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Answered: - Hindawi Publishing Corporation ISRN Hypertension Volume 20


Does the attached article support evidence based practice? If so how?


Hindawi Publishing Corporation

 

ISRN Hypertension

 

Volume 2013, Article ID 671691, 10 pages

 

http://dx.doi.org/10.5402/2013/671691

 


 

Research Article

 

A Qualitative Study of Patient Perspectives about Hypertension

 

Emily P. Jolles,1 Raj S. Padwal,2 Alexander M. Clark,3 and Branko Braam1

 

1

 


 

Division of Nephrology and Immunology, Department of Medicine, University of Alberta, Edmonton, AB, Canada T6G 2G3

 

Division of General Internal Medicine, Department of Medicine, University of Alberta, Edmonton, AB, Canada T6G 2G3

 

3

 

Faculty of Nursing, University of Alberta, Edmonton, AB, Canada T6G 2G3

 

2

 


 

Correspondence should be addressed to Branko Braam; branko.braam@ualberta.ca

 

Received 11 January 2013; Accepted 5 February 2013

 

Academic Editors: G. Davidai, H. Komine, and A. A. Noorbala

 

Copyright ? 2013 Emily P. Jolles et al. This is an open access article distributed under the Creative Commons Attribution License,

 

which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

 

To understand hypertensive patients? perspectives regarding blood pressure and hypertension treatment, this qualitative study

 

applied semistructured interviews of hypertensive patients. Participants were recruited from two hypertension clinics at the

 

University of Alberta in Edmonton, Canada. To be eligible for inclusion, patients had to be aged 18 years or older, diagnosed

 

with hypertension by a healthcare provider, and currently taking an antihypertensive medication. Participants were stratified in the

 

analysis according to blood pressure control. Twenty-six patients (mean age 57; 62% female) were interviewed, of which 42% were

 

on target and 58% were not. Three underlying themes emerged from the interviews: (a) knowledge of blood pressure relating to

 

diagnosis and management and control of hypertension, (b) integration of hypertension management into daily routine, and (c)

 

feelings and beliefs of wellness. None of the above themes were associated with better control. Knowledge gaps were found, which

 

emphasize the need for further patient education and physician training. Feelings and beliefs of wellness, and not knowledge, were

 

important factors in home assessment of blood pressure. The absence of connections between control of hypertension and the

 

identified domains indicates that current approaches could benefit from the development of a more personalized approach for

 

education and communication.

 


 

1. Introduction

 

Hypertension is highly prevalent, and although rates of detection and control of hypertension are improving in many

 

countries, uncontrolled hypertension remains common [1]

 

and medication and lifestyle adherence remains low. Nonadherence leads to substantial avoidable healthcare costs [2]

 

because of inefficiencies in care delivery, discarded medications, and expenditures related to preventable hypertensionrelated sequelae [3]. Nonpharmacological interventions to

 

improve hypertensive medication adherence are usually very

 

complex involving both educational and behavioural interventions and data examining efficacy have not been consistent [4]. Improved understanding of the psychology of the

 

hypertensive patient seems desirable.

 

A number of patient-related barriers to optimizing blood

 

pressure (BP) control have been identified. These include lack

 

of patient knowledge, difficulty of treating an asymptomatic

 

condition, personal beliefs that conflict with hypertension

 

treatment goals, and other patient issues such as social

 


 

economic status, cultural beliefs, access to care, psychosocial

 

factors, and health literacy [5]. Additional obstacles include

 

a lack of communication and trust between patients and care

 

providers, high medication costs, high drug burden, failure to

 

attend follow-up appointments, and discontinuation of therapy due to drug side effects [5?10]. There is limited data available about patients? personal perspectives regarding obstacles

 

to hypertension control [11, 12]. We therefore performed a

 

qualitative study consisting of semistructured interviews to

 

explore hypertensive patients? views on their disease state and

 

issues related to optimizing BP control.

