New self-management technologies for the treatment of hypertension: general practitioners’ perspectives

New self-management technologies for the treatment of hypertension: general practitioners’... Abstract Background Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve hypertension self-management. In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how general practitioners (GPs) feel about and engage with the growth of these new methods of self-management of blood pressure. Aim To explore GPs’ perspectives of self-management technology to support medication adherence and blood pressure control in patients with hypertension. Design and setting This was a qualitative interview study based in the West of Ireland. Ten GPs who were purposively sampled participated in semi-structured interviews. Thematic analysis was carried out on the data. Results Three major themes were identified: current reach and future potential, empowerment and responsibility. Conclusions GPs could see the benefit of using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management. Concerns relating to the increased workload associated with a potentially unmanageable quantity of information and an increase in healthcare use among the ‘worried well’ also emerged strongly from the data. Blood pressure monitors self care, hypertension, primary health care, qualitative research, technology Introduction Interventions to enhance adherence to anti-hypertensives often involve self-monitoring of blood pressure [e.g. (1–3)] and contain medication reminders such as environmental prompts or cues [e.g. (4)]. There is evidence to suggest that these methods have established efficacy to improve adherence (5–7). Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve medication taking behaviours. In the case of hypertension, they may provide a feasible method of supporting reminder strategies and self-monitoring of blood pressure (8). It is widely recognized that significant numbers of patients are already engaging with this type of technology, as there is sometimes more health technology available to patients in their home environment than there is provided by their general practitioners (GPs) (9). In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how GPs feel about and engage with the growth of these new methods of self-management of blood pressure. While self-monitoring of blood pressure is recommended in the UK as detailed in the NICE 2011 and ESH/ESC Europe 2013 guidelines, a recent thematic synthesis on the topic (10) found that GPs were uncertain on how to integrate it into everyday practice as there are no clear current clinical guidelines. A recent UK qualitative study on primary care practitioners’ views on the HOME BP system (an online intervention for hypertension management, including self-monitoring of blood pressure and home titration) described both primary care practitioners’ benefits and concerns. They felt that this specific system could empower patients to self-manage health and potentially save both patient and primary care practitioner time but were worried about the accuracy of the data and the potential to increase health anxiety (11). While much of the qualitative research to date on this topic has focused on GP’s views on specific digital interventions, e.g. (11–14), there is relatively limited data on the attitudes of GPs to this kind of technology to support hypertension medication adherence more generally. Therefore, the aim of this qualitative research is to explore GPs’ perspectives of contemporary self-management technology to support medication adherence and blood pressure control in patients with hypertension. Method The study is reported using the consolidated criteria for reporting qualitative research (COREQ) checklist (15) for focus groups to ensure rigor in reporting in how the study was conducted (Supplementary Table S1). Recruitment GPs from the west of Ireland were recruited purposively based on age, gender, years of practice, practice size and practice location (urban/rural). Ten interviews were conducted in total. See Table 1 for characteristics of participants. In order to be responsive to, and incorporate findings from the data as they emerged, an iterative approach was used (16). As is common in qualitative sampling methodology recruitment continued until data saturation was reached and no new themes emerged (17). Table 1. Characteristics of interviewed GPs, n = 10 Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) View Large Table 1. Characteristics of interviewed GPs, n = 10 Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) View Large Interviews The interview topic guide was developed by reviewing other qualitative research in the area. This topic guide was then reviewed by the research team and piloted on one GP. This led to the final topic guide (Supplementary Table S2). When asking GPs about contemporary self-management technologies, the interviewer described a typical hypertension management smartphone app that would be seen on the global app market. These tend to consist of two parts—the first is a reminder to take medication, the second is home BP monitoring where the patient has a home BP monitor which is connected to the app via Bluetooth. The monitor sends the BP values to the app and produces a graph of BP measurements. The interviews were semi-structured and carried out by one researcher (EM) who travelled to the GPs’ clinics. The participants individually consented to the interviews being conducted and recorded and to anonymous quotations being used. Transcription was conducted by the research team as it has been argued that transcription helps the interpretive process and should be seen as the first step in the process of data analysis (18). Analysis The five stage of thematic analysis (familiarization, generation of codes, searching for themes, reviewing themes and defining themes) (19) were followed. Coding was partially conducted with another researcher (MC) from a different professional background (nursing) to the main investigator (psychology) for inter-coder reliability (20). To heighten reflexivity, four members of the research team (two health psychologists, a GP and a nurse) joined the lead researcher (PhD candidate in health psychology) to review all the data and contribute to the thematic analysis (21). NVivo (version 11) was used to organize and code the transcripts to facilitate the analysis and comparison of relationships between codes (22). Results Participant characteristics are shown in Table 1. Three main themes were identified in the data: current reach and future potential, empowerment and responsibility. Current reach and future potential The first theme that was generated was current reach and future potential. This refers to the GPs’ understanding of who is currently using this type of technology to manage hypertension and who might be suitable candidates to target for this type of intervention either now or in the future. GPs were aware that a lot of the public are already very engaged with technology in general, particularly the younger generation. They anticipated that these patients could be using smartphones for health reasons, as they were already using