Implementing a digital intervention for managing uncontrolled hypertension in Primary Care: a mixed methods process evaluation

Kate Morton, Laura Dennison, Rebecca Band, Beth Stuart, Laura Wilde, Tara Cheetham-Blake, Elena Heber, Joanna Slodkowska-Barabasz, Paul Little, Richard J. McManus, Carl R. May, Lucy Yardley, Katherine Bradbury

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    6 Citations (Scopus)
    32 Downloads (Pure)


    Background: A high proportion of hypertensive patients remain above the target threshold for blood pressure, increasing the risk of adverse health outcomes. A digital intervention to facilitate healthcare practitioners (hereafter practitioners) to initiate planned medication escalations when patients’ home readings were raised was found to be effective in lowering blood pressure over 12 months. This mixed-methods process evaluation aimed to develop a detailed understanding of how the intervention was implemented in Primary Care, possible mechanisms of action and contextual factors influencing implementation. Methods: One hundred twenty-five practitioners took part in a randomised controlled trial, including GPs, practice nurses, nurse-prescribers, and healthcare assistants. Usage data were collected automatically by the digital intervention and antihypertensive medication changes were recorded from the patients’ medical notes. A sub-sample of 27 practitioners took part in semi-structured qualitative process interviews. The qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics and correlations to explore factors related to adherence. The two sets of findings were integrated using a triangulation protocol. Results: Mean practitioner adherence to escalating medication was moderate (53%), and the qualitative analysis suggested that low trust in home readings and the decision to wait for more evidence influenced implementation for some practitioners. The logic model was partially supported in that self-efficacy was related to adherence to medication escalation, but qualitative findings provided further insight into additional potential mechanisms, including perceived necessity and concerns. Contextual factors influencing implementation included proximity of average readings to the target threshold. Meanwhile, adherence to delivering remote support was mixed, and practitioners described some uncertainty when they received no response from patients. Conclusions: This mixed-methods process evaluation provided novel insights into practitioners’ decision-making around escalating medication using a digital algorithm. Implementation strategies were proposed which could benefit digital interventions in addressing clinical inertia, including facilitating tracking of patients’ readings over time to provide stronger evidence for medication escalation, and allowing more flexibility in decision-making whilst discouraging clinical inertia due to borderline readings. Implementation of one-way notification systems could be facilitated by enabling patients to send a brief acknowledgement response. Trial registration: (ISRCTN13790648). Registered 14 May 2015.

    Original languageEnglish
    Article number57
    JournalImplementation Science
    Issue number1
    Publication statusPublished - 26 May 2021

    Bibliographical note

    Funding Information:
    The HOME BP intervention was developed using LifeGuide software, which was partly funded by the NIHR Southampton Biomedical Research Centre (BRC).

    Funding Information:
    This independent research was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme (Grant Reference Number RP-PG-1211-20001). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR, or the Department of Health.

    Publisher Copyright:
    © 2021, The Author(s).

    Copyright 2021 Elsevier B.V., All rights reserved.


    • Blood pressure
    • Digital intervention
    • Hypertension
    • Mixed methods
    • Normalisation Process Theory
    • Process evaluation

    ASJC Scopus subject areas

    • Health Policy
    • Health Informatics
    • Public Health, Environmental and Occupational Health


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