Improving the management of Hypertension in Kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes

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Improving the management ofHypertension in Kazakhstan:implications for improving clinicalpractice, patient behaviours and healthoutcomesA. Nugmanova a , G. Pillai b , D. Nugmanova c & D. Kuter da ZdravPlus Project , Abt Associates Inc. , Almaty, Kazakhstanb ZdravPlus Project , John Snow Inc. , Boston, MA, USAc Kazakhstan Association of Family Physicians and FamilyMedicine, Department of Almaty Postgraduate Institute forPhysicians , Almaty, Kazakhstand ZdravPlus Project , Abt Associates Inc. , Madison, WI, USAPublished online: 03 Apr 2008.

To cite this article: A. Nugmanova , G. Pillai , D. Nugmanova & D. Kuter (2008) Improving themanagement of Hypertension in Kazakhstan: implications for improving clinical practice, patientbehaviours and health outcomes, Global Public Health: An International Journal for Research,Policy and Practice, 3:2, 214-231, DOI: 10.1080/17441690701872664

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Improving the management of Hypertension inKazakhstan: implications for improving clinicalpractice, patient behaviours and health outcomes

A. NUGMANOVA1, G. PILLAI2, D. NUGMANOVA,3 & D. KUTER4

1ZdravPlus Project, Abt Associates Inc., Almaty, Kazakhstan, 2ZdravPlus Project, John

Snow Inc., Boston, MA, USA, 3Kazakhstan Association of Family Physicians and Family

Medicine, Department of Almaty Postgraduate Institute for Physicians, Almaty,

Kazakhstan, and 4ZdravPlus Project, Abt Associates Inc., Madison, WI, USA

AbstractThis paper presents findings from the assessment of a strategy aimed at improving case-finding and management of hypertension patients. Study findings suggest that providers’orientation to clinical guidelines, public information on hypertension risks, promotion ofyearly blood pressure screening, and universal access to an outpatient drug benefitpackage, improve case-finding and management. In addition, training of providers at pilotsites resulted in a substantial and significant difference in patient care and healthoutcomes. Provider training and tools, especially focused on effective patient counselling,made a significant contribution to increased case-finding, patient adherence to prescribeddrugs, reducing salt, and increasing regular exercise. However, further refinements arerequired to achieve the expected adherence of patients to medication and lifestyle advice.In the pilot area, we compared two samples of patients before and after the initiation ofthe intervention. We found an increase in the proportion of patients with blood pressureB140/90 mmHg, and a significant decrease in the proportion of patients with bloodpressure ]160/100 mmHg. The strategy involved the joint efforts of the ResearchInstitute of Cardiology and Internal Diseases, Karaganda Drug Information Centre,Karaganda Oblast Health Department, Kazakhstan Association of Family Physicians,Almaty Postgraduate Institute for Physicians, and USAID ZdravPlus Project in CentralAsia.

Keywords: Hypertension, cardiovascular disease, quality improvement, clinical practiceguideline, Kazakhstan, Central Asia

Correspondence: Azhar Nugmanova, ZdravPlus Project, 39 Begalina Street, Almaty 050010,Kazakhstan. E-mail: [email protected]

Global Public Health, April 2008; 3(2): 214�231

ISSN 1744-1692 print/ISSN 1744-1706 online # 2008 Taylor & Francis

DOI: 10.1080/17441690701872664

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Introduction and background

Cardiovascular disease (CVD) is responsible for nearly 30% of all deaths

worldwide (Gaziano et al. 2006). Hypertension is the most common CVD, and

its complications (stroke, heart attack, ischemic heart disease, renal dysfunction,

and heart failure) result in death and disability (Kearney et al. 2005). Case-

finding presents a challenge, since patients can live with the condition,

unnoticed and worsening, until a debilitating event occurs. Early diagnosis

and appropriate case management through medication and lifestyle counselling

have been shown to be effective (Lewington et al. 2002, Whelton et al. 2002).

In Kazakhstan, the burden of disease from CVD and hypertension is significant,

and the need to improve the identification and care of patients with

hypertension is paramount. The Research Institute of Cardiology and Internal

Diseases, Karaganda Drug Information Centre, Karaganda Oblast Health

Department, Kazakhstan Association of Family Physicians, Almaty Postgradu-

ate Institute for Physicians, and USAID ZdravPlus Project in Central Asia

combined efforts to develop, test, and scale up a strategy to improve case-

finding, care, and treatment of patients with hypertension. As in other former

Soviet Union countries, in Kazakhstan hypertension was regarded as an

intermittent condition to be treated with rapidly acting medication, often

injected to quickly lower blood pressure and calm the patient, then stopped

until the next hypertensive ‘crisis’. Patients think the purpose of treatment is for

relief of current symptoms, rather than a long-term and continuous treatment to

maintain lower blood pressure.