 


 

2. Methods

 

2.1. Patient Recruitment and Inclusion. Patients were recruited from two hypertension clinics at the University of Alberta

 

(Edmonton, Midwestern Canada). Inclusion criteria were age

 

over 18 years; ability to read, speak, and write English; hypertension defined as either having a BP over the desired target,

 


 

2

 

patients? BP was either <140/90 mm Hg or <130/80 mm Hg in

 

case of DM or CKD, or being on antihypertensive therapy;

 

absence of cognitive dysfunction; use of at least one hypertensive drug; agreeing to sign informed consent. Each patient

 

was mailed a pamphlet as part of the appointment scheduling,

 

and, during the appointment, recruiting physicians asked

 

patients whether they would be willing to participate in the

 

study. Written information about the study was then provided

 

by the study coordinator and informed consent was obtained.

 

Patients received a $50 reimbursement for participation in the

 

study for the time spent on the interview and costs of parking

 

and travel. Ethical approval was obtained from the University

 

of Alberta Health and Research Ethics Board; all participating

 

patients signed consent to participate in the study.

 

2.2. Conducting Qualitative Interviews. Patients were consented and interviewed by EPJ, and all interviews were

 

audio-taped and transcribed verbatim. The interviewer stated

 

that she was interested in patients? perspective on hypertension management and ensured confidentiality that patients?

 

answers would not be reported back to the referring doctor.

 

Interviews were conducted in a neutral, nonclinical setting.

 

The sample was substratified according to hypertension

 

control (controlled versus uncontrolled). Patients were considered ?on target? if BP was either <140/90 mm Hg or

 

<130/80 mm Hg in case of DM or renal impairment defined

 

by estimated GFR <90 mL/min/1.72 m2 as derived from the

 

MDRD equation.

 

An interview topic guide was developed using the current

 

literature in the field and based on expert opinion. Interviews were semistructured, 30?60 minutes in duration, and

 

designed to elicit patients? perspectives using open-ended

 

questions to trigger responses and prompts/probes as necessary for clarification purposes. Two pilot interviews were

 

conducted and transcribed, after which the interview guide

 

was refined, and then the remaining interviews were conducted. The pilot interviews were included in the analysis.

 

Specific interview topics were definitions of high BP, the

 

consequences of uncontrolled hypertension, current BP in

 

relation to targets, methods to lower BP, medication adverse

 

effects, and barriers to and facilitators of routine drug intake

 

and adherence.

 

2.3. Analysis. Data analysis was organized using NVIVO8

 

(QSR International), a computer program that organizes

 

repeating themes and aids in the coding of transcripts.

 

Themes were derived from a review of the literature and by

 

cataloguing reoccurring themes from the interviews [13].

 

Additionally, descriptive statistics such as lab values and

 

demographic variables were extracted from charts and added

 

to the dataset for analysis. To ensure rigour, a selection of early

 

transcripts was reviewed independently by 2 researchers (E. P.

 

Jolles and A. M. Clark). Themes emerging from the interviews

 

were used to create categories and subcategories for the

 

coding framework. Interviews were conducted until data

 

saturation was reached and new themes were no longer

 

emerging.

 


 

ISRN Hypertension

 

Table 1: Baseline characteristics.

 

Risk factor

 

Female (%)

 

Age, years

 

SBP, mm Hg

 

DBP, mm Hg

 

BP at or above target

 

Total cholesterol, mmol/L?

 

LDL cholesterol, mmol/L

 

Creatinine, mmol/L

 

eGFR, mL/min/1.73 m2

 

Diagnosis of diabetes mellitus

 

Diagnosis of prediabetes

 

Fasting glucose, mmol/L

 

BMI > 30 kg/m2

 

Smoking: never/past/current

 

Framingham cardiac event score?

 

High/moderate/low

 

?

 


 

Values

 

62%

 

57 ?/? 16

 

134 ?/? 17

 

79 ?/? 11

 

58%

 

4.9 ?/? .93

 

2.8 ?/? .93

 

93 ?/? 29

 

72 ?/? 23

 

12%

 

23%

 

5.8 ?/? 1.5

 

42%

 

58%/35%/7%

 

8%/23%/65%

 


 

One patients information not available.

 


 

3. Results

 

3.1. Patient Population. Twenty-six patients (62% female;

 

majority Caucasian), aged 57 ? 16 years (range 26?84), were

 

included in analysis. Baseline characteristics are provided in

 

Table 1. Sixty-five percent of the participants were prescribed

 

more than one drug for hypertension. The most commonly

 

prescribed antihypertensive drug class was inhibitors of the

 

renin-angiotensin system (62%). Forty-two percent of the

 

patients were at or below target BP levels.

