
==== Front
Prev Med Rep
Preventive Medicine Reports
2211-3355

S2211-3355(24)00282-1
10.1016/j.pmedr.2024.102867
102867
Infectious Disease
Blood pressure control in Türkiye: A primary healthcare pilot study
Ekinci Banu a
Chatterjee Saion b
Ucuncu Ilayda a
Ozkan Altunay Zubeyde a
Nayir Tufan a
Sis Secil a
Yilmaz Aslan Esin a
Cobanoglu Nevin a
Sarıoglu Gulay a
Tamkoc Gurbuzturk Fatma a
Toker Sila c
Ozkan Secil d
Erguder Toker c
a Department of Chronic Diseases and Elderly Health, General Directorate of Public Health, Ministry of Health, Ankara, Türkiye
b World Health Organization European Office for the Prevention and Control of NCDs, Copenhagen, Denmark
c World Health Organization Türkiye Country Office, Ankara, Türkiye
d Department of Public Health, Gazi University, Ankara, Türkiye
22 8 2024
10 2024
22 8 2024
46 10286717 6 2023
14 8 2024
15 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
Highlights

• Pre- and post-tests scores of family healthcare workers (health knowledge and the effect of the training) increased.

• At the end of the study, it was observed that there was an increase in the measurement and recording of blood pressure.

• The prescribing rate for antihypertensive medication increased.

Hypertension is present in almost a third of Türkiye’s adult population. The Ministry of Health of the Republic of Türkiye in conjunction with the World Health Organization, rolled out a pilot primary health care model from February 2019 to 2020 to improve hypertension screening, management, and follow-up across the provinces of Erzincan, Çankırı and Uşak. The model was conducted in selected family health centers for one year and included multiple interventions – training of multidisciplinary primary care teams, implementation of evidence-based, standardised clinical guidelines related to monitoring and treatment of hypertension, clinical supervision and performance monitoring, and provision of health education to hypertensive individuals. Repeat surveys of population-based random samples of 975 patients were taken before (December 2018) and after (February 2020) model implementation to evaluate its effect on care delivery. There was an almost 6.5-fold increase in the measurement and subsequent recording of blood pressure compared to before model implementation (from 50 to 323). Blood pressure control improved to 58 % of measured individuals compared to 46 % of those measured at initial evaluation. The frequency of measuring risk factors and outcomes related to hypertension at least once a year increased for creatinine from 71 % to 79 %, fasting blood glucose from 70 % to 78 %, and tobacco use from 22 % to 31 %. Prescription of antihypertensive drugs increased from 49 % to 61 %. With improvements in hypertension-related care in all measures and across all regions, this primary healthcare model represents a potential paradigm for nationwide implementation.

Keywords

Hypertension
Primary health care (PHC)
Quality improvement
Capacity building
NCD management model
Abbreviations

FMIS Family Medicine Information System
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pmc1 Introduction

Hypertension is an important risk factor for noncommunicable diseases (NCDs), and is a major cause of premature death worldwide, claiming the lives of more than 10 million people per year (WHO, 2023a).

In Türkiye, it was estimated that 8.4 % of total deaths were related to hypertension in 2018 (TURKSTAT, 2020). According to the 2017 National Household Health Survey in Türkiye (NHHST), the prevalence of hypertension in people aged 18 and over in Türkiye was 28.8 %, with almost a quarter of these individuals receiving some form of management. The survey also found cardiovascular disease (CVD) risk assessment and management is implemented in less than 50 % of primary health care (PHC) institutions (NHHST, 2017). This is despite the high overall insurance coverage (98 %), use of electronic medical record systems and access to medical therapeutics.

Considering the influence of lifestyle factors on the development of hypertension, PHC has a core role in the identification, management, and ongoing monitoring of HT (Stanaway et al., 2018). Effective management of NCDs not only curbs its impact but may also alleviate the attendant financial burden on households, while also contributing to the economic sustainability of healthcare systems (WHO, 2023a, WHO, 2023b, WHO, 2018).

In the prevention of long-term diseases and in the promotion of health; The level of access to health services, the level of health literacy and the health education given by health professionals to those who benefit from the service are among the important factors (WHO, 2022, WHO, 2023b).

We present the feasibility and outcomes of new model of care related to hypertension control in the PHC setting, as part of a comprehensive model designed for the proactive management and prevention of complications of chronic diseases in Türkiye (MOHT, 2017, MOHT, 2018). Between February 2019 and 2020, multidisciplinary teams in a PHC setting (consisting of family physicians, nurses and community pharmacists), were trained to implement evidence-based clinical protocols for the diagnosis and management of hypertension and subsequently evaluated through clinical experience and performance monitoring and focus groups. This project, a collaboration between the World Health Organization (WHO) and Republic of Türkiye Ministry of Health, is a precursor to a potentially nationwide intervention model program.

