Interviews were conducted with seventeen clinicians in fourteen countries, all of whom were medical doctors. No participants dropped out of the study at any stage. The characteristics of the study participants are displayed in Table 1. Two clinicians worked in LICs, ten were from middle-income countries (MICs), and five worked in HICs. Additionally, seven doctors had experience in creating hypertension guidelines.
Table 1
Participant characteristics
Characteristic
|
Number (%)
|
Gender
|
Female
|
5 (29.4)
|
Male
|
12 (70.6)
|
Countries (n = 14)
|
Azerbaijan
|
1 (5.9)
|
China
|
1 (5.9)
|
Hungary
|
2 (11.8)
|
India
|
2 (11.8)
|
Jamaica
|
1 (5.9)
|
Kyrgyz Republic
|
1 (5.9)
|
Nepal
|
2 (11.8)
|
Nigeria
|
1 (5.9)
|
South Africa
|
1 (5.9)
|
Sudan
|
1 (5.9)
|
Uganda
|
1 (5.9)
|
United Arab Emirates
|
1 (5.9)
|
United Kingdom
|
1 (5.9)
|
United States
|
1 (5.9)
|
National income level of country
|
Low
|
2 (14.3%)
|
Lower middle
|
4 (28.6%)
|
Upper middle
|
5 (28.6%)
|
High
|
6 (28.6%)
|
Years of healthcare experience
|
< 10
|
7 (41.2)
|
10–19
|
3 (17.6)
|
20–29
|
1 (5.9)
|
30–39
|
4 (23.5)
|
Not recorded
|
2 (11.8)
|
Clinical specialism
|
Cardiologist
|
6 (35.3)
|
Clinical physiologist
|
1 (5.9)
|
General practitioner
|
5 (29.4)
|
General practitioner trainee
|
2 (11.8)
|
Internal medicine trainee
|
2 (11.8)
|
Nephrologist
|
1 (5.9)
|
Healthcare setting
|
Hospital
|
12 (70.6)
|
|
Rural
|
2 (11.8)
|
Medium-sized town
|
2 (11.8)
|
Urban
|
4 (23.5)
|
Capital city
|
4 (23.5)
|
General practice
|
5 (29.4)
|
|
Rural
|
1 (5.9)
|
Urban
|
1 (5.9)
|
Capital city
|
3 (17.6)
|
The three main themes identified corresponded to the levels at which influencing factors were perceived to be operating (Fig. 1). These themes were: 1) Health system centred influences, 2) Healthcare worker centred influences, 3) Patient centred influences.
1) Health system centred influences
Accessibility of resources relating to the health system was discussed in terms of barriers or facilitators to the use of hypertension guidelines. Common factors elucidated were accessibility of treatment (including availability of equipment and antihypertensives), human resources, and access to healthcare settings.
a. Accessibility of equipment
Many healthcare workers explained that their ability to follow hypertension guidelines for diagnosis and management was heavily influenced by the equipment and investigations available in their healthcare setting. Some doctors working in LMICs reported low availability of diagnostic and monitoring tools such as home BP monitoring machines. This sometimes affected guideline use as doctors felt that they could not adequately monitor patients’ hypertension, leading to a variety of consequences such as delayed diagnosis and late patient presentation to health services with complications.
A number of clinicians from lower MICs expressed difficulties with diagnosing certain comorbid conditions that were accounted for in their hypertension guideline treatment algorithms, due to a scarcity of diagnostic resources in their healthcare setting. A doctor working in a rural hospital in a lower MIC expressed his inability to follow the chronology of antihypertensive drug classes for CKD patients:
“In the guidelines it has been mentioned that for patients with chronic kidney disease we have to follow a different [treatment] pattern. But where I’m working, I can’t generally identify the individuals with chronic kidney disease. I can’t separate them.”
b. Accessibility of medications: availability and affordability
The availability and affordability of medications recommended by guidelines was deemed by most clinicians to be influencing what drugs they could prescribe, with availability of medications in pharmacies and the affordability of antihypertensives the main contributors to accessibility. Accessibility of medications was discussed at both the level of the healthcare system and the patient, due to patients’ ability to afford medication relying on health system infrastructure and insurance policies in addition to their own finances. Most doctors reported no issues with accessing drug classes recommended by guidelines, but some clinicians in both HICs and LMICs expressed issues with their hospital’s restocking of drugs and unavailability of drugs considered less cost-effective.
