To understand hypertensive patients' perspectives regarding blood pressure and hypertension treatment, this qualitative study applied semistructured interviews of hypertensive patients. Participants were recruited from two hypertension clinics at the University of Alberta in Edmonton, Canada. To be eligible for inclusion, patients had to be aged 18 years or older, diagnosed with hypertension by a healthcare provider, and currently taking an antihypertensive medication. Participants were stratified in the analysis according to blood pressure control. Twenty-six patients (mean age 57; 62% female) were interviewed, of which 42% were on target and 58% were not. Three underlying themes emerged from the interviews: (a) knowledge of blood pressure relating to diagnosis and management and control of hypertension, (b) integration of hypertension management into daily routine, and (c) feelings and beliefs of wellness. None of the above themes were associated with better control. Knowledge gaps were found, which emphasize the need for further patient education and physician training. Feelings and beliefs of wellness, and not knowledge, were important factors in home assessment of blood pressure. The absence of connections between control of hypertension and the identified domains indicates that current approaches could benefit from the development of a more personalized approach for education and communication.
Hypertension is highly prevalent, and although rates of detection and control of hypertension are improving in many countries, uncontrolled hypertension remains common [
A number of patient-related barriers to optimizing blood pressure (BP) control have been identified. These include lack of patient knowledge, difficulty of treating an asymptomatic condition, personal beliefs that conflict with hypertension treatment goals, and other patient issues such as social economic status, cultural beliefs, access to care, psychosocial factors, and health literacy [
Patients were recruited from two hypertension clinics at the University of Alberta (Edmonton, Midwestern Canada). Inclusion criteria were age over 18 years; ability to read, speak, and write English; hypertension defined as either having a BP over the desired target, patients' BP was either <140/90 mm Hg or <130/80 mm Hg in case of DM or CKD, or being on antihypertensive therapy; absence of cognitive dysfunction; use of at least one hypertensive drug; agreeing to sign informed consent. Each patient was mailed a pamphlet as part of the appointment scheduling, and, during the appointment, recruiting physicians asked patients whether they would be willing to participate in the study. Written information about the study was then provided by the study coordinator and informed consent was obtained. Patients received a $50 reimbursement for participation in the study for the time spent on the interview and costs of parking and travel. Ethical approval was obtained from the University of Alberta Health and Research Ethics Board; all participating patients signed consent to participate in the study.
Patients were consented and interviewed by EPJ, and all interviews were audio-taped and transcribed verbatim. The interviewer stated that she was interested in patients’ perspective on hypertension management and ensured confidentiality that patients’ answers would not be reported back to the referring doctor. Interviews were conducted in a neutral, nonclinical setting. The sample was substratified according to hypertension control (controlled versus uncontrolled). Patients were considered “on target” if BP was either <140/90 mm Hg or <130/80 mm Hg in case of DM or renal impairment defined by estimated GFR <90 mL/min/1.72 m2 as derived from the MDRD equation.
An interview topic guide was developed using the current literature in the field and based on expert opinion. Interviews were semistructured, 30–60 minutes in duration, and designed to elicit patients’ perspectives using open-ended questions to trigger responses and prompts/probes as necessary for clarification purposes. Two pilot interviews were conducted and transcribed, after which the interview guide was refined, and then the remaining interviews were conducted. The pilot interviews were included in the analysis. Specific interview topics were definitions of high BP, the consequences of uncontrolled hypertension, current BP in relation to targets, methods to lower BP, medication adverse effects, and barriers to and facilitators of routine drug intake and adherence.
Data analysis was organized using NVIVO8 (QSR International), a computer program that organizes repeating themes and aids in the coding of transcripts. Themes were derived from a review of the literature and by cataloguing reoccurring themes from the interviews [
Twenty-six patients (62% female; majority Caucasian), aged
Baseline characteristics.
Risk factor | Values |
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Female (%) | 62% |
Age, years | 57 ±/− 16 |
SBP, mm Hg | 134 ±/− 17 |
DBP, mm Hg | 79 ±/− 11 |
BP at or above target | 58% |
Total cholesterol, mmol/L* | 4.9 ±/− .93 |
LDL cholesterol, mmol/L | 2.8 ±/− .93 |
Creatinine, mmol/L | 93 ±/− 29 |
eGFR, mL/min/1.73 m2 | 72 ±/− 23 |
Diagnosis of diabetes mellitus | 12% |
Diagnosis of prediabetes | 23% |
Fasting glucose, mmol/L | 5.8 ±/− 1.5 |
BMI > 30 kg/m2 | 42% |
Smoking: never/past/current | 58%/35%/7% |
Framingham cardiac event score* |
8%/23%/65% |
Three underlying themes emerged from the interviews: knowledge of BP, management integration of hypertension management into the daily routine, and individual patient feelings and beliefs of wellness that impact hypertension control (Figure
Themes mentioned by patient population.