2 Methods

2.1 Study design

This study was designed to evaluate the effect of a primary healthcare pilot model between February 2019 and 2020 using both quantitative surveys (pre- and post-intervention evaluations) and qualitative focus group discussions.

A repeat survey study was carried out between February 2019 and 2020 across 3 pilot provinces of Türkiye selected by random sampling method – Erzincan, Çankırı and Uşak – which met the following inclusion criteria for the provision of PHC services: rural and urban distribution of family health centres (FHCs), sufficient resources to treat patients with hipertension, and a 5 % deviation from the national average for CVD-related mortality. Additionally, provinces selected were not participating in other projects that could impact the outcome of this study at the time and were situated in different geographical regions of the country. Primary health care (PHC) services are delivered by multiple family medicine units (FMUs; a unit consists of family physician (FP) and family health worker (FHW) located in Family Health Centers (FHCs).

Family health centers were determined by taking into account the population distribution of each province and district: 12 family health centers from Uşak and 7 from Çankırı and Erzincan were selected.

The study population was derived from individuals diagnosed with hypertension as recorded in their healthcare records in 2019 (according to ICD codes I10-I15) aged 18 years and over from 256 family medicine units located across three provinces from the Ministry of Health’s General Directorate of Health Information Systems. Using household sampling 331 (95 % CI and 15 % non-response adjustment 281/0.85 = 331 in each of the three provinces) individuals diagnosed with hypertension (Ramzy, 2019) were randomly selected from each province to represent the age and gender distribution of the province's population for an overall study sample of 993 individuals.

Independent variables measured included age, gender and risk factors for hypertension: tobacco use, cholesterol, body mass index (BMI), creatinine, glucose, haemoglobin A1c (HbA1c) level, and proteinuria. Blood pressure control was defined as a systolic blood pressure (SBP) less than 140 mmHg and/or a diastolic blood pressure (DBP) less than 90 mmHg, 6-months after the start of treatment. As per the study protocol, blood pressure monitoring was to occur every 3 months with at least 4 recordings per year. Blood pressure control was determined according to 2 consecutive blood pressure readings, ideally in the final six months of data collection.

Focus group interviews using a standard questionnaire (see supplement) was used to evaluate the perspectives of family physicians, family health workers, pharmacists and patients.

2.2 Study implementation

Relevant study data for study participants were collected from General Directorate of Health Information Systems in February 2019, including recorded blood pressure measurements, the frequency of blood pressure measurements, blood pressure control at guideline targets, the presence of concomitant risk factors for hypertension/biochemical and medical complications of hypertension (Appendix 1), to assess the routine care of patients in the preceding year and existing practices of family health workers in relation to hypertension monitoring. Final evaluations of practices and patient records were conducted during February 2020 in participating family health centers, retrieving all blood pressure values recorded within the electronic registry system.

Provincial training of all healthcare workers (family physicians, family health workers, and pharmacists) during a 2-day in-person training program (with 24 trainers) and evidence-based clinical protocols were implemented, consisting of hypertension education, history-taking and physical examination, training and information on further investigations and management (medial and lifestyle) as well as chronic disease management more broadly. Family physicians received detailed training on treatment options, cardiovascular disease risk assessment, and motivational interviewing of the patient, with practical case studies used to reiterate training. During training, the importance of using awareness materials for patients was emphasized and posters and brochures were distributed during the implementation phase.

Clinical supervision and performance monitoring were also implemented as part of the intervention (Appendix 2). To evaluate the effectiveness of training, pre- and post-training tests were administered. Separately, a survey was carried out to evaluate healthcare worker satisfaction of their training.

Data collectors from the Ministry of Health were provided brief on-the-job training on the use of the assessment form (Appendix 1) and use of electronic medical record systems.

At the final stage of the study, focus group interviews were undertaken to assess the perspectives of family physicians (31), family health workers (31), pharmacists (26) and patients (35). A compilation of views on the project benefits and areas for improvement were gathered and summarised. Interviews were held with 4 groups in 3 provinces with a total of 12 sessions in February 2020.

The Gazi University Ethics Committee provided ethical approval (Date/No: 12/12/2018-E.164440) for the project.

The data was compiled by Ministry of Health employees, in accordance with the Turkish Personal Data Protection Law, anonymously from the electronic health records of patients applying for health services and without obtaining separate consent (the patient's application to health institutions affiliated with the Ministry of Health is considered as de facto consent) (ROT, 2016).

2.3 Data source

Data for the study was derived from patient records contained on the family medicine information system (FMIS). Data related to patient examinations, diagnoses and medications were retrieved. In both the initial and final evaluation, the last recorded value of the independent variables were used for analyses. Project indicators were tracked for the duration of the study related to blood pressure control in hypertension patients.

A survey (see supplement) embedded within the electronic medical records was used to capture initial and final assessment information.