For practicing physicians clinical practice guidelines, based on randomized

clinical trials, are being introduced and access to current research findings has

improved but remains limited. The development of the clinical practice guide-

lines, used in this study, and the testing of proposed implementation strategies is

new in the health system in Kazakhstan. In addition, this study tests the value of

complementary clinical training and population education to support newly

recommended practice.

The implementation strategy was meant to inform all primary care physicians

of evidence-based guideline, including those in both non-pilot and pilot facilities.

However, additional provider training and patient education occurred only in

pilot facilities. Thus, both non-pilot and pilot facilities were exposed to the

following:

1. Dissemination of an evidence-based clinical practice guideline (CPG) on

management of hypertension, and orientation of primary care providers to its

use, in 2004 (Dzhusipov et al. 2004, ZdravPlus Project 2004).

2. Introduction of a national outpatient drug benefit package, making hyper-

tension drugs available and affordable to patients, in January 2006.

3. Campaigns to raise patient awareness about routine blood pressure

measurements for screening purposes, in June 2006.

Management of Hypertension in Kazakhstan 215

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Pilot facilities, in addition, were exposed to the following:

1. Training of providers in use of the CPG, with focus on: (a) blood pressure

screening of all adult patients; (b) follow-up blood pressure measurements

for those identified with blood pressure]140/90 mmHg; (c) selection and

prescription of appropriate medications; (d) counselling of patients on

regular and long-term use of medications, and tips to remember daily drug

intake, reduction in salt, fat, cigarettes, and alcohol; and (e) regular exercise,

in October 2005.

2. Introduction of tools to prompt providers to practice according to the CPG

and to clinical training, especially related to patient counselling and

recording of tests, in November 2005.

3. Introduction of a quality improvement system, based on self-monitoring, for

doctors and facilities, in November 2005.

Although both non-pilot and pilot facilities were exposed to interventions to

improve hypertension case-finding, patient care, and treatment, only the pilot

area facilities were exposed to the added inputs of provider training and tools.

These added inputs were initiated based on the observation that the dissemina-

tion of the CPG and population campaigns did not seem to generate desired

changes in clinical practice, patient behaviours, or health outcome.

Conceptual framework, study design, and data sources

Our basic premise was that provider training, with emphasis on patient

counselling on regular use of medications and lifestyle changes, was required in

addition to dissemination of clinical guideline, population campaigns, and the

outpatient drug benefit package (Cranney et al. 2001, Cuspidi et al. 2002,

Roumie et al. 2006). To assess this hypothesis, we applied a quasi-experimental,

pre- and post-test, pilot and non-pilot, control groups design (Fisher et al. 1991).

Non-pilot and pilot facilities

Five non-pilot and six pilot government outpatient facilities, with similar

characteristics, were selected from Karaganda, an industrial city with an

estimated population of 450,000. Patients seek care at non-pilot or pilot facilities,

based primarily at the facility closest to their residence. Facilities were selected

following informal discussions with providers and health authorities based on

comparable features, such as staffing and patient load (see Table 1). Non-pilot

facilities included two polyclinics and three family group practices, where 74.5%

of the 170,226 patients were over 18 years old. Pilot facilities included two

polyclinics and four family group practices, where 72.7% of the 115,765 patients

were adults over age 18. The study randomly selected patients from non-pilot and

pilot sites, who were registered and seeking care from these sites.

216 A. Nugmanova et al.

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Time 1 and Time 2 (T1, T2). The assessment compares data from two periods of

time. Time 1, before the intervention, refers to October 2004 to September 2005.

Time 2, after initiation of the intervention, refers to the period from October

2005 to September 2006.

Data sources, sampling, and sample size. Multiple sources of data were used for

analysis to triangulate and validate findings. This included an external audit of

3,758 patient records to assess hypertension screening practice; an external audit

of 3,069 records of patients registered with hypertension, and a patient survey

involving door-to-door interviews with 467 patients having hypertension, to

assess provider and patient behaviours and blood pressure outcomes (see

Table 2). For the patient screening assessment, patient records for each of the

two study periods were selected randomly, and retrospectively, from among all

charts of patients over age 18, with at least one clinic visit during that year. If the

chart selected did not fulfil these criteria, the next chart was selected. For the

audit of records of patients with hypertension, records were randomly selected

from all patients registered with hypertension. For the patient survey, patients

were randomly selected from the list of all patients registered with hypertension.

