This study investigated general practitioners’ needs for continuing education and knowledge of hypertension prevention, which are closely associated with their understanding and use of the national hypertension prevention and control guidelines. For the questions regarding hypertension prevention knowledge, the average accuracy rate of all 19 items was 49.2%, ranging from 10.5% to 94.7%, suggesting that the knowledge level of general practitioners in Xuhui District, Shanghai was low. Physicians with better understanding of hypertension (i.e., higher accuracy in questionnaire answers) were more likely to be younger, with at least an undergraduate education level (i.e., having a bachelor or higher in medical degree vs. professional school education), fewer years of working experience (indicating more recent education and training) and working in a training-base. Regarding training needs, most general practitioners reported being willing to attend training courses regularly. Their preferred frequency of training courses was once every 2 ~ 3 months, and the most preferred course was “medical treatment of hypertension” followed by “education for hypertensive patients (including non-pharmacologic lifestyle treatment). The most favored training approaches were expert lectures and case study. These findings indicate that physicians are eager to receive more training on addressing hypertension prevention in their communities. The increasing prevalence of hypertension and the related high risk for cardiovascular disease is a growing public health problem. Based on the quantity and structure of the Chinese population in 2010, about 200 million patients are projected to have hypertension in China, or about 2 hypertensive patients in every 10 adults . Causes of the high prevalence of hypertension may be attributed to various factors, including socio-demographic factors such as older age, lower educational levels, lower income and living alone . The public’s lack of awareness of the presence of hypertension and lack of compliance with treatment after diagnosis are also implicated . Genetic causes have been indicated as well, including the α-adducin Gly460Trp gene polymorphism, which is linked to essential hypertension susceptibility, especially in Han Chinese . To address the high prevalence of hypertension, the Chinese government has officially released a “Chinese Hypertension Prevention Guide,” which is the first authoritative practical hypertension prevention and treatment guide available to Chinese practitioners and the public . The guide is directed to urban communities and rural health service organizations to serve as the standard teaching guide for training primary care physicians. However, the knowledge level of general practitioners in Xuhui District, Shanghai as evidenced in the present study, is relatively low, suggesting that a considerable percentage of general practitioners do not carefully read and adhere to the published guidelines.
Barriers to adherence to national guidelines in China were suggested by results of this study. General practitioners reported four main obstacles in their practice: poor patient compliance, not enough time for medical consultation, lack of their own knowledge related to hypertension and lack of technique in behavioral medicine. Although most physicians thought that health education could influence lifestyle changes in hypertensive patients to some extent, 7 in 10 physicians reported spending only one third to one quarter of their practice time in medication consultation to educate patients about lifestyle changes that may help to reduce blood pressure and benefit their health status. Similar barriers to adherence to national and international hypertension guidelines are reported by general practitioners in other countries. The main obstacles to guideline use in Ireland as support for ambulatory blood pressure monitoring is physicians’ time and the costs related to monitoring, as well as a lack of remuneration . In Sweden, general practitioners report accepting higher blood pressure levels than clinical guidelines advise are appropriate . Physicians included in that study reported that the advanced age of older adult hypertensive patients was a barrier to effective pharmacologic management of hypertension and that benefits of pharmacologic treatment are not obvious. About half of the physicians used risk assessment tools and nine out of ten informed their patients about the target levels for blood pressure. In Saudi Arabia, low rates for control of hypertension prompted an evaluation of primary care physicians’ adherence to clinical practice guidelines . In that study, only 5% of physicians measured blood pressure with patients sitting and standing, correct diagnoses of systolic and diastolic blood pressure was inconsistent among physicians, clinical examination items were not completed by all physicians, recommended diagnostic laboratory tests were missed (e.g., serum creatinine, lipid profile) and first-line anti-hypertensive agents (thiazide diuretics) were only prescribed by less than one-fifth of all participating physicians . In Australia, a survey of general practice supervisors and registrars showed that hypertension was the most common problem seen by general practitioners but remained undertreated; reasons for undertreatment included lack of clarity and consistency in evidence-based guidelines, especially regarding first line treatment . However, nearly 75% to 80% of untreated hypertensive adults in an Australian hypertensive medication survey had their blood pressure measured within 12 months preceding the survey [18, 19]. In Croatia, the majority of physicians said that they support using guidelines for evaluating cardiovascular risk, but only half of physicians used them and their knowledge of specific guidelines was unsatisfactory . In that study, despite the fact that most risk factors for cardiovascular disease are modifiable and that Joint European guidelines on cardiovascular disease prevention target high-risk patients, the trends in management were described as disappointing, including that guidelines seem to be ignored . Overall, physicians in the above studies seemed doubtful that guidelines actually improve patient outcomes.
In summary, responses from general practitioners in this study implied that they did not conduct hypertension consultations effectively due to lack of consultation time, which was compounded by patients’ poor compliance with physicians’ instructions. Although the healthcare network in China includes community health service centers that provide public health services and patient education in residential communities, with management and follow-up of residents’ chronic diseases (e.g., hypertension, diabetes mellitus) performed by smaller clinics, there is clearly a need for a well-organized program for hypertension monitoring and consultation so that all hypertensive patients can receive necessary attention and education by trained physicians. The need to promote the national guidelines is obvious. The question of how to promote them remains, especially given the structure of the community health centers and the mixed educational backgrounds of general practitioners working in these centers. China has tried to standardize care throughout the national healthcare network and improve care delivered by the community health centers. Our study results do show that physicians working in the training base with a series of teaching, assessing and evaluating systems and settings for hypertension prevention perform better than those that are in general healthcare centers. This makes a strong case for continuing education for general practitioners.
The new, updated Chinese Hypertension Prevention Guide  sets the standard for blood pressure in normal adults as 140/90 mm/Hg or below, encourages modification of lifestyle factors by all adults as a preventive measure and stresses the long-term stable control of blood pressure as one of the modifiable risk factors for cardiovascular and cerebrovascular disease, which both have high morbidity and mortality in China. The guidelines could result in improving community health if they could be promoted sufficiently to increase both physician and public awareness. The status of hypertension management in China in 2002 was characterized by patients’ low awareness rate (not aware of their high blood pressure) (44.7%), low treatment rate (poor compliance with prescribed antihypertensive medication) (28.2%) and low control rate (poor achievement of recommended blood pressure control < 140/90 mm Hg) (8.1%) . Since then, a wide range of health education and promotion has been conducted through the efforts of various levels of government and medical organizations, but surveys still show a year-to-year increasing trend in hypertension [1, 2], indicating modest success, if any, in improving prevention and control in the Chinese population. The new evidence-based guidelines are available and a strategy for promoting them to physicians must be designed and implemented. Education can possibly be prioritized based on general practitioners’ individual levels of medical education, emphasizing training for hypertension prevention and treatment. Meanwhile, patients’ knowledge and awareness are important to preventing and controlling hypertension and available media should be used to communicate prevention information to the public. A dialogue between patients and general practitioners could ultimately benefit both the health status of the patients and the general practice of community health centers.
The present study is limited because it only surveyed general practitioners in one district of one city in China. Results may not represent the state of general practice throughout the country or in different types of institutions in the national healthcare network. Also, although we evaluated general practitioners’ interest in receiving certain types of education and training to address hypertension in their communities, specific areas of weakness in their knowledge of hypertension were not evaluated in depth. In addition, our survey instrument was self-reported and general practitioners’ hypertension-related skills and knowledge should ideally be measured quantitatively with an instrument designed and validated for that purpose.