Introduction

Primary aldosteronism (PA) is a prevalent but largely underrecognized condition. As the most common cause of endocrine hypertension, PA affects approximately 10% of individuals with hypertension1,2. The condition’s prevalence increases significantly among patients with resistant hypertension, reaching as high as 60%3. The hypersecretion of aldosterone in PA can be attributed to either an aldosterone-producing adenoma or bilateral adrenal hyperplasia4,5. Given the substantial cardiovascular and metabolic risks associated with untreated PA, early diagnosis and targeted treatment are essential for reducing morbidity and mortality6. The global underdiagnosis of PA remains a significant clinical challenge, with recent international studies suggesting that less than 1% of patients with PA receive proper diagnosis despite its prevalence of approximately 10% among hypertensive patients7,8. In China specifically, despite having one of the world’s largest hypertensive populations, PA screening rates remain suboptimal, with significant regional variations in clinical practice9. This diagnostic gap results in preventable cardiovascular complications and increased healthcare costs.

The Knowledge, Attitude, and Practice (KAP) model delineates a framework where knowledge serves as the foundation for behavior change, while attitudes and beliefs act as the driving forces behind such changes10. According to the KAP theory, the evolution of human behavior can be segmented into three phases: acquiring knowledge, developing attitudes/beliefs, and ultimately forming practices/behaviors11. Although acquiring knowledge initiates cognitive change, it does not directly result in behavioral modifications. Instead, it first alters perceptions, which then influence behavior through this new understanding12. The order in which these elements are addressed is critical in altering the practice patterns of physicians13.

Primary aldosteronism often remains underdiagnosed or overlooked due to the subtlety of its early symptoms, leading to delays in treatment. Given the scarcity of KAP studies focused on this topic, our research aims to explore the KAP of healthcare workers towards primary aldosteronism. By concentrating on healthcare workers, the study intends to enhance early detection and improve management practices in areas with significant awareness and treatment gaps. This targeted approach holds the potential to diminish the morbidity and mortality associated with primary aldosteronism by improving clinical practices and boosting the capability of healthcare workers to effectively diagnose and manage the condition. Unlike previous studies that have primarily focused on screening rates or clinical outcomes, our research uniquely examines the underlying factors affecting healthcare workers’ ability to diagnose and manage PA, providing critical insights into specific knowledge deficits and attitudinal barriers that contribute to underdiagnosis. By employing a comprehensive KAP framework and structural equation modeling, this study offers a novel perspective on how knowledge acquisition influences clinical practice both directly and through attitudinal mediation in the context of PA management. Accordingly, the aim of this study was to assess the knowledge, attitudes, and practices (KAP) of healthcare workers regarding primary aldosteronism in Shanxi Province and to identify key factors associated with proactive clinical practices. These findings have important implications for designing targeted educational interventions that can address the specific gaps identified, potentially improving PA detection rates and patient outcomes in regions with limited resources.

Methods

Study design and subjects

This multi-center cross-sectional study enrolled doctors from the cardiology, endocrinology, and urology departments of hospitals at Shanxi Province in China between 1st and 7th August 2024. The inclusion criteria were: (1) Physicians in the cardiology, endocrinology, and urology departments of secondary and tertiary hospitals in Shanxi Province, including resident physicians, attending physicians, associate chief physicians, and chief physicians; (2) currently employed. The exclusion criteria were: (1) Those who are no longer in practice, such as retired physicians or those who are currently on sick leave; (2) physicians with psychiatric or psychological disorders. This study was approved by the Ethics Committee of Shanxi Provincial People’s Hospital (No. 612), and all participants provided written informed consent.