them for managing many other parts of their lives. I suppose people are so dependent on their phones now and they’re using them for so much, I certainly think that if not now, over the next ten years, that 30 year old crowd, that 30, 40 year old generation now would be moving on. And certainly they’re a group that would certainly be using their phones; you could say day in, day out but it’s even minute in, minute out, you see it with some people. I suppose personally like, my banking, I’m doing that off my mobile and my shopping, I’m doing that off my mobile. [Female, 35] They also recognized that technology is rapidly growing and there is a need to come to terms with that. They expressed an awareness of how common using technology to manage chronic conditions could be in the future as smartphone penetration grows. I think it’s ridiculous to think that they won’t become more prevalent and more used across numerous conditions as time goes on. [Male, 37] They were readily able to identify patients who they thought would be willing to engage with technology to manage their hypertension. Some people, the young hypertensives who are managing their medication amongst lots of other things, young kids, business whatever, superb, they’re already efficient you know, if you want something done ask a busy person. Those people would appreciate that vehicle for keeping their BP down. [Male, 43] These patients tended to be younger, technology-savvy and motivated about their healthcare. While GPs did think that using technology was a good choice for these types of patients, they expressed concerns about the patients’ motivations. One concern was that the only type of patient who would use technology would already be highly motivated about their health, and would not necessarily need the extra facilitation that such technology would provide. And the other thing is I would say that patients that will use the apps would probably be compliant anyway! [Female, 33] Some also felt that this technology, while having potential to be useful could actually have relatively limited impact as it wouldn’t reach the people who need it most, whether it was through their lack of motivation or their circumstances. One GP outlined a particular situation where he felt this was the case. I would be slightly concerned that the people who are most likely to use the app are the least likely to forget their medication in the first. I mean, in particular patients, I’m just thinking of one patient in particular who is high risk with high BP, she’s had a subarachnoid already so BP is crucial that it’s monitored. She has impaired glucose as well, impaired kidney function but socially it’s a disaster what’s going on at home. So I just don’t see that those apps are going to be a help to her who is probably the type of patient who we most want to help. So I think they’re definitely going to have a role, but are they going to have a role for those patients who are most likely to benefit, I’m not sure. [Male, 50] As well as being unsure if this technology would reach the right patient, GPs also stated concerns about technology reaching the wrong patient. Several talked about the risk of home blood pressure monitoring leading to unnecessary anxiety in patients. They can bring problems and particularly anxious people; it can really feed into their anxiety. That really can be a problem. And you know, can start a cycle of phone calls in the middle of the night. [Female, 37] Empowerment The second theme that was identified was empowerment. GPs spoke about how patients using this kind of technology could empower their practice. The unreliable nature of office blood pressure readings was mentioned across all interviews. Many of the GPs quickly acknowledged that using technology to monitor and store blood pressure readings over time would enable them make more accurate clinical judgements. Yeah well any time I sit down with a hypertensive patient, I’m conscious of the fact that whenever I take their BP as a spot reading in the office, it’s often hopelessly inaccurate. So anything we can do to make better clinical decisions around that I think we should welcome. [Male, 44] They also recognized that having this data around blood pressure measurements would make some conversations with the patient easier. Several GPs spoke about how difficult it is to explain to consequences of high blood pressure and the need for anti-hypertensives, particularly when the patient doesn’t feel ill. They thought that having a visualization of the effect of anti-hypertensives on the patients’ blood pressure would be a useful aid in explaining this. Because often times if you speak of long term risks and benefit, that doesn’t necessarily ring true to the patient as much as seeing a graph and being able to track it themselves. [Female, 33] They also talked about this visualization of blood pressure readings could empower the patient. Many felt that by being able to see a reduction in blood pressure, patients would be more motivated to change their lifestyles or keep adhering to their medication. If you have an app that will enable you to keep a record, and again that added action of recording and inputting means that the patients probably buy in a bit more. So you would expect that their compliance would be a lot better if that was the case because they feel more involved and that they have ownership of it. [Male, 37] However, this empowerment of the patient was not always seen as a positive thing. One GP spoke about how some of her patients who regularly use an app for adherence to the contraceptive pill take the more senior role in their conversations—the opposite of the traditional doctor–patient relationship. I mean lot of the ones that they’re using in terms of contraception, they’re showing me what they’re using, I wouldn’t be advising on any of those—it’s the other way around. [Female, 35] This disruption of the power dynamic within the consultation lead to a certain amount of concern in GPs, as they were worried that patients were not appropriately educated and could be accessing and acting on incorrect information. Patients are using technology and accessing information and it’s not necessarily always the right information. I mean I have websites that I get information from or recommend to patients because so many people are coming and I think our workload is increasing because of people’s access to information that isn’t necessarily correct, the Dr. Google effort, it can be awful. [Female, 35] They were aware that technology is becoming increasingly common and seemed to recognise that they may not be the only source of information and advice for a patient. Overall what I think is happening is that the public are accelerating well ahead of where we as a service are. [Male, 50] Responsibility The final theme identified was responsibility. GPs had various thoughts and concerns about how responsibility of the patient’s health would be managed when using technology. They felt that they would have to know a lot about an app before they would be happy to recommend it to a patient. They were also very aware, that as the authority figure, that they would need to check all aspects of an app before they can