Data were entered in Excel 2002 (10.650.6626) SP3, and were imported and

analysed in SPSS for Windows, version 10.0.5.

Similar to other studies that use programme data, there were inherent

limitations. Provider practices, assessed using provider-maintained records of

patients, tend to exaggerate actual behaviour toward expected behaviour.

However, patient interviews were used to validate trends in reported provider

practices (Milchak et al. 2004, Rao et al. 2006, Ardery et al. 2007). Self-reported

Table 2. Primary data: sample size and methodology.

Non-pilot Pilot

Audit of patient records T1 T2 T1 T2 Total Sampling methodology

Screening 940 940 939 939 3758 Simple random samplingCase management 636 825 763 845 3069 Simple random samplingPatient survey 0 0 227 240 467 Simple random sampling

Table 1. Comparison of non-pilot and pilot facilities on key characteristics.

Non-pilot Pilot

Number of visits per person per year 3.9 3.9Number of visits per doctor per month 288 264Number of doctors per 1,000 population 1.14 1.24Total number of doctors 194 143Adults over 18 years 126,834 84,148Total number of population 170,226 115,765

Source: Health Information System of Karaganda Oblast Health Department.


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patient behaviour also carries the bias of responding according to expected

behaviour, and responses in the survey, long after the clinic visit, are vulnerable to

recall bias. However, blood pressure, measured at the end of patient interviews,

provides a biological marker that can be associated with reported behaviour,

allowing us to make stronger conclusions about the effect of the intervention.

Results

Case-finding

Available, feasible, and accurate means of detecting hypertension, and the clear

benefit of treatment, have led to the widespread acceptance of routine blood

pressure screening and the incorporation of this practice in the CPG (Sheridan

et al. 2003). One goal of our intervention strategy was to improve case-finding

among adults by promoting, at least yearly, blood pressure screening of adult

patients. A second goal was to increase follow-up blood pressure monitoring for

persons found to have blood pressure ]140/90 mmHg.

The intervention strategy for increasing the number of cases found included the

following:

1. Provider training in hypertension risk factors, the need for routine blood

pressure measurements, and systems to prompt providers to take and record

blood pressure measurement in patient records.

2. Patient education and counselling about hypertension risk factors and the

need for routine blood pressure measurements.

In addition, in both non-pilot and pilot facilities, in June 2006 a public campaign

was conducted throughout the city to increase awareness of cardiovascular

disease. This campaign included blood pressure measurements and the referral

for people found with blood pressure ]140/90 mmHg or with hypertension risk

factors. It should be noted that the assessment of increased case-finding through

routine blood pressure measurements was limited to clinic patients, and did not

include the general population where there are, undoubtedly, numerous people

with undiagnosed disease.

The comparison of patient records before and after the initiation of the

intervention, in non-pilot and pilot facilities, indicated a clear and significant

improvement in provider practices related to screening adult patients for high

blood pressure. Pilot facilities had a significant increase in: the percentage of adult

patients screened for high blood pressure (70.3�81.0%: pB0.005); the percen-

tage of patients followed-up if discovered to have high blood pressure]140/90

mmHg (71.4�89.9%: pB0.005); and the number of patients who registered for

management of hypertension once the diagnosis was made (53.0�75.1%:

pB0.005). In comparison, non-pilot facilities did not have a significant change

in these indicators.

When we compare non-pilot and pilot facilities at Time 2, pilot facilities are

significantly better than non-pilot facilities in the percentage of patients


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screened and followed, but not in their registration of patients with hypertension

(see Table 3). This comparison at Time 2 should take into consideration that at

Time 1 the non-pilot facilities were significantly better in registering patients

with hypertension compared to the pilot facility (68.5% compared to 53.0%),

while at Time 2 the increased performance of the pilot facilities, following the

intervention, narrowed the difference between non-pilot and pilot facilities

(69.7% vs. 75.1%). Also noteworthy is that among patients with hypertension in

the pilot facilities at Time 2, the mean age is significantly younger in

comparison to Time 1 and to the non-pilot areas (60.690.42 compared to

61.990.44 at Time 1; and in non-pilot facilities the mean age was 63.590.42

[pB0.05] at Time 2 in comparison with 62.490.48 at Time 1). This may

reflect the success of pilot facilities in case-finding among younger people.

