Abstract
Background:
Rural regions of Kazakhstan face persistent barriers to specialist access. Arterial hypertension (AH) remains highly prevalent, while limited digital literacy may restrict the uptake of telemedicine solutions.
Objective:
To evaluate medical and digital literacy, patient satisfaction, and perceived barriers associated with cardiology teleconsultations for AH in rural Kazakhstan, and to explore changes in patient trust and demographic differences between survey phases.
Methods:
A two-phase service evaluation was conducted. Phase 1 (offline, February 2023) surveyed rural adults with AH (n = 134). Phase 2 implemented mobile-based cardiology teleconsultations (July 2023–January 2024) and included a post-consultation online survey (n = 51, September–December 2024). Descriptive data were summarized as n (%) or mean ± SD; inferential analyses included Welch’s t-test (age), the Wilcoxon signed-rank test (trust before/after), Spearman correlation (digital literacy—trust), the chi-square test (gender—satisfaction), and Kruskal–Wallis (age group—satisfaction).
Results:
In Phase 1, awareness of hypertension and complications was high (96% and 76%), but knowledge of risk factors was lower (78%). Most participants owned a BP monitor (81%) and could measure blood pressure at home (78%); 40% did so daily. Digital engagement was limited—73% were unfamiliar with “digital medicine,” and 75% did not use health apps. In Phase 2, 82% of patients found teleconsultations convenient, and 90% rated remote care as excellent or good; 73% rated physician performance as excellent. Reported barriers included poor internet connectivity (43%), and most consultations occurred via mobile phones (92%). The mean participant age declined from 59 ± 11 years (offline) to 48 ± 13 years (online) (Welch’s t p < 0.0001). Trust in telemedicine significantly increased after the consultation (Wilcoxon p < 0.00001). Satisfaction did not differ by gender (p = 0.79) or age group (p = 0.349). A simplified cost analysis indicated ∼66.7% lower per-visit cost compared with in-person consultations.
Conclusions:
Mobile teleconsultations for hypertension management were feasible, well accepted, and associated with a significant improvement in patient trust among rural populations. Targeted efforts to improve digital literacy and connectivity could enhance equitable adoption. Early economic signals support integrating teleconsultations into routine rural health care services.
Keywords
Introduction
Kazakhstan’s vast geography and sparse rural settlement patterns create persistent barriers to timely specialist care. Arterial hypertension (AH) remains highly prevalent and a major contributor to mortality, making scalable outpatient models a public health priority.1,2 Recent national regulations have formalized the provision of remote medical services, positioning teleconsultations as a pragmatic route to expand access within existing health-system workflows.3,4
Despite this enabling policy context, real-world adoption in rural settings is constrained by limited digital literacy and connectivity, as well as variable patient trust in remote care.5,6 Evidence from high-income settings supports telemedicine’s feasibility for chronic disease management,7–9 yet context-specific data from Central Asia—especially on patient experience, trust, and barriers in routine practice—remain scarce.1,2 Addressing these gaps is essential to inform equitable scale-up.
This study reports a two-phase service evaluation of mobile teleconsultations for patients with AH in rural Kazakhstan. We assess (1) medical and digital literacy, (2) patient satisfaction and perceived barriers, and (3) changes in trust before versus after a real teleconsultation encounter. We also explore demographic differences between survey phases and provide a simplified cost signal comparing remote versus in-person visits. By focusing on patient-reported outcomes and implementation-relevant barriers within a national telemedicine policy environment, the study aims to generate actionable evidence for rural service delivery and inform scale-up strategies.
Materials and Methods
Study design and setting
This two-phase service evaluation was conducted among rural residents of the Akmola region of Kazakhstan. Phase 1 (February 2023) comprised an offline survey in the district center, Derzhavinsk, and three surrounding villages (Taldy-Tasty, Otradnoye, and Pyatigorsk). Phase 2 (July 2023–January 2024) delivered remote cardiology teleconsultations through WhatsApp video calls integrated with the national information system Damumed.