recommend it to patients. Sure, about the app I’d need to know, who was behind it and who’s making all the money. These are key points in medicine—who is making the money and where is the money going. And what is their motivation for targeting the patient group. You’d have to have clearly seen the insides and outsides of the app and you’d want to want to be very guarded against pharma agendas, loaded into apps … suggesting drugs.. You’d also need to be very aware of incorrect advice, incorrect information being provided in the apps. [Male, 38] In terms of division of responsibility between the doctor and the patient, opinion differed depending on the type of technology. When considering patients using a digital reminder to help them to remember to take their medication, GPs were happy to encourage this, as it was the patients’ own responsibility. Yeah, I’ve no problem with it, you set it and you get reminders, people do it for pills all the time, put alarms on to remember it in the morning. Yeah so I’ve no problem with digital reminders or whatever. [Male, 38] However, when reflecting on patients using home blood pressure monitors where the readings could be sent directly to the GPs’ offices, the perspectives were more complex. They were concerned about what this meant for their duty of care. Several talked about how it was already difficult to define where duty of care begins and ends. They feared that technology may amplify this concern as it created the potential for the beginning and end of duty of care to change and possibly expand. There was an immediate worry about receiving blood pressure measurements and not being able to act on them. There are issues with information being sent in outside of office hours, and responsibility if there are acute or urgent BP measurements. So you might have something that needs action and needs to be acted on and then if you’re not able to get in contact with that person... . [Male, 37] The overworked state of primary care in Ireland was also mentioned—although there was some dissonance on the role technology played in this. Some felt that as GPs are quite overburdened and under resourced that this technology could move responsibility to patient for their own care which would be helpful. Everyone agrees that the current, and it’s not just Ireland, its everywhere, that the current healthcare systems are struggling with capacity so the more that patients can do, I think the better as an overall principle. [Male, 50] Other respondents indicated that more responsibility would be shifted onto them rather than the patient. They spoke about how the difficulties of taking this responsibility on and how it may have limited applicability to the current context and culture of general practice in Ireland. I think we’re going to be slow to adopt them as GPs but that’s a complete fear around increased workload. You can’t be crying poor all the time but you can’t comprehend anything that’s going to add to your workload that isn’t necessarily going to have clear outcomes, clear improvement outcomes. [Female, 37] Discussion Summary The data from these interviews provide valuable insights into GPs’ perspectives on using contemporary self-management technology to support the management of hypertension in the community. Three major themes were identified. These were current reach and future potential, empowerment and responsibility. Overall GPs could see the benefit in using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management, but this was weighed against their concerns. Concerns primarily centred on increased workload as GPs feared having to manage large amounts of data and were concerned about who was responsible for this data. In addition, there was the potential for, in some cases, increased healthcare use among those with health anxiety i.e. the ‘worried well’ phenomenon. Potential disruption of the traditional doctor–patient relationship also emerged as a significant concern. Strengths and limitations This study provides novel and timely data on GPs’ perspectives of using contemporary self-management technology to support the management of patients with hypertension. While the number of GP participants was lower than some related studies on this topic, the sampling methodology was determined a priori and the 10 interviews achieved data saturation. Additionally, one-on-one interviewing allowed GPs to express their individual opinions without the social desirability biases that might pertain in focus groups or other group based methods of data collection. Reflexivity was increased by the multidisciplinary research team coming together to review the data, however, it is possible to also view this as a limitation as the team may have taken a different emphasis from that of an independent observer. Another obvious limitation of the work is that the views of this relatively small sample from one geographical location may not comprehensively capture the perspectives of GPs as a whole, however the consistency of the data with findings from other contexts (11,23) suggest that these findings have external validity. It may also have been of benefit to include practice nurses as they also typically constitute part of the primary care team, therefore, we acknowledge that these data have not captured the full primary care team’s perspective. Comparison with existing literature The findings of this study support previous reviews of the research in the field of using self-management technology to manage chronic conditions in general. A recent meta-ethnography of digital interventions for self-management of chronic physical health conditions by Morton et al. (23) concluded that health care professionals were less positive about using technology than patients were, as they had concerns about the increased workload. Increased workload in primary care in both the UK and Ireland has become a major concern in recent years. Croxson et al. (24) report that GPs in England describe their working days as being long and intense, leading to worries over the wellbeing of GPs and their ability to provide high quality care to their patients. As with the current study, the evidence from this review of qualitative research suggested that health care professionals’ concerns around technology were at least as strong as the perceived clinical benefits. A recent meta-synthesis (25) on clinician’s role in self-management approaches, including technology, reported that clinicians can find sharing control of the condition management with the patient to be challenging. This was observed in the current study under the emergent theme of ‘empowerment’. Mudge et al. (25) report that some specific skills such as practicing reciprocity in communication style, peer support and self-reflection were helpful in shifting clinician’s ways of practice from a paternalistic to a more collaborative approach. It is possible that these strategies may also be helpful for GPs as the use of these technologies grows. In terms of hypertension, Bradbury et al. (11) conducted a similar qualitative study with health care professionals and the HOME BP online system. They also found that health care professionals were concerned about increasing patient