Provider and patient practices to manage hypertension

Another goal of the intervention strategy in pilot facilities was to improve case

management among patients with hypertension who were registered for care at

the facility. Previous experience has shown that a clinical guideline alone does not

always lead to improved practice unless additional inputs are present (Cranney

et al. 2001). The intervention strategy and added provider training focused on

achieving improvements in three critical areas of clinical practice: (1) prescription

of evidence-based medications along with advice on their regular and long term

use (ALLHAT 2002); (2) counselling on healthy lifestyles, with emphasis on

reducing salt and fat intake, and increasing regular exercise (Cutler 1993, Miller

et al. 2002); and (3) obtaining and recording ECG, urinalysis, blood glucose,

serum creatinine, and cholesterol tests, for patient management and care

(Cuspidi et al. 2002).

The intervention strategy to improve case management involved:

1. Patient assessment and diagnosis, and related medications and lifestyle

advice for case management, including additional clinical training, doctors’

reminders, and introduction of a quality improvement system.

2. Patient counselling on how to achieve long-term and regular medication use,

regular exercise, control of salt and fat intake, and reductions in smoking

and/or alcohol consumption. Patient counselling was complemented with

written materials and the option to participate in classes for patients with

hypertension.

3. Monitoring physicians’ use of five essential tests, with feedback.

In addition, in both the non-pilot and pilot facilities, the following interventions

influenced provider practices:

1. Dissemination of clinical guideline on diagnosis and management of patients

with hypertension, and informational sessions on their content and use.

2. Introduction of outpatient drugs benefits package that made first-line

medications affordable and available.


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Table 3. Case-finding practices.

Comparison of Time 1 to Time 2Comparison of non-pilot(NP) to pilot (P) facilities

Non-pilot Pilot Time 1 Time 2

T1N�940% (n)

T2N�940% (n) T1-T2

T1N�939% (n)

T2N�939% (n) T1-T2 NP-P NP-P

BP measured at least once 68.1 (640) 69.0 (649) x2�0.200p�0.691

70.3 (660) 81.0 (761) x2�29.500p�0.000

x2�1.069p�0.318

x2�36.122p�0.000

If BP ]140/90 mmHgFollow-up measure

78.0 (131) 80.0 (140) x2�0.212p�0.692

71.4 (120) 89.9 (195) x2�21.628p�0.000

x2�0.906p�0.209

x2�7.582p�0.009

If BP ]140/90 Patientregistered

68.5 (115) 69.7 (122) x2�0.064p�0.816

53.0 (89) 75.1 (163) x2�20.526p�0.000

x2�8.435p�0.005

x2�1.424p�0.255

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The assessment strategy involved the comparison of data from before and after

the initiation of the intervention, in non-pilot and pilot facilities, and a patient

questionnaire, only in pilot facilities. The population sampled was similar in

non-pilot and pilot facilities at Time 1 by sex (p�0.767), but different at Time

2 because of increased case-finding among younger people in the pilot facilities.

At Time 1, it should be noted, the mean age in the non-pilot facilities did not

vary from that of the pilot facilities (62.3590.48 vs. 61.9090.44; F�0.498:

p�0.05).

Hypertension medication: provider prescription and patient adherence. The national

CPG promotes practices which are supported by evidence-based studies,

including: (1) use of thiazide diuretics to prevent cardiovascular complications

of hypertension (ALLHAT 2002); (2) use of beta-blockers, angiotensin-convert-

ing enzyme inhibitors (ACE inhibitors), and long acting dihydropyridine calcium

channel blockers (CCBs) (Neal et al. 2000); (3) use of more than one drug for

patients with moderate or severe hypertension (Law et al. 2003); (4) prioritized

control of systolic blood pressure to successfully prevent complications (Lewing-

ton et al. 2002); and (5) lifestyle interventions are extremely important, along

with the use of medication (Whelton et al. 2002). An emphasis was also placed on

regular, consistent, and long-term use of medication to respond to the usual local

pattern of episodic use. Thus, the CPG encourages the use of thiazide diuretics,

beta-blockers, ACE inhibitors, and CCBs, often in combination, to achieve a

usual blood pressure of less than 140/90 mmHg, with long-term maintenance

therapy, to maintain the improvement, similar to recommendations in other

commonly used guidelines, such as JNC-7 (Chobanian et al. 2003) and BHS-IV

(Williams et al. 2004).

