| |

Received: 28 January 2019    Revised: 15 April 2019    Accepted: 29 April 2019

DOI: 10.1111/jch.13592

ORIG INAL PAPER

Hypertension knowledge, attitudes, and practices of nurses

and physicians in primary care in Ulaanbaatar Mongolia

Maral Myanganbayar BMedSc1  | Uurtsaikh Baatarsuren MD1 |

Guanmin Chen MD, PhD2 | Norm R. C. Campbell MD3  | Roberta Bosurgi BSc, MSc4 |
Geoffrey So BSc, MSc4 | Tsolmon Unurjargal MD, PhD5 | Myagmartseren
Dashtseren MD, PhD5 | Namkhaidorj Tserengombo MD, PhD6 | Batbold Batsukh MD7 |
Andreas Bungert PhD1 | Naranbaatar Dashdorj PhD1 | Naranjargal Dashdorj MD, PhD1

1
Onom Foundation: Onom Foundation
Central Office, Ulaanbaatar, Mongolia Abstract
2
Research Facilitation, Analytics, Alberta Increased blood pressure is a leading risk for death globally, and interventions to en‐
Health Services 1101, Foothills Medical
hance hypertension control have become a high priority. An important aspect of clinical
Centre, Calgary, AB, Canada
3
Departments of Medicine, Physiology
interventions is understanding the knowledge, attitudes, and practices (KAP) of differ‐
and Pharmacology, Community Health ing primary healthcare practitioners. We examined KAP surveys from 803 primary care
Sciences Libin Cardiovascular Institute
of Alberta, O’Brien Institute for Public
practitioners in Ulaanbaatar, Mongolia (response rate 80%), using a comprehensive
Health, University of Calgary, Calgary, AL, KAP survey developed by the World Hypertension League (WHL). The WHL KAP sur‐
Canada
4
vey uniquely includes an assessment of key World Health Organization recommended
Novartis Foundation, Basel, Switzerland
5 interventions to enhance hypertension control. There were few substantive differ‐
Mongolian National University of Medical
Sciences, Ulaanbaatar, Mongolia ences between healthcare professional disciplines. Primary care practitioners mostly
6
Ulaanbaatar Songdo Hospital, Ulaanbaatar, had a positive attitude toward hypertension management. However, confidence and
Mongolia
7 practice in performing specific tasks to control hypertension were suboptimal. A low
The First Central Hospital of Mongolia,
Ulaanbaatar, Mongolia proportion indicated they systematically screened adults for hypertension and many
were not aware of the need to or were confident in prescribing more than two antihy‐
Correspondence
Naranjargal Dashdorj, MD, PhD, Onom pertensive medications. It was the practice of a high proportion of doctors to not phar‐
Foundation: Onom Foundation Central
macologically treat most people with hypertension who were at high cardiovascular
Office, 3 Bogd Javzandamba Street, 15
Khoroo, Khan‐Uul District, Ulaanbaatar risk. There was a reluctance by physicians to task share hypertension diagnosis, drug
17011.
prescribing and assessing cardiovascular risk to nurses. The minority of health care
Emails: ndashdorj@gmail.com; dashdorj@
onomfoundation.org professions use a hypertension management algorithm, and few have patient registries
Funding information with performance reporting functions. There were few substantive differences based
Novartis Foundation on the age, gender, and years of clinical practice of the practitioners. The study findings
support the need for standardized education and training of primary care practitioners
in Ulaanbaatar to enhance hypertension control.

1 |  I NTRO D U C TI O N
Increased blood pressure is a leading risk for death globally with
approximately 1.4 billion people having hypertension worldwide.1,2
The staggering global burden of disease has resulted in multiple
calls to action to prevent and control hypertension. 3-6 Low‐mid‐
dle‐income countries (LMIC) have a greater burden of disease
associated with hypertension than high‐income countries, and
LMIC face numerous barriers to improve healthcare delivery with
limited resources.1,5 However, there are few published population