anxiety. However, the authors note that in previous research on home blood pressure monitoring [e.g. (12,26)], evidence has emerged that patients do not exhibit increases in anxiety while measuring blood pressure at home. In fact, it has already been shown that technology has the potential to trigger a complex yet engaging behavioural change process for patients for the management of hypertension, hence enabling individuals to take ownership of their own health and healthcare at a time and place of their own choosing (27). As it will not be possible to turn back the clock on such technological advancement, it would seem the only decision to be made by health care professionals will be how they will engage with this process of change. Implications for research and practice Newer technologies such as mobile information and communication devices and the internet have been embraced across the globe despite technological challenges and concerns regarding privacy and security. In the design and development of technology-based self-management tools for the treatment of hypertension, flexibility and security are vital to allow and encourage patients to customize, personalize and engage with their devices (27). This study has clearly recognized that patients’ use of technology may have the potential to increase the amount of blood pressure data available to health care professionals. Provided the quality of this data is assured, then it will enable health care professionals to make better clinical decisions in the management of hypertension. This more collaborative approach in patient care could also facilitate greater awareness and increased self-management by patients themselves. The reluctance of health care professionals to engage with newer technologies is evident from the data in this study. This reticence is likely to change if the emergence of newer technologies was accompanied by the emergence of an evidence base demonstrating effectiveness and cost-effectiveness. In addition, health regulation bodies may also have a role in quality control and the provision of explicit guidelines in relation to such interventions. Examples of this that already exist are the NHS Health Apps library in the UK which provides patients with access to a list of recognized and endorsed health apps. Overall GPs could see the benefit in using technology, such as more accurate blood pressure data and potential to engage patients in self-management, but this currently seems to be outweighed by their concerns. Concerns primarily centred on increased workload as GPs feared that more blood pressure data would lead to more responsibility for an unmanageable quantity of information and an increase in healthcare use among the ‘worried well’. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: Irish Research Council Government of Ireland Postgraduate Scholarship (Project ID: GOIPG/2014/786) Ethical approval: the Clinical Research Ethics Committee, Galway University Hospitals (reference number CA 1627, 17 November 2016). All participants provided written informed consent. Conflict of interest: none. Acknowledgements The authors would like to acknowledge and thank the study participants. References 1. Hosseininasab M , Jahangard-Rafsanjani Z , Mohagheghi A et al. Self-monitoring of blood pressure for improving adherence to antihypertensive medicines and blood pressure control: a randomized controlled trial . Am J Hypertens 2014 ; 27 : 1339 – 45 . Google Scholar CrossRef Search ADS PubMed 2. Márquez-Contreras E , Martell-Claros N , Gil-Guillén V et al. ; Compliance Group of the Spanish Society of Hypertension (SEE) . Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study . J Hypertens 2006 ; 24 : 169 – 75 . Google Scholar CrossRef Search ADS PubMed 3. Margolius D , Bodenheimer T , Bennett H et al. Health coaching to improve hypertension treatment in a low-income, minority population . Ann Fam Med 2012 ; 10 : 199 – 205 . Google Scholar CrossRef Search ADS PubMed 4. Morrissey EC , Durand H , Nieuwlaat R et al. Effectiveness and content analysis of interventions to enhance medication adherence and blood pressure control in hypertension: a systematic review and meta-analysis . Psychol Health 2017 : 1 – 38 . 5. Glynn LG , Murphy AW , Smith SM et al. Self-monitoring and other non-pharmacological interventions to improve the management of hypertension in primary care: a systematic review . Br J Gen Pract 2010 ; 60 : e476 – 88 . Google Scholar CrossRef Search ADS PubMed 6. Vervloet M , Linn AJ , van Weert JC et al. The effectiveness of interventions using electronic reminders to improve adherence to chronic medication: a systematic review of the literature . J Am Med Inform Assoc 2012 ; 19 : 696 – 704 . Google Scholar CrossRef Search ADS PubMed 7. Fletcher BR , Hartmann-Boyce J , Hinton L et al. The effect of self-monitoring of blood pressure on medication adherence and lifestyle factors: a systematic review and meta-analysis . Am J Hypertens 2015 ; 28 : 1209 – 21 . Google Scholar CrossRef Search ADS PubMed 8. Band R , Bradbury K , Morton K et al. Intervention planning for a digital intervention for self-management of hypertension: a theory-, evidence- and person-based approach . Implement Sci 2017 ; 12 : 25 . Google Scholar CrossRef Search ADS PubMed 9. Young AJ . New technologies and general practice . Br J Gen Pract 2016 ; 66 : 601 – 2 . Google Scholar CrossRef Search ADS PubMed 10. Fletcher BR , Hinton L , Hartmann-Boyce J et al. Self-monitoring blood pressure in hypertension, patient and provider perspectives: a systematic review and thematic synthesis . Patient Educ Couns 2016 ; 99 : 210 – 9 . Google Scholar CrossRef Search ADS PubMed 11. Bradbury K , Morton K , Band R et al. Understanding how primary care practitioners perceive an online intervention for the management of hypertension . BMC Med Inform Decis Mak 2017 ; 17 : 5 . Google Scholar CrossRef Search ADS PubMed 12. Jones MI , Greenfield SM , Bray EP et al. Patient self-monitoring of blood pressure and self-titration of medication in primary care: the TASMINH2 trial qualitative study of health professionals’ experiences . Br J Gen Pract 2013 ; 63 : e378 – 85 . Google Scholar CrossRef Search ADS PubMed 13. Hallberg I , Ranerup A , Kjellgren K . Supporting the self-management of hypertension: patients’ experiences of using a mobile phone-based system . J Hum Hypertens 2016 ; 30 : 141 – 6 . Google Scholar CrossRef Search ADS PubMed 14. Leon N , Surender R , Bobrow K et al. Improving treatment adherence for blood pressure lowering via mobile phone SMS-messages in South Africa: a qualitative evaluation of the SMS-text Adherence SuppoRt (StAR) trial . BMC Fam Pract 2015 ; 16 : 80 . Google Scholar CrossRef Search ADS PubMed 15. Tong A , Sainsbury P , Craig J . Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups . Int J Qual Health Care 2007 ; 19 : 349 – 57 . Google Scholar CrossRef Search ADS PubMed 16. Ziebland S , McPherson A . Making sense of qualitative data analysis: an introduction with illustrations from DIPEx (personal experiences of health and illness) . Med Educ 2006 ; 40 : 405 – 14 . Google Scholar CrossRef Search ADS PubMed 17. Glaser BG , Strauss AL , Strutzel E . The discovery of grounded theory; strategies for qualitative research . Nurs Research . 