“In our set up amlodipine is much more expensive than nifedipine. So, most of the time we are tempted to prescribe nifedipine because it’s cheaply available and more affordable for the patient.” (GP in a LIC)
The majority of clinicians from LMICs expressed the view that insurance policies dictated whether patients could afford many medications, also feeling limited by the range of antihypertensives that were covered by governmental free healthcare. A GP from an upper MIC reflected upon the factors influencing the medications prescribed for her patients: “The choice of medication usually would be dependent on which setting the patient goes to and what the patient can afford.” A few clinicians in European HICs found the European Society of Cardiology/European Society of Hypertension (ESC/ESH) recommendation for initiating single-pill combination therapy challenging due to low availability in pharmacies, which they felt was a result of its shorter shelf-life and lower profitability for pharmacies.
c. Workforce
A problem identified by hospital specialists practicing in LMICs was the limited number of specialist doctors in their settings. A consequence was that they had limited time to counsel patients and could not ensure close adherence to the guidelines as a result. An additional difficulty was the shortage of senior colleagues in rural hospitals, expressed by a few clinicians in both LMICs and HICs. Doctors felt they could not easily seek advice when faced with complex patients that hypertension guidelines did not cater for. A nephrologist from a lower MIC reflected on the challenges:
“Well, it’s quite difficult to use guidelines when you are working in a rural centre. Because number one, the best practice is not there…so the [clinical] experience will not be there. And unfortunately, you don’t have any senior colleagues in these areas.”
d. Access to healthcare settings
Healthcare workers across all national income settings reported distance to GP surgeries or hospitals, the time taken to attend doctors’ appointments, and the cost of travel for patients as factors influencing patient compliance with treatment. Some clinicians regarded poor national healthcare infrastructure as the cause, especially in rural or semi-rural areas. A GP from a European HIC explained how far rural patients’ far travel to reach specialist centres placed greater pressure on rural GPs:
“How far a doctor is, how far they have to travel to get an ultrasound or to get a cardiology specialist. In the countryside it’s much, much worse and there’s a higher challenge for GPs to solve their problems in general.”
2) Healthcare worker centred influences
Clinicians regarded generic guideline features such as usability and trust in the evidence-base that informs recommendations as important influences. Factors specific to clinicians such as knowledge and beliefs, and relevance to patient populations were deemed important.
a. Usability of guidelines
Guideline usability was identified by all doctors as an important influencing factor. Many doctors expressed the importance of format, with a preference for brief, simplified guidelines. The ease of use was synonymous with their ability to quickly read the guideline and refer back to it, as most doctors reported having insufficient time to read through long, complicated texts due to heavy workloads and the plethora of guidelines that exist for different medical conditions. This was felt by both GPs and hospital specialists across all national income settings.
The majority of participants expressed that they had simplified and shortened hypertension guidelines to make them easier to understand and use by other healthcare professionals regularly managing hypertensive patients within their department. Language of guidelines was a barrier identified by a few clinicians from LMICs only, especially in rural settings where English was often not spoken by clinicians. They recognised this as a barrier for non-English speaking doctors’ ability to access international guidelines, sometimes mitigated through its translation into the national language.
b. Trust in guidelines
Most participants expressed a preference for international guidelines over national or local guidelines due to having a greater level of trust in how they were formed and their subsequent reliability. This appeared to hinge on the high value placed on evidence-based medicine and rigorous scientific trials, often from HICs, that formed international guideline recommendations. The importance of strength of evidence was manifested by some participants’ (all of whom were hospital specialists from HICs) disapproval of the 2017 ACC/AHA guideline’s lowered threshold for diagnosing hypertension, despite its use of HIC level data:
“We think that the American guideline was a bit too quickly released and it was not really adjusted for the GP’s everyday practice… so we thought that it was wiser to stay with the European guideline.” (GP from a European HIC)
It was also perceived as having too small an evidence-base to substantiate a diagnostic change of such significance, as explained by a HIC cardiologist:
“We think it was a little bit too slim, or a little bit too early to follow this based on only one trial. We need many more trials before we go for this severe change.”
Increased trust in international guidelines was contributed to by how regularly they were updated, which most participants recognised as crucial to maintaining current, up-to-date clinical practice. All participants from LICs and lower MICs recognised that their national guidelines were often outdated or non-existent.
c. Knowledge, attitudes and views about guidelines’ purpose
Clinicians’ views about what role guidelines played in clinical practice influenced their use. They were recognised as reference tools for standardising clinical practice as many doctors were aware of variation in hypertension management within their country. Guidelines were seen to positively contribute to consistent patient care across GP and hospital settings, as well as forming a useful reference point for their personal practice.
