Study participants
75/91 randomised women (82%) consented to participate in the qualitative study. Of these, 34/38 (90%) from the intervention group and 34/37 (92%) from the control group completed at least one interview. 32/34 of the intervention group and 26/34 of the control group completed two interviews. The baseline characteristics of the interviewees from the two groups were similar (Table 2 and Additional File 2).
Qualitative analysis
From complete coding of the 126 interview transcripts, several overarching themes emerged: control; convenience; confidence, communication and knowledge; concern; constraints; and components of the intervention (Figure 1). Control was revealed as a major factor influencing participants’ experiences of their healthcare. Time pressures were a key concern, so ease of healthcare access was critical. There was extensive discussion surrounding communication with healthcare practitioners, patient confidence, education and knowledge, as well as evaluation of factors affecting stress and anxiety. Constraints to self-management were explored, as were participants’ positive and negative experiences of the different components of the intervention. Participants did not provide feedback on the findings.
Intriguingly, amongst the control group, 13/34 (38%) explicitly stated they had undertaken HBPM at some stage, and 21/34 (62%) unequivocally expressed a preference for HBPM.
Control of condition
Participants frequently reflected that self-management enhanced their feelings of control: “With this study very in control, because I can check it every day, and then obviously act on that” (SM7); “every time I used to go to the doctors and come back and stuff I kind of didn’t know where I was at; it kind of felt a bit out of control, and that definitely changed post-birth” (SM25).
The views from control group participants were more inconsistent. Some were vocal that they lacked control: “I am going in to get it checked, but I don’t feel that I have much control over what happens” (UC22). Others felt that more information might have been helpful: “apart from taking the tablets, I didn’t know what my blood pressure was. It might have been nice to be able to do that” (UC15). Some participants did report feeling in control, stemming from confidence in the care provided by their GP: “I’m mainly making decisions alongside the GP. I just get her agreement with it” (UC1). One participant specifically valued the input from a professional: “I felt more confident that they’ve done it, rather than if I was doing it myself” (UC10).
The extent to which participants felt they shared responsibility with their healthcare team was variable. Some women who were self-managing did report sharing responsibility evenly with their GP: “it felt like he [the GP] was kind of backing it that it’s a good thing” (SM22). Others from the intervention group acknowledged that they had often assumed a greater share of the responsibility, but did not in general view this as a negative consequence of self-management: “more onus is put on me, which I think’s the right thing” (SM19). One woman from the intervention group reflected she might have liked direct contact with a healthcare professional when adjusting her medication: “normally I’d be seeing a GP and could have discussions about stopping my medication” (SM9). However, this was isolated, and this participant had some conflicting views about her management, as she also said, “My GP has not had any input into anything so I haven’t had to see him, and I was personally happy because my medication was taken away really quickly” (SM9).
Participants from the control group also reported variable levels of responsibility sharing. Some did not feel they had much input: “I don’t actually know what’s constantly going on, just the fact that it’s controlled by other people so… so you don’t really share” (UC8). Others felt they played a greater role: “I could somehow… well not really maybe influence because you can’t influence it as a patient, but still you are given the sensation you can participate in the whole thing” (UC2).
Women felt that HBPM produced a more realistic picture of their BP: “it’s more accurate and you can do it at your own sort of leisure as well” (UC34). Participants in the intervention group noted that they liked to check their BP if they developed symptoms: “if I felt… a bit funny or queasy… I could just go and check and it was kind of that reassurance” (SM25). Some women believed that they were better able to detect issues with their BP: “I wouldn’t have known it was low if I didn’t have the monitor to do it myself, and then it could have gone too low” (SM15).
Women in both groups discussed antihypertensive adjustment as a component of control. Women in the intervention group frequently referred to the speed of reduction in response to their BP readings, which, in general, was perceived as positive: “if I was going to the GP I would have waited two weeks and been on the full medication, and nobody really wants to be on medication if they don’t need to be” (SM31). Women felt that HBPM enabled more appropriate, and often more rapid, cessation of antihypertensive medication: “looking at how fast my medications came down, surely if I was going to see a doctor I’d still be on it without really needing to be” (SM13). One woman did express some concerns about the speed at which her medication reduced: “I think because of the monitoring that cut it down very quickly… I was almost reluctant to cut it down so quickly” (SM12) and another reported doing additional checks as the medication was decreased: “particularly when I had to reduce medication, just to check that it was holding on, so I checked at different times as well” (SM32).
