and other rural regions; the region has a higher disease prevalence (32.2% vs. 23.2%) and lower treatment (41.3% vs. 45.8%) and control rates (3.2% vs. 16.8%) for hypertension than the national average. 3,15 Further, the control rate for hypertension in this region is far less than the rural average control rate (13.1%). 3 However, most of the previous studies conducted on the management of chronic diseases in urban and rural areas in China focus on areas located in the plains, 10,16,17 ignoring the situation in Tibetan areas of the plateau. 18 In this study, we investigated the local healthcare resources and the ability of physicians to adequately manage hypertension in a high-altitude Tibetan area in Southwest China. We evaluated the hypertension-related knowledge, attitudes, and primary care practices of these physicians, along with the training requirements to provide education and skill-development courses for hypertension management in the future.

Study design
A cross-sectional survey was conducted for this study in October 2020.
We identified 132 rural physicians working in 18 township hospitals

Statistical analysis
Continuous variables are expressed as mean ± standard deviation (SD). Categorical variables are presented as frequencies (percentages). To summarize the knowledge, attitude, priority, practice, and confidence aspects of the KAP survey, we calculated the score for each part as the number of correct or desirable answers divided by the total score obtained for each part, presented as median percentage (P25, P75). The total score for each section was 100.
The chi-square test was used to compare the differences between the training status and requirements of the rural physicians. Statistical analysis was performed using SPSS version 23.0 (IBM Corp., Armonk, NY, USA), and statistical significance was set at p < .05.

Healthcare resources characteristics
Eighteen township hospitals were included, covering a population of 47 710 people, with a total of 132 rural physicians. The local physician-to-population ratio was 2.77 physicians per 1000 people.
Of the enrolled institutions, 58.8% were equipped with validated electronic equipment for hypertension measurements. Nearly three quarters of the institutions were equipped with blood and urine test analyzers. None of these hospitals were equipped with a 24h ambulatory blood pressure monitoring device; the equipment for hypertension-related target organ damage, including cardiac ultra-

Demographic information
A total of 132 respondents were included in our study (

Knowledge, attitudes, and practices of primary care physicians
The overall KAP survey results and the detailed answers to each question are presented in Table 3  Some physicians also stated that the patients did not prioritize hypertension management (52.2%).

Practice
The average score for optimal routine practice was low (

Confidence
The average score for confidently performing optimal hypertension management activities was low (35.60%). One in three physicians suggested that they were sufficiently confident to prescribe three or more antihypertensive regimes in a single patient, with 57.6% confident in prescribing two drug agents. Without additional training, 33.3% indicated that they could optimally use a hypertension registry, and 18.9% would confidently use a treatment algorithm or pathway. Confidence in perfectly completing routine tasks in diagnosing and managing hypertension without training was 23.5-40.2%. The physicians were least confident about assessing patients' adherence to antihypertensive drug therapy (23.5%).

Current training status and future training requirements
In the previous year, 78.03% of the participants had received less than 12 days of training; 9.85% had received more than 24 days of training.
Regarding the method of training, the most common training format was conference sessions (63.64%), followed by remote or video education (39.39%), and self-education or proficiency tests (29.55%). Clinical skills (61.36%), preventive healthcare knowledge (53.03%), and medication knowledge (43.94%) were most taught in the training sessions, in that order.
In terms of training time requirement, 46.21%, 25.00%, and 28.79% of the physicians indicated that the average training time should be less than 12 days, 12-24 days and more than 24 days per year, respectively. Remote or video education from senior professionals (55.30%) and on-site guidance from senior professionals (46.21%) seemed to be the most popular training formats, followed by clinical further education (42.42%). Most physicians (80.30%) preferred to receive clinical skills training, while 75.76% of them were also interested in preventive healthcare knowledge (Table 4).

Difference between training status and requirements
The differences between the current training status and future training requirements were statistically significant (Table 4).
Regarding the training time, 12.12% and 9.85% of the physicians received 12-24 days and more than 24 days of training per year, respectively; however, 53.79% preferred a training time of 12 days or longer. Meanwhile, the percentage of those who received less than 12 days of training decreased from 78.03% to 46.21%.
The demand for guidance from professionals, clinical further education, and remote/video education increased markedly, particularly in terms of guidance from senior doctors (16.67% vs. 46.21%). The highest discrepancy between the requirement and current status was for the conference sessions (66.67% vs. 38.64%); self-education or proficiency tests (25.76%) and school training (19.70%) were the least preferred training methods.
A higher demand was observed for training in clinical skills, preventive health knowledge, and medication knowledge than that currently provided, suggesting that the training provided was not sufficient for the physicians that were surveyed.

DISCUSSION
In this study, we investigated the medical resources related to hypertension management in the Sichuan Tibetan area, along with the KAP and training status of the physicians. Our results indicate that the hypertension management abilities of physicians in these areas require significant improvement; this partly explains the low hypertension control rate in these poor areas.
The implementation of the EPHS reforms in 2009 has been effective for public health development, with public health services being accessible to more people in China. 10 However, inequality in hypertension management has persisted. The quality of hypertension management correlates to many factors, including social attention, medical resources, and patients' involvement. 16 Compared with residents living in urban or rich regions, those living in poor or rural areas are less likely to be aware of their health conditions or receive timely treatment or blood pressure management. 16  Adherence to the Chinese hypertension guidelines is key for highquality primary care hypertension management; however, physicians in China's Tibetan areas were not sufficiently trained in these guidelines.
To our knowledge, this is the first study in China to use the KAP scale to evaluate primary care physicians' hypertension management ability.
The following physician-related issues in hypertension management were highlighted based on our survey: the physicians (1)  to the poor hypertension management quality as our previous study suggested in this high-altitude region, which was mainly characterized by a high disease prevalence and a relatively low control rate. 15 Previously, our team had launched a hypertension management improvement project. 26 We developed an Internet-based hypertension management system, the Red Shine Chronic Disease Management System (RSCDMS), aiming at providing patients with high-quality management by physicians under the guidance of specialists to help these physicians improve their clinical disease management abilities. 26 We hypothesized that by using this system to address the issues identified above, online training courses could be provided based on the physicians' needs, and a real-time hierarchical medical system could be created for the high-altitude remote areas.
This study has several limitations. First, we only included physicians from a county in the Sichuan Tibetan region, which created a selec-tion bias. In the future, we plan on trying to get more funding support to help use a multi-stage, stratified, random sampling method to enroll the participants in the Tibetan areas, and conducting the survey in the urban community health service centers and rural township hospitals in the plain regions of Sichuan Province. Second, there may be a response bias, as some physicians might have preferred to choose the "obvious" right answers or randomly chosen one option, yet the current answers could still reflect the limited management ability here.

CONCLUSIONS
This study suggests a lack of effective medical resources, and the deficiencies in the knowledge and practices of primary care physicians in the Sichuan Tibetan area. In the future, long-term guidance relationships must be built between professionals in tertiary hospitals and physicians at high altitudes, so that training courses can be provided based on the specific issues identified in this study.