Questionnaire introduction

Following the development of the questionnaire, a pilot test was conducted with 44 participants, yielding a reliability score of 0.861. The finalized questionnaire, presented in Chinese, encompassed four sections: demographic information, and the dimensions of knowledge, attitude, and practice. The knowledge section comprised eight questions, each scored 1 for correct responses and 0 for incorrect or unclear responses, resulting in a possible total score ranging from 0 to 8. The attitude section contained six questions, assessed using a five-point Likert scale ranging from “strongly disagree” (1 point) to “strongly agree” (5 points), with potential scores varying between 6 and 30. The practice section also consisted of eight questions, evaluated on a five-point Likert scale from “always” (5 points) to “never” (1 point), allowing for scores between 8 and 40. Adequate knowledge, positive attitudes, and proactive practices were defined as achieving scores surpassing 70% of the maximum possible score in each respective section14. The total sample size for the study was 337, with the questionnaire’s items demonstrating a Cronbach’s α coefficient of 0.873, indicative of good internal consistency. The questionnaire was disseminated to participants via WeChat groups. The English version questionnaire was inserted as an Appendix. The complete questionnaire items for the knowledge, attitude, and practice dimensions, along with the correct answers for the knowledge items, are presented in Table S1 in the supplementary materials. This allows readers to fully evaluate the content validity of the assessment tool used in this study.

Statistical analysis

All statistical analyses were performed using SPSS 27.0 (IBM, Armonk, NY, USA) and Amos 26.0. Descriptive analysis was carried out on the demographic information and the scores of knowledge (K), attitude (A), and practice (P) dimensions of the respondents. Continuous variables were reported as means and standard deviations (SD), whereas categorical variables and questionnaire responses were presented as frequency (percentage). Differences in the scores of knowledge, attitude, practice, and job burnout among various demographic groups were analyzed using independent sample tests: the Mann–Whitney U test was applied for two-group comparisons and the Kruskal–Wallis H test for comparisons involving three or more groups. Spearman rank correlation was employed to evaluate the relationships between the scores of knowledge, attitude, and practice. Both single and multivariate logistic regression analyses were utilized to investigate risk factors within the practice dimension. Structural equation modeling (SEM) was conducted to explore the interconnections among the KAP dimensions. Statistical significance was set at a P-value of less than 0.05.

Results

Demographic characteristics

Initially, a total of 357 questionnaires were received. The following data were excluded: (1) 1 response with a completion time of less than 60 s; (2) 17 responses that failed the trap question (an attention-check question embedded within the survey to identify respondents who were not carefully reading the questions); (3) 2 responses that selected 'C' for all knowledge questions, indicating uncertainty. This left 337 valid responses for analysis, with an effectiveness rate of 94.40%. Among them, 174 (51.63%) were female, 177 (52.52%) were aged up to 40 years, 149 (44.21%) had worked for at least 15 years, 120 (35.61%) had intermediate professional title, 146 (43.32%) worked in cardiology department, 207 (61.42%) had managed patients with primary aldosteronism, 233 (69.14%) had managed patients with no more than 5 cases. The mean knowledge, attitude, and practice scores were 4.42 ± 1.56, 26.46 ± 2.65, and 29.27 ± 7.42, separately. Analyses of demographic characteristics found that participants’ knowledge, attitude, and practice scores varied across hospital level (P < 0.001, P = 0.002, P < 0.001), type of hospital (P < 0.001, P < 0.001, P < 0.001), whether managed patients (P < 0.001, P = 0.004, P < 0.001), and number of patients managed (P < 0.001, P = 0.004, P < 0.001). Meanwhile, participants with different professional titles (P < 0.001) and current departments (P < 0.001) were more likely to have different knowledge scores. Participants with different gender (P = 0.046) and research status (P = 0.034) were more likely to have different attitude scores. Participants with different gender (P = 0.008), age (P = 0.028), professional title (P < 0.001), current department (P < 0.001), and research status (P < 0.001) were more likely to have different practice scores (Table 1).