Variables examined included tobacco use, systolic blood pressure and diastolic blood pressure for those who had blood pressure measured, cholesterol, BMI, creatinine, urinalysis, FBG, HbA1c, CVD risk score, past medical history, medication use, and lifestyle recommendations.

2.4 Data analysis

Package programs were used to access descriptive and statistical information about the data obtained in the study. Frequency, percentage and mean were used in the presentation of descriptive data of the sample. After determining distribution of data, parametric test methods were used in statistical analysis of continuous and quantitative data, and nonparametric test methods in the analysis of non-continuous and categorical data using IBM SPSS Statistics for Windows, Version 23.0. (Armonk, NY).

3 Results

In the final study survey, 94 % of the selected sample group of hypertensive patients participated and 60 % were female, and 56 % were over 65 years of age (Table 1). 31 patients in the initial evaluation and 64 patients in the final evaluation were excluded from the evaluation due to reasons such as lack of data, death, change of physician.Table 1 Distribution of hypertensive individuals (18 years and over) by age and gender at in pre-implementation survey and post- implementation survey (n, %), Türkiye, 2019 and 2020.

Age Group	Initial Assessment (Feb 2019)	Final Assessment (Feb 2020)	
Male	Female	Total	Male	Female	Total	
(n)	(%)	(n)	(%)	(n)	(%)	(n)	(%)	(n)	(%)	(n)	(%)	
18–44	27	3	34	4	61	6	35	4	35	4	70	7	
45–65	162	17	225	23	387	40	137	14	212	22	349	37	
65+	195	20	319	33	514	53	210	22	318	34	528	56	
Total	384	40	578	60	962	100	382	40	565	60	947	100	

3.1 Assessment of hypertension

The prevalence of hypertension in the project provinces and throughout Türkiye was examined using the Ministry of Health records in June 2018 prior to commencement of the project. Hypertension prevalence was estimated to be 21 % in Erzincan, 24 % in Uşak, 23 % in Çankırı and 24 % in Türkiye overall.

Routine patient care was assessed prior to the implementation of the project. Hypertension tended to be diagnosed at a secondary care facility. Hypertension diagnosis in primary care was highest in the Çankırı province, with adequate blood pressure control in 46 % of these individuals.

Compared to the initial sample survey assessment, there was a 29 % increase in the rate of recording blood pressure, a 12 % improvement in blood pressure control in the final sample survey assessment, with 34 % of patients blood pressure recorded, and 58 % of those individuals with blood pressure within target limits.

There was an increase in the cases of hypertension diagnosed in primary care in all three provinces post implementation model in the final survey.

3.2 Blood pressure control

The blood pressure within the recommended ranges of the small number of individuals recorded at the baseline assessment was 46 % (23 out of 50 individuals). The number of patients whose blood pressure was recorded during the final evaluation after the implementation of the project increased 8-fold and the blood pressure within the recommended range was 58 %.

3.3 Assessment of hypertension-related examination findings and investigations

Along with blood pressure recording, relevant indices and examination findings to assess complications related to hypertension were reviewed. The proportion of BMI recorded increased from 12 % at the initial assessment to 23 % at the final assessment.

The proportion of creatinine value at least once in the previous year increased from 71 % to 79 %, rate of measuring FBG value at least once from 70 % to 78 %, tobacco use registration rate 9 % increased to 22 %. The proportion of individuals whose cholesterol was measured in the final assessment increased to 69 % (Fig. 1).Fig. 1 Change in physical examination and laboratory examination percentages of hypertensive patients by provinces and total (%), Türkiye, 2019.

3.4 Prescribing practice

The proportion of individuals who were not prescribed antihypertensive medications according to national treatment guidelines despite having been diagnosed with hypertension was 26 % in the initial assessment and19 % in the final assessment.

An improvement in regular antihypertensive medication use (patients with reports of regularly filling prescriptions every three months) was noted, increasing from 49 % to 61 %. The most common medication used to treat hypertension was an angiotensin receptor blocker at 25 % (256), followed by a beta-blocker at 23 % (241). However, as the type of medication use was outside of the project scope these was not reassessed in the final assessment.

The health records of the study sample were examined to determine if there were any records of counselling recommendations for healthy diet, physical activity, tobacco and alcohol use. Lifestyle change recommendations were made for 9 % (83) of hypertensive patients at the initial assessment, and 23 % (218) of hypertensive patients in the final assessment.

3.5 Training of healthcare workers

When comparing the family physicians’ group and the family health workers group, it was observed that participants in both groups achieved the same average levels of success throughout the provinces. Both groups improved upon pre-training test results by an average of 70 %.