Women in the control group relayed positive and negative experiences of medication adjustment: “it’s been monitored carefully and the medication reduced gradually, which I think stabilised my blood pressure” (UC16). Some women managed by their GPs did report concerns about the rate of adjustment, in both directions: “perhaps I should have come off slightly earlier, but that was my fault being busy” (UC23) and “So, I think they took, took me off it too soon” (UC7). Some participants in the control group also employed HBPM to guide adjustment: “I was also self-monitoring… I’ve called them [the GP] and said this is what my blood pressure’s doing, what, what should we do with the medication rather than waiting for an appointment” (UC9).
Convenience: time pressures, access to healthcare and relationships with practitioners
Women explicitly referred to multiple competing time pressures, and cited this as a reason why they might prefer to self-manage: “It might be good to monitor it yourself because obviously with a baby it’s a bit of a pain sometimes having to go to the doctors” (UC17). Women liked the flexibility that HBPM provided: “it’s been convenient to use it at home… I take it with me wherever I go; if I go away for a couple of days… it’s really handy” (SM20); and felt it saved them time: “it’s time saving… if I have to go to the hospital or GP just to check my… I have to do lots of arrangements” (SM1).
Access to care was variable in both groups. Some reported that it was straightforward to get a GP appointment at their convenience: “My GPs are brilliant… they will book last minute appointments… they do cater for you” (UC29). Whereas another participant recounted, “getting an appointment… it seems a sort of dark art” (UC22). Continuity emerged as an important factor influencing how women perceived the quality of care: “I try and see the same GP at the surgery and I think that helps with continuity” (UC27). Where participants achieved regular contact with their usual GP this experience was beneficial: “I think it was once a week I used to talk to the GP … when I started going down in the medication she used to do it slowly do I didn’t have any problems” (UC12). Where continuity of care lapsed, women reported issues: “I had an interesting experience with one slightly unhelpful duty GP” (SM27).
Consistency of care was influenced by the need for handover of care, and communication between different groups of healthcare professionals. Participants reported some problems with inconsistency of message: “the community midwives completely ignored that and kept sending me back into hospital… to the point that the doctors in hospital said, ‘… we don’t want to see you here unless your blood pressure’s above 160 and 110.’ They wrote that on my notes, and even so the community midwives kept trying to send me any time it was above 140 over 100” (SM32).
Participants reported a number of strategies employed by GP surgeries to improve access, including provision of an automated BP machine in reception, coupled with the facility to submit readings to GPs automatically: “this machine in health centre, so I always can give a receipt from these to the reception, and they usually pass it straight away to GPs” (UC3). Several participants reported effective use of telephone consultations: “my doctor was quite good in that I’d phone her and say my blood pressure’s doing this, and she’d adjust” (UC9).
Participants’ relationships with their healthcare providers affected patient care in many cases, with women frequently citing good relationships as one factor underpinning positive encounters: “I feel very confident… they’re so nice… they’re very helpful” (UC3). However, there were some reports of poor relationships negatively impacting on care quality: “They’re not like my old surgery at all… I suppose I’m trying to put it off a bit going.” (UC21). Some women reported an active dislike of attending their doctors as a reason they would prefer to self-monitor: “I hate going to the doctors, and you can do it you know whenever you want at home… it’s so much easier” (SM29). Several participants relayed suffering with white coat syndrome, and felt that HBPM was advantageous for them: “I found it useful just because it means I get a more accurate reading when I’m not stressed when I’m at home” (SM9). A number of participants highlighted that self-management may reduce the burden on the NHS: “Big cost saving I think for the NHS really” (SM17).