 

3.2. Qualitative Interviews. Three underlying themes

 

emerged from the interviews: knowledge of BP, management

 

integration of hypertension management into the daily

 

routine, and individual patient feelings and beliefs of wellness

 

that impact hypertension control (Figure 1). Detailed themes

 

mentioned most often by patients are listed in Table 2 and

 

are stratified by patients on and off target.

 

3.3. Knowledge about Hypertension. Patients widely reported

 

that hypertension was a health concern to them. However,

 

while patients possessed some general knowledge of their

 

condition and hypertension, the level and sophistication of

 

this knowledge varied widely (Table 3). About half (54%) of

 

patients were able to recall that optimal BP was 120/80 mm Hg

 

or could identify their target BP threshold (<140/90 mm Hg

 

and <130/80 mm Hg for those with DM or CKD). Neither

 

patient sex nor achieved BP levels were related to knowledge

 

about targets. However, most patients (92%) were aware of

 

methods that could or would be likely to lower their BP. The

 

majority (92%) knew their current BP. Seventy-three percent

 

of patients could recall consequences of hypertension, such

 

as cardiovascular events and renal disease, but patients

 

struggled to define hypertension.

 


 

ISRN Hypertension

 


 

3

 

Table 2: Themes mentioned by patient population.

 


 

Theme and subtheme

 


 

Attitude

 

Wishes to lower or eliminate the need for medication

 

Holistic approach

 

Belief in the benefits of medication

 

Mention family history of HTN

 

Knowledge

 

BP consequences

 

Home monitoring

 

Current BP

 

Ways to lower BP

 

Side effects

 

Recall target or optimal BP

 

Knowledge-seeking (internet search, books, magazines)

 

Lifestyle

 

Diet-facilitators

 

Diet-barriers

 

Exercise-facilitators

 

Exercise-barriers

 

Salt and hypertension

 

Weight

 

Stress

 

Feelings and beliefs of health and wellness

 

Physical manifestations

 

Integration: routine

 

Routine to aid in medication adherence

 

Coping with travel

 

Healthcare providers

 

Facilitators

 

Barriers

 


 

Total

 

26

 


 

On target

 

11

 


 

Not on target

 

15

 


 

62%

 

30%

 

80%

 

61%

 


 

27%

 

15%

 

38%

 

23%

 


 

35%

 

15%

 

42%

 

38%

 


 

73%

 

88%

 

92%

 

85%

 

80%

 

54%

 

23%

 


 

31%

 

42%

 

42%

 

38%

 

42%

 

31%

 

8%

 


 

42%

 

46%

 

50%

 

47%

 

38%

 

23%

 

15%

 


 

38%

 

58%

 

19%

 

54%

 

88%

 

50%

 

46%

 


 

19%

 

27%

 

11%

 

27%

 

35%

 

15%

 

27%

 


 

19%

 

31%

 

8%

 

27%

 

53%

 

35%

 

19%

 


 

57%

 


 

15%

 


 

42%

 


 

88%

 

73%

 


 

38%

 

38%

 


 

50%

 

35%

 


 

69%

 

54%

 


 

31%

 

23%

 


 

38%

 

31%

 


 

Patients indicated that healthcare providers did communicate information about hypertension; however, around half

 

of patients had additional questions. Some patients perceived

 

that their doctors were ?too busy? to answer additional

 

questions. Patients (69%) mentioned that other healthcare

 

providers, such as pharmacists and specialists, often provided

 

more education than physicians.

 


 

Patients stated that they were comfortable and quick to

 

discuss adverse effects with their doctor so that medication

 

could be changed. The most commonly perceived side effects

 

were edema (19%), dizziness (19%), increased urination

 

(15%), headaches (12%), dry throat/cough (8%), nausea and

 

vomiting (8%), loss of sexual desire (8%), feeling lethargic

 

(8%), heartburn (4%), hair loss (4%), and constipation (4%).