J Clin Hypertens. 2019;00:1–8. ©2019 Wiley Periodicals, Inc. |  1

wileyonlinelibrary.com/journal/jch  
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2       MYANGANBAYAR et al.
interventions in LMIC demonstrated to enhance hypertension
7
control.
Better Hearts Better Cities is a global initiative by the Novartis
Foundation to improve hypertension control and management in
low‐income urban settings.8 In 2016, Better Hearts Better Cities ini‐
tiated an intervention in Ulaanbaatar, the capital city of Mongolia.8
Mongolia has a single universal public healthcare system that
provides free medical visits and subsidized medications as a strong
foundation for interventions to control hypertension. However, the
hallmark of uncontrolled hypertension, hemorrhagic stroke, has a
rate in Mongolia that is almost four times the world average.9 Clearly,
there is an urgent need for markedly improving prevention and con‐
trol of hypertension in Mongolia.
In 2013, the World Hypertension League (WHL) conducted a
“needs assessment” of national hypertension organizations, which
ranked conducting training sessions for healthcare professionals as
the second top priority for interventions.10 Part of the Better Hearts
Better Cities intervention is the establishment of an enhanced hy‐
pertension education and skills development program for primary
healthcare professionals. To assist in designing the education and
skills development program, it is important to understand the
baseline knowledge, attitudes, and practices (KAP) of healthcare
professionals.
There are few KAP studies on healthcare professionals and
none that we are aware of that directly compare different primary
healthcare disciplines (nurses and physicians), the breadth of hy‐
pertension management, and the core interventions promoted
as global best practices (eg, task sharing, use of simple treatment
algorithms and validated automated blood pressure devices, reg‐
istries with performance reporting functions) by the World Health
Organization (WHO, https​://www.who.int/cardi​ovasc​ular_disea​
ses/heart​s/en/, accessed March 30, 2019). The WHL recently de‐
veloped a novel hypertension KAP survey to comprehensively
evaluate hypertension management at the primary care level and
including the core WHO interventions.11 Previously, we have re‐
ported results of a modified version of the WHL KAP survey, exam‐
ining physicians from primary healthcare centers in Ulaanbaatar. 8,11
Overall, knowledge of hypertension clinical practice, confidence in
managing hypertension, and specific clinical practices were subop‐
timal but physicians prioritized and had a positive attitude toward
8 pertension should be advised in all patients (response choice True/
hypertension management in their clinics.
To enhance hypertension control, it is important that all primary
healthcare professionals have similar core knowledge, a positive at‐
titude and high priority for hypertension management, appropriate
clinical practices and provide consistent and appropriate advice to
patients. Further, in designing training interventions it is important
to understand if different primary care disciplines have different
training needs. This paper examines the KAP of different healthcare
professional disciplines in primary care. To our knowledge, this is the
first survey that comprehensively compares hypertension KAP in
different primary care disciplines and includes the core WHO inter‐
ventions in Hearts (https​://www.who.int/cardi​ovasc​ular_disea​ses/
heart​s/en/, accessed March 30 2019).
2 | M E TH O DS
A KAP survey questionnaire, originally designed by the WHL, was dis‐
tributed to eight districts involving 138 primary healthcare centers in
Ulaanbaatar, Mongolia (population over 1.3 million).8 The survey was
previously pilot tested with over 20 healthcare professionals in five pri‐
mary healthcare centers of two distinct districts to assess their ability to
understand the questions and the length of time it took them to com‐
plete the survey. Each primary healthcare center director was briefed
on how to carry out the survey and that completion of the whole survey
was mandatory for healthcare professionals working at primary health‐
care centers as part of a hypertension quality of care program. Up to
40  minutes was provided to finish the questionnaire. Respondents
were asked to complete the survey without discussing answers among
each other. Questionnaires were collected by the research team one
week after distribution for each district. After collection, each question‐
naire was checked on completeness and if incomplete, it was sent back
to the clinics for completion. The survey took place from December
2016 to May 2017 including 1009 healthcare professionals (general
practitioners, family doctors, internal medicine specialists, and nurses),
and 803 surveys were returned (response rate of 80%).
The WHL survey design was based on the confidence convic‐
tion model. 8,11 Components of the questionnaire included gen‐
eral characteristics of respondents (six questions), knowledge of
hypertension and the 2010 Mongolian hypertension guidelines
(16 questions), attitudes (five questions), and practices (14 ques‐
tions) toward hypertension management, as well as hypertension
management priorities (seven questions) and confidence (three
questions). Most questions had multiple components. Examples of
questions are as follows:
2.1 | Knowledge
What is the recommended daily level of salt consumption for people who
have hypertension? (response choices 1‐2 g, 2‐3 g, 3‐4 g, <5 g, and <10 g).
2.2 | Attitude
Counseling about lifestyle interventions to prevent and control hy‐
False).
2.3 | Practice
In what percent of adults with hypertension does the clinic where
you work recommend the following lifestyles? Reducing the amount
of salt in the diet (response choices 0%‐100% in 10% intervals).
2.4 | Priority
How do you prioritize the following hypertension management ac‐
tivities compared to the work you already must do in a usual day.
MYANGANBAYAR et al. |
      3

