Developing the evidence base for a digital intervention to enhance adherence to medication in people with hypertension
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Background. Hypertension is a chronic condition in which the blood vessels have persistently raised pressure. It is a major modifiable risk factor for both cardiovascular and cerebrovascular disease. Hypertension is estimated to affect one billion people worldwide and is therefore a global health challenge. The pharmacological treatment of hypertension has led to substantial benefits in the prevention of morbidity and mortality from cardiovascular and cerebrovascular disease. However, despite their established efficacy, there is a significant problem of non-adherence to anti-hypertensive medications in those diagnosed and prescribed this treatment; therefore the effectiveness of current medications is sub-optimal. Traditionally, intervention to enhance adherence to anti-hypertension have been delivered face to face or over the telephone. Digital interventions, such as those delivered via smartphone apps, offer a new, scalable and potentially cost-effective way to improve adherence to anti-hypertensive medications. However as the growth of these platforms has been relatively recent, little is known about the development, acceptability, usability and feasibility of these type of interventions. Aim. The aim of this research is to develop the evidence base for a digital intervention to enhance medication adherence in people living with hypertension. Methods. The studies conducted in this research were based on the development phase of the UK Medical Research Council Framework for developing complex interventions. In the first study a systematic review and meta-analysis was conducted to identify evidence base related to interventions to enhance adherence in hypertension. In order to characterise the technology base, the second study was a content analysis of smartphone apps to enhance medication adherence. Two qualitative studies were then conducted, the first with GPs and the second with patients with hypertension in order to explore their thoughts and views around using a smartphone app to manage their medication adherence. Thematic analysis was conducted in both these studies. Findings. The systematic review found tentative evidence to suggest that medication adherence interventions significantly lower blood pressure values. However, there was substantial heterogeneity amongst the included RCTs and many potential biases as the number of low risk of bias studies was limited. The content analysis of existing mobile phone applications highlighted a lack of behavioural theory and evidence integrated into commercially available medication adherence apps. Participants in both qualitative studies (GPs and patients with hypertension) could see benefit as well as expressing concern about a digital intervention such as a smartphone app. Both parties felt it could be empowering but also had reservations about the possible anxiety inducing nature of excessive engagement with the intervention. Conclusion. The findings of this research contribute to insights in relation to the development of a digital intervention to enhance medication adherence in hypertension. The use of theory, systematic review and qualitative work means that this research was an appropriate enhancement of the evidence base and provides a platform for future intervention development.