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Behavioural Change for Hypertension

Hypertension (or high blood pressure) is a common chronic condition, with 47% of people in the United States1, 26% in the United Kingdom2, and 34% of people in Australia3 living with this diagnosis. Florence can support patients and clinicians at all stages of hypertension management by supporting the performance of healthy lifestyle and self-management behaviours. In this blog, I outline Florence Intelligent Health Messaging as a behaviour change intervention to support patients with hypertension.  The management of hypertension is also key to the management of patients with multiple chronic conditions (“MCC”).  I will cover the use of Florence in managing MCC in a separate blog.

Hypertension as a ‘behavioural’ problem

A ’behavioural problem’ is one that is caused by the performance, or lack of performance, of behaviours. Hypertension is a good example of such a problem, as the risk factors for elevated blood pressure can be attributed to a range of lifestyle behaviours, either alone or in combination. Hypertension can be managed by modifying these behaviours as well as by adding in a new behaviour, medication taking, as this is the primary management strategy. However, it is also well established that upon receiving a diagnosis of hypertension, many patients do not initiate, or maintain, the behavioural changes required to control their blood pressure. Thus, hypertension management, becomes a behavioural problem, and this is illustrated in Figure 1.

Hypertension

Behavioural solutions for patients

Changing behaviours is difficult, and with a diagnosis of hypertension comes advice to change several behaviours all at once. All the behaviours linked to hypertension are habitual in nature. They are behaviours which people have performed every day for most of their lives and changing them will be hard. Some patients will face insurmountable barriers to changing behaviours. Trying and failing at one behavioural change may also put patients off even attempting any of the others. And this is a problem, as tackling any one of these behaviours can make a small but significant impact on blood pressure control (see Table 1).

Behaviour or outcomeAnticipated BP reduction
Weight lossReduction in 1mmHg of both SBP and DBP for each 1kg lost up to ideal body weight
Healthy diet (DASH)Up to 11 mmHg reduction in SBP
Reduced intake of dietary sodiumUp to 5 mmHg reduction in SBP for each 1g reduction
Enhanced intake of dietary potassiumUp to 4 mmHg reduction in SBP for achieving 3.5-5g per day threshold
Physical activityUp to 5 mmHg reduction in SBP for achieving 90-150 minutes/ week of aerobic exercise
Physical activityUp to 4 mmHg reduction in SBP for achieving 90-150 minutes/ week of dynamic resistance exercise
Alcohol intake3-4 mmHg reduction in SBP with complete abstinence or intake limited to <2 standard drinks per day with 2 days off per week
DASH: Dietary Approaches to Stop Hypertension; DBP: Diastolic Blood Pressure; SBP: Systolic Blood Pressure
Table 1 Behaviors and outcomes on blood pressure adapted from World Heart Federation Roadmap for Hypertension4

Florence as a behaviour change tool

Florence’s predominant mechanism for management of hypertension is supporting patients to perform the behaviour of self-monitoring of blood pressure as part of Home Blood Pressure Monitoring (HBPM) and providing feedback on what these results mean. Of course, this is the introduction of another behaviour, asking patients to use a new piece of equipment, understand the results, and report these using our SMS based system. We’ve also considered this, and the automated feedback that Florence provides, means that patients are supported to take on this new behaviour. Our analysis has found that 95% of patients (N=763) feel confident taking their blood pressure at home with support from Florence.

Confidence

This is important, because completing this HBPM results in two further mechanisms. Providing BP readings to clinicians, supports them to perform their own care management behaviour(s), for example providing advice to patients or changing a medicine.

“Significantly more [medication] changes, 0.31 vs 0.08 were made to the medications of [Florence] intervention patients, compared with [usual care] control patients over the 3-month program.”
Extract from AIM Evaluation by Cottrell et al.5 (UK)

With Florence, if I’ve got a patient on my dashboard, I know I’m going to see that patient, I’m going to follow up with them. It’s reassuring for patients too – if they’ve got reminders, they know what they’re supposed to be doing.”
Matthew Davies, Clinical Pharmacist at NHS Bedfordshire, Luton and Milton Keynes Integrated Care Board6 (UK)

The second mechanism following the performance of the self-monitoring of blood pressure behaviour (and sending this to Florence) is that it provides feedback to the patient. This may cause the patient to engage in or change a range of other behaviours.