Counsel about lifestyle interventions to prevent and control hyper‐
tension (response choices 1‐10 with 1 being highest priority and 10
being lowest priority).
2.5 | Confidence
Without additional training how confident do you feel in your ability
to optimally perform the following activities in diagnosing and man‐
aging hypertension? Counsel about lifestyle interventions to prevent
and control hypertension (response choices 1‐10 with 1 being no
confidence and 10 being 100% confident).
The survey was also specifically designed to assess interventions
proposed by the World Health Organization as part of its HEARTS
program including task sharing, use of simple treatment algorithms,
and registries with performance reporting.12 Modifications to the
WHL survey for Mongolia included revising questions to assess the
Mongolian hypertension recommendations. The Mongolian hyper‐
tension guidelines are similar to most western guidelines but the tar‐
get for diastolic blood pressure is 85 mm Hg and has some different
lifestyle recommendations.
Most questions had the potential for 10 categorical responses.
Where possible, answer options to questions were grouped into
“correct” or “incorrect,”, “undesirable answer” or “desirable answer,”
“high priority” or “low priority,” as well, an intermediate option was
included depending on the question and distribution of responses.8
The desired/undesired category was used when there was no single
correct answer but a range of potential responses (eg, for a high‐risk
patient where there is no specific recommended follow‐up inter‐
val, shorter lengths of follow‐up were classified as “desired” while
longer follow‐up lengths were classified as “undesired”). Detailed
questions and grouped responses are presented in Tables S1‐S14.
The Supplementary Files are intended to aid scientists who want to
know the detailed questions asked and the responses.
During the survey, nurses did not fill out most questions involv‐
ing treatment and diagnosis of hypertension, despite repeated re‐
quest. We excluded from analysis those questions from disciplines
(eg, nurse, general doctor) where the non‐response rate was greater
than 15%. We included separate tables for questions that excluded
nurses (see Tables S8‐S10).
2.6 | Analysis
We summarized the continuous variables as mean ± SD. The WHL sur‐
vey questions were grouped into knowledge, attitude, practice, prior‐
ity, and confidence. Primary care disciplines were grouped into nurses,
general doctors, family doctors, and internal medicine specialists. We
grouped age into three categories: <35 years, 35‐55 years, and >age
55 years; gender into two categories (male and female) and grouped

TA B L E 1   Baseline characteristics by demographic factors and professional profile

General
Characteristics Total Family doctors practitioners Specialists Nurses P‐value

