Barriers and Determinants to the Underutilized Hypertension Screening in Primary Care Patients in Hong Kong: A Mixed-Method Study
Abstract
:1. Introduction
- (i)
- patients’ demographic factors associated with no HT screening were identified.
- (ii)
- Barriers to HT screening were identified by qualitative interviews. Patients who had not had HT screening in the past two years, as identified from the survey, were purposefully sampled based on their demographics, which is expected to further explain findings from (i).
2. Materials and Methods
2.1. Participants
2.2. Instruments
2.3. BP measurements and Body Mass Index
2.4. Sample Size Calculation for Questionnaire Survey
- z is the z score.
- ϵ is the margin of error.
- n is the population size.
- is the population proportion.
2.5. Qualitative Interview
2.6. Statistical Analysis
3. Results
3.1. Quantitative Results
3.1.1. Participant Characteristics
3.1.2. The Proportion with no HT Screening in GOPC
3.1.3. Factors Associated with no HT Screening in the Previous Two Years or Ever
3.2. Qualitative Results
3.2.1. Individual Barriers: Insufficient Knowledge about HT
3.2.2. Individual Barriers: Feeling Suspicious, Careless, or Even Denial
3.2.3. Social Barriers
3.2.4. Healthcare Service Barriers
3.3. Mixed-Method Analysis Results
4. Discussions
4.1. Summary
4.2. Implication for Practice
4.3. Implications for Research
4.4. Strength and Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
Abbreviations
BP | Blood pressure |
GOPC | General outpatient clinic |
HK | Hong Kong |
HT | Hypertension |
PC | Primary care |
References
- Mills, K.T.; Bundy, J.D.; Kelly, T.N.; Reed, J.E.; Kearney, P.M.; Reynolds, K.; Chen, J.; He, J. Global Disparities of Hypertension Prevalence and Control: A Systematic Analysis of Population-Based Studies From 90 Countries. Circulation 2016, 134, 441–450. [Google Scholar] [CrossRef] [PubMed]
- World Health Organization. Improving Hypertension Control in 3 Million People: Country Experiences of Programme Development and Implementation; World Health Organization: Geneva, Switzerland, 2020. [Google Scholar]
- Flint, A.C.; Conell, C.; Ren, X.; Banki, N.M.; Chan, S.L.; Rao, V.A.; Melles, R.B.; Bhatt, D.L. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N. Engl. J. Med. 2019, 381, 243–251. [Google Scholar] [CrossRef] [PubMed]
- Centre for Health Protection Department of Health. Hong Kong Reference Framework for Hypertension Care for Adults in PC Settings (Patient Version). 2018. Available online: https://www.fhb.gov.hk/pho/files/e_hypertension_care_patient.pdf (accessed on 1 July 2022).
- AHA/ACC. 2017 Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults A Report of the American College of Cardiology/American Heart Association T. J. Am. Coll. Cardiol. 2017, 4, e127–e248. [Google Scholar]
- Lu, J.; Lu, Y.; Wang, X.; Li, X.; Linderman, G.C.; Wu, C.; Cheng, X.; Mu, L.; Zhang, H.; Liu, J.; et al. Prevalence, awareness, treatment, and control of hypertension in China: Data from 1·7 million adults in a population-based screening study (China PEACE Million Persons Project). Lancet 2017, 390, 2549–2558. [Google Scholar] [CrossRef] [PubMed]
- Panoulas, V.F.; Metsios, G.S.; Pace, A.V.; John, H.; Treharne, G.J.; Banks, M.J.; Kitas, G.D. Hypertension in rheumatoid arthritis. Rheumatology 2008, 47, 1286–1298. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- World Health Organization. A Global Brief on Hypertension: Silent Killer, Global Public Health Crisis; World Health Organization: Geneva, Switzerland, 2013. [Google Scholar]
- Petrie, J.R.; Guzik, T.J.; Touyz, R.M. Diabetes, hypertension, and cardiovascular disease: Clinical insights and vascular mechanisms. Can. J. Cardiol. 2018, 34, 575–584. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Unger, T.; Borghi, C.; Charchar, F.; Khan, N.A.; Poulter, N.R.; Prabhakaran, D.; Ramirez, A.; Schlaich, M.; Stergiou, G.S.; Tomaszewski, M.; et al. 2020 International Society of Hypertension global hypertension practice guidelines. Hypertension 2020, 75, 1334–1357. [Google Scholar] [CrossRef] [PubMed]
- Weiss, R.S. Learning from Strangers: The Art and Method of Qualitative Interview Studies; Simon and Schuster: New York, NY, USA, 1995. [Google Scholar]
- Meyer, D.Z.; Avery, L.M. Excel as a qualitative data analysis tool. Field Methods 2009, 21, 91–112. [Google Scholar] [CrossRef] [Green Version]
