Ulrika Bengtsson

Developing an interactive mobile phone self-report system for self-management of hypertension. Part 1 : Patient and professional perspectives

Abstract Low adherence remains a struggle in hypertension management, despite improvement efforts. Presuming that increased patient participation is a possible approach, we collaborated with patients and healthcare professionals to design a self-report system to support self-management. The study aimed to explore and describe relevant aspects of hypertension and hypertension treatment, for use in the development of an interactive mobile phone self-report system. It further aimed to suggest which clinical measures, lifestyle measures, symptoms and side-effects of treatment would be meaningful to include in such a system. Five focus group interviews were performed with 15 patients and 12 healthcare professionals, and data was analysed using thematic analysis. Patients suggested trust, a good relationship with caregivers, and well-being as important aspects of hypertension self-management. Furthermore, they regarded blood pressure, dizziness, stress, headache and tiredness as important outcomes to include. Patients sought to understand interconnections between symptoms and variations in blood pressure, whilst healthcare professionals doubted patients’ ability to do so. Healthcare professionals emphasized accessibility, clear and consistent counselling, complication prevention and educational efforts. The study presents aspects of importance for follow-up to understand the interplay between blood pressure and daily life experiences for patients with hypertension.

Phases in development of an interactive mobile phone-based system to support self-management of hypertension

Hypertension is a significant risk factor for heart disease and stroke worldwide. Effective treatment regimens exist; however, treatment adherence rates are poor (30%–50%). Improving self-management may be a way to increase adherence to treatment. The purpose of this paper is to describe the phases in the development and preliminary evaluation of an interactive mobile phone-based system aimed at supporting patients in self-managing their hypertension. A person-centered and participatory framework emphasizing patient involvement was used. An interdisciplinary group of researchers, patients with hypertension, and health care professionals who were specialized in hypertension care designed and developed a set of questions and motivational messages for use in an interactive mobile phone-based system. Guided by the US Food and Drug Administration framework for the development of patient-reported outcome measures, the development and evaluation process comprised three major development phases (1, defining; 2, adjusting; 3, confirming the conceptual framework and delivery system) and two evaluation and refinement phases (4, collecting, analyzing, interpreting data; 5, evaluating the self-management system in clinical practice). Evaluation of new mobile health systems in a structured manner is important to understand how various factors affect the development process from both a technical and human perspective. Forthcoming analyses will evaluate the effectiveness and utility of the mobile phone-based system in supporting the self-management of hypertension.

Improved Blood Pressure Control Using an Interactive Mobile Phone Support System.

This explorative, longitudinal study evaluated the effect of the daily use of a mobile phone‐based self‐management support system for hypertension in reducing blood pressure (BP) among 50 primary care patients with hypertension over 8 weeks. The self‐management system comprises modules for (1) self‐reports of BP, pulse, lifestyle, symptoms, and well‐being; (2) delivery of reminders and encouragements; and (3) graphical feedback of self‐reports. Daily use of the support system significantly reduced BP (systolic BP −7 mm Hg, diastolic BP −4.9 mm Hg) between baseline and week 8, with daily improvements leveling off as the study progressed. Three homogenous subsets of patients were identified who, despite different initial BP levels, showed similar decreases in BP during the study, indicating that patients benefited irrespective of baseline BP. In showing significant reductions in BP, our results suggest that the self‐management support system may be a useful tool in clinical practice to help patients self‐manage their hypertension.

Developing an interactive mobile phone self-report system for self-management of hypertension. Part 2: Content validity and usability

Abstract Self-management support tools using technology may improve adherence to hypertension treatment. There is a need for user-friendly tools facilitating patients’ understanding of the interconnections between blood pressure, wellbeing and lifestyle. This study aimed to examine comprehension, comprehensiveness and relevance of items, and further to evaluate the usability and reliability of an interactive hypertension-specific mobile phone self-report system. Areas important in supporting self-management and candidate items were derived from five focus group interviews with patients and healthcare professionals (n = 27), supplemented by a literature review. Items and response formats were drafted to meet specifications for mobile phone administration and were integrated into a mobile phone data-capture system. Content validity and usability were assessed iteratively in four rounds of cognitive interviews with patients (n = 21) and healthcare professionals (n = 4). Reliability was examined using a test–retest. Focus group analyses yielded six areas covered by 16 items. The cognitive interviews showed satisfactory item comprehension, relevance and coverage; however, one item was added. The mobile phone self-report system was reliable and perceived easy to use. The mobile phone self-report system appears efficiently to capture information relevant in patients’ self-management of hypertension. Future studies need to evaluate the effectiveness of this tool in improving self-management of hypertension in clinical practice.