Table 1 Demographic characteristics and knowledge, attitude, and practice scores.
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Knowledge, attitude and practice dimensions

The distribution of knowledge dimensions shown that the three questions with the highest number of participants choosing the “Not Sure” option were "Primary aldosteronism can be classified into 5 types based on different etiologies, including aldosterone-producing adenoma, idiopathic hyperaldosteronism, primary adrenal hyperplasia, familial hyperaldosteronism, and ectopic aldosterone-secreting tumor." (K1) with 20.47%, "There are currently four main diagnostic tests for primary aldosteronism, including the oral sodium loading test, fludrocortisone suppression test, saline infusion test, and captopril challenge test." (K6) with 20.47%, and "Imaging examinations often cannot detect small adenomas or differentiate non-functional tumors from aldosterone-producing tumors. Adrenal vein sampling (AVS) is the most reliable and accurate method to distinguish between unilateral and bilateral secretion." (K7) with 18.99% (Table S1). On the attitude dimension, 33.23% were neutral, 11.87% disagreed, and 4.15% strongly disagreed with the statement, "I believe I have sufficient knowledge and skills to manage patients with primary aldosteronism." (A4). In addition, when it comes to the current state of clinical practice of this disease (A6), 24.33% were neutral (Table S1). When it comes to related practices, 39.76% rarely and 13.95% never participated in research or academic conferences related to primary aldosteronism (P7), 22.26% rarely and 11.28% never made a classification diagnosis based on the patient’s clinical characteristics, biochemical indicators, imaging findings, and adrenal vein sampling (P6) (Table S1).

Spearman correlation analysis

Spearman correlation analysis showed that there were significant positive correlations between knowledge and attitude (r = 0.279, P < 0.001), knowledge and practice (r = 0.347, P < 0.001), as well as attitude and practice (r = 0.507, P < 0.001) (Table 2).

Table 2 Spearman correlation analysis.
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Multivariate logistic regression analysis

Multivariate logistic regression showed that attitude score (OR = 1.403, 95% CI 1.234–1.596, P < 0.001), city-level hospital (OR = 6.265, 95% CI 1.574–24.938, P = 0.009), provincial-level hospital (OR = 13.383, 95% CI 2.330–76.882, P = 0.004), had managed patients with primary aldosteronism (OR = 2.506, 95% CI 1.247–5.038, P = 0.010), and managed 5 cases or more patients (OR = 5.919, 95% CI 1.928–18.174, P = 0.002) were independently associated with proactive practice (Table 3).

Table 3 Multivariate logistic regression analysis on practice.
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Mediation analysis

The mediation analysis showed that knowledge had a direct effect on attitude (β = 0.450, P = 0.012). Additionally, knowledge had a direct effect on practice (β = 0.461, P = 0.006), and an indirect effect on practice (β = 0.095, P = 0.030) (Table 4; Fig. 1). The fitting index of the structural model (CMIN/DF = 3.097; IFI = 0.840; TLI = 0.818; CFI = 0.839) outperformed the respective threshold value, signifying that the data satisfactorily fit the structural model (Table S2).

Table 4 Mediation analysis.
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Fig. 1
figure 1

Structural equation modeling results. Structural Equation Model illustrating the relationships among Knowledge, Attitude, and Practice variables. Each latent variable (Knowledge, Attitude, Practice) is represented by ellipses and observed indicators (K1-K8, A1-A6, P1-P8) by rectangles. Path coefficients indicate the strength of relationships between variables, with arrows representing the direction of influence. Measurement errors (e1-e23) are associated with each observed variable. This model evaluates the influence of Knowledge on Attitude and Practice, as well as the effect of Attitude on Practice.

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Discussion

The study highlights a crucial gap in the knowledge of healthcare workers regarding primary aldosteronism in Shanxi Province, despite their positive attitudes and proactive practices towards managing the condition. It is recommended that targeted educational interventions be developed to enhance the knowledge base of healthcare workers, which could further strengthen their attitudes and practices, ultimately improving patient management outcomes for primary aldosteronism.