Following training, it was observed that family physicians and family health workers carried out monitoring for hypertension in line with evidence-based guidelines in all provinces. The distribution of post-training test scores were skewed to higher scores indicating the positive impact of training (Fig. 2).Fig. 2 Pre-test and post-test score averages for healthcare workers by province and total (n), Türkiye, 2019. Note: NCDs: Non-communicable diseases, CVR: Cardiovascular risk.

When the total success rate of the training is evaluated, the success of healthcare professionals increased by 60 % in Çankırı, 69 % in Erzincan, 74 % in Uşak and 70 % in total.

3.6 Focus group interviews

Post-implementation interviews with family physicians and family health workers reported an increase in awareness of hypertension screening and management practices among personnel over the course of the project.

Screening at the frequency recommended by the project guidelines was difficult in some instances due to capacity constraints.

Common consensus among family physicians, family health workers and pharmacists participating in the focus group discussion was the need for increased public awareness and education of hypertension to improve control; the use standardised clinical algorithms to screen, diagnose and treat patients; the need for easier access and maintenance of patient data; and the need for continuing professional development to maintain knowledge and skills.

4 Discussion

This study was designed to evaluate the effect of standardized clinical protocols for blood pressure measurement and control in primary health care. The implementation of our pilot model, including healthcare worker education, patient health literacy initiatives, and voluntary monitoring systems of blood pressure control, led to increased compliance with blood pressure monitoring at family healthcare centers across all study regions (including the increased detection of patient with hypertension), as well as increased data recording of blood pressure and risk factor screening associated with hypertension

The study found increased compliance with blood pressure monitoring in family health centers through clinical experience and performance monitoring, including diagnosing and identifying new patients in electronic health records and recording data and risk factor parameters.

Proactive management of NCDs in primary health care is recommended by WHO to member countries (WHO, 2015, WHO, 2020a, WHO, 2020, WHO, 2020c). Along with Türkiye’s national NCD management model, this project sought to incorporate blood pressure screening as part of chronic disease management in primary health care, use evidence-based guidelines and standards and strengthen capacity of primary healthcare professionals.

The inherent features of primary care, i.e., continuity, coordination and comprehensiveness, make it well placed to manage chronic conditions (WHO, 2002). Evidence increasingly highlights the importance of reorienting health policy and healthcare towards chronic care systems, including primary care that are proactive rather than reactive (Rothman et al., 2003). Countries with strong primary care systems tend to have better health outcomes at a lower cost (Ham, 2010).

The results of capacity training survey among healthcare workers revealed the need for training to be rolled out across the country to equip personnel with the skills and competencies to implement hypertension screening and follow-up guidelines.

A key deficiency found from focus group interviews was that despite the relatively high level of blood pressure measurements, subsequent record keeping in relevant electronic health record systems was substandard. There were no other record keeping mechanisms in place, such as a physical patient card.

Aligned to WHO’s and Türkiye’s NCD management models, the scope of the project initially included performance payments and software-related interventions (to unify electronic health record systems across family medicine centres) but were not able to be incorporated within the timeframe of the study (WHO, 2020c, WHO, 2020).

The country model and the study in the effective management of non-communicable diseases; the strengths (training of all primary health care workers in the selected provinces, implementation of evidence-based standard protocols, etc.) and weaknesses (lack of performance payment, lack of data in local health records, etc.) of the study were revealed.

Our study highlights the benefit of implementing chronic disease screening and follow-up guidelines in primary healthcare and optimizing the skill mix of healthcare professionals to provide more responsive and effective healthcare. Given the risk that hypertension carries for several other NCDs, the importance and benefit of monitoring and managing hypertension in the population is an important priority.

Funding

The project was technically and financially supported by the Resolve to Save Lives (RTSL) (https://resolvetosavelives.org/) is an initiative of the global public health organization Vital Strategies which is funded by Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation and WHO at three levels (Headquarters, Regional Office for Europe and Country Office in Turkey).

CRediT authorship contribution statement

Banu Ekinci: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Conceptualization. Saion Chatterjee: Conceptualization, Writing – review & editing, Writing – original draft, Visualization. Ilayda Ucuncu: Writing – review & editing, Writing – original draft. Zubeyde Ozkan Altunay: Investigation. Tufan Nayir: Investigation. Secil Sis: Validation, Software, Methodology, Investigation, Formal analysis. Esin Yilmaz Aslan: Investigation. Nevin Cobanoglu: Investigation. Gulay Sarıoglu: Investigation. Fatma Tamkoc Gurbuzturk: Investigation. Sila Toker: Investigation, Funding acquisition. Secil Ozkan: Validation, Software, Methodology, Investigation, Formal analysis. Toker Erguder: Writing – review & editing, Writing – original draft, Supervision, Resources, Project administration, Methodology, Funding acquisition.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Appendix A Supplementary data

The following are the Supplementary data to this article:Supplementary Data 1

Supplementary Data 2

Supplementary Data 3

Data availability

Data will be made available on request.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.pmedr.2024.102867.
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