 


 

3.4. Knowledge about Antihypertensive Medication. When

 

asked about the function of medication, most patients did

 

not know the exact mechanism of action of the pills. The

 

consistent exception to this was diuretics, which patients

 

referred to as a ?water pill.? Patients described the water pill

 

as ?flushing the system instead of building up,? ?makes you pee

 

more,? and ?takes certain things out of your system like sodium

 

and different things out of your blood stream.? All patients

 

viewed their BP medication as being all quite similar (i.e., did

 

not believe that one was more ?powerful? or ?important? than

 

another).

 

More than half of patients (69%) attributed health

 

issues to side effects from their antihypertensive medication.

 


 

3.5. Knowledge Regarding Lifestyle. Patients understood that

 

lifestyle modifications could decrease BP. The majority of

 

patients (85%) mentioned changes such as reducing salt

 

intake and checking for sodium content (88%), exercising

 

(69%), following a healthier diet (eating more fruits and

 

vegetables) (69%), losing weight (46%), decreasing stress

 

(38%), quitting smoking (12%), decreasing caffeine intake

 

(8%), and lowering alcohol intake (4%). While quitting smoking does not decrease BP (CHEP 2011 guidelines), smokers

 

did state that among ways to lower BP, quitting smoking

 

would be relevant. Surprisingly, few patients (12%) indicated

 

that incomplete adherence to lifestyle modification advice

 

was preventing them from decreasing medications.

 


 

4

 


 

ISRN Hypertension

 


 

Management of

 

hypertension

 

Routines

 

Medication

 


 

Lifestyle

 

Barriers

 


 

Barriers

 


 

Knowledge

 

Define

 

hypertension,

 

optimal

 

and target

 

blood

 

pressure

 


 

Routine/schedule

 

interrupted

 


 

Diet

 

Lack of time,

 

motivation, routine,

 

spending extra money

 


 

Pill dosettes, aid from spouse

 

Coping

 

Weather,

 

disability/injury,

 

time/busy, lack of

 

energy, lack of

 

motivation or routine,

 

lack of social support

 


 

Define consequences

 

or ways to lower blood

 

pressure

 


 

Medication

 

mechanism

 

Low knowledge

 

?

 


 

Exception: diuretic

 


 

Lifestyle

 

modifications

 

High knowledge; not

 

always implemented

 


 

Facilitators

 


 

Exercise

 


 

Medium knowledge

 


 

High knowledge

 


 

Feelings

 

and beliefs

 

Physical

 

manifestations for "Feelings" marker for

 

blood pressure blood pressure control

 

Cue to

 

check

 

blood

 

pressure,

 

take

 

action

 

(go to the

 

doctor)

 


 

Negative effects

 

experiences of

 

hypertension were

 

perceived as higher

 

blood pressures by

 

some patients

 


 

Strategies for travel,

 

forgetting pills

 


 

Facilitators

 

Diet

 

Spouse support, use of

 

precut fresh foods and

 

salt-free foods by

 

reading labels, making

 

time, and creating a

 

routine

 

Exercise

 

Home exercise

 

equipment, better

 

weather, video

 

exercise games

 


 

Figure 1: Diagram depicting key patient themes.

 


 

3.6. Pragmatism and Routines: Integration of Medication

 

into Daily Life. The most frequently mentioned barrier to

 

medication adherence was a lack of a structured routine or

 

a change in the existing routine (88% mentioned routine)

 

for self-administering BP medications (Table 4). Patients

 

reported greatest success when they were able to seamlessly

 

integrate their medication into their daily life. Patients had

 

difficulty when schedules and routines were interrupted

 

unless they had coping strategies to deal with these issues

 

(e.g., carrying around extra pills and traveling with pill

 

boxes). Of the 81% of respondents that commented on missed

 

doses, 54% denied missing any dose and 27% reported that

 

they ?sometimes? missed a dose either due to forgetting or

 

a change in routine. When asked what would happen if a

 

dose was missed, respondents reported that they would take

 

the next scheduled dose (and by doing so, they would miss

 

a dose). Additionally, some stated that they may experience

 


 

some side effects (headache, BP fluctuations, and feeling

 

tired) from a missed dose. Monetary issues were only cited

 

by 8% of patients.