Participants
Adults (≥18 years) with a documented diagnosis of AH and suboptimal blood pressure control were eligible. Suboptimal control was defined as systolic blood pressure ≥140 mmHg and/or diastolic blood pressure ≥90 mmHg on at least two consecutive measurements, in accordance with European Society of Cardiology hypertension guidelines. Exclusion criteria were acute coronary events, recent revascularization or stroke (<3 months), pregnancy, advanced heart failure (NYHA III–IV or LVEF <30%), and cognitive impairment preventing meaningful participation. Patient selection was based on medical records and preliminary interviews with a cardiologist.
Procedures
During Phase 1, participants completed the questionnaire “Medical Awareness and Digital Literacy,” paired with in-person cardiology visits. The questionnaire assessed:
knowledge of AH, its risk factors and complications; health behaviors and lifestyle; awareness and use of mobile health applications; perceptions of digital medicine and access to care; awareness of the national Patient Health Management program.
At the end of each in-person visit, the cardiologist explained the Phase 2 teleconsultation process. During Phase 1, the cardiologist also conducted on-site consultations in all three villages and informed patients that online follow-up could be provided if needed. The local primary care physician determined which patients required further specialist evaluation based on symptoms, blood pressure logs, and clinical findings. Only those with persistent elevated blood pressure or ongoing concerns were referred for Phase 2 teleconsultations through the national Damumed system. Referred patients appeared in the cardiologist’s CMIS (Comprehensive Medical Information System) schedule, and the local primary care physician prepared them for the remote visit by ensuring the availability of recent laboratory tests and a 12-lead ECG.
Data analysis
Descriptive statistics were expressed as n (%) or mean ± SD. Welch’s t-test compared mean ages between phases; the Wilcoxon signed-rank tested trust before/after teleconsultations; Spearman correlation assessed digital literacy—trust; chi-square (χ2) and Kruskal–Wallis tests examined satisfaction differences by gender and age. Two-sided p < 0.05 was considered significant.
Ethical approval
Phase 1 was approved by the Ethics Committee of the National Research Oncology Center LLP (Protocol No. 19, 27 February 2023). Phase 2 was approved by the Ethics Committee of the Salidat Kairbekova National Scientific Center for Health Development (Protocol No. 1, 6 September 2024). All participants provided written informed consent.
Statistical analysis
Descriptive statistics summarized participant characteristics. Continuous variables (e.g., age) were reported as mean ± standard deviation (SD), and categorical variables (e.g., gender, device use, telemedicine awareness) as counts and percentages.
Normality of distributions was tested using the Shapiro–Wilk test and variance homogeneity with Levene’s test. Because of unequal variances, the mean age between pre- and post-teleconsultation groups was compared using Welch’s t-test. Changes in trust toward telemedicine before and after consultations were evaluated using the Wilcoxon signed-rank test. Correlations between digital literacy and trust were analyzed with Spearman’s rank correlation. Gender differences in satisfaction were examined using Pearson’s chi-square test, and age-group differences with the Kruskal–Wallis test.
All tests were two-sided, and p < 0.05 was considered statistically significant. Analyses were performed using IBM SPSS Statistics v27.0 and Python-based packages (SciPy, StatsModels). Missing data were minimal (<5%) and handled by listwise deletion.
Results
Phase 1—Baseline survey of rural patients (n = 134)
Participant characteristics and awareness indicators are summarized in Table 1.
Descriptive Characteristics of Rural Survey Respondents (n = 134)
Among 134 respondents, most were female (78%) with a mean age of 59 ± 11 years. The majority owned a home blood-pressure monitor (81%) and could measure BP independently (78%); 40% measured daily, 45% only when unwell, and 15% never measured.
Lifestyle indicators showed generally healthy habits: 90% did not consume alcohol, 13% smoked, and physical activity was reported as average in 56%, low in 28%, and high in 16%. Eighty percent were satisfied with local health care, although 27% reported frequent stress.
Awareness of hypertension and its consequences was high (96% and 76%, respectively), while understanding of risk factors was slightly lower (78%). Only 19% had heard of the national Patient Health Management program, 20% were familiar with health-related mobile apps, and 7% reported actual use. Most participants (82%) were on antihypertensive therapy. Despite limited digital awareness, 93% expressed trust in Kazakhstan’s health care system.
Phase 2—Teleconsultation evaluation (n = 51)
Detailed responses regarding satisfaction, barriers, and perceived advantages are presented in Table 2.