Number 804 (100%) 312 (38.8%) 117 (14.6%) 38 (4.7%) 337 (41.9%)  
Age (years) 37.4 (±11.9) 36.4 (±12.6) 29.3.0 (±7.3) 41.0 (±12.7) 40.8 (±10.9) 0.000a
Gender (n%)
Female 753 (93.8%) 281 (90.1%) 104 (88.9%) 35 (92.1%) 333 (98.8%) 0.000 b
Male 50 (6.2%) 30 (9.6%) 13 (11.1%) 3 (7.9%) 4 (1.2%)
Total 804 (100%)          
Years working
<5 y 332 (42.7%) 154 (51.3%) 84 (73.0%) 11 (29.7%) 81 (25.4%) 0.000 b
≥5 y 445 (57.3%) 146 (48.7%) 31 (27.0%) 26 (70.3%) 238 (74.6%)
Total 777 (100%)          
Clinic Chief/Supervisor 82 (10.1%) 58 (70.7%) 12 (14.6%) 9 (11.0%) 3 (3.7%) 0.000 b
Learnt HTN Guideline 684 (86.1%) 298 (95.8%) 113 (97.4%) 35 (92.1%) 238 (72.3%) 0.000 b
Trained on HTN guideline 297 (37.8%) 114 (37.1%) 47 (40.5%) 15 (39.5%) 121 (37.2%) 0.916b
Uses HTN Guideline 305 (39.5%) 151 (49.8%) 56 (48.7%) 11 (30.6%) 87 (27.4%) 0.000 b
always
Manages HTN patients 685 (89.0%) 274 (91.3%) 107 (93.0%) 32 (86.5%) 272 (85.5%) 0.050 b
most days
Manages HTN patients 41 (5.3%) 9 (3.0%) 4 (3.5%) 1 (2.7%) 27 (8.5%)
weekly
Manages HTN patients 44 (5.7%) 17 (5.6%) 4 (3.5%) 4 (10.8%) 19 (6.0%)
less than weekly
a
One‐way ANOVA.
b
Chi‐square.
4       |
those who worked <5 years and 5 years or more. The difference among
each group was compared by one‐way ANOVA for normal distribution
variables or by Kruskal‐Wallis for abnormal distribution variables in
the categorical variables (Tables 1 and 2). For categorical variables, we
calculated the frequencies and percentages, and the chi‐square test
was used to compare the difference between groups. The data were
analyzed using SPSS version 23.0. Analyses were only conducted for
categories of questions and not individual questions.
3 |   R E S U LT S
Table 1 presents the characteristics of different healthcare professional
disciplines. Most of the respondents in each professional group were
female (753, mean age 37.6 ± 12.0 yrs., Table 1) with 50 males (mean
age 31.1 ± 10.2), 803 in total. The healthcare professionals were nurses
(n = 337), family doctors (n = 312), or general practice doctors (n = 117),
but a few physicians practicing primary care had internal medicine spe‐
ciality training (n = 38). Majority of the family doctors and general prac‐
titioners had <5 years of working experience, while most of the internal
medicine specialists and nurses had worked more than 5 years.
The major categories of KAP survey questions overall and for the
different healthcare professionals are in Table 2, while the responses
to the individual KAP questions are included in the Supplementary
Tables of this paper (Tables S1‐S14). Over 85% of the healthcare
professionals treated people with hypertension most days and over
90% of the physicians and 72.3% of the nurses indicated that they
had learnt about the Mongolian hypertension guideline (Table 1).
Around 38% of the healthcare professionals responded that they
have had training on the Mongolian guideline within the last 2 years
but only 27.4% of the nurses, 30.6% of internal medicine specialists,
and less than half of the family and general physicians answered that
they used the guideline in all hypertensive patients (Table 1).
3.1 | Knowledge
There was no substantive difference between the types of health‐
care professionals on hypertension management knowledge
(P  =  0.867, Table 2, Tables S1‐S3). The average knowledge score
TA B L E 2   The knowledge of correct/desired (Mean ± SD) comparisons between profession groupsa
General practi‐
  Overall (%) tioners (%)
General knowledge 47.0 (±29.2) 48.9 (±29.1)
Attitude 72.1 (±15.3) 68.1 (±30.1)
Practice 28.8 (±17.9) 25.3 (±12.2)
Priority 83.8 (±15.0) 83.5 (±15.3)
Confidence 56.6 (±20.4) 56.8 (±20.8)
a
This table excludes diagnosis and treatment questions.
b
Kruskal‐Wallis test.
c
Specialists are significantly different to Nurses and General Practitioners.
d
Specialists are significantly different to Nurses and Family Doctors.
MYANGANBAYAR et al.
was poor. Between 67% and 81% of the physicians answered cor‐
rectly 140 and 90 mm Hg as the lowest level of usual systolic/dias‐
tolic blood pressure considered to be hypertensive in the Mongolian
guidelines while only half of the nurses responded correctly. The
systolic hypertension control threshold was correctly identified
by approximately 27% of physicians and 20% of nurses as a blood
pressure of <140 mm Hg while diastolic pressure control threshold
according to Mongolian guideline as <85 mm Hg was correctly iden‐
tified by 15%‐16% of physicians and 7.5% of nurses. The majority of
the physicians and nurses indicated lower than recommended blood
pressure targets. Most of the healthcare professionals chose more