After getting a prescription from the physician, patients go to an assigned

drugstore, where government subsidized medications are available at half price.

ACE inhibitors, thiazides, beta-blockers, and CCBs are all included in CPG, and

are available at subsidized cost, but ACE inhibitors continue to be most

commonly used, similar to other countries (Cuspidi et al. 2002). Both non-pilot

and pilot facilities, demonstrated a significant increase in prescribing practices of

appropriate first-line medications for hypertension (see Table 4). This effect is

attributed to both non-pilot and pilot facilities having an orientation to the correct

choice of hypertensive drugs, and to increased availability and affordability of

these drugs as a result of the outpatient drugs benefit package.

There was a significant increase in the use of thiazides in the pilot facilities

(p�0.000), whereas there was no significant increase in the non-pilot facilities.

This may be due to the emphasis given in the clinical trainings on thiazides

being unsurpassed in preventing cardiovascular complications in clinical trials.

Also noteworthy is the dramatic difference between non-pilot and pilot facilities,

in provider advice on the importance of regular and long-term use of

hypertensive medications (p�1.000 in non-pilot facilities and pB0.000 in pilot

facilities). At Time 2, in non-pilot facilities, 5.8% recorded giving advice on


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Table 4. Medications prescribed.



T1 T2 T1 T2N�553 N�788 N�707 N�825

Groups of medications % (n) % (n) T1-T2 % (n) % (n) T1-T2 NP-P NP-P

Thiazides 25.7 (142) 28.7 (226) x2�1.471 29.8 (211) 51.9 (428) x2�76.029 x2�2.671 x2�89.979p�0.238 p�0.000 p�0.114 p�0.000

Beta-blockers 22.8 (126) 36.4 (287) x2�28.352 18.2 (129) 37.6 (310) x2�69.582 x2�3.960 x2�0.230p�0.000 p�0.000 p�0.048 p�0.643

ACE inhibitors 61.8 (342) 66.9 (527) x2�3.610 62.5 (442) 64.7 (534) x2�0.804 x2�0.060 x2�0.828p�0.063 p�0.394 p�0.815 p�0.372

CCBs 7.8 (43) 9.5 (75) x2�1.229 6.4 (45) 10.3 (85) x2�7.604 x2�0.951 x2�0.278p�0.283 p�0.006 p�0.373 p�0.618

Any of above 4 62.2 (344) 83.1 (655) x2�74.823 59.2 (404) 83.8 (691) x2�113.768 x2�1.194 x2�0.118p�0.000 p�0.000 p�0.292 p�0.738

Advice: Regular use1 5.2 (29) 5.8 (46) x2�0.217 9.2 (65) 23.8 (196) x2�57.134 x2�7.011 x2�101.494p�0.718 p�0.000 p�0.009 p�0.000

Source: Records of patients with hypertension1Advice on regular and long-term use of medications provided.

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regular and long-term use of medications, in comparison with 23.8% in pilot

facilities (pB0.05).

Patient survey data from pilot facilities confirmed the positive trend in provider

prescription practices of first-line medications (thiazides, beta-blockers, ACE

inhibitors, or CCBs), which significantly increased from 64.7% at Time 1, to

73.6% at Time 2 (p�0.043), as well as a significant change in the percentage of

patients who reported taking their medication that morning (see Table 5). Both at

Time 1 and Time 2, 90�91% of patients reported having prescribed medications

in the house at the time of the interview.

While these data indicate significant improvements in doctors’ prescribing

practices and patient compliance, nearly half of all patients at Time 2 still

reported not taking prescribed medications on the day of the interview. As a first

step to exploring refinements to our strategy to promote patient adherence to

drug intake, we asked the reasons why patients did not take medicines as

prescribed (see Table 6). The analysis reflects the need for tools to remind

patients to take medications on schedule and every day. To address the needs of

patients who report a lack of money to buy drugs, strategies to expand the

number of drugstores with subsidized drugs and reducing the co-payment are

under discussion.

Lifestyle: provider advice, patient knowledge and patient adherence. The CPG

incorporated and strengthened emphasis on the importance of patient counselling

Table 5. Comparison of patient receiving advice and taking first-line medications.

Advice and practice

Time 1N�227% (n)

Time 2N�240% (n) x2 p-value

Prescription: received prescription to takefirst line medications

64.7 (143) 73.6 (173) 4.251 0.043

Practice: took first line medications 50.2 (114) 68.3 (164) 15.887 0.000Practice: took the medication this morning 38.3 (87) 51.3 (123) 7.874 0.005

Source: Survey of patients with hypertension.