“Flo engages the patient in their own health management. It provides feedback immediately, the patient doesn’t have to wait for me to text them. They can make pre-determined adjustments to their treatment plan, whilst still keeping me informed.”
Ruth Tainter, Nurse Practitioner at Coastal Health Center, Ellsworth Maine7 (US)

One of these could be to prompt the patient to ask their clinician for help to control their blood pressure, which also supports clinician behaviours. Receiving feedback of having higher than normal blood pressure is also likely to increase motivation to perform blood pressure-lowering behaviours such as quitting smoking, increasing physical activity, making dietary changes, adjusting alcohol intake, or taking their antihypertensive medication. Our data analysis shows that 91% of patients feel more confident that they understand their blood pressure when they use Florence to support HBPM.

“Florence reminders are also very useful in following exercise and diet.”
Patient feedback from Sandwell and West Birmingham Case Study8

Slide1

Importance of Patient Engagement

As with all digital health tools, these behavioural changes cannot be achieved if patients do not engage. Looking at our Florence data, we know that our solution is highly engaging and acceptable for patients, leading to a much higher likelihood of achieving patient behavioural change.

First, patients found our SMS-based solution easy to use, with 97% of patients (N=7,525) agreeing that they found Florence easy to use for reporting HBPM readings for hypertension.

Slide5

Patients also report that they prefer to send these readings using Florence, rather than attend the practice to get their blood pressure checked in clinic, with 91% (N=901) preferring this method of care delivery.

“Doing the BP at home is less stressful as it is a more relaxed environment.”
Patient feedback from Sandwell and West Birmingham Case Study8

Slide3

Overall, we have found that 96% of patients (N=1,381) would recommend Florence to friends and family to support hypertension.

Slide4

Implications for multiple chronic condition management

Hypertension is also a well-established causative factor for many other long-term conditions, such as ischemic heart disease, chronic kidney disease, and heart failure. It is also commonly co-morbid with diabetes.

With increasing numbers of people living with multiple chronic conditions, it’s no longer enough to offer a digital health solution for just one chronic condition. The good news is that taking a behavioural approach helps us, as the behaviours targeted here for hypertension have much wider health benefits and a synergistic effect on co-morbid conditions. And because Florence is an extremely flexible digital health tool, we can work towards a holistic approach to chronic care management to improve outcomes across multiple chronic conditions simultaneously. More on that, in the next blog!

References

  1. CDC. Hypertension Prevalence in the U.S. | Million Hearts®. Centers for Disease Control and Prevention. Published March 22, 2021. Accessed March 28, 2023. https://millionhearts.hhs.gov/data-reports/hypertension-prevalence.html
  2. Prevalence | Background information | Hypertension | CKS | NICE. Accessed March 28, 2023. https://cks.nice.org.uk/topics/hypertension/background-information/prevalence/
  3. High blood pressure, High blood pressure. Australian Institute of Health and Welfare. Published July 19, 2019. Accessed March 28, 2023. https://www.aihw.gov.au/reports/risk-factors/high-blood-pressure/contents/high-blood-pressure
  4. Jeemon P, Séverin T, Amodeo C, et al. World Heart Federation Roadmap for Hypertension – A 2021 Update. Glob Heart. 2021;16(1):63. doi:10.5334/gh.1066
  5. Cottrell E, Chambers R, O’Connell P. Using simple telehealth in primary care to reduce blood pressure: a service evaluation. BMJ Open. 2012;2(6):e001391. doi:10.1136/bmjopen-2012-001391
  6. Archer-Williams A. “The key to adopting new technology is inclusivity” Dr Jonathan Serjeant and Matthew Davies on implementing Florence in Bedfordshire. Health Tech Newspaper. Published March 22, 2023. Accessed April 4, 2023. https://htn.co.uk/2023/03/22/the-key-to-adopting-new-technology-is-inclusivity-dr-jonathan-serjeant-and-matthew-davies-on-implementing-florence-at-blmk-icb/
  7. Diabetes and Hypertension management in Maine USA – Generated Health. Accessed April 4, 2023. https://generatedhealth.com/video/diabetes-and-hypertension-management-in-maine-usa
  8. Chronic Disease Management: Providing a “convenient” and “relaxed environment” to help patients stabilise blood pressure – Type 1 and 2 Diabetes and Hypertension – Generated Health. Published May 30, 2018. Accessed April 4, 2023. https://generatedhealth.com/chronic-disease-management-stabilise-blood-pressure
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