Theme and subtheme | Total | On target | Not on target |
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Attitude | |||
Wishes to lower or eliminate the need for medication | 62% | 27% | 35% |
Holistic approach | 30% | 15% | 15% |
Belief in the benefits of medication | 80% | 38% | 42% |
Mention family history of HTN | 61% | 23% | 38% |
Knowledge | |||
BP consequences | 73% | 31% | 42% |
Home monitoring | 88% | 42% | 46% |
Current BP | 92% | 42% | 50% |
Ways to lower BP | 85% | 38% | 47% |
Side effects | 80% | 42% | 38% |
Recall target or optimal BP | 54% | 31% | 23% |
Knowledge-seeking (internet search, books, magazines) | 23% | 8% | 15% |
Lifestyle | |||
Diet-facilitators | 38% | 19% | 19% |
Diet-barriers | 58% | 27% | 31% |
Exercise-facilitators | 19% | 11% | 8% |
Exercise-barriers | 54% | 27% | 27% |
Salt and hypertension | 88% | 35% | 53% |
Weight | 50% | 15% | 35% |
Stress | 46% | 27% | 19% |
Feelings and beliefs of health and wellness | |||
Physical manifestations | 57% | 15% | 42% |
Integration: routine | |||
Routine to aid in medication adherence | 88% | 38% | 50% |
Coping with travel | 73% | 38% | 35% |
Healthcare providers | |||
Facilitators | 69% | 31% | 38% |
Barriers | 54% | 23% | 31% |
Diagram depicting key patient themes.
Patients widely reported that hypertension was a health concern to them. However, while patients possessed some general knowledge of their condition and hypertension, the level and sophistication of this knowledge varied widely (Table
Quotes of patients with respect to knowledge regarding blood pressure management.
Theme | Quotes |
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Knowledge |
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Knowledge and HCP |
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Knowledge and HCP |
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Knowledge: BP medication |
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Knowledge: BP medication |
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Side effects |
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Side effects |
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Knowledge-lifestyle |
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Knowledge-lifestyle |
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Knowledge-lifestyle |
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Patients indicated that healthcare providers did communicate information about hypertension; however, around half of patients had additional questions. Some patients perceived that their doctors were “too busy” to answer additional questions. Patients (69%) mentioned that other healthcare providers, such as pharmacists and specialists, often provided more education than physicians.
When asked about the function of medication, most patients did not know the exact mechanism of action of the pills. The consistent exception to this was diuretics, which patients referred to as a “water pill.” Patients described the water pill as “
More than half of patients (69%) attributed health issues to side effects from their antihypertensive medication. Patients stated that they were comfortable and quick to discuss adverse effects with their doctor so that medication could be changed. The most commonly perceived side effects were edema (19%), dizziness (19%), increased urination (15%), headaches (12%), dry throat/cough (8%), nausea and vomiting (8%), loss of sexual desire (8%), feeling lethargic (8%), heartburn (4%), hair loss (4%), and constipation (4%).
Patients understood that lifestyle modifications could decrease BP. The majority of patients (85%) mentioned changes such as reducing salt intake and checking for sodium content (88%), exercising (69%), following a healthier diet (eating more fruits and vegetables) (69%), losing weight (46%), decreasing stress (38%), quitting smoking (12%), decreasing caffeine intake (8%), and lowering alcohol intake (4%). While quitting smoking does not decrease BP (CHEP 2011 guidelines), smokers did state that among ways to lower BP, quitting smoking would be relevant. Surprisingly, few patients (12%) indicated that incomplete adherence to lifestyle modification advice was preventing them from decreasing medications.
The most frequently mentioned barrier to medication adherence was a lack of a structured routine or a change in the existing routine (88% mentioned routine) for self-administering BP medications (Table
Quotes of patients regarding routines in the management of their blood pressure.