Table 6. Reasons for non-adherence to prescribed drug regimen.

Reasons % (n)

Forgetfulness 54.6 (131)No symptoms of high blood pressure on that day 54.2 (130)Side effects 48.3 (116)Wanted a holiday from medicines 42.5 (102)No perceived benefit or effect from the medicine 40.0 (96)Affordability: lack money to buy the drugs 29.2 (70)Perceived harm from the medicine 29.2 (70)

Source: Survey of patients with hypertension


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on non-pharmacological lifestyle factors, that impact the management of

hypertension, based on evidence that supports the important role of reducing

salt, fat, alcohol, and cigarettes, controlling weight, and increasing regular

exercise (Sheridan et al. 2003).

In pilot facilities, there was a substantial and significant change in the

proportion of patients with hypertension who received counselling on salt

intake, exercise, and diet/weight control (pB0.005). In non-pilot facilities, an

increase was also observed, but this increase is not statistically significant,

except for advice on salt intake (pB0.005) (see Table 7). At Time 2, pilot

facilities compared to non-pilot facilities had a significantly larger proportion of

patients receiving advice on salt intake (pB0.05), exercise (pB0.100), and diet/

weight control (pB0.01), which is impressive considering the significantly

poorer baseline status of pilot facilities compared to non-pilot facilities at Time

1 (pB0.005).

Patient survey data from pilot facilities confirmed an increase in the receipt of

lifestyle advice on salt intake, diet and weight control, regular exercise, and

smoking cessation, and an increase in patient knowledge of salt reduction and

weight control as a means of controlling hypertension (see Table 8). However,

with the exception of an increase in the percentage of patients who report

exercising at least two times in the past 7 days, there were no significant changes

in reported lifestyle practices related to salt intake, diet or weight control, or

smoking. While the results on health worker compliance to providing patient

advice is encouraging, the change in self-reported patient behaviours is

discouraging, and suggests the need to develop more effective and targeted

counselling on lifestyle changes associated with hypertension control.

Monitoring health condition using biomedical tests: provider advice and patient

adherence. The national CPG incorporated the recommendation that patients

with hypertension be monitored, at least annually, using the following tests:

ECG, urinalysis, blood glucose, serum creatinine, and cholesterol. This was

based on the understanding that doing these tests helps doctors and patients

evaluate the risk of cardiovascular events, helps address and treat common co-

existing conditions, helps identify target organ damage resulting from hyperten-

sion, and provides regular feedback on patient and provider efforts to manage

the condition (Cuspidi et al. 2002). Assessment of provider compliance to tests,

suggested in the CPG and patient compliance to doctors’ advice to complete

the tests, was measured by test results being attached, or recorded, in patient

records (see Table 9).

In both non-pilot and pilot facilities, access to tests was equally available and

there was an increase, from Time 1 to Time 2, in the percentage of patients

with tests recorded. However, in the non-pilot facilities, the change was

significant only for cholesterol (pB0.05) and serum creatinine (pB0.10), while

in the pilot facilities the change was significant for all five of the tests

(pB0.005). It should be noted that at Time 1, non-pilot facilities had a higher


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Table 7. Life style recommendations recorded as provided in patient records.

Comparison of Time 1 to Time 2Comparison non-pilot (NP)

to pilot (P) facilities

Non-pilot Pilot T1 T2

Lifestyle

T1N�636% (n)

T2N�825% (n) T1-T2

T1N�763% (n)

T2N�845% (n) T1-T2 NP-P NP-P

Reduce salt 65.3 (415) 72.1 (595) x2�7.942p�0.005

54.8 (418) 76.3 (645) x2�83.088p�0.000

x2�15.778p�0.000

x2�3.870p�0.05

Regular exercise 48.7 (310) 53.0 (437) x2�2.569p�0.113

31.7 (242) 57.0 (482) x2�103.886p�0.000

x2�42.088p�0.000

x2�2.797p�0.104

Diet/weight control 72.8 (463) 76.6 (632) x2�2.773p�0.100

62.3 (475) 81.7 (690) x2�75.623p�0.000

x2�17.456p�0.000

x2�6.455p�0.011

Source: Records of patients with hypertension.