aggressive than recommended salt intake advice and physical activ‐
ity for hypertensive patients. All questions were answered by more
than 85% of each healthcare professional discipline.
3.2 | Attitude
Overall score on attitude questions was 72.1% with a slightly but
not statistically better attitude score for nurses (88.3%) and internal
medicine specialists (74.0%) than general practitioners (68.1%) and
family doctors (69.9%, P = 0.589, Table 2 and Table S4). The very high
rate of missing values (>90% lack of responses to many questions)
from nurses on attitude questions relating to drug therapy makes
the higher score for nurses on these questions potentially unreliable
(Table S4). Physicians had a high response to this category of ques‐
tions (minimum of 87.2% response for one question and >95% for all
other questions). Ninety percent of healthcare professionals viewed
having a reliable high‐quality supply of medications of being of high
importance with no difference between disciplines. For task sharing,
over 90% of responding nurses supported that with adequate train‐
ing they should be able to measure blood pressure, counsel about
healthy lifestyles, assess cardiovascular risk, and prescribe or change
medications in an approved treatment algorithm. A high non‐re‐
sponse rate from nurses to the assessment of cardiovascular risk and
prescribing or changing medications makes those results less relia‐
ble. The different physician disciplines had <20% support for nurses
prescribing or changing medications, <3/4th supported nurses as‐
sessing cardiovascular risk, and <80% supported nurses measuring
blood pressure or counseling about lifestyle interventions.
Family doctors Internal medicine
(%) specialists (%) Nurses (%) P‐valueb
48.7 (±29.8) 49.3 (±31.4) 41.4 (±29.1) 0.867
69.9 (±30.2) 74.0 (±24.4) 88.3 (±3.0) 0.589
27.0 (±10.9) 40.2 (±18.9) 21.6 (±10.6) 0.004c
86.0 (±15.2) 80.1 (±14.8) 85.7 (±14.6) 0.001d
59.3 (±20.9) 63.0 (±23.8) 47.1 (±17.8) 0.132
MYANGANBAYAR et al.
3.3 | Practice
Overall score in the clinical practice question section was low at
28.8% with internal medicine specialists being higher (40.2%) than
nurses (21.6%) and general practitioners (25.3%, P = 0.004, Table 2).
Except for questions relating to drug treatment, missing values from
nurses were low (<6%) for all questions and even lower for the dif‐
ferent categories of physicians (Tables S5‐S7).
More than 75%‐85% of the physicians and nurses indicated that
they used an aneroid blood pressure measuring device at their clin‐
ics. 37.8% of the nurses and <20.5% of the physicians answered that
a validated electronic device was used.
55.3% of the nurses and 70%‐75% of the physicians answered
cardiovascular risk were assessed using either or both a risk chart
and a risk calculator. When asked if the clinic they worked had a reg‐
istry of people with hypertension, 85%‐94.7% of the physicians and
94% of the nurses reported that either or both a paper registry and
computerized registry of everyone with hypertension were used.
Importantly, <15% of any healthcare profession discipline indicated
the registry could provide reports on patients who have not had a
blood pressure measured, who missed a visit, who had been diag‐
nosed, treated, or controlled. 30.5% of the nurses and 33%‐39.3% of
the physicians indicated that a hypertension care pathway or algo‐
rithm is used at their clinic.
Only 16.4%‐18.9% of physicians and even lower, 6.8% of the
nurses responded that they routinely measured blood pressure and
screened for hypertension at all adult visits. The minority of doctors
and nurses reported that they counseled on lifestyle changes, prop‐
erly measuring blood pressure at home, treatment, and adherence
to drugs in 90%‐100% of adults with hypertension. Both physicians
and nurses indicated that lack of time, patients’ affordability to treat‐
ment and recommended lifestyle and importance unawareness were
major barriers to optimize hypertension management and reported
that they spent 8‐10  minutes on average for each hypertensive
patient.
There was a very high non‐response rate for nurses on practice
questions relating to drug treatment but over 85% of physicians re‐
sponded to these questions. Nurses were excluded from the analy‐
ses where the response rate was <85% (data excluding nurses where
the response rate was  <  85% are in Table S8‐S10). The treatment
question scores for physicians were generally low and similar be‐
tween physician disciplines; the overall physician results have been
previously reported. 8 Only 13% of general practitioners and 24.7%
of both family doctors and internal medicine specialists answered