Theme | Quotes |
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Routine |
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Routine |
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Monetary issues |
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Routine-support |
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Routine-coping |
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Routine-coping |
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Routine-coping |
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Routine |
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Lifestyle-barriers |
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Routine-lifestyle |
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Dietary adherence-spousal support |
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Facilitators of adherence included having an established routine and using reminder tools to ensure medication is taken on a daily basis. Almost all patients (88%) mentioned that using day-labeled pill boxes and making pills visible, along with establishing a routine that incorporates drug administration, ensured daily adherence. This could be summarized by one patient:
Barriers to maintain a healthy diet were mentioned by 58% of respondents (work schedule, too busy to cook, frequently eating out/prepared meals, lack of routine or motivation, and costs) and 38% mentioned facilitators (spouse support, use of precut fresh foods and salt-free foods, label reading, time management, and creating a routine) for healthy eating. Exercise barriers (weather, disability/injury, time/busy, lack of energy, lack of motivation or routine, and lack of social support) were mentioned by 54% of patients, while only 19% mentioned facilitators for increasing activity levels (exercise equipment or video games in home and better weather). Thoughts about being overweight were expressed by 50% of the patients (63% of females and 30% of males).
Despite hypertension often being described as being “silent” and asymptomatic, 69% of participants experienced symptoms that they attributed to elevated BP levels (Table
Patient quotes about feelings and beliefs of wellness.
Theme | Quote |
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Feelings and beliefs |
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Feelings and beliefs |
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Feelings and beliefs |
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Feelings and beliefs |
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Feelings and beliefs |
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Feelings and beliefs |
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Natural remedies |
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Over half of patients (62%) mentioned that they wanted to reduce their antihypertensive pill burden or discontinue pills altogether. Twenty-three percent of the respondents reported trying nontraditional approaches and remedies before conventional drug therapy because they either did not want to take prescribed pills or felt there were “more natural ways” to lower BP.
This study explored barriers to and facilitators of hypertension management from the patients’ perspective by using semistructured interviews. Three recurrent themes were identified: knowledge, routines, and personal beliefs and feelings of wellness. Paradoxically, more knowledge about BP and its treatment was not associated with better control. Patients recognized the importance of routines for medication adherence; yet, they ascribed many symptoms to the side effects of drugs. Interestingly, physical and psychological factors were interpreted to be reflecting the prevailing BP level.
As mentioned, knowledge did not correlate with BP control in this study. This was remarkable, considering that the recruited patients were from specialist hypertension clinics, which distribute educational materials at the time of the appointment regarding optimal BP levels, home monitoring, lifestyle changes, and ways to lower BP. Other studies reported similar findings in regard to BP target knowledge and recall of information [
Knowledge by itself may not impact adherence, but perhaps it is the way that knowledge is presented together with patient-related factors such as personal beliefs. For instance, patients mentioned that incomplete adherence to lifestyle modification was preventing them from reducing their pill burden. This indicates that patients are aware of the impact of lifestyle modifications, however, failed to translate this into implementation. Knowledge has been shown to enhance behaviour changes [
A lack of a routine for medication use was the most frequently reported barrier to proper BP control. The presence of an established routine was identified as a key facilitator of achieving control. While not extensively described in the literature, habits and routine can impact management of hypertension [
Our study reveals that patients’ feelings and beliefs of wellness can impact adherence to physician recommendations of daily medication and lifestyle changes. Despite clinical literature that describes hypertension as asymptomatic, our findings are consistent with other qualitative studies where patients describe physical symptoms of hypertension [
Perception of disease is important as well. In a study of hypertensive patients, those that rated their overall health as good/excellent were less likely to have controlled hypertension, along with those younger (<45 years) and those unaware of family history [
Summarizing, we identified several individual patient issues relevant to the treatment of hypertension. Patient knowledge, routines, and beliefs about their health could interfere with hypertension management. This suggests combining educational materials with more intense behavioural modifications, including coping and changes in routine, and incorporating principles of health literacy and cultural competence could bring benefit to hypertension management. Lastly, the role of the provider is “the most important interaction in ensuring adequate medication adherence” [
The authors would like to thank the patients who participated in this study and Ms. Melisa Spaling for her input and suggestions for the paper. The Department of Medicine and Alberta Health Services supported this study (Emerging Team Grant). Dr. Braam is a Heart and Stroke Foundation of Canada New Investigator.