- Khatib, R.; Schwalm, J.D.; Yusuf, S.; Haynes, R.B.; McKee, M.; Khan, M.; Nieuwlaat, R. Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: A systematic review and meta-analysis of qualitative and quantitative studies. PLoS ONE 2014, 9, e84238. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Jokisalo, E.; Kumpusalo, E.; Enlund, H.; Takala, J. Patients’ perceived problems with hypertension and attitudes towards medical treatment. J. Hum. Hypertens. 2001, 15, 755–761. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Rajpura, J.; Nayak, R. Medication adherence in a sample of elderly suffering from hypertension: Evaluating the influence of illness perceptions, treatment beliefs, and illness burden. J. Manag. Care Pharm. 2014, 20, 58–65. [Google Scholar] [CrossRef] [PubMed]
- Goldbeck, R. Denial in physical illness. J. Psychosom. Res. 1997, 43, 575–593. [Google Scholar] [CrossRef] [PubMed]
- Fleming, S.; Atherton, H.; McCartney, D.; Hodgkinson, J.; Greenfield, S.; Hobbs, F.D.; Mant, J.; McManus, R.J.; Thompson, M.; Ward, A.; et al. Self-screening and non-physician screening for hypertension in communities: A systematic review. Am. J. Hypertens. 2015, 28, 1316–1324. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Yang, W.Y.; Melgarejo, J.D.; Thijs, L.; Zhang, Z.Y.; Boggia, J.; Wei, F.F.; Hansen, T.W.; Asayama, K.; Ohkubo, T.; Jeppesen, J.; et al. Association of office and ambulatory blood pressure with mortality and cardiovascular outcomes. JAMA 2019, 322, 409–420. [Google Scholar] [CrossRef] [PubMed]
- Bo, Y.; Kwok, K.O.; Chung, V.C.; Yu, C.P.; Tsoi, K.K.; Wong, S.Y.; Lee, E.K. Short-term reproducibility of ambulatory blood pressure measurements: A systematic review and meta-analysis of 35 observational studies. J. Hypertens. 2020, 38, 2095. [Google Scholar] [CrossRef] [PubMed]
- Kaczorowski, J.; Chambers, L.W.; Dolovich, L.; Paterson, J.M.; Karwalajtys, T.; Gierman, T.; Farrell, B.; McDonough, B.; Thabane, L.; Tu, K.; et al. Improving cardiovascular health at population level: 39 community cluster randomised trial of Cardiovascular Health Awareness Program (CHAP). BMJ 2011, 342, d442. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Morris, Z.S.; Wooding, S.; Grant, J. The answer is 17 years, what is the question: Understanding time lags in translational research. J. R. Soc. Med. 2011, 104, 510–520. [Google Scholar] [CrossRef] [PubMed]
- Guirguis-Blake, J.M.; Evans, C.V.; Webber, E.M.; Coppola, E.L.; Perdue, L.A.; Weyrich, M.S. Screening for hypertension in adults: Updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2021, 325, 1657–1669. [Google Scholar] [CrossRef] [PubMed]
- Wood, S.; Greenfield, S.M.; Haque, M.S.; Martin, U.; Gill, P.S.; Mant, J.; Mohammed, M.A.; Heer, G.; Johal, A.; Kaur, R.; et al. Influence of ethnicity on acceptability of method of blood pressure monitoring: A cross-sectional study in PC. Br. J. Gen. Pract. 2016, 66, e577–e586. [Google Scholar] [CrossRef] [PubMed] [Green Version]
- Shimbo, D.; Artinian, N.T.; Basile, J.N.; Krakoff, L.R.; Margolis, K.L.; Rakotz, M.K.; Wozniak, G. Self-measured blood pressure monitoring at home: A joint policy statement from the American Heart Association and American Medical Association. Circulation 2020, 142, e42–e63. [Google Scholar] [CrossRef] [PubMed]
Independent Variables | n | % | Mean (SD) |
---|---|---|---|
All participants | 428 | ||
Gender | |||
Female | 217 | 50.70% | |
Age | 56.2 (15.6) | ||
Marital status | |||
Not married | 85 | 19.90% | |
Married | 343 | 80.10% | |
Measured level of BP | |||
BP ≥ 140/90 | 197 | ||
BP < 140/90 | 231 | ||
Self-perceived BP condition | |||
Normal | 120 | 28.00% | |
Abnormal | 36 | 8.40% | |
Do not understand BP index | 272 | 63.60% | |
Family history of HT | |||
Yes | 187 | 43.70% | |
No | 204 | 47.70% | |
Don’t know | 37 | 8.60% | |
Clinic visit in 2 years | |||
Yes | 307 | 71.10% | |
BMI | 24.7 (9.6) |
Independent Variables | Never Measured BP (% within Groups) | Univariate | Regression | Not Measure BP in 2 Years (% within Groups) | Univariate | Regression | ||
---|---|---|---|---|---|---|---|---|
p-Value † | p-Value * | Odd Ratio | p-Value † | p-Value * | Odd Ratio | |||
Gender | 0.004 | 0.004 | 0.007 | 0.007 | ||||
Female ** | 59 (31.2%) | 81 (39.1%) | ||||||
Male | 87 (45.5%) | 1.843 | 109 (52.4%) | 1.713 | ||||
Age | <0.0001 ‡ | <0.0001 ‡ | ||||||