two or more antihypertensive drugs are required to achieve blood
pressure control.
Less than half of the physicians reported that antihypertensive
drug therapy would be recommended to 61%‐100% of adults with
more than 30% 10‐year risk of a cardiovascular event. Similarly, in
several other high‐risk patient scenarios, the majority of physicians
did not recommend antihypertensive drug therapy to a high propor‐
tion of patients.
|
      5
3.4 | Priority
The overall priority score was high at 83.8%, with internal medicine
specialists (score 80.1%) having a slightly lower overall priority score
than nurses (score 85.7%) and family doctors (score 86.0%, P = 0.001,
Table 2, Table S11‐S13). Prescribing antihypertensive drugs was a high
priority for 63.9% of internal medicine specialists while >80% of phy‐
sician disciplines indicated it was a high priority. All disciplines highly
prioritized assessing cardiovascular risk, counseling about lifestyle, and
assessing adherence. Most disciplines including nurses highly prioritized
a physician making the diagnosis of hypertension as opposed to a non‐
physician, about 3/4ths that cardiovascular risk was assessed objec‐
tively, and over ninety percent supported that a whole team approach
was used to emphasize the importance of hypertension control and
adherence. Fewer than 80% highly prioritized the core WHO HEARTS
module recommendations for using a simple treatment algorithm and a
registry with performance reporting. All disciplines had a high response
rate to all questions except for nurses on priority questions specific to
drug treatment where there was a response rate of <85%.
3.5 | Confidence
The overall confidence score was only 56.6% with a non‐statistically
significant tendency for nurses to have lower confidence in perform‐
ing hypertension management tasks (P = 0.132, Table 2, Table S14). All
disciplines had a high response rate to all questions except for nurses
on priority questions specific to drug treatment where there was a
response rate of <85%. Only 70.2%‐78.1% of the physicians indicated
that they were confident (without additional training), counsel about
hypertension and its adverse effects, adherence to drugs, antihyper‐
tensive drugs, or lifestyle changes to achieve target blood pressures.
Well under half of the physicians indicated that they feel confident in
prescribing three or more antihypertensive drugs. Just 41.7%‐56.8%
and 36.9%‐54.1% of the physician disciplines would recommend an‐
tihypertensive drug therapy to 91%‐100% of the adults whose usual
systolic blood pressure was 160 mm Hg or more and diastolic blood
pressure was 100  mm  Hg or more, respectively. Only 29.1%‐31.6%
of the doctor disciplines and 22.3% of the nurses indicated they were
80%‐100% confident to implement and use treatment algorithms or
pathways in their clinic without additional training and 31.3%‐35.8%
of the physician disciplines and 26.3% of the nurses indicated they
could optimally use a hypertension registry without additional train‐
ing. Confidence in optimally performing routine activities in diagnos‐
ing and managing hypertension without training was 68.2%‐82.9% for
doctors and 57.0%‐61.1% for nurses.
3.6 | Results by age, gender, and years in
clinical practice
We found few substantive differences in the overall results based
on practitioners' gender, age, or years in practice. There were no
statistically significant differences (P  >  0.1) in those who were
 |
6       MYANGANBAYAR et al.
different age categories (age  <  35  years, 35‐55  years, and >age
55 years) or who had been in clinical practice fewer than 5 years
(vs those who worked 5 or more years) with the exception that
internal medicine specialists who had worked for <5  years prior‐
itized hypertension‐related activities slightly less than the other
healthcare disciplines (internal medicine specialists score 71.6%
vs 81.9%‐86% for other disciplines, P < 0.000). In the age category
over age 55 years, all types of practitioners except family doctors
and nurses prioritized hypertension activities slightly differently
(average scores 77.6%‐92.2%, P < 0.001). Also, in the age category
over age 55 years, internal medicine specialists had a higher desir‐
able practice score than nurses and family doctors (average score
41.5% vs 20.4% and 27.7%, P = 0.006). Female internal medicine
specialists prioritized hypertension activities slightly lower (av‐
erage score 79.8%) than female nurses and family doctors (aver‐
age score 85.6% and 86.3%, respectively, P < 0.001). Male family
doctors prioritized hypertension activities slightly lower (average
