Original Research
Identifying patient-related barriers in hypertension control: a multi-centered, mixed-method study in Greek rural practices
AUTHORS
Zoi Tsimtsiou1 MD, MSc, PhD, Research Fellow *
Stamatia Kokkali 2 MD, MSc, PhD, Research Fellow
Athina Tatsioni3 MD, PhD, Associate Professor of General Practice
Sofia Birka4 MD, PhD
Valentina Dislian6 MD, MSc
Martha Andreou 7 MD 
Anna Bettina Haidich8 PhD, Associate Professor of Medical Statistics
Eirini Oikonomidou9 MD, MSc, PhD
AFFILIATIONS
1 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki, Department of Hygiene, Social-Preventative Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki and Health Centre of Evosmos, 56224 Evosmos, Thessaloniki, Greece
2 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki, Department of Hygiene, Social-Preventative Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki and Health Centre of N. Kallikrateia, 63080 N. Kallikrateia, Chalkidiki, Greece
3 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki, and Research Unit for General Medicine and Primary Health Care, Faculty of Medicine, School of Health Sciences, University of Ioannina, 45110 Ioannina, Greece
4 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki, and Health Centre of Evosmos, 56224 Evosmos, Thessaloniki, Greece
5 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki and Health Centre of Kapandriti, 19014 Kapandriti, Athens, Greece
6, 7 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki and Health Centre of Avdira, 67061 Avdira, Xanthi, Greece
8 Department of Hygiene, Social-Preventative Medicine and Medical Statistics, School of Medicine, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
9 Research Committee of Greek Association of General Practitioners, 54625 Thessaloniki and Health Centre of N. Kallikrateia, 63080 N. Kallikrateia, Chalkidiki, Greece
ACCEPTED: 10 September 2020
early abstract:
Introduction: Treated, but uncontrolled hypertension is a worldwide challenge. Exploring patient's perspective in different cultures and contexts could contribute to a more comprehensive understanding of poor blood pressure (BP) control. This study aimed in investigating patients' knowledge and attitudes towards BP management in order to identify possible barriers in achieving effective control.
Methods: A mixed-methods study- using both quantitative and qualitative research methodology- was conducted by twelve general practitioners- working in rural areas- in five different prefectures in Greece. A 42-item, pre-tested questionnaire was completed by the hypertensive patients that visited the practices and were included among the 20 first patients for 20 consecutive working days. The included participants were patients: a) with diagnosed hypertension who received BP-lowering medication, b) aged over 18 years old, c) in physical and mental condition that allowed the conduction of the interview, d) with adequate understanding of the Greek language, e) who provided signed informed consent. The open-ended questions used to identify the patient-related barriers in hypertension control were analyzed using thematic content analysis.
Results: A total of 613 hypertensive patients were recruited (response rate 91%); mean age was 71.5 years old (SD 9.4, range: 34-100) and 39.5% (242) were male. Uncontrolled BP was found in 41.3% (253), out of which 67.6% (171) considered their BP controlled, 18.6% (47) uncontrolled, while 13.8% (35) were unaware of their status. Women were more likely to achieve BP control (OR 1.44, 95% CI 1.04, 2.00). As many as 287 (46.8%) patients knew the optimal values for BP. The identified barriers in hypertension control were grouped in the six themes: 1. Knowledge gaps, 2. Intolerance of adverse events, 3. Negligence, 4. Unmet individual preferences, 5. Financial barriers and 6. Overtreatment of hypertension.
Conclusion: Physicians should be aware of the possible disconnection between their patient's perceived and actual BP control, with often overestimation of BP control rates and the lack of knowledge on targeted BP level. They should bear in mind that covering their patients' knowledge gaps is essential in empowering them to get more actively involved in the management of their chronic condition. Simultaneously, physicians should aim in eliciting each patient's attitudes, concerns about adverse events, individual preferences, as well as possible financial barriers and negligence in an effort to actually see the antihypertensive treatment "thought their patients’ eyes" and eliminate possible barriers in medication adherence. The provision of patient-centered care remains the gold pathway to eliminate patient-related barriers and achieve higher levels of BP control.