1968 ; 17 : 364 . Google Scholar CrossRef Search ADS 18. Bailey J . First steps in qualitative data analysis: transcribing . Fam Pract 2008 ; 25 : 127 – 31 . Google Scholar CrossRef Search ADS PubMed 19. Braun V , Clarke V . Using thematic analysis in psychology . Qual Res Psychol 2006 ; 3 : 77 – 101 . Google Scholar CrossRef Search ADS 20. Pope C , Ziebland S , Mays N . Qualitative research in health care. Analysing qualitative data . BMJ 2000 ; 320 : 114 – 6 . Google Scholar CrossRef Search ADS PubMed 21. Richards L. Handling Qualitative Data: A Practical Guide . London, UK : Sage , 2014 . 22. Pitney W , Parker J. Qualitative Research in Physical Activity and the Health Professions . Champaign, IL : Human Kinetics , 2009 . 23. Morton K , Dennison L , May C et al. Using digital interventions for self-management of chronic physical health conditions: a meta-ethnography review of published studies . Patient Educ Couns 2017 ; 100 : 616 – 35 . Google Scholar CrossRef Search ADS PubMed 24. Croxson CH , Ashdown HF , Hobbs FR . GPs’ perceptions of workload in England: a qualitative interview study . Br J Gen Pract 2017 ; 67 : e138 – 47 . Google Scholar CrossRef Search ADS PubMed 25. Mudge S , Kayes N , McPherson K . Who is in control? Clinicians’ view on their role in self-management approaches: a qualitative metasynthesis . BMJ Open 2015 ; 5 : e007413 . Google Scholar CrossRef Search ADS PubMed 26. McManus RJ , Mant J , Bray EP et al. Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial . Lancet 2010 ; 376 : 163 – 72 . Google Scholar CrossRef Search ADS PubMed 27. Glynn L , Casey M , Walsh J , Hayes PS , Harte RP , Heaney D . Patients’ views and experiences of technology based self-management tools for the treatment of hypertension in the community: a qualitative study . BMC Fam Pract 2015 ; 16 : 119 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Family Practice Oxford University Press

New self-management technologies for the treatment of hypertension: general practitioners’ perspectives

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Abstract

Abstract Background Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve hypertension self-management. In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how general practitioners (GPs) feel about and engage with the growth of these new methods of self-management of blood pressure. Aim To explore GPs’ perspectives of self-management technology to support medication adherence and blood pressure control in patients with hypertension. Design and setting This was a qualitative interview study based in the West of Ireland. Ten GPs who were purposively sampled participated in semi-structured interviews. Thematic analysis was carried out on the data. Results Three major themes were identified: current reach and future potential, empowerment and responsibility. Conclusions GPs could see the benefit of using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management. Concerns relating to the increased workload associated with a potentially unmanageable quantity of information and an increase in healthcare use among the ‘worried well’ also emerged strongly from the data. Blood pressure monitors self care, hypertension, primary health care, qualitative research, technology Introduction Interventions to enhance adherence to anti-hypertensives often involve self-monitoring of blood pressure [e.g. (1–3)] and contain medication reminders such as environmental prompts or cues [e.g. (4)]. There is evidence to suggest that these methods have established efficacy to improve adherence (5–7). Digital health interventions, such as those that can be delivered via smartphone applications (apps) or wireless blood pressure monitors, offer a new, scalable and potentially cost-effective way to improve medication taking behaviours. In the case of hypertension, they may provide a feasible method of supporting reminder strategies and self-monitoring of blood pressure (8). It is widely recognized that significant numbers of patients are already engaging with this type of technology, as there is sometimes more health technology available to patients in their home environment than there is provided by their general practitioners (GPs) (9). In Ireland, as is common in the UK, the majority of hypertension management occurs in general practice. Therefore, it is crucial to investigate how GPs feel about and engage with the growth of these new methods of self-management of blood pressure. While self-monitoring of blood pressure is recommended in the UK as detailed in the NICE 2011 and ESH/ESC Europe 2013 guidelines, a recent thematic synthesis on the topic (10) found that GPs were uncertain on how to integrate it into everyday practice as there are no clear current clinical guidelines. A recent UK qualitative study on primary care practitioners’ views on the HOME BP system (an online intervention for hypertension management, including self-monitoring of blood pressure and home titration) described both primary care practitioners’ benefits and concerns. They felt that this specific system could empower patients to self-manage health and potentially save both patient and primary care practitioner time but were worried about the accuracy of the data and the potential to increase health anxiety (11). While much of the qualitative research to date on this topic has focused on GP’s views on specific digital interventions, e.g. (11–14), there is relatively limited data on the attitudes of GPs to this kind of technology to support hypertension medication adherence more generally. Therefore, the aim of this qualitative research is to explore GPs’ perspectives of contemporary self-management technology to support medication adherence and blood pressure control in patients with hypertension. Method The study is reported using the consolidated criteria for reporting qualitative research (COREQ) checklist (15) for focus groups to ensure rigor in reporting in how the study was conducted (Supplementary Table S1). Recruitment GPs from the west of Ireland were recruited purposively based on age, gender, years of practice, practice size and practice location (urban/rural). Ten interviews were conducted in total. See Table 1 for characteristics of participants. In order to be responsive to, and incorporate findings from the data as they emerged, an iterative approach was used (16). As is common in qualitative sampling methodology recruitment continued until data saturation was reached and no new themes emerged (17). Table 1. Characteristics of interviewed GPs, n = 10 Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) View Large Table 1. Characteristics of interviewed GPs, n = 10 Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) Characteristic Mean age, years (range) 45 (34–72) Female, n (%) 3 (30) Urban, n (%) 4 (40) Practice size, patients (range) 4110 (1500–10000) Mean years of practice (range) 16 (2–43) View Large Interviews The interview topic guide was developed by reviewing other qualitative research in the area. This topic guide was then reviewed by the research team and piloted on one GP. This led to the final topic guide (Supplementary