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Worldwide, hypertension control rates remain suboptimal despite clinically effective antihypertensive drug therapy. Patient failure to take medication as prescribed (ie, nonadherence) is the most important factor contributing to poor control. Smartphone apps can facilitate the delivery of evidence-based behavior change techniques to improve adherence and may provide a scalable, usable, and feasible method to deliver self-management support.
The aim of this study is to explore patients’ experiences of the usability and feasibility of smartphone apps to support self-management and improve medication adherence in hypertension.
A qualitative descriptive study was conducted. A total of 11 people living with hypertension from the West of Ireland were sampled purposively and interviewed about their experience of using a self-management app for a 4-week period, which included two key functionalities: self-monitoring of blood pressure (BP) and medication reminders. Thematic analysis was carried out on the semistructured interview data.
Participants’ age ranged from 43 to 74 years (mean 62 years, SD 9.13). Three themes were identified: digital empowerment of self-management, human versus digital systems, and digital sustainability. Although patients’ experience of using the technology to self-monitor BP was one of empowerment, characterized by an enhanced insight and understanding into their condition, control, and personal responsibility, the reminder function was only feasible for patients who reported unintentional nonadherence to treatment. Patients experienced the app as a sustainable tool to support self-management and found it easy to use, including those with limited technological competence.
The study’s findings provide new insights into the experience of using apps to support medication adherence in hypertension. Overall, the data support apps as a usable and feasible method to aid self-management of hypertension and highlight the need for personalized functionality, particularly with regard to medication adherence reminder strategies. The study’s findings challenge the perspective that the use of these technologies to support self-management can inevitably add to the burden of treatment experienced by patients.
Hypertension has been identified as the leading modifiable risk factor for cardiovascular disease and consequently represents a major cause of premature morbidity and mortality due to adverse cardiovascular and cerebrovascular events [
Some intervention approaches to support self-management of hypertension and enhance adherence have been shown to be effective in improving BP control [
Despite the potential of such devices to improve adherence, a contemporary theoretical perspective proposes that newer technologies that encourage a proactive approach to patient care and can be easily shifted from the clinic to the community may serve to place new demands on patients, causing them to experience an increased burden of treatment [
A qualitative descriptive study was conducted. The Consolidated Criteria for Reporting Qualitative Research Checklist was used to ensure explicit reporting on how this study was carried out (
Participants were recruited through Croí (the West of Ireland Cardiac Foundation), a heart and stroke charity located in Galway city. Recruitment emails advertising the study were sent to database records of individuals who had used the charity’s service until March 2019. Interested patients living with hypertension contacted the primary researcher by telephone or email to obtain further study information and ensure eligibility. To be eligible for participation, patients must have been prescribed at least one form of antihypertensive therapy and own an Android smartphone. Purposive sampling was used to achieve adequate variability in age, sex, and complexity of the medication regime.
The smartphone app used is called
Participants attended an initial session during which they downloaded the app and created their personal profile. They were then provided with a home BP monitor (A&D Medical model UA-767S-W) and shown how to navigate the equipment. Participants were requested to use these materials to support hypertension self-management for 4-weeks. To ensure participants became familiar with app functionalities, it was recommended that they took BP readings at least twice per week (unless they had a pre-established self-monitoring routine). The 1-month feasibility duration was based on previous mobile health feasibility studies using 2- to 4-week periods [
Semistructured, face-to-face interviews were facilitated and audio-recorded by the primary researcher (CM, a female MSc graduate in health psychology with experience and training in qualitative research methods of both collection and analysis) to elicit patients’ experiences of using the app. The interview topic guide, which was centered around questions relating to feasibility and usability, was composed by reviewing qualitative research in the area and revised during the data collection process to be responsive to unforeseen issues. Therefore, an iterative approach was adopted to ensure that the researcher did not restrict the analysis to only issues anticipated as relevant [
The System Usability Scale (SUS) [
Interviews were transcribed verbatim and analyzed using thematic analysis, following the six phases proposed by Braun and Clarke [
Ethical approval was sought and granted for this study by the School of Psychology Research Ethics Committee at the National University of Ireland, Galway.
Patient characteristics are summarized in
Patient characteristics (N=11).
Characteristics | Values | |||
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Age (years), mean (range) | 62 (43-74) | ||
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Female, n (%) | 6 (54) | ||
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Urban, n (%) | 8 (73) | ||
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Married, n (%) | 9 (82) | ||
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Single, n (%) | 2 (18) | ||
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Working full-time, n (%) | 4 (36) | ||
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Working part-time, n (%) | 1 (9) | ||
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Unemployed, n (%) | 1 (9) | ||
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Retired, n (%) | 5 (46) | ||
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Private health insurance, n (%) | 5 (46) | ||
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Number of antihypertensive medications, mean (range) | 1.73 (1-3) | ||
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>12 months since diagnosis, n (%) | 11 (100) | ||
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Presence of multimorbid conditions, n (%) | 9 (82) | ||
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Previous use of a smartphone to manage hypertension, n (%) | 1 (9) | ||
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SUSa score, mean (range) | 89.1 (70-97.5) | ||
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High | 7 (64) | |
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Medium | 4 (36) |
aSUS: System Usability Scale.