Marital status | <0.0001 | <0.0001 | <0.0001 | <0.0001 | ||||
Not married ** | 44(55.7%) | 52 (65.80%) | ||||||
Married | 102 (29.2%) | 0.341 | 138 (41.1%) | 0.362 | ||||
BP measurement | 0.001 | 0.003 | ||||||
BP ≥ 140/90 | 49 (28.8%) | 71 (37.8%) | ||||||
BP < 140/90 | 97 (46.2%) | 119 (52.4) | ||||||
Self-perceived BP condition | 0.019 | 0.017 | 0.005 | 0.004 | ||||
Normal | 35 (31.8%) | 1.66 | 45 (38.5%) | 0.588 | ||||
Abnormal | 8 (23.5%) | 2.417 | 10 (27.8%) | 0.362 | ||||
Do not understand BP index ** | 103 (43.6%) | 135 (51.5%) | ||||||
Employment status | 0.003 | 0.003 | 0.005 | 0.004 | ||||
Employed | 75 (41.7%) | 1.597 | 95 (48.5%) | 1.411 | ||||
Unemployed | 16 (51.6%) | 2.384 | 19 (57.6%) | 2.036 | ||||
Retired | 30 (28.8%) | 0.906 | 43 (37.1%) | 0.884 | ||||
Student | 8 (80.0%) | 8.941 | 9 (90.0%) | 13.5 | ||||
Housewife ** | 17 (30.9%) | 24 (40.0%) | ||||||
Marital status | <0.0001 | <0.0001 | <0.0001 | <0.0001 | ||||
Not married ** | 44(55.7%) | 52 (65.80%) | ||||||
Married | 102 (29.2%) | 0.341 | 138 (41.1%) | 0.362 | ||||
Family history | <0.0001 | <0.0001 | <0.0001 | <0.0001 | ||||
Yes | 47 (27.8%) | 0.317 | 63 (34.8%) | 0.365 | ||||
No | 82 (45.6%) | 0.689 | 108 (53.5%) | 0.786 | ||||
Don’t know ** | 17 (54.8%) | 19 (59.4%) | ||||||
Clinic visit in 2 years | 0.001 | 0.001 | 0.001 | 0.001 | ||||
Yes | 92 (33.5%) | 0.475 | 122 (40.7%) | 0.474 | ||||
No ** | 54 (51.4%) | 68 (59.1%) | ||||||
BMI | 0.757 | 0.527 |
Themes | Sub-Theme | Codes | Quotes |
---|---|---|---|
Individual barrier | Insufficient knowledge about HT | Low perceived severity | “I was not aware of the information about hypertension until today when I was told to have hypertension. I know it is difficult to manage.”—participant 13, male, aged 74 |
“I don’t know if it is high or not, and it won’t cause death. I am not fat and still young, I didn’t expect I would have high blood pressure.” Participant 4, female, aged 53 | |||
“I didn’t know HT would cause harm to my body.”—participant 5, male aged 43 | |||
Wrong interpretation of HT | “My Blood pressure is not high; it’s not over 150 yet.” participant 5, male, aged 43 | ||
“My BP is 140 which is in a normal range.” Participant 8, male, aged 62, Participant 21, male, aged 83 & Participant 23, male, aged 72 | |||
“I am not scared as I don’t understand what the number means. Why would I measure if I don’t know what it means?”—participant 3, female, aged 80; participant 4, female, aged 53 & participant 10, female, aged 72 | |||
Thought it will recover over time | “I think the blood pressure will return to normal afterwards.”—participant 16, female, aged 18 & participant 17, male, aged 50 | ||
HT would not lead to death | “I don’t know if it is high or not, and it won’t cause death. I am not fat and still young, I didn’t expect I would have high blood pressure.”—participant 4, female, aged 53 | ||
HT does not cause harm to health | “That was just a number to me, I don’t even know if it is high or low. I don’t know what I can do after the measurement. What is the point of measuring? It is so disturbing!”—participant 6, male, aged 19 | ||
Misunderstanding on the pathophysiology of HT | “I would know if I had hypertension. I can feel it if I have it, even diabetes can be felt by yourself. I also read medical book, so I know I don’t have hypertension.”—participant 7, male, aged 62 | ||
Low health literacy in general | “I am not scared as I don’t understand what the number means.”—participant 3, female, aged 80; participant 4, female, aged 53 & participant 10, female, aged 72 | ||
Feeling suspicious, careless or even denial | Low self-awareness | “I’m too young to get into this (HT)”—participant 16, male, aged 22 and participant 6, male, aged 19 | |
Low sense of urgency | “Why do I need to measure (blood pressure) at a young age?”—participant 16, female, aged 18 | ||
“My family does not have a history of hypertension; I don’t think I need to be worried.”—participant 23, male, aged 22 | |||
Denial | “I did not pay attention, so I did not measure. I don’t care at all; medical consultation is meaningless.”—participant 3, female, aged 80 | ||
Optimistic about their own health | “I think I am healthy without any severe diseases, and I am able to walk and eat normally. I don’t think I will have hypertension.”—participant 4, female, aged 53, participant 6, male, aged 19 & participant 21, male, aged 81 | ||