Table S2). When asking GPs about contemporary self-management technologies, the interviewer described a typical hypertension management smartphone app that would be seen on the global app market. These tend to consist of two parts—the first is a reminder to take medication, the second is home BP monitoring where the patient has a home BP monitor which is connected to the app via Bluetooth. The monitor sends the BP values to the app and produces a graph of BP measurements. The interviews were semi-structured and carried out by one researcher (EM) who travelled to the GPs’ clinics. The participants individually consented to the interviews being conducted and recorded and to anonymous quotations being used. Transcription was conducted by the research team as it has been argued that transcription helps the interpretive process and should be seen as the first step in the process of data analysis (18). Analysis The five stage of thematic analysis (familiarization, generation of codes, searching for themes, reviewing themes and defining themes) (19) were followed. Coding was partially conducted with another researcher (MC) from a different professional background (nursing) to the main investigator (psychology) for inter-coder reliability (20). To heighten reflexivity, four members of the research team (two health psychologists, a GP and a nurse) joined the lead researcher (PhD candidate in health psychology) to review all the data and contribute to the thematic analysis (21). NVivo (version 11) was used to organize and code the transcripts to facilitate the analysis and comparison of relationships between codes (22). Results Participant characteristics are shown in Table 1. Three main themes were identified in the data: current reach and future potential, empowerment and responsibility. Current reach and future potential The first theme that was generated was current reach and future potential. This refers to the GPs’ understanding of who is currently using this type of technology to manage hypertension and who might be suitable candidates to target for this type of intervention either now or in the future. GPs were aware that a lot of the public are already very engaged with technology in general, particularly the younger generation. They anticipated that these patients could be using smartphones for health reasons, as they were already using them for managing many other parts of their lives. I suppose people are so dependent on their phones now and they’re using them for so much, I certainly think that if not now, over the next ten years, that 30 year old crowd, that 30, 40 year old generation now would be moving on. And certainly they’re a group that would certainly be using their phones; you could say day in, day out but it’s even minute in, minute out, you see it with some people. I suppose personally like, my banking, I’m doing that off my mobile and my shopping, I’m doing that off my mobile. [Female, 35] They also recognized that technology is rapidly growing and there is a need to come to terms with that. They expressed an awareness of how common using technology to manage chronic conditions could be in the future as smartphone penetration grows. I think it’s ridiculous to think that they won’t become more prevalent and more used across numerous conditions as time goes on. [Male, 37] They were readily able to identify patients who they thought would be willing to engage with technology to manage their hypertension. Some people, the young hypertensives who are managing their medication amongst lots of other things, young kids, business whatever, superb, they’re already efficient you know, if you want something done ask a busy person. Those people would appreciate that vehicle for keeping their BP down. [Male, 43] These patients tended to be younger, technology-savvy and motivated about their healthcare. While GPs did think that using technology was a good choice for these types of patients, they expressed concerns about the patients’ motivations. One concern was that the only type of patient who would use technology would already be highly motivated about their health, and would not necessarily need the extra facilitation that such technology would provide. And the other thing is I would say that patients that will use the apps would probably be compliant anyway! [Female, 33] Some also felt that this technology, while having potential to be useful could actually have relatively limited impact as it wouldn’t reach the people who need it most, whether it was through their lack of motivation or their circumstances. One GP outlined a particular situation where he felt this was the case. I would be slightly concerned that the people who are most likely to use the app are the least likely to forget their medication in the first. I mean, in particular patients, I’m just thinking of one patient in particular who is high risk with high BP, she’s had a subarachnoid already so BP is crucial that it’s monitored. She has impaired glucose as well, impaired kidney function but socially it’s a disaster what’s going on at home. So I just don’t see that those apps are going to be a help to her who is probably the type of patient who we most want to help. So I think they’re definitely going to have a role, but are they going to have a role for those patients who are most likely to benefit, I’m not sure. [Male, 50] As well as being unsure if this technology would reach the right patient, GPs also stated concerns about technology reaching the wrong patient. Several talked about the risk of home blood pressure monitoring leading to unnecessary anxiety in patients. They can bring problems and particularly anxious people; it can really feed into their anxiety. That really can be a problem. And you know, can start a cycle of phone calls in the middle of the night. [Female, 37] Empowerment The second theme that was identified was empowerment. GPs spoke about how patients using this kind of technology could empower their practice. The unreliable nature of office blood pressure readings was mentioned across all interviews. Many of the GPs quickly acknowledged that using technology to monitor and store blood pressure readings over time would enable them make more accurate clinical judgements. Yeah well any time I sit down with a hypertensive patient, I’m conscious of the fact that whenever I take their BP as a spot reading in the office, it’s often hopelessly inaccurate. So anything we can do to make better clinical decisions around that I think we should welcome. [Male, 44] They also recognized that having this data around blood pressure measurements would make some conversations with the patient easier. Several GPs spoke about how difficult it is to explain to consequences of high blood pressure and the need for anti-hypertensives, particularly when the patient doesn’t feel ill. They thought that having a visualization of the effect of anti-hypertensives on the patients’ blood pressure would be a useful aid in explaining this. Because often times if you speak of long term risks and benefit, that doesn’t necessarily ring true to the patient as much as seeing a graph and being able to track it themselves. [Female, 33] They also talked about this