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proportion of patients with tests recorded. This fact should be considered when

comparing non-pilot and pilot facilities at Time 2, where their differences in

tests for urine and blood glucose are not significantly different, but their

differences in tests for ECG (pB0.10), serum creatinine (pB0.005), and

cholesterol are significant and impressive (pB0.005).

Patient health outcomes, blood pressure, treatment outcome. The goals of all the

efforts were not just to improve provider compliance to the CPG and patient

compliance to provider advice but, ultimately, to improve patient health outcomes

as measured by a decrease in blood pressure and reduction of complications

related to high blood pressure. Like many similar studies, this was difficult to

establish with statistical significance (Landon et al. 2007). However, while the

changes are not significant in the non-pilot facilities, the change in proportion of

Table 8. Lifestyles: reported advice, knowledge, and practice.

Lifestyle advice, knowledge, and practice

Time 1N�227% (n)

Time 2N�240% (n) x2 p-value

Salt reductionAdvice: reported receipt of advice to reduce salt 35.7 (81) 52.5 (126) 13.370 0.000Knowledge: unprompted mention of reducingsalt as a means of controlling blood pressure

27.3 (62) 49.2 (118) 23.521 0.000

Practice: reported ‘yes’ to ‘Did you add salt tomeals before tasting the food?’

23.4 (53) 19.6 (47) 0.983 0.367

Diet/weight controlAdvice: reported receipt of advice to reduce fat 30.0 (68) 42.9 (103) 8.444 0.004Knowledge: unprompted mention of reducingfat as a means to control blood pressure

18.5 (42) 36.7 (88) 19.161 0.000

Practice: reported ‘yes’ to ‘Is your weight lessthan it was 1 year ago?’

26.4 (60) 18.8 (39) 5.556 0.135

Body mass index less than 25 (not overweight) 19.4 (44) 22.9 (550) 0.654 0.155

Regular exerciseAdvice: reported receipt of advise to exercise 2 ormore times/week

12.8 (29) 22.5 (54) 7. 549 0.007

Knowledge: unprompted mention of exercise asa means to control blood pressure

19.4 (44) 15.4 (37) 1.280 0.273

Practice: reported 2 or more days of exercise,walk, or jog in the past 7 days

32.6 (74) 47.5 (114) 10.770 0.001

Smoking*Advice: reported receipt of advice to quitsmoking (smoker: n�26 T1, n�38 T2)

38.5 (10) 52.6 (20) 1.245 0.314

Practice: reported smoking in past 24 hours 11.5 (26) 15.8 (38) 1.892 0.180


*We do not have data on the percentage of persons who stopped smoking of those who were

previously smoking, but there was no significant change in the percentage of the total population

who report smoking in the past 24 hours. The number of person is too small to do any meaningful

analysis.


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Table 9. Tests recommended, completed, and recorded in patient records.



Tests

T1N�636% (n)

T2N�825% (n) T1-T2

T1N�763% (n)

T2N�845% (n) T1-T2 NP-P NP-P

ECG 65.3 (415) 64.2 (530) x2�0.160p�0.699

61.7 (471) 68.6 (580) x2�8.454p�0.004

x2�1.852p�0.181

x2�3.620p�0.062

Urinalysis 75.2 (478) 76.5 (631) x2�0.36p�0.579

71.2 (543) 78.9 (667) x2�12.992p�0.000

x2�2.802p�0.103

x2�1.447p�0.240

Blood Glucose 74.5 (474) 75.4 (622) x2�0.144p�0.715

67.9 (518) 77.5 (655) x2�18.822p�0.000

x2�7.410p�0.007

x2�1.043p�0.327

Serum creatinine 34.7 (221) 39.8 (328) x2�3.842p�0.057

19.8 (151) 51.8 (438) x2�177.367p�0.000

x2�39.759p�0.000

x2�24.521p�0.000

Cholesterol 33.6 (214) 39.9 (329) x2�5.972p�0.016

16.6 (127) 50.1 (423) x2�198.923p�0.000

x2�54.401p�0.000

x2�17.478p�0.000

Source: Records of patients with hypertension.

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patients with blood pressure ]160/100 mmHg (stage 2 disease) declined in the

pilot facilities, from 33.1% at Time 1 to 27.7% at Time 2 (pB0.05). In addition,

there was an increase in persons with blood pressure B140/90 mmHg from

26.6% at Time 1 to 30.3% at Time 2 (p�0.112). The data suggest a downward

trend in the blood pressure levels of patients in the pilot facilities. These data

should be reviewed and interpreted, keeping in mind the short duration of

exposure to the intervention strategy (less than 12 months for all patients) and the

fact that the intervention also increased the number of younger patients and

lowered the mean age in pilot facilities.