The theme of digital empowerment of self-management refers to patients’ experiences of using the technology to self-monitor BP and is represented by two subthemes:
The thing about [using the app] is that it is more regular...up to this I would only use the monitor when I felt I had high BP...doing it on regular basis is a better monitoring system, whereas mine was ad hoc.
Several patients valued the output information produced by the self-monitoring function and felt it provided them with a greater insight into the state of their BP. The retrieval of visual feedback in the charts offered to participants more meaningful information and a feeling of empowerment:
The good thing about the app was I could see it visually; visual things mean a lot more to me.
All the information it gave me about the state of the BP [was the most helpful aspect of the app]...I could see the different measurements myself and see the charts up and down.
Many participants expressed how visualizing BP data in the charts made their condition more tangible, whereas the visual qualities in the app helped others make sense of and interpret BP readings. Some acknowledged that using the self-monitoring function had provided them with an enhanced understanding of the asymptomatic nature of hypertension and the hazards of judging their condition by how they felt, thereby reconstructing the way they perceived their condition:
You are getting an accurate account of what’s happening in your body...normally you are judging yourself by how you feel...I was surprised my BP was higher than I thought...that made me aware sometimes I might feel good and be busy, but I was overlooking.
Visualizing fluctuations in BP readings was perceived as interesting by several and sparked curiosity. Fluctuations in readings despite feelings of accurate medication-taking behaviors evoked a sense of concern in some patients regarding whether their medication was working to control their BP. For others, the retrieval of consistent readings verified that their BP was under control:
It was a nice app...it told me my BP was fluctuating even though it was the same time of day. I am considering going back to my doctor and showing him the results on my follow-up...there might be another tablet that might be better.
Many patients expressed how their newly established self-monitoring regime had provided them with an improved feeling of control over their condition between consultations in primary care. They described how this had offered them reassurance and had promoted an increased feeling of responsibility for one’s health. One participant described how she thought this improved feeling of control might function to decrease health anxiety in patients who were worried about their BP:
When you go and get your BP taken and you’re put on medication if everything is going as it should you may not go back to the doctor, you don’t know what’s going on...six months can make a big change. I just heard of another person, they are panicked about their BP and ringing the doctor...if you had this at home you might calm down...you have this back up to know that everything is controlled...you’re looking after yourself and have your own check.
Several of the participants described how their improved feeling of responsibility would help them
If there were any unusual stuff happening, I’d pick it up...sometimes you go to a GP to get a check-up, but you wouldn’t pick it up there and then...if you are doing this self-checking yourself...if there is something unusual happening you could take action.
Feeling empowered, some reported instances during which the app had encouraged them to play an active role in consultations. This occurred when patients used the app to guide conversation with their general practitioner (GP). A few patients underwent ambulatory monitoring, followed by the detection of uncontrolled BP and, in turn, experienced changes to their medication:
I showed it to my doctor, and she did a blood pressure monitor...[It] advised that my blood pressure was very high...I feel glad I found it out.
The theme of
For those patients who reported they might frequently forget to take medication (ie, unintentional nonadherence) and could recognize their current medication-taking system was not perfect, the medication reminder was experienced as useful:
Some mornings I was rushing and only for it did beep I probably would have forgotten to take them...it’s a tool, it helps because we can forget easily.
I mean the reminder was good because it told you at the time to take your medication and there is a chance with me, I would forget...there was a couple of times I totally forgot.
One participant described how the medication reminder was becoming integrated into his everyday routine:
The reminder was excellent...I’d look at the clock and say it wasn’t some message coming in...I knew it was time to take my medication.
The medication reminder was experienced as less practical among patients who expressed a strong satisfaction with their current
I didn’t need reminding about my tablets in all the years I’m on them I’ve probably forgotten to take them twice ever...it’s part of my routine after breakfast and before I go to bed...having said that I am going on holidays in a few weeks, it will be good for that.
One patient described how she had tried to stick to the time-based reminder but reverted to
I thought the reminder was good...if I was somebody starting off that hadn’t made all these habits...but for me after 25 or 30 years I couldn’t do it, I think it’s just old habits die hard.
The final theme to be identified was
Most participants reported no concerns about using the technology going forward. Several reported that the app and monitor were easy to use despite limited technological competence:
Technology over the last couple of years...what I could do before I have kind of forgotten. I mean I [still] found the app very...once you did one or two testings with it, it became automatic.