visualization of blood pressure readings could empower the patient. Many felt that by being able to see a reduction in blood pressure, patients would be more motivated to change their lifestyles or keep adhering to their medication. If you have an app that will enable you to keep a record, and again that added action of recording and inputting means that the patients probably buy in a bit more. So you would expect that their compliance would be a lot better if that was the case because they feel more involved and that they have ownership of it. [Male, 37] However, this empowerment of the patient was not always seen as a positive thing. One GP spoke about how some of her patients who regularly use an app for adherence to the contraceptive pill take the more senior role in their conversations—the opposite of the traditional doctor–patient relationship. I mean lot of the ones that they’re using in terms of contraception, they’re showing me what they’re using, I wouldn’t be advising on any of those—it’s the other way around. [Female, 35] This disruption of the power dynamic within the consultation lead to a certain amount of concern in GPs, as they were worried that patients were not appropriately educated and could be accessing and acting on incorrect information. Patients are using technology and accessing information and it’s not necessarily always the right information. I mean I have websites that I get information from or recommend to patients because so many people are coming and I think our workload is increasing because of people’s access to information that isn’t necessarily correct, the Dr. Google effort, it can be awful. [Female, 35] They were aware that technology is becoming increasingly common and seemed to recognise that they may not be the only source of information and advice for a patient. Overall what I think is happening is that the public are accelerating well ahead of where we as a service are. [Male, 50] Responsibility The final theme identified was responsibility. GPs had various thoughts and concerns about how responsibility of the patient’s health would be managed when using technology. They felt that they would have to know a lot about an app before they would be happy to recommend it to a patient. They were also very aware, that as the authority figure, that they would need to check all aspects of an app before they can recommend it to patients. Sure, about the app I’d need to know, who was behind it and who’s making all the money. These are key points in medicine—who is making the money and where is the money going. And what is their motivation for targeting the patient group. You’d have to have clearly seen the insides and outsides of the app and you’d want to want to be very guarded against pharma agendas, loaded into apps … suggesting drugs.. You’d also need to be very aware of incorrect advice, incorrect information being provided in the apps. [Male, 38] In terms of division of responsibility between the doctor and the patient, opinion differed depending on the type of technology. When considering patients using a digital reminder to help them to remember to take their medication, GPs were happy to encourage this, as it was the patients’ own responsibility. Yeah, I’ve no problem with it, you set it and you get reminders, people do it for pills all the time, put alarms on to remember it in the morning. Yeah so I’ve no problem with digital reminders or whatever. [Male, 38] However, when reflecting on patients using home blood pressure monitors where the readings could be sent directly to the GPs’ offices, the perspectives were more complex. They were concerned about what this meant for their duty of care. Several talked about how it was already difficult to define where duty of care begins and ends. They feared that technology may amplify this concern as it created the potential for the beginning and end of duty of care to change and possibly expand. There was an immediate worry about receiving blood pressure measurements and not being able to act on them. There are issues with information being sent in outside of office hours, and responsibility if there are acute or urgent BP measurements. So you might have something that needs action and needs to be acted on and then if you’re not able to get in contact with that person... . [Male, 37] The overworked state of primary care in Ireland was also mentioned—although there was some dissonance on the role technology played in this. Some felt that as GPs are quite overburdened and under resourced that this technology could move responsibility to patient for their own care which would be helpful. Everyone agrees that the current, and it’s not just Ireland, its everywhere, that the current healthcare systems are struggling with capacity so the more that patients can do, I think the better as an overall principle. [Male, 50] Other respondents indicated that more responsibility would be shifted onto them rather than the patient. They spoke about how the difficulties of taking this responsibility on and how it may have limited applicability to the current context and culture of general practice in Ireland. I think we’re going to be slow to adopt them as GPs but that’s a complete fear around increased workload. You can’t be crying poor all the time but you can’t comprehend anything that’s going to add to your workload that isn’t necessarily going to have clear outcomes, clear improvement outcomes. [Female, 37] Discussion Summary The data from these interviews provide valuable insights into GPs’ perspectives on using contemporary self-management technology to support the management of hypertension in the community. Three major themes were identified. These were current reach and future potential, empowerment and responsibility. Overall GPs could see the benefit in using these technologies, such as more accurate blood pressure data and potential to engage patients in self-management, but this was weighed against their concerns. Concerns primarily centred on increased workload as GPs feared having to manage large amounts of data and were concerned about who was responsible for this data. In addition, there was the potential for, in some cases, increased healthcare use among those with health anxiety i.e. the ‘worried well’ phenomenon. Potential disruption of the traditional doctor–patient relationship also emerged as a significant concern. Strengths and limitations This study provides novel and timely data on GPs’ perspectives of using contemporary self-management technology to support the management of patients with hypertension. While the number of GP participants was lower than some related studies on this topic, the sampling methodology was determined a priori and the 10 interviews achieved data saturation. Additionally, one-on-one interviewing allowed GPs to express their individual opinions without the social desirability biases that might pertain in focus groups or other group based methods of data collection. Reflexivity was increased by the multidisciplinary research team coming together to review the data, however, it is possible to also view this as a limitation as the team may have taken a different emphasis from that of an independent observer. Another