Experience with Online Teleconsultations and Perceived Barriers (n = 51)
The mean age of participants was 48 ± 13 years, and 86% were female. Most respondents found online consultations convenient (82%) and rated the overall quality of remote care as excellent or good (90%). Satisfaction with the consultation was high—63% “fully satisfied” and 33% “rather satisfied.”
Physician performance received particularly positive feedback (73% rated “excellent”). The most frequent difficulty was slow internet connection (43%), while 53% reported no technical problems. Almost all patients (92%) used mobile phones for teleconsultations.
The main reported advantages were time saving and avoidance of queues (75%), followed by the ability to combine work and consultation (18%) and accessibility for disabled or home-bound individuals (8%). Sixty-three percent believed teleconsultations could improve the health care system. Attitudes toward telemedicine improved notably after direct experience: initially 40% were positive, 39% uncertain, and 21% negative.
Additional Statistical Analyses
Age differences before and after teleconsultations
Participants in the offline survey were significantly older than those completing the online post-consultation survey (59 ± 11 vs. 48 ± 13 years; Welch’s t, p < 0.0001), indicating that younger patients were more likely to engage in teleconsultations.
Change in trust toward telemedicine
Patient trust in telemedicine increased markedly following direct experience (Wilcoxon p < 0.00001), confirming that practical exposure enhanced acceptance of remote care.
Digital literacy and trust
No significant correlation was observed between digital literacy and trust (Spearman p > 0.05), likely reflecting homogeneity in responses.
Gender differences in satisfaction
Satisfaction levels did not differ by gender (χ2 p = 0.79), suggesting comparable acceptance among men and women.
Age-group differences in satisfaction
Satisfaction was also consistent across age categories (<40, 40–59, >60 years; Kruskal–Wallis p = 0.349).
Discussion
This study evaluated medical and digital literacy, patient satisfaction, and perceived barriers related to teleconsultations for AH in rural Kazakhstan. Although awareness of hypertension and its complications was high, digital literacy was limited—most patients were unfamiliar with digital medicine and did not use mobile health applications.6,10 This imbalance between medical awareness and digital engagement highlights the need for targeted education to enable broader telemedicine adoption.
Patients expressed strong satisfaction with teleconsultations. Convenience, time savings, and reduced travel were the main advantages, consistent with evidence from other low-resource settings.5,8,9 These findings confirm that even simple, mobile-based platforms such as WhatsApp can deliver acceptable and trusted care when integrated into existing health-system workflows. 10 The high ratings of physician performance and overall service quality further demonstrate the feasibility of teleconsultations in primary care.
Younger participants were more likely to engage in online consultations, reflecting higher digital readiness, while older adults may face barriers related to skills, device access, or connectivity.11,12 Trust in telemedicine significantly improved after direct experience, reinforcing the importance of practical exposure in overcoming initial skepticism. 13
Overall, the results align with prior international evidence showing that patient familiarity and supportive communication are central to sustained telehealth engagement.7–9,14 For Kazakhstan, expanding digital literacy programs, ensuring stable internet access, and embedding teleconsultations into routine rural care could enhance continuity, equity, and cost efficiency.2–4
Comparison with Global Research
Our findings align with international literature demonstrating the benefits of telemedicine for hypertension management. A systematic review by Khanijahani et al. (2022) confirmed that telemedicine improves blood-pressure control, patient engagement, and communication with clinicians.13,15 Similar to global trends, our results show high patient satisfaction and acceptance of remote consultations, emphasizing the feasibility of telemedicine in everyday clinical practice.7–9
Consistent with Piette et al. (2015), 10 younger adults in our study were more likely to adopt digital health tools, while older patients faced greater barriers. Prior evidence from the Journal of Clinical Hypertension also highlights the economic value of telemedicine, reducing costs for both patients and institutions—a pattern reflected in our estimated 66% lower per-visit cost.16,17
Furthermore, research in Hypertension (American Heart Association) showed sex- and age-related differences in blood-pressure control; women in later adulthood were more engaged in disease management. 18 The predominance of female participants (78%) in our sample supports this observation and suggests that women may serve as early adopters of teleconsultation services in rural communities.
Together, these parallels indicate that Kazakhstan’s telemedicine experience follows broader international patterns while contributing new data from a rural, middle-income country context.