Difficulties with travel to GP surgeries were reported as a barrier to accessing healthcare. Some women were unable to drive, sometimes as a result of delivery by caesarean section, resulting in them relying on friends and family for transport: “I’ve not been able to drive, actually go[ing] to the GP and have my blood pressure checked would just be a real faff” (SM17). Other participants described difficulty in walking to appointments or sitting in waiting rooms following birth: “it was really uncomfortable to sit for half an hour, so by the time I got upstairs, my blood pressure was high” (SM33).
Confidence, communication and knowledge
In general, participants reported high confidence levels when communicating with healthcare professionals: “I felt confident about talking to them about what was going to happen and I felt quite confident about negotiating with them” (SM4). Women strongly articulated the bearing that both adequate and inadequate understanding had upon these interactions. Positive experiences included: “I think having the element of control and knowing what my blood pressure is, um, and learning a bit more about what blood pressure actually is… it’s made me feel more confident when I’ve actually had to speak to them about it” (SM5). Women from the intervention group were explicit that specific knowledge of BP readings was helpful: “I have got control over seeing my readings, so I feel confident discussing them with them” (SM23).
The perception that they were listened to, substantially influenced participants’ experiences of interactions with healthcare professionals. Some participants reported very positive encounters: “a very good thing about her [the GP] was that she was really listening to what I was saying… we were actually collaborating” (UC2). Others’ experiences were more variable: “I got quite irate with a midwife because I felt she wasn’t listening to me” (UC13). A number of participants reflected on negative episodes: “Them listening is a different story… I feel like it was me more talking and them just sort of ticking boxes” (UC34); “I can talk to my doctor about what I think I need, but he seems to overrule me” (UC32).
Women’s views of their GPs’ understanding of HDP varied. Some felt GPs’ knowledge was good, “I think they’re very knowledgeable actually” (SM34), whilst others expressed that they did not expect their GPs to be experts, “GPs … they’re not specialists in everything so it’s hard for them to take confidence” (SM6). One participant acknowledged the difficulties GPs might face in adopting care from the hospital team: “you know the hospital controlled it all… the GP would just say, ‘Well whatever they’ve said’, rather than you know taking the step to say, ‘Right, well let’s have a look and reduce it now’” (SM7). In contrast, some women did convey concern about GPs’ and midwives’ knowledge: “they needed a bit of guidance themselves, the doctors” (UC17).
Concern
The impact, of HDP and their management, on women’s personal anxiety and stress varied markedly. Several women reported very little intrinsic anxiety and very little effect from their condition and its management: “To be honest I didn’t really have any anxiety about it” (SM25). However, others reported this resulting in significant anxiety: “I suffer with anxiety… knowing it was high made me really concerned” (SM5). Similarly relationships with partners, existing children, other family and friends were affected in very disparate ways. A considerable number of women reported little or no negative effects, and several in fact reported strengthening of relationships: “everyone just comes together as well so it’s not all negative; a lot of positives that comes from it as well” (UC33). Multiple women reflected that their partner had suffered considerable stress: “my poor husband’s been through the ringer… he’s more stressed” (UC30). Women also acknowledged the impact of their condition on other children, “she’s seen me get my blood pressure done, probably a bit too much for a four year old” (UC30), and other family members: “Mum always thought I was going to die” (SM15).
A concern expressed about self-monitoring is the potential to increase patients’ anxiety about their health (15). The majority categorically stated that self-management reduced their anxiety: “It was just great having the daily check; I think that made me really calm” (SM6); “It’s reduced my anxiety and put me back in control” (SM26). One participant (SM9) held complex views of her BP management: on the one hand she reported, “it decreased it [my anxiety] as in I didn’t have to drive all these children to the doctors and wait there… Saved me some stress”. However, in stark contrast she also found having a monitor at home stressful: “I think having a doctor there to reassure me makes it easier” and “I had to have it [the monitor] sitting in my room looking at me, and I’m someone who hasn’t… just hates that”. Another participant, who reported suffering with anxiety, provided an alternative perspective: “I thought actually there might be a big negative for me. But no I don’t think it’s made me anxious… I think it’s done the opposite” (SM5).