 

Facilitators of adherence included having an established

 

routine and using reminder tools to ensure medication is

 

taken on a daily basis. Almost all patients (88%) mentioned that using day-labeled pill boxes and making pills

 

visible, along with establishing a routine that incorporates

 

drug administration, ensured daily adherence. This could be

 

summarized by one patient: ?. . . Wash your face, brush your

 

teeth, and take your pills? (male, on target). Patients described

 

additional strategies to optimize adherence including pill

 

counting prior to embarking on a trip and carrying special

 

traveling boxes for extra pills in case that some were lost or

 

misplaced. Lastly, 12% of patients mentioned that spouses and

 

family members helped remind them to take their pills and

 

refill their prescriptions.

 


 

ISRN Hypertension

 


 

5

 


 

Table 3: Quotes of patients with respect to knowledge regarding blood pressure management.

 

Theme

 


 

Knowledge

 


 

Knowledge and HCP

 


 

Knowledge and HCP

 


 

Knowledge: BP medication

 


 

Knowledge: BP medication

 

Side effects

 


 

Side effects

 


 

Knowledge-lifestyle

 


 

Knowledge-lifestyle

 


 

Knowledge-lifestyle

 


 

Quotes

 

Well it is definitely not a good thing for the body. I mean it can cause a lot of problems to kidneys and strokes

 

and you know make your heart work faster and therefore weaken it. You know, it is great when you exercise

 

and you get your heart going faster, but when your heart has to pump faster just to, kind of you know, deal

 

with your everyday life I mean it is not, it is not very clever at all. It is not very beneficial to you to have high

 

blood pressure. (female, on target)

 

P: Yeah I suppose I do not ask them because [?] I, I they will take the readings and they will vary. I assume

 

that if, if they had concerns they would ask me, and I do not want to be a hypochondriac or be a [chuckles]

 

asking rhetorical questions that do not really have an answer to them, so. And I sort of respect their time so

 

[?] and, and they might seem like silly questions so.

 

I: Do you get that feeling from something that they did or is that more?

 

P: No, just respect their time and know that [?] I just maybe think they are [?] dumb questions perhaps or

 

taking up the doctor?s time asking so. (male, on target)

 

I: Do you have a good understanding about what high blood pressure is? So if your doctor was in the room

 

right now would you have questions for him that you still do not really understand?

 

P: What causes high blood pressure? Right. Why do they put you on medication, things like that.

 

I: Right.

 

P: They should answer that and talk about it.

 

P: The only person who will do that [?] is a pharmacist. They will explain it more than the doctors. ?Cause

 

the doctors are in and out, they?re so busy. (male, not on target)

 

I: Do you have any idea of what it does for you? Or how it works or?

 

P: No. I do not. (male, not on target)

 

I can?t say as I do [know what each pill does], I know it?s supposed to lower my blood pressure. So I know that

 

the water pill is very helpful. Um other than that, I do not know technically what mine does. (female, on

 

target)

 

Um, no I mean [?] if the side effects, if the sexual thing was a proven side effect [?] I would have to make a

 

decision because [?] I might go off it just to see if it changed much. (male, on target)

 

Yeah. No the other ones I was on were nasty. Like within, within four hours of taking it, I would be head over

 

the toilet bowl, sick, migraine [?] nasty. ? ? ? but my hair was falling out and the pharmacist said, yeah the

 

diuretic can do that. So I asked my doctor, please change. And he went through this whole mess of all these

 

other ones that we were trying that just made me deathly ill. (female, not on target)

 

P: Yeah, well every time I go to the doctor [?] he always goes over it and you know tells me what I should be

 

doing. And I guess, if I did exactly what he said, more than likely I would not have high blood pressure. (male,

 

not on target)

 

P: No I mean cognitively I know that stop smoking and lose weight and get active is the best thing you can do

 

for blood pressure. I am sure eating well and cutting out is probably another good thing too but I like salt so, I

 

mean I know what I should be doing it?s just that I am not doing it.

 

I: Is that what it is or what is getting in the way?

 

P: Nothing, but sheer apathy.

 

P: Or [?] laziness. I sit at work all day.

 

P: Maybe something happening? You?d think that two hundred over whatever it was blood pressure would

 

make me pick up and notice and start doing things but, I do not know, I really don?t know.

 

P: It is stupid, it is really stupid.

 

I: Not to do anything or?

 

P: Yes! I am sixty for God?s sake. I mean life is not getting any shorter or any longer. Do I need to be taking

 

care of this now. (female, on target)

 

P: Yeah. I think, I do not know, maybe somebody would have to tell me, if you do not stop eating so much salt,

 

you?re going to be dead in five years.

