How do safety-net patients view high blood pressure? A pilot study to inform quality improvement efforts in a student-run clinic

Background:Hypertension or high blood pressure (HBP) is a leading risk factors for cardiovascular disease and affects approximately 68 million Americans. This burden is disproportionately high among homeless patients and those of low socio-economic status. From a clinical perspective, management of HBP includes lifestyle modifications and pharmacological therapy that have been shown to effectively reduce the risk of mortality and morbidity. However, these benefits rely heavily on patient’s understanding of the associated disease burden and importance of effective control and adherence, and very little information is available on these domains for the underserved and economically disadvantaged individuals.

Objective:To understand the knowledge, attitudes and perceived barriers related to the burden and control of HBP.

Methods:Patients ≥ 18 years diagnosed with essential hypertension (systolic BP ≥ 140 mmHg or diastolic BP ≥90 mmHg) without a history of mental illness were identified by clinic staff to meet with student investigator, trained in qualitative data collection. Following verbal consent, patients were interviewed using semi-structured questionnaire that included open-ended questions. Audio-recording of the interviews were transcribed and thematically analyzed using back-audit trail. Discrete responses were summarized using descriptive statistics.

 Results: Between 08/25/13 and 12/15/13, 15 patients were interviewed for mean (SD) duration of 11.9 (6.2) minutes. Eight (53%) patients were ≥60 years of age, 13 (87%) patients African American (n=8) with all patients reporting at least high school education. Some key cardiovascular risk factors identified were as follows: 47% patients currently smoked, 60% reported alcohol use, 82% had BMI ≥25 kg/sq.m. All patients were prescribed anti-hypertensive medications but 11 (73%) patients had elevated BP at the time of the study. Qualitative analyses of data from 10 patients revealed that patients who were given educational materials could not recall the information or relied on non-clinic sources (website, TV shows, public library). Patient-perceived reasons for HBP varied from genes (n=7) to emotions (n=4) and although most patients recognized the related health burden, denial, burden of management and misinformation were some key underlying themes.  

Conclusion: Preliminary results from our study of safety-net patients reflect variations in patient perceptions related to high blood pressure. Further analyses are planned to establish focus areas for quality improvement initiatives targeting this chronic condition in this high-risk, underserved setting.