Several women from the intervention group highlighted that self-management reduced their anxiety, relative to usual care from the GP: “going in to the doctors and things like that, yeah makes it worse for me… if they take it manually you don’t even know what it is; sometimes they don’t even tell you” (SM23); “I felt more relaxed because you let me monitor it at home. Had you made me go to the doctors, might have been a bit more worried perhaps” (SM34). Some did comment on the impacts of the standard care structure: “being told that someone’s coming out at some point today to come and like do something. So, you’re sat waiting in, nor doing something because you want to make sure that it’s OK… It was stressful to be honest” (UC34).
Constraints
Some women reported concerns, often theoretical, about HBPM. Two acknowledged that, had they had problems, they would have wanted direct contact with a healthcare professional: “I think if I found I had very, very strong symptoms and I wanted to speak to a GP I would…” (SM20); “if I wasn’t feeling well I would probably want, every so often still someone anyway” (SM12). Another reflected on the importance of measuring BP correctly: “when you’re doing it yourself to make, you know are you sure you’re doing it right” (UC25).
Two participants highlighted specific practical difficulties with HBPM: “actually it’s very difficult to put a blood pressure cuff on yourself when there’s nobody else at home” (SM5); “because just finding the time to sit quietly to do your blood pressure can be tricky if you’ve got no-one there to hold the baby” (SM31). A minority of women from both groups recognised that whilst they might have preferred self-management, it might not suit everyone: “like a hypochondriac it’s better not to. So I think you need to analyse the patient before” (UC12); “some people do not want to [self-monitor] maybe, or some people are not able to” (UC2); “maybe other people may like the assurance of going to a doctor” (SM25).
Participants encountered variable experiences when interacting with healthcare professionals whilst self-monitoring. Some had very positive experiences, with GPs and midwives proactively asking about readings, and being happy for patients to take ownership: “when speaking to my GP about things, again the self-checking of that it gives them reassurance that you’ve got it rather than just being reliant on the appointments” (SM19). Others, however, thought their GPs felt rather uninvolved: “the GP finding it difficult; not feeling totally informed which was partly about me bringing the paperwork with me” (SM6). Some reported healthcare professionals not trusting HBPM: “I think intrinsically they were a bit sort of dubious about whether I could do it myself and whether I would be doing it accurately” (SM27).
Components of the intervention: participants’ experiences
Women identified specific strengths of this self-management intervention, including the speed of response: “it’s been good getting the quick responses back” (SM6). Women reported that the system was clear when instructing them how to change their medication: “sorting out my medication when the text told me to… so I found that quite good” (SM4). Some women found the reminders helpful: “I ain’t got the best memory, and they kept texting me to remind me” (SM15). Women generally found the telemonitoring services (SMS service and smartphone app) straightforward to setup and use: “they’re really easy to use; it was just the text message every day – really straightforward” (SM11). Participants also reported that the BP monitor was uncomplicated: “the machine’s straightforward” (SM21); “I think the cuff’s easy to use” (SM19).
Over the course of the trial a few isolated issues with self-management did arise. Women reported some quirks with the app, which led to them being unable to read notifications without logging into the website: “alerts come through to say there’s messages, but I can’t actually see where the messages are” (SM17). A small number of participants encountered difficulties with the pre-specified format of the SMS messages initially: “[at] the start, I didn’t notice the codes or… yeah but once that was… it was easy” (SM33).
Quantitative analysis of pre-coded numerical responses
The first part of the semi-structured interviews was administered to both groups, and their summarised responses compared over the trial period (Table 3). Five questions were asked, however, data relating to one question (about the impact on relationships) is not presented, as during analysis an error in how the Likert scale was used by one of the interviewers was identified (only affecting this single question).
Both groups felt more in control of their condition postpartum compared to during pregnancy (pre-randomisation), but at both follow-up time points the intervention group scored this question more highly than did the control group: adjusted difference at four weeks 0.6 (95% confidence interval (CI) 0.2 to 1.1); adjusted difference at six months 0.7 (95% CI 0.3 to 1.2). For the remaining questions no significant differences were seen between groups (Table 3).
The mean scores for questions specific to the intervention group were all high (Table 4), suggesting participants felt the intervention was well suited to managing their BP, straightforward to use and enhanced their lifestyle. Participants were very positive that they would utilise self-management techniques in the future, and would recommend them to friends and family.