Patient contributions during primary care consultations for hypertension after self-reportingvia a mobile phone self-management support system

Abstract Objective: This paper reports on how the clinical consultation in primary care is performed under the new premises of patients’ daily self-reporting and self-generation of data. The aim was to explore and describe the structure, topic initiation and patients’ contributions in follow-up consultations after eight weeks of self-reporting through a mobile phone-based hypertension self-management support system. Design: A qualitative, explorative study design was used, examining 20 audio- (n = 10) and video-recorded (n = 10) follow-up consultations in primary care hypertension management, through interaction analysis. Clinical trials registry: ClinicalTrials.gov NCT01510301. Setting: Four primary health care centers in Sweden. Subjects: Patients with hypertension (n = 20) and their health care professional (n = 7). Results: The consultations comprised three phases: opening, examination and closing. The most common topic was blood pressure (BP) put in relation to self-reported variables, for example, physical activity and stress. Topic initiation was distributed symmetrically between parties and BP talk was lifestyle-centered. The patients’ contributed to the interpretation of BP values by connecting them to specific occasions, providing insights to the link between BP measurements and everyday life activities. Conclusion: Patients’ contribution through interpretations of BP values to specific situations in their own lives brought on consultations where the patient as a person in context became salient. Further, the patients’ and health care professionals’ equal contribution during the consultations showed actively involved patients. The mobile phone-based self-management support system can thus be used to support patient involvement in consultations with a person-centered approach in primary care hypertension management Key points   The clinical consultation is important to provide opportunities for patients to gain understanding of factors affecting high blood pressure, and for health care professionals to motivate and promote changes in life-style. This study shows that self-reporting as base for follow-up consultations in primary care hypertension management can support patients and professionals to equal participation in clinical consultations. Self-reporting combined with increased patient–health care professional interaction during follow-up consultations can support patients in understanding the blood pressure value in relation to their daily life. These findings implicate that the interactive mobile phone self-management support system has potential to support current transformations of patients as recipients of primary care, to being actively involved in their own health.

Experiences, expectations and challenges of an interactive mobile phone-based system to support self-management of hypertension : patients' and professionals' perspectives

Background A well-controlled blood pressure (BP) reduces cardiovascular complications. Patient participation in care using technology may improve the current situation of only 13.8% of adults diagnosed with hypertension worldwide having their BP under control. Objective The objective of this study was to explore patients’ and professionals’ experiences of and expectations for an interactive mobile phone-based system to support self-management of hypertension. Methods The self-management system consists of: 1) a mobile phone platform for self-reports, motivational messages and reminders; 2) a device for measuring BP and 3) graphical feedback of self-reports. Patients diagnosed with high BP (n=20) and their treating professionals (n=7) participated in semi-structured interviews, after 8 weeks use of the system in clinical practice. Data were analyzed thematically. Results The self-reporting of BP, symptoms, medication use, medication side effects, lifestyle and well-being was perceived to offer insight into how daily life activities influenced BP and helped motivate a healthy lifestyle. Taking increased responsibility as a patient, by understanding factors affecting one’s well-being, was reported as an enabling factor for a more effective care. Based on the experiences, some challenges were mentioned: for adoption of the system into clinical practice, professionals’ educational role should be extended and there should be a reorganization of care to fully benefit from technology. The patients and professionals gave examples of further improvements to the system, for example, related to the visualization of graphs from self-reports and an integration of the system into the general technical infrastructure. These challenges are important on the path to accomplishing adoption. Conclusion The potential of a more autonomous, knowledgeable and active patient, through use of the interactive mobile system would improve outcomes of hypertension treatment, which has been desired for decades. Documentation and visualization of patients’ self-reports and the possibilities to communicate these with professionals may be a significant resource for person-centered care.

Links between blood pressure and medication intake, well-being, stress, physical activity and symptoms reported via a mobile phone-based self-management support system : a cohort study in primary care

Objectives To explore relationships between patients’ self-monitoring of blood pressure (BP) and their concurrent self-reports of medication intake, well-being, stress, physical activity and symptoms. Design This study is a secondary analysis of a prospective study exploring the 8-week effectiveness of a mobile phone-based self-management support system for patients with hypertension. Setting Four primary healthcare centres situated in urban and suburban communities in Sweden. Participants 50 patients undergoing treatment for hypertension. Primary and secondary outcome measures Associations between systolic (SBP) and diastolic blood pressure (DBP) and 10 self-report lifestyle-related variables were analysed using linear mixed effects modelling. Results Medication intake, better well-being, less stress and greater physical activity were associated variously with lower same-day SBP and DBP. The single strongest association was found between medication intake and SBP, where failure to take medications was associated with an estimated 7.44 mm Hg higher SBP. To a lesser degree, medication intake was also associated with DBP, where DBP was 4.70 mm Hg higher in cases where medications were not taken. Well-being and stress were consistently associated with SBP and DBP, whereas physical activity was associated with only SBP. None of the symptoms—dizziness, headache, restlessness, fatigue or palpitations—were significantly associated with BP. Conclusions Our findings that BP was associated with patients’ BP management behaviours and experiences of well-being and stress, but not symptoms suggest that enabling persons with hypertension to monitor and track their BP in relation to medication intake, physical activity, well-being, stress and symptoms may be a fruitful way to help them gain first-hand understanding of the importance of adherence and persistence to treatment recommendations. Trial registration number NCT01510301; Pre-results.