“The challenge we have is that when we have physicians, new graduates who are coming out to the field, they sometimes have challenges if they meet diseases they have never managed before… if you are looking at some references, it also gives you confidence that you are doing the right thing.” (GP from an African MIC)
A handful of participants said they followed national guidelines because they had been adapted from international or other national guidelines by a governmental health body or national hypertension society. Therefore, they felt that they had increased appropriateness for their local setting. Many GPs across income settings referred to the idea of growing familiarity with guidelines developing through repeated use over time. This meant they only explicitly referred to guidelines in cases which were less routine for them or that they were less clinically familiar with, but implied implicit use of the guideline through internalising its content. A GP from an upper MIC explained:
“Over time, there are guidelines you have become comfortable with, the medications that work, so it kind of becomes second nature…so, the only time you would need to go back to the guidelines is if you’re having difficulty controlling the blood pressure.”
d. Relevance to patient populations
Almost all doctors found difficulty in applying guidelines to certain patient subgroups. They identified the elderly, very young, patients with multiple comorbidities, polypharmacy, resistant hypertension, hypertensive emergencies, rare diseases, patients presenting with end-organ damage, non-compliant patients and specific ethnic populations, such as South Asian and Afro-Caribbean, as very challenging. Many doctors reported seeking alternative information sources to aid decision-making, including asking senior colleagues, reading published papers in medical journals, and searching the internet for similar cases. Some clinicians emphasised the importance of acting in patients’ best interests and felt that holistic patient management was crucial in such circumstances. Ethnicity-specific challenges arose in terms of the applicability of hypertension risk scores and the choice of medication at each treatment step. Many clinicians believed insufficient trial level data for certain ethnic subgroups meant guidelines could not be made as relevant to their particular population.
3) Patient centred influences
Clinicians recognised a disparity in the lifestyle recommendations provided by hypertension guidelines and their perception of patients’ willingness or ability to enact lifestyle recommendations. These were discussed in terms of patient motivations and health literacy. Affordability of treatment was inextricably bound to the structure and provision of the health system, limiting guideline use in certain patient circumstances.
a. Clinician perceived patient motivations and health literacy
Almost all doctors across all resource settings expressed difficulties in engaging patients with lifestyle advice provided by hypertension guidelines, often framed as patients’ unwillingness to attempt or maintain lifestyle improvements, or an inadequate understanding of hypertension, its risk factors and sequelae.
Doctors’ perception of patients as unwilling or resistant to lifestyle advice represented a tension between doctors and patients in the context of guideline recommendations. Although most doctors felt that they were able to communicate the lifestyle recommendations provided by guidelines to their patients, they postulated various reasons as to why advice was challenging to follow, most of which implied fault of the patient: low motivation and commitment to making healthier choices and monitoring BP at home, apathy, poor acceptance of diagnosis, and reluctance to diverge from cultural norms. However, some clinicians alluded to the influence of wider determinants of health, such as education, rather than the fault the individual.
Most clinicians felt they regularly encountered patients who were misinformed about hypertension treatment’s preventive rather than curative nature, and had poor understanding of the importance of reducing risk factors. The perceived insufficient knowledge of hypertension was often referred to by clinicians as ‘poor health literacy’ which the media, as well as socio-economic factors such as educational attainment, contributed to. Low educational attainment contributing to poor patient health literacy was expressed by clinicians from LMICs or those working in rural settings, often resulting in late presentation to health services.
The consequences of fundamental gaps in patients’ knowledge about hypertension affected clinicians’ use of guidelines in two main ways. Some clinicians expressed that applying guidelines became a lengthy process when patients were uninformed or misinformed about the condition or the implications of treatment as they had to spend time addressing these. Secondly, a handful of clinicians in lower MICs decided to create initiatives that addressed the barriers as a prior step to the use of hypertension guideline lifestyle recommendations. A South African GP outlined a personal initiative to address lifestyle modifications that acknowledged the social and cultural context of their clinic’s local setting:
“We’ve created support groups for uncontrolled hypertensive and obese people where they come together every Thursday…I put together an approach that’s based on the township reality, the reality of the people who live there. So they kind of support each other and help each other lose weight and give each other advice.”
b. Accessibility of medications: availability and affordability
Patients’ ability to afford the prescribed antihypertensives was an important influencing factor identified in most resource settings. Some clinicians stated expensive health insurance as limiting patients’ compliance with treatment and felt that they could not achieve best practice, deviating from guideline recommendations. A consequence of cost constraints, raised by a cardiologist from a MIC, was that some patients bought the cheapest version of a medication, which “maybe doesn’t work well because it is very cheap and is not so effective as a branded drug or a generic with a higher price.” Therefore, the recommendation of certain drugs in the guideline can be viewed as limiting its usefulness within clinicians’ settings.