Viewing blood pressure through the eyes of a patient: a mixed-method study at a student-run safety-net clinic

Vritti Gupta1, Lakshmi Venkitachalam1, Karen Williams1, Angela Barnett1,2, Miranda Huffman1,2

1UMKC School of Medicine; 2Truman Medical Centers

Introduction High blood pressure (BP) is a leading

risk factor for cardiovascular disease and affects approximately 68 million Americans

This burden is disproportionately high among patients of low socio-economic status

Objective To understand the knowledge,

attitudes and perceived barriers to optimal BP control among patients seeking care at Sojourner Free Health Clinic (SFHC), a weekend urban safety-net clinic

Methods Study Sample

Inclusion Criteria: o Patients ≥ 18 years ageo Documented history of high BP

(Systolic BP ≥ 140 mmHg or Diastolic BP ≥90 mmHg)

Exclusion Criteria: History of mental illness

Data Collection and Analysis

Semi-structured questionnaire with open-ended questions

Audio-recording of the interviews were transcribed and thematically analyzed

Results Between 08/25/13 and 11/10/13, ten

patients were interviewed for a mean (SD) of 13.4 (5.4) minutes

Quantitative Characteristics: N (%)* *unless otherwise indicated

Qualitative Responses: N patients Attributed high BP to o Hereditary 7 o Lifestyle behavior 4 o Emotions 4

8 patients identified SFHC as the primary source for medications

3 out of 6 patients reported that lifestyle modifications were not addressed during the current visit

4 patients reported receiving informational handouts; 3 of these patients could not recall the information

Summary and Conclusion Knowledge and attitudes regarding the high BP

varied among patients seeking care at the SFHC

Preliminary results highlight opportunities for improving the delivery of care

TABLE 1: Qualitative analysis of participant responses related to High BP (N responses)

Focus areas Exemplar Quotes

What does HBP mean to them?

• Negative Consequences (n=4)

“Death sentence“, “Increases the chances of a stroke"; "Could cause heart disease"

• Physical symptoms, lack of control (n=1)

"Your head hurts a lot sometimes, when it starts, pills don’t help, you just have to wait until it goes away."

What happens if blood pressure is not under control?• Fear of death (n=2) “If it’s not treated, then I could die” • Health complications

(n=6)“High blood pressure affects your internal organs, so that if it’s too high it can damage them, shut them down"

• Symptoms (n=2) "It can cause dizziness”;”as a man, it can affect your manhood a little bit because the blood doesn’t flow the way it should"

• No perceived cardiovascular risk (n=1)

"I do not associate a heart condition... with high blood pressure per se"

Why do they think they have HBP?• Hereditary (n=7) “Hereditary, stress, number of things, I assume"

• Widespread (n=1) “Almost like an epidemic or something of some sort, because a lot people have had it"

Emotions (n=4) "I do notice that when I’m stressed, my blood pressure seems to go up….don’t have to get upset because that plays a factor too"

• Lifestyle/Behaviors (n=4) “Eating a lot of salty foods...Not eating and exercising…days at a time drinking and not taking my medication. Stress. Cigarette, alcohol, drugs"

• Denial (n=1) "I do like eating potato chips, but I don’t think that gave me high blood pressure"

Do you know of any lifestyle changes that need to be made to control HBP?• Stress (n=4) "Stay away from stress, people who give me stress"

• Diet (n=1) “Stay away from certain spices, or sugar, food that’s high in different negative things”

• Alcohol (n=1) "I imagine drinking affects it too"• Physical Activity (n=1) "You have to get out there and walk and if you can

walk for 40 minutes per day, that’s a good thing."

• Workload (n=1) "Basically I have other problems... with diabetes ..get my weight down... so much goes not maintaining your high blood pressure and diabetes... trying to diet and exercise ...so I might be able to live a couple more years"

Next steps Evaluate student perception of delivery of care

in this vulnerable cohort Improve discharge planning process Tailor informational handouts to improve

retention and recall by patients

TABLE 2: Domains related to adherence with prescribed practices for BP management

Domain Exemplar Quotes

• Misinformation "I do not rely upon this place [SJC] to have my BP checked. I do not feel I need to need to check it [BP]. “

• Burden of Management

“Don’t follow it to the book...when I’m hungry I eat…isn’t always healthy…certain foods that are good for are potentially higher priced”

• Denial “When I’m ready to quit smoking, I’ll stop…doesn’t affect me…not coughing…not wheezing…not out of breath...if it starts bothering me instantly, I’ll stop.."

• Self-efficacy ”Watch my sodium intake…do a little cardio….trying to watch my soda pop intake…cut back on the alcohol. I’ve never done drugs, so I don’t have that problem."

• Unadaptable "No. Because food just don’t taste right without salt."

• Accountability "I’m in a situation and I know what causes my situation and you either do something about it or you just fall off and die."

• Avoid bad outcomes

"Yes, I don’t want to get on dialysis."

Acknowledgement: Study funded by Sarah Morrison

Student Research Award.

Age ≥50 years 9 (90%)

Male 9 (90%)

African American 8 (80%)

Some college education 6 (60%)

Body mass index ≥30 kg/m2 7 (70%)

Smoking or Alcohol use 8 (80%)

Family history of high BP 6 (60%)

Pharmacological therapy 10 (100%)

Systolic BP, mean (SD) mmHg 137 (18)

Diastolic BP, mean (SD) mmHg 89 (10)

Systolic BP ≥140 or Diastolic BP ≥ 90 mmHg

6 (60%)