obvious limitation of the work is that the views of this relatively small sample from one geographical location may not comprehensively capture the perspectives of GPs as a whole, however the consistency of the data with findings from other contexts (11,23) suggest that these findings have external validity. It may also have been of benefit to include practice nurses as they also typically constitute part of the primary care team, therefore, we acknowledge that these data have not captured the full primary care team’s perspective. Comparison with existing literature The findings of this study support previous reviews of the research in the field of using self-management technology to manage chronic conditions in general. A recent meta-ethnography of digital interventions for self-management of chronic physical health conditions by Morton et al. (23) concluded that health care professionals were less positive about using technology than patients were, as they had concerns about the increased workload. Increased workload in primary care in both the UK and Ireland has become a major concern in recent years. Croxson et al. (24) report that GPs in England describe their working days as being long and intense, leading to worries over the wellbeing of GPs and their ability to provide high quality care to their patients. As with the current study, the evidence from this review of qualitative research suggested that health care professionals’ concerns around technology were at least as strong as the perceived clinical benefits. A recent meta-synthesis (25) on clinician’s role in self-management approaches, including technology, reported that clinicians can find sharing control of the condition management with the patient to be challenging. This was observed in the current study under the emergent theme of ‘empowerment’. Mudge et al. (25) report that some specific skills such as practicing reciprocity in communication style, peer support and self-reflection were helpful in shifting clinician’s ways of practice from a paternalistic to a more collaborative approach. It is possible that these strategies may also be helpful for GPs as the use of these technologies grows. In terms of hypertension, Bradbury et al. (11) conducted a similar qualitative study with health care professionals and the HOME BP online system. They also found that health care professionals were concerned about increasing patient anxiety. However, the authors note that in previous research on home blood pressure monitoring [e.g. (12,26)], evidence has emerged that patients do not exhibit increases in anxiety while measuring blood pressure at home. In fact, it has already been shown that technology has the potential to trigger a complex yet engaging behavioural change process for patients for the management of hypertension, hence enabling individuals to take ownership of their own health and healthcare at a time and place of their own choosing (27). As it will not be possible to turn back the clock on such technological advancement, it would seem the only decision to be made by health care professionals will be how they will engage with this process of change. Implications for research and practice Newer technologies such as mobile information and communication devices and the internet have been embraced across the globe despite technological challenges and concerns regarding privacy and security. In the design and development of technology-based self-management tools for the treatment of hypertension, flexibility and security are vital to allow and encourage patients to customize, personalize and engage with their devices (27). This study has clearly recognized that patients’ use of technology may have the potential to increase the amount of blood pressure data available to health care professionals. Provided the quality of this data is assured, then it will enable health care professionals to make better clinical decisions in the management of hypertension. This more collaborative approach in patient care could also facilitate greater awareness and increased self-management by patients themselves. The reluctance of health care professionals to engage with newer technologies is evident from the data in this study. This reticence is likely to change if the emergence of newer technologies was accompanied by the emergence of an evidence base demonstrating effectiveness and cost-effectiveness. In addition, health regulation bodies may also have a role in quality control and the provision of explicit guidelines in relation to such interventions. Examples of this that already exist are the NHS Health Apps library in the UK which provides patients with access to a list of recognized and endorsed health apps. Overall GPs could see the benefit in using technology, such as more accurate blood pressure data and potential to engage patients in self-management, but this currently seems to be outweighed by their concerns. Concerns primarily centred on increased workload as GPs feared that more blood pressure data would lead to more responsibility for an unmanageable quantity of information and an increase in healthcare use among the ‘worried well’. Supplementary Material Supplementary data are available at Family Practice online. Declaration Funding: Irish Research Council Government of Ireland Postgraduate Scholarship (Project ID: GOIPG/2014/786) Ethical approval: the Clinical Research Ethics Committee, Galway University Hospitals (reference number CA 1627, 17 November 2016). All participants provided written informed consent. Conflict of interest: none. Acknowledgements The authors would like to acknowledge and thank the study participants. References 1. Hosseininasab M , Jahangard-Rafsanjani Z , Mohagheghi A et al. Self-monitoring of blood pressure for improving adherence to antihypertensive medicines and blood pressure control: a randomized controlled trial . Am J Hypertens 2014 ; 27 : 1339 – 45 . Google Scholar CrossRef Search ADS PubMed 2. Márquez-Contreras E , Martell-Claros N , Gil-Guillén V et al. ; Compliance Group of the Spanish Society of Hypertension (SEE) . Efficacy of a home blood pressure monitoring programme on therapeutic compliance in hypertension: the EAPACUM-HTA study . J Hypertens 2006 ; 24 : 169 – 75 . Google Scholar CrossRef Search ADS PubMed 3. Margolius D , Bodenheimer T , Bennett H et al. Health coaching to improve hypertension treatment in a low-income, minority population . Ann Fam Med 2012 ; 10 : 199 – 205 . Google Scholar CrossRef Search ADS PubMed 4. 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Telemonitoring and self-management in the control of hypertension (TASMINH2): a randomised controlled trial . Lancet 2010 ; 376 : 163 – 72 . Google Scholar CrossRef Search ADS PubMed 27. Glynn L , Casey M , Walsh J , Hayes PS , Harte RP , Heaney D . Patients’ views and experiences of technology based self-management tools for the treatment of hypertension in the community: a qualitative study . BMC Fam Pract 2015 ; 16 : 119 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2017. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Family PracticeOxford University Press

Published: Oct 27, 2017

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