The factors influencing clinician use of hypertension guidelines in different resource settings: a qualitative study investigating clinicians’ perspectives and experiences

Abstract

Background Hypertension accounts for the greatest burden of disease worldwide, yet hypertension awareness and control rates are suboptimal, especially within low- and middle-income countries. Guidelines can enable consistency of care and improve health outcomes. A small body of studies investigating clinicians’ perceptions and implementation of hypertension guidelines exists, mostly focussed on higher income settings. This study aims to explore how hypertension guidelines are used by clinicians across different resource settings, and the factors influencing their use. Methods A qualitative approach was employed using convenience sampling and in-depth semi-structured interviews. Seventeen medical doctors were interviewed over video or telephone call from March to August 2020. Two clinicians worked in low-income countries, ten in middle-income countries, and five in high-income countries. Interviews were recorded, transcribed, and coded inductively. Reflexive thematic analysis was used. Results Themes were generated at three levels at which clinicians perceived influencing factors to be operating: healthcare worker, healthcare worker interactions with patients, and the wider health system. Within each level, influencing factors were described as barriers to and facilitators of guideline use. Variation in factors occurred across income settings. At the healthcare worker level, usability of guidelines, trust in guidelines, attitudes and views about guidelines’ purpose, and relevance to patient populations were identified as themes. Influencing factors at the health system level were accessibility of equipment and medications, workforce, and access to healthcare settings. Influences at the patient level were clinician perceived patient motivation and health literacy, and access to, and cost of treatment, although these represented doctors’ perceptions rather than patient perceived factors. Conclusions This study adds a high level global view to previous studies investigating clinician perspectives on hypertension guideline use. Guidelines should be evidence-based, regularly updated and attention should be given to increasing applicability to LMICs and a range of healthcare professionals.

Management of Hypertension in the Asia-Pacific Region: A Structured Review

“…Golestaneh and colleagues identified a number of barriers to guideline implementation in resource-limited settings, including: (1) length and complexity of guidelines (brief, simplified guidelines were preferred); (2) access to international guidelines, particularly for physicians with English as a second language; (3) trust in guidelines (physicians had greater trust in the quality of international than local guidelines); (4) perceived lack of relevance of the guidelines for certain patient groups (e.g. very young patients, those with multiple comorbidities or taking multiple medications, patients with resistant hypertension or target organ damage); (5) patients’ health literacy and ability to make lifestyle changes; (6) availability and affordability of recommended treatments; (7) lack of access to resources such as BP monitors, diagnostic services for target organ damage; and (8) patient’s ability to afford and/or travel to access services [ 164 ]. Many of these issues are present in Asia-Pacific, including lack of infrastructure (e.g.…”

“…A unified guideline across Asia-Pacific may contribute towards better detection, treatment and control of hypertension, and would be easier to update as newer treatments and management strategies become available. However, such a guideline needs to have a clear and uncomplicated message with an easy-to-follow algorithm to make it easy to implement in a range of settings, including resource-limited settings and by physicians whose first language is not English [ 164 ].…”

“…Once hypertension has been diagnosed, physicians in Asia-Pacific need to ensure that patients are treated to achieve target BP, and not just to achieve lower BP, since time at target BP is an important determinant of cardiovascular outcomes [ 169 ]. A simple unified Asia-Pacific guideline for hypertension management may help improve BP control, particularly if the guideline considers the potential barriers to guideline implementation described above [ 164 ]. Such a guideline may be particularly helpful in small and/or resource-limited countries, where the cost/time required for national guideline development may be prohibitive.…”

Resistant Hypertension: Disease Burden and Emerging Treatment Options

“…Several potential reasons explain why guidelines for RHT treatment often are not followed. Importantly, treatment guidelines are long and complex, and many physicians do not read them in detail [39]. Other treatment barriers involve those related to patients (eg, poor adherence and persistence with prescribed treatments, lack of access to a usual site of care, or poor health literacy) as well as obstacles related to the clinician and health care system (eg, therapeutic inertia, poor communication with patients, and fragmentation of care) [3,38].…”