score 82.0%, P = 0.001) than all other practitioners (average score
85.9%‐93.1%) and male nurses prioritized hypertension activities
slightly higher than doctors who were general practitioners (av‐
erage score 93.1% vs 88.3%, P  <  0.001). Male internal medicine
specialists scored lower on desirable hypertension practices than
all other types of practitioners (average score 5.6% vs 21.1% to
27.6%, P = 0.001).
4 |  D I S CU S S I O N
Our expectation was that there would be substantive differences
in the KAP of the different healthcare professional disciplines and
hence that the hypertension training and education program would
need to be designed to address these differences. However, few of
the differences between the different disciplines were statistically
significant and even when statistically significant, the differences
were mostly inconsequential. It is notable that drug treatment of hy‐
pertension is outside of the regulatory scope of practice of nurses
in Mongolia and uniformly the response rate from nurses the drug
treatment question domains was low precluding valid assessment in
nurses. Nurses were less aware of the threshold blood pressure for
diagnosis and control of hypertension, scored slightly lower on desir‐
able hypertension practices, and were less likely to routinely screen
for hypertension but more likely to use a validated electronic blood
pressure monitor. Doctors with specialty training mostly scored
similarly to those without specialty training except on clinical prac‐
tice. Clinical practice scores were <50% desirable for all disciplines.
We found gender, age, or years in practice had little overall impact
on responses. Our KAP survey results are compatible with similar
education and training needs in the different disciplines. When clinic
manager advice was sought regarding separating training for nurses
and doctors, they favored integrated training.
The survey results show that the major deficiencies in KAP pre‐
viously published for primary doctors are consistent for nurses, as
well as doctors who have specialty internal medicine training, are
general practitioners, or are family doctors.8 The most notable find‐
ings were a lack of systematic screening for hypertension; low clini‐
cal knowledge especially regarding the importance of hypertension
control in those at high cardiovascular risk; and a lack confidence
to prescribe multiple antihypertension drugs. Validated electronic
blood pressure devices were used infrequently, and few current
registries could perform the major functions required to enhance
hypertension control (ie, identify those who had been screened,
diagnosed, treated and controlled, or missed appointments). The
previous strengths in primary care physicians were also consistent
across primary care disciplines including a high priority for hyper‐
tension diagnosis and management and support for adopting the
HEARTS interventions. Thus, education programs for the difference
in healthcare disciplines overall have similar needs.
The survey examined several domains recommended by global
hypertension initiatives such as WHO HEARTS, namely task shar‐
ing, use of simple hypertension treatment algorithms, and regis‐
tries with reporting function.13,14 Nurses were highly supportive
of performing several hypertension management tasks if they
had adequate training. Expanding the scope of practice of nurses
was less supported by doctors especially for nurses prescribing or
changing medications by an approved protocol. Less than 3/4th of
any discipline indicated they used objective assessments of car‐
diovascular risk, <40% a simple treatment algorithm, and <15% a
registry with quality of care reporting functions. Less than 3/4th
prioritized an objective cardiovascular risk assessment and less
than 4/5ths highly prioritized using a simple treatment algorithm
and a registry with performance reporting. Importantly, no disci‐
pline was more than 40% confident in implementing a treatment
algorithm or a registry with performance reporting. The survey
therefore indicates significant barriers to implementing these rec‐
ommended interventions and supports the need for enhanced ed‐
ucation and training.
The survey has several limitations. It was unexpected that in
a mandatory quality control survey, a high proportion of nurses
would refuse to answer drug treatment questions. The surveys
were resent to clinics to be completed up to four times to increase
the response rate to the drug treatment questions. Resending
the questionnaires did not impact the response rate to these
questions. Current regulations in Mongolia preclude nurses from