The findings of this study underscore the complex interplay among KAP related to PA among healthcare professionals. Significant disparities in KAP scores were observed across several demographic and institutional factors, particularly professional title, hospital tier, and previous experience managing PA cases. These variations may be partially attributed to systemic differences in institutional capacity, diagnostic capabilities, and access to continuous professional development. For example, China’s hierarchical medical system (HMS) has improved the distribution of material medical resources but has shown limited effectiveness in addressing disparities in human resources such as clinical expertise and diagnostic skills, particularly between lower- and higher-tier hospitals15. Higher-level hospitals often benefit from more structured clinical governance, access to advanced diagnostic tools-such as adrenal vein sampling-and stronger research infrastructures, all of which contribute to enhanced clinician awareness and competency in PA diagnosis and management. Moreover, specialized departments are more frequently exposed to complex or treatment-resistant cases of hypertension, which may necessitate heightened clinical vigilance and greater adherence to PA screening protocols. A study comparing public and private community health centers in Shenzhen, for example, showed that public institutions were more likely to follow hypertension management protocols and ensure treatment adherence, reflecting how institutional structure influences practice quality16. These institutional and structural advantages, combined with hierarchical differences in training exposure and resource distribution, likely contribute to the observed variation in KAP outcomes across different healthcare settings. Additionally, differences in access to and preferences for continuing medical education may further reinforce knowledge disparities. Recent evidence from a national discrete choice experiment in China demonstrated that health workers’ participation in CME is shaped by perceived utility, learning mode, and workload, suggesting that CME opportunities are not equally accessible or effective across all professional levels17. Future research should consider integrating qualitative assessments and facility-level data to further elucidate the contextual factors influencing these disparities.

Notably, our results revealed that healthcare professionals holding higher professional titles (associate senior and senior) and those working in higher-tier hospitals (city-level and provincial-level) exhibited significantly greater knowledge and more proactive clinical practices. Although our study did not directly assess participation in continuing medical education (CME) or specific training programs, the observed association between professional title and knowledge levels reflects the structure of the Chinese medical career advancement system, which emphasizes the accumulation of clinical experience and demonstrated competency over time. Prior studies have suggested that senior professionals are more likely to be exposed to a wider range of clinical cases and learning environments18,19, and that physicians with advanced professional titles typically have improved access to educational resources, structured training pathways, and continuing development opportunities within the Chinese healthcare system20,21. Though our data cannot definitively attribute the observed differences to specific educational interventions, these findings are consistent with established patterns in medical professional development. Future studies should include detailed assessment of CME participation and specialized training to better understand the factors contributing to knowledge differences across professional ranks.

Healthcare workers who had managed a greater number of primary aldosteronism cases showed markedly higher knowledge and practice scores. This finding aligns with literature suggesting that direct clinical experience plays a critical role in reinforcing knowledge and translating it into skilled practice22,23. The practical exposure to complex cases likely enhances understanding and proficiency beyond what is achievable through theoretical training alone. These differences were further substantiated by the multivariate logistic regression analysis, which showed that positive attitude scores, higher hospital levels, and increased experience with primary aldosteronism were significant predictors of proactive practice.

The study also noted minor but significant differences in practice scores based on gender and age, with males and those above 40 years of age scoring higher. This could be attributed to potentially greater exposure to varied clinical situations over time24, which might not significantly impact attitudes but does influence practical capabilities. The minimal impact on knowledge scores by age could indicate that initial education or ongoing training opportunities are uniformly accessed, thus not differentiating knowledge accumulation significantly across age groups. Workers in specialized departments like cardiology and endocrinology did not exhibit significantly different attitudes compared to their peers in other departments, possibly due to a generalized professional commitment to patient care. However, their knowledge and practices scores were higher, likely reflecting specialized training and more frequent encounters with conditions like primary aldosteronism in their specific fields25,26.

The correlation and mediation analyses further solidified the role of knowledge as a fundamental driver of both attitudes and practices. The significant positive correlations between these elements underscore the theoretical framework that knowledgeable healthcare workers are likely to develop more favorable attitudes, which in turn facilitate better clinical practices27,28. The mediation effect observed, where knowledge influences practice through attitudes, emphasizes the critical need for educational programs that not only transfer information but also positively shape perceptions and attitudes towards disease management.