“My family and spouse got hypertension as well; I think I don’t have hypertension.”—participant 7, male, aged 62 & participant 4, female, aged 53 | |||
Suspicious of the BP machine accuracy | “I think the machines at the clinics are broken.”—participant 17, male, aged 50 | ||
Social barrier | Work Constraints | Work disrupting healthy lifestyle | “I have no time for sleep; how would I have time to take care of my health, say measure BP?”—participant 2, male, aged 24 |
Lack of physical activity | “Working inhibits me from doing physical activities. There is a limited choice of food in my canteen. I would work out and eat healthily before joining the company”—participant 2, male, aged 24 | ||
Unhealthy eating habits | “I did not pay attention to choosing healthy food as there is not much promotion of healthy food around my workplace. Sometimes my emotions quite fluctuate which might also lead to hypertension?”—participant 4, female, aged 53 & participant 2, male, aged 24 | ||
“I am too busy at work and do not wish to spare time on healthy food choice.”- participant 18, male, aged 31 | |||
Lack of informal care | Lack of care from social support | “I cannot take care of my own health. No one takes care of me as they all go to work. The government did not offer assistance when I left the clinic”—participant 3, female, aged 80 | |
“I haven’t measured it for a long time. The district counsellor measured BP for us, but there are no such events now.”—participant 20, male, aged 83 | |||
Healthcare service barrier | Insufficient resources in the society | Hard to find BP machine | “The number of BP machines in the GOPC reduced from 7 to 3. It is not easy to find one in the community.”—participant 22, male, aged 72 |
Financial difficulties | “If I have to measure, I have to go somewhere to find the BP measuring machine, else I would have to spend several hundred to buy one!”—participant 14, male, aged 75 | ||
BP machine too expensive for individuals with low SES |
Quantitative Findings | Qualitative Findings |
---|---|
Although HT screening in GOPC is free and encouraged, most patients do not screen for HT | Multiple individual, social and healthcare barriers were identified |
Most patients misinterpreted their BP values | Patients had poor knowledge about HT |
Younger age was associated with no HT screening | Younger patients regard HT as a disease only affecting elderly people |
Being a student or unemployed were associated with no HT screening | Low availability in living surroundings and schedule constrictions hindered BP measurement |
Being single was associated with no HT screening | Patients’ spouses might have experienced BP related diseases which would lead to a higher awareness; No caregivers at home to provide assistance |
Having no family history of HT was associated with no HT screening | Low awareness on measuring BP was found among patients without a family history of HT as they considered themselves to be a lower risk population |
Absence of clinic visit in 2 years was associated with no HT screening | A lack of BP devices in the community hindered HT screening |
Patients who could not interpret their BP values and those who regarded their index as normal tended not to measure | Patients regarded their BP as normal and considered themselves as healthy |
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Chu, R.Y.-K.; Dong, D.; Wong, S.Y.-S.; Lee, E.K.-P. Barriers and Determinants to the Underutilized Hypertension Screening in Primary Care Patients in Hong Kong: A Mixed-Method Study. Int. J. Environ. Res. Public Health 2023, 20, 985. https://doi.org/10.3390/ijerph20020985
Chu RY-K, Dong D, Wong SY-S, Lee EK-P. Barriers and Determinants to the Underutilized Hypertension Screening in Primary Care Patients in Hong Kong: A Mixed-Method Study. International Journal of Environmental Research and Public Health. 2023; 20(2):985. https://doi.org/10.3390/ijerph20020985
Chicago/Turabian StyleChu, Rachel Yui-Ki, Dong Dong, Samuel Yeung-Shan Wong, and Eric Kam-Pui Lee. 2023. "Barriers and Determinants to the Underutilized Hypertension Screening in Primary Care Patients in Hong Kong: A Mixed-Method Study" International Journal of Environmental Research and Public Health 20, no. 2: 985. https://doi.org/10.3390/ijerph20020985