prescribing. The response rate from nurses to all other question
domains and from all other disciplines were uniformly very high.
To address bias related to question non‐response, the survey
was analyzed including all questions regardless of response rate
and by excluding questions with a non‐response rate of 15% or
more. This sensitivity analysis indicated that including questions
with non‐response rate of 15% or more had little impact on the
results. Nevertheless, analyses where the response rate is <85%
must be viewed cautiously. The overall response rate to the survey
was 80%, which is consistent with high‐quality clinical surveys,
none the less, the survey could be impacted by selection bias.15
Potential reasons that were stated for not completing the survey
included medical leaves and vacations. It is also possible that some
MYANGANBAYAR et al.
healthcare professionals may use other national hypertension
guidelines than the Mongolian guidelines. This is not likely to be
a major factor for most questions as the Mongolian hypertension
guidelines are largely consistent with most other national hyper‐
tension guidelines. Many of the questions may have a social desir‐
ability bias to provide answers that are desirable rather than their
actual knowledge, attitude, or practice. Similarly, it is possible that
the clinic supervisors influenced the respondents answering ques‐
tions by prior education or other prompting to improve responses.
Nearly, all respondents indicated the survey was too long. A newer
iteration of the survey could examine a more select number of do‐
mains and remove questions less important to developing training
curricula.
In the Better hearts Better Cities Program in Ulaanbaatar, clinic
disciplines are now trained together. The clinical curriculum was
designed to address the major issues identified in this KAP sur‐
vey, and a follow‐up survey is being planned after the main pro‐
gram interventions have been implemented. The original World
Hypertension League KAP survey is available for other programs
to use.11 Other interventions in the Better Hearts Better Cities
Program in Ulaanbaatar include a multisectoral stakeholder steer‐
ing group, public advocacy, and communications, the development
of new Mongolian hypertension recommendations that include a
simplified diagnostic and therapeutic algorithm, a registry with per‐
formance reporting, and an independent monitoring and evaluation
program.
C O N FL I C T O F I N T E R E S T
NRCC is a member of World Action on Salt and Health (a dietary salt
reduction organization) and was a paid consultant to the Novartis
Foundation (2016‐2017) which involves travel expenses and per‐
sonal fees for site visits, a one‐time contract to develop a survey
and was a paid member of an advisory board for Midmark in 2017.
RB and GS are employees of the Novartis Foundation. The other au‐
thors do not have conflicts of interest to disclose.
AU T H O R S C O N T R I B U T I O N S
Maral Myanganbayar BMedSc collected the data, performed the
analysis, and wrote the paper. Uurtsaikh Baatarsuren MD collected
the data, performed the analysis, assistance with writing the paper,
reviewed and approved the paper. Guanmin Chen MD PhD assisted
with the statistics and analyses, reviewed, and approved the paper.
Norm RC Campbell MD conceived and designed the study, assis‐
tance with writing the paper, reviewed, and approved the paper.
Roberta Bosurgi BSc MSc conceived and designed the study, re‐
viewed, and approved the paper. Geoffrey So BSc MSc conceived
and designed the study, reviewed, and approved the paper. Tsolmon
Unurjargal MD PhD consulted on modifying the survey to be adapt‐
able for Mongolian healthcare professionals, reviewed, and ap‐
proved the paper. Myagmartseren Dashtseren MD PhD consulted
on modifying the survey to be adaptable for Mongolian healthcare
|
      7
professionals, reviewed, and approved the paper. Namkhaidorj
Tserengombo MD PhD consulted on modifying the survey to be
adaptable for Mongolian healthcare professionals, reviewed, and ap‐
proved the paper. Batbold Batsukh MD consulted on modifying the
survey to be adaptable for Mongolian healthcare professionals, re‐
viewed, and approved the paper. Andreas Bungert PhD collected the
data, reviewed, and approved the paper. Naranbaatar Dashdorj PhD
collected the data, reviewed, and approved the paper. Naranjargal
Dashdorj MD PhD conceived and designed the study and supervised
the whole research.
ORCID
Maral Myanganbayar  https://orcid.org/0000-0003-0971-3405
Norm R. C. Campbell  https://orcid.org/0000-0002-1093-4742
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