The knowledge scores among healthcare workers about primary aldosteronism reflect significant gaps, particularly concerning the main manifestations of the condition such as hypertension and hypokalemia, and the role of aldosterone-to-renin ratio (ARR) in screening. With a substantial percentage of respondents uncertain or incorrect about these basic facets, there is a clear need for focused educational interventions. To effectively address the identified knowledge gaps in PA, particularly in the areas of disease classification and diagnostic procedures, it is essential to implement structured, evidence-based educational interventions. We propose the establishment of targeted training programs that emphasize both theoretical and practical components of PA diagnosis, including the accurate application and interpretation of confirmatory tests such as the saline infusion test, oral sodium loading test, and adrenal vein sampling. These programs should be embedded within CME frameworks and enriched with interactive, case-based learning modules and simulated clinical scenarios to reinforce critical decision-making skills. Moreover, the integration of standardized diagnostic checklists for PA into electronic medical record (EMR) systems could facilitate clinical adherence to screening guidelines and streamline diagnostic workflows. To ensure the long-term effectiveness of these interventions, it is also advisable to incorporate routine knowledge assessments and individualized feedback mechanisms, which can aid in the early detection and continuous correction of specific learning deficiencies29,30.

Attitudes towards the management of primary aldosteronism are generally positive, yet discrepancies such as a considerable number of healthcare workers feeling insufficiently skilled to manage the condition highlight areas for improvement. To improve this, it is recommended to establish continuous professional development programs, including workshops and simulation training, which have been shown to boost confidence and competence in managing specialized conditions31,32. Furthermore, creating peer support networks and mentorship programs could provide ongoing support and encouragement, helping to transform positive attitudes into competent practices.

The practice scores reveal that activities such as screening for primary aldosteronism in newly diagnosed hypertensive patients are not consistently performed, with many healthcare workers only sometimes or rarely engaging in recommended practices. This inconsistency can be partly attributed to the reported gaps in knowledge and confidence. Enhancing practice can be achieved by integrating decision support tools into clinical practice, such as checklists or software that prompts healthcare workers when screening or testing is indicated, proven to increase adherence to clinical guidelines33,34. Additionally, practical training, specifically in the use of diagnostic tests like the ARR, and management protocols for primary aldosteronism, should be provided. By focusing on these practical skills in training, healthcare workers can be more prepared to apply their knowledge effectively in clinical settings35,36,37.

This study has several limitations that should be considered. First, the cross-sectional design restricts our ability to infer causal relationships between healthcare workers’ knowledge, attitudes, and practices. Second, the sample is confined to Shanxi Province, which may limit the generalizability of the findings to other regions with different healthcare settings and educational backgrounds. Regional disparities in healthcare infrastructure, including variations in clinical training systems, availability of diagnostic tools such as adrenal vein sampling, and the implementation of screening guidelines for hypertension, may affect the applicability of our findings to provinces with differing resources and policies. Therefore, future studies involving a more geographically diverse sample are needed to validate these results across broader contexts. Finally, while the assessment of knowledge is relatively objective with clear correct and incorrect answers, our evaluation of attitudes and practices relies on self-reported data rather than direct observation of clinical behavior. This methodological approach may introduce social desirability bias, as respondents might have reported more positive attitudes and more adherent practices than they actually demonstrate in clinical settings. This limitation is particularly relevant for the practice dimension, where there may be a significant gap between reported and actual clinical behaviors. Future studies could benefit from incorporating direct observational methods or clinical audits to validate self-reported practices. Additionally, our study has geographic and specialty-specific limitations that may affect its external validity. The sample is confined to healthcare workers in Shanxi Province, which may not be representative of other provinces in China or healthcare systems internationally due to regional variations in medical education, healthcare resources, and practice patterns. Furthermore, our study focused specifically on specialists in cardiology, endocrinology, and urology departments, excluding general practitioners and physicians from other specialties who may encounter patients with hypertension and could play a crucial role in the initial detection and referral of potential PA cases. Future research should aim to include a more geographically diverse sample across multiple provinces and expand the scope to include primary care physicians and other relevant specialties to provide a more comprehensive assessment of PA management across the healthcare continuum.

In conclusion, healthcare workers in Shanxi Province exhibit inadequate knowledge but positive attitudes and proactive practices toward primary aldosteronism, indicating a disparity that may impact patient care. It is recommended to enhance education and training programs for healthcare workers to improve their knowledge of primary aldosteronism, which may positively influence their attitudes and practices. Future interventional studies are needed to directly assess whether such educational initiatives translate to improved patient outcomes.