Practical Implications
These findings highlight the need to strengthen the integration of telemedicine within Kazakhstan’s health care system, particularly in underserved rural regions. Broader adoption requires improving public awareness of available telemedicine services and enhancing patient digital literacy. In our study, most respondents were unfamiliar with mobile health tools, underscoring the need for nationwide education initiatives and user-friendly digital platforms such as Damumed.
To engage older adults, digital literacy programs should be complemented by simplified interfaces, targeted training, and support from clinical staff during remote visits or survey completion. Telephone-based follow-up and caregiver assistance may also facilitate participation.
The high level of trust in Kazakhstan’s health care system suggests strong readiness for innovation if infrastructure remains reliable and equitable. Ensuring stable internet access and continuing to embed teleconsultations into routine care could improve service continuity, reduce travel burden, and promote digital inclusion for rural populations.
Economic Efficiency of Telemedicine
Telemedicine substantially reduced the cost of care compared with traditional in-person visits. The average cost of a face-to-face consultation in Kazakhstan was ∼11,500 KZT (∼25 USD), while a teleconsultation cost ∼4,000 KZT (∼8.7 USD), representing an estimated 66% reduction per encounter.18,19 These findings are consistent with international evidence showing that telehealth can lower health care expenditures. 17
Based on the 127 patients who received remote consultations, the projected savings totaled ∼1 million KZT (∼2,070 USD). Such reductions translate into tangible financial relief for both patients and health care providers, particularly in geographically remote regions.10,17
However, limited digital literacy remains a barrier to maximizing these economic advantages. In our sample, most participants were unfamiliar with health-related mobile applications.6,10 Expanding digital-literacy training and simplifying telehealth interfaces could further enhance accessibility, efficiency, and cost savings. 10
Study Limitations
This study has several limitations.
First, the sample sizes in the two phases differed (134 vs. 51 participants), which may have introduced selection bias.
Second, the study focused exclusively on rural regions of Kazakhstan, limiting the generalizability of findings to urban or international populations.
Third, all data were self-reported, which may involve recall or response bias.
Fourth, clinical outcomes after teleconsultations were not assessed; therefore, the long-term impact on blood-pressure control cannot be determined.
Despite these limitations, the study provides valuable real-world insights into patient satisfaction, digital literacy, and trust in telemedicine among rural populations in a middle-income country.
Future Research Directions
Future research should monitor the long-term effectiveness of teleconsultations and their impact on clinical outcomes in patients with hypertension. Further studies are also needed to evaluate the cost-effectiveness of telemedicine implementation and to develop strategic recommendations for optimizing digital health services in Kazakhstan.
To improve engagement of older adults, targeted educational initiatives could include online courses, brief instructional videos, and in-person training sessions delivered through rural health posts (Feldsher-Accoucheur Points, FAPs). Involving family doctors in demonstrating digital tools during regular visits may further facilitate patient participation and confidence in teleconsultations.
Conclusion
This study demonstrated high patient satisfaction with teleconsultations and confirmed telemedicine’s potential as an effective approach for managing AH in rural Kazakhstan. Key barriers—limited digital literacy and inadequate internet infrastructure—require targeted attention from both policymakers and health care providers.
Educational initiatives for patients and clinicians, along with continued improvements in digital infrastructure, are essential for scaling telemedicine nationwide. Economic analysis showed a 66% reduction in consultation costs, reinforcing the financial advantages of digital care models. Integrating teleconsultations into national health care policy could enhance access, efficiency, and equity of services for underserved populations.
Future work should examine long-term clinical outcomes, treatment adherence, and health-system impacts to ensure sustainable implementation of telemedicine in Kazakhstan.
Ethics Approval and Consent to Participate
The first-phase survey was approved by the Ethics Committee of the National Scientific Oncology Center LLP (Protocol No. 19, 27 February 2023). The second-phase survey was approved by the Ethics Committee of the Salidat Kairbekova National Scientific Center for Health Development (Protocol No. 1, 6 September 2024). All participants provided written informed consent prior to enrollment.
Authors’ Contributions
A.B. conceived and designed the study, performed the teleconsultations, carried out the statistical analysis, and drafted the article. G.K., T.S., and S.I. contributed to data interpretation, contextual expertise, and critical article review. All authors read and approved the final version of the article.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No external funding was received for this study.
Data Availability
The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.