Most participants expressed that they intended to continue using the technology after the study. The self-monitoring function was a major motivation for continued use. Many patients who did not own a monitoring device acknowledged that they intended to buy one. Perceiving the app as being beneficial in consultations encouraged sustainability:
I am actually going to buy a monitor of my own and if the app stays there I am going to continue taking readings...I will have it there to show the trend in my blood pressure, so I can pass it on to a doctor.
Important improvement suggestions included making the reminder more intrusive by adding an audio signal or a
I find in life, it’s called the KISS principle...keep it straight and simple...and the app in my opinion is easy to use...you have to make it easy to use...remember your clients that you are giving it to are not savvy...
The data from these interviews provide new insights into patients’ experiences of the usability and feasibility of smartphone apps to improve adherence to hypertension. The patient experience of using the technology to support self-monitoring of BP was one of empowerment, characterized by an enhanced insight and understanding of hypertension, an improved feeling of control over health, reassurance, and increased patient responsibility. Patients’ experiences of using the technology to support reminder strategies were more varied; although the reminder function was useful for patients who reported unintentional nonadherence to treatment, it was less practical for those who reported existing context-based medication-taking habits. Overall, most patients experienced the technology as sustainable, reporting that they intended to continue to engage with the app in the future. Patients were confident in their use of the technology by the end of the feasibility period despite limited digital competence. This was complemented by descriptive data, which demonstrated that all participants scored above average on the SUS, a robust evaluation tool of perceived
This study provides timely data on the use of technology to support self-management of hypertension and to the researcher’s knowledge is the first to use qualitative methods to examine patients’ experiences of the usability and feasibility of smartphone apps specifically for medication adherence in hypertension. This extends research in this area [
One limitation is the potential of sampling bias. Although purposive sampling was used, the sample was from a single geographic location and limited to Android smartphone users. It is also possible that this sample captures a more positive patient experience of self-management technologies, as it is based only on a subsample of patients who volunteered to participate and who had prior involvement with Croí, the Irish heart and stroke charity. This is due to the potential likelihood of the participants reflecting a more motivated, technologically inclined, and adherent group. It must also be recognized that all the patients had a hypertension diagnosis of >12 months, which could have influenced the findings.
Our findings support previous research investigating patients’ experiences of self-management technologies across other illness contexts. A metaethnography on digital interventions to support self-management covering a range of conditions (eg, asthma, chronic obstructive pulmonary disease, diabetes) has found that patients monitoring their health felt reassured by the insight provided and felt they had more meaningful conversations with health care practitioners [
Our findings support previous literature from a number of areas including information visualization, human-computer interaction, and medicine, which argues that making health data visible creates opportunities for patients to make sense of their illness, which in turn may lead to more effective self-management [
The findings of this study also lend support to emerging research that points to the possible utility of digital technology, especially smartphone apps, to support reminder strategies in some patients who report unintentional nonadherence to treatments (eg, [
Ineffective communication with patients with hypertension is correlated with poor adherence to antihypertensive therapy, and effective communication has been identified as an important obstacle for practitioners, largely due to a lack of understanding of hypertension in patients [
The findings of this study have important implications for optimizing technological design. In addition to considering the feasibility of the suggestions made by these patients to promote the sustainability of the app, the authors recommend that future developers of adherence technologies for hypertension design contextual-based reminder functionalities to support habit development in patients who report unintentional nonadherence. Prospective memory is an important component of medication adherence and is supported by context-based cues more effectively than time-based cues [
Finally, it is noteworthy that a large proportion of participants who were living with hypertension in this study reported the presence of multimorbidity (defined as the presence of two or more chronic health conditions coexisting in one individual). Epidemiologic evidence suggests that multimorbidity is now the norm, rather than the exception [
The patients in this qualitative study experienced the technology as a usable and feasible method to support self-monitoring of BP. However, to experience the technology as feasible to support reminder strategies, this study’s findings suggest that the patients must first have found a need that their current medication-taking systems could not fill. The technology was generally experienced by these patients as a sustainable tool to support hypertension self-management in the long term. Overall, the data support apps as a usable and feasible method to support self-management and highlight the need for personalized functionality in relation to medication adherence reminder strategies. This study adds to a growing body of literature that challenges the perspective that the use of such self-management technologies will inevitably add to the patient burden of treatment [
Consolidated Criteria for Reporting Qualitative Research Checklist.
Interview Topic Guide.
blood pressure
Common-Sense Self-Regulation Model
general practitioner
System Usability Scale
The authors would like to acknowledge Professor Liam Glynn from the University of Limerick for providing BP monitors. The authors would also like to acknowledge the team at Croí for helping to facilitate recruitment and data collection. Finally, we would like to acknowledge and thank all the participants.
None declared.