Patient and healthcare provider barriers to hypertension awareness, treatment and follow up: a systematic review and meta-analysis of qualitative and quantitative studies.
BACKGROUND
Although the importance of detecting, treating, and controlling hypertension has been recognized for decades, the majority of patients with hypertension remain uncontrolled. The path from evidence to practice contains many potential barriers, but their role has not been reviewed systematically. This review aimed to synthesize and identify important barriers to hypertension control as reported by patients and healthcare providers.


METHODS
Electronic databases MEDLINE, EMBASE and Global Health were searched systematically up to February 2013. Two reviewers independently selected eligible studies. Two reviewers categorized barriers based on a theoretical framework of behavior change. The theoretical framework suggests that a change in behavior requires a strong commitment to change [intention], the necessary skills and abilities to adopt the behavior [capability], and an absence of health system and support constraints.


RESULTS
Twenty-five qualitative studies and 44 quantitative studies met the inclusion criteria. In qualitative studies, health system barriers were most commonly discussed in studies of patients and health care providers. Quantitative studies identified disagreement with clinical recommendations as the most common barrier among health care providers. Quantitative studies of patients yielded different results: lack of knowledge was the most common barrier to hypertension awareness. Stress, anxiety and depression were most commonly reported as barriers that hindered or delayed adoption of a healthier lifestyle. In terms of hypertension treatment adherence, patients mostly reported forgetting to take their medication. Finally, priority setting barriers were most commonly reported by patients in terms of following up with their health care providers.


CONCLUSIONS
This review identified a wide range of barriers facing patients and health care providers pursuing hypertension control, indicating the need for targeted multi-faceted interventions. More methodologically rigorous studies that encompass the range of barriers and that include low- and middle-income countries are required in order to inform policies to improve hypertension control.
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
Rasha
R
Khatib
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada ; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Jon-David
JD
Schwalm
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada ; Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada ; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Salim
S
Yusuf
Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada ; Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
R Brian
RB
Haynes
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Martin
M
McKee
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.
Maheer
M
Khan
Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada ; Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
Robby
R
Nieuwlaat
D001364:Awareness; D005500:Follow-Up Studies; D006801:Humans; D006973:Hypertension / Q000523:psychology* / Q000628:therapy*