The results from the patient survey validate the trend above, and provide

stronger evidence of a positive treatment effect among patients in the pilot

facilities (see Table 10). Here there is a significant increase from Time 1 to Time

2 in patients with blood pressure B140/90 mmHg, and a significant decrease in

patients with very high blood pressure from 51.6 to 35.8%.

Replication and scale up

Based on initial observations of positive changes in pilot facilities, replications of

the pilot strategy have been initiated in other facilities in Karaganda, as well as in

three additional regions in the country, with support from the Kazakhstan

Association of Family Physicians. National protocols for hypertension were

revised in 2006, incorporating key elements from the national CPG on

hypertension, to facilitate more widespread use by providers in the country.

The training approach, used in pilot sites, has been developed and incorporated

by the postgraduate institute into continuing medical education for primary care

providers and a computer-based learning model on recommended clinical

practices, including patient diagnosis and counselling, is in the process of

finalization with the intended purpose of exposing more doctors to CPG

guidelines and patient counselling skills associated with improved patient advice,

adherence, and outcomes. The initiatives for replication are largely driven by

motivated providers, who are leading the process with anticipated, but not yet

clear, investment for national level coverage.

Table 10. Results: measurement of blood pressure during the patient survey.

BP level

Time 1(N�215)

% (n)

Time 2(N�229)

% (n) T1�T2

B140/90 mmHg 14.0 (30) 26.2 (60) x2�10.292, p�0.001140�159/90�99 mmHg 34.4 (74) 38.0 (87) x2�0.612, p�0.489]160/100 mmHg 51.6 (111) 35.8 (82) x2�11.294, p�0.001



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Conclusion

In both non-pilot and pilot areas, a basic package of health system inputs,

including orientation of providers to the clinical guideline, information to the

public on hypertension risks and annual screening, and an outpatient drug

benefit package, increased the number of new patients found and the use of

recommended medications. The strategy used in pilot facilities included

additional training to providers, as well as tools to prompt recommended

practices for doctors and to encourage compliance by patients. In pilot sites,

there were significantly greater improvements in case-finding, recommended

clinical practices, patient compliance to advice on medications and regular

exercise, and on blood pressure outcomes. However, study findings also suggest

the need for refinements in patient counselling, to further improve patient

adherence to regular use of required medications and lifestyle practices. Using

only patient survey information, where we compared two samples of patients,

before and after initiation of the intervention, we also found that in the pilot

area there was an increase in the proportion of patients with blood pressure

B140/90 mmHg, and a significant decrease in the proportion of patients with

stage two disease, or blood pressure]160/100 mmHg. The study results

demonstrate the added, and significant, value of complementing CPG with

clinical training and patient education, as well as tools to prompt provider and

patient behaviour. In addition, re-orientation of providers to client-oriented care

facilitates patient behaviours associated with improved health status.

Acknowledgements

We would like to express our appreciation to the United States Agency of

International Development (USAID); Sheila O’Dougherty (Regional Project

Director, ZdravPlus Project); Liza Myglina (Kazakhstan Country Manager/

Regional Programme Manager, ZdravPlus Project); Karaganda Oblast Health

Department for supporting all activities done within the project; Drug Informa-

tion Centre in Karaganda, Dr. Bahytgul Emekbaeva and Dr. Alexander Gulyaev

for participating in all stages of the project; Director of the Cardiology Institute,

Dr.Alikhan Dzhusipov, and his staff for collaboration in project implementation;

Kazakhstan Association of Family Physicians and its Karaganda branch (Dr.

Lyudmila Makazhanova and Dr. Baurzhan Omarkulov); and doctors from

Karaganda PHC facilities for active participation in all activities described;

Oleg Storozhenko (Regional EBM/CPG Director, ZdravPlus Project) for help

and comments given during project planning and implementation; the Health

Information System team of Karaganda oblast, for data collection and presenta-

tion; Hilda Kuter, for editing and giving recommendations in writing the article;

Timur Balabaev, for help in providing statistical analyses; and all patients with

hypertension who participated in the surveys. We thank the staff of the family

medicine departments of Almaty Postgraduate Institute for Physicians and

Karaganda State Medical Academy for providing clinical training and support.


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Documents

Improving the management of Hypertension in Kazakhstan: implications for improving clinical practice, patient behaviours and health outcomes