 

I: Okay.

 

P: And then I?d be like oh crap,

 

I: So that would be your motivation?

 

P: Yeah. (female, not on target)

 


 

6

 


 

ISRN Hypertension

 

Table 4: Quotes of patients regarding routines in the management of their blood pressure.

 


 

Theme

 

Routine

 


 

Routine

 

Monetary issues

 

Routine-support

 

Routine-coping

 

Routine-coping

 

Routine-coping

 

Routine

 


 

Lifestyle-barriers

 


 

Routine-lifestyle

 

Dietary adherence-spousal

 

support

 


 

Quotes

 

P: I?ve never missed it. I get right panicky if I have to miss it. And I know, you know the doctors have said, if

 

you miss one day it?s not going to, you know, but I don?t like to miss no. I don?t miss.

 

I: What are you worried about if you miss?

 

P: Actually I can?t tell you what I worry about, I just think it?s not probably a good thing. (female, on target)

 

It really doesn?t happen unless [?] um if schedules are all screwed up, if we?re away somewhere or travelling

 

yeah. Which doesn?t happen more than you know, a couple times a year. (female, not on target)

 

P: Well it?s not cheap. And then you know, it?s like taking the medication right? I can?t even afford it right now.

 

The healthier I stay, the better, cheaper it is for me. (male, not on target)

 

Yes sometimes wife tell me [?] [name] take all pills! Alright told [name] are you taking all together like this?

 

(male, not on target)

 

I?m a frequent traveler so I carry my pills. Take them, take them and yeah I?m [?] very rarely might I miss a

 

day of taking them but most of the time I take them. (male, on target)

 

But it?s quite easy when you have them in your little containers. (female, not on target)

 

Oh I for years was really bad. I have a dosette now and I faithfully, got it all numbered the days of the month.

 

(male, not on target)

 

It?s not going to be a problem. I?ve been doing it for years, So it?s part of my ritual. It?s just the way it is. You have

 

high blood pressure and you take it you don?t forget. (male, on target)

 

Um [?] but of course really the only setback is to that is because of my lifestyle I am very busy, and you don?t

 

always have time to eat healthy. But that?s, you know, you know I try and eat healthy and exercise as much as I

 

can. I think that?s the part that stresses me out a little bit is that [?] um you know, I know I should be losing

 

weight and I know I should be doing it for my health, but I just have to get to I know it?s important medically.

 

Um [?] you know but with lifestyle it is really hard to do that. (patient 13, female, on target)

 

Yeah sometimes weekends aren?t the best for me [laughs] And I?m a bit worried about that if I retire ?cause I

 

think sometimes um [?] I eat a better diet on workdays because I have to make a lunch and take it. [?] I

 

think I?m just on more of a routine. (female, not on target)

 

P: And salt free diet, or salt reduced.

 

I: And how do you follow a salt free diet?

 

P: My wife takes care of it. (male, on target)

 


 

3.7. Integration of Exercise and Diet Routine: Barriers and

 

Facilitators. Barriers to maintain a healthy diet were mentioned by 58% of respondents (work schedule, too busy to

 

cook, frequently eating out/prepared meals, lack of routine

 

or motivation, and costs) and 38% mentioned facilitators

 

(spouse support, use of precut fresh foods and salt-free foods,

 

label reading, time management, and creating a routine) for

 

healthy eating. Exercise barriers (weather, disability/injury,

 

time/busy, lack of energy, lack of motivation or routine, and

 

lack of social support) were mentioned by 54% of patients,

 

while only 19% mentioned facilitators for increasing activity

 

levels (exercise equipment or video games in home and better

 

weather). Thoughts about being overweight were expressed

 

by 50% of the patients (63% of females and 30% of males).

 

3.8. Feelings and Beliefs of Wellness. Despite hypertension often being described as being ?silent? and asymptomatic, 69% of participants experienced symptoms that they

 

attributed to elevated BP levels (Table 5) so that personal

 

feelings and/or beliefs had an impact on hypertension management. Patients mentioned physical manifestations such

 

as headaches (38%), loss of energy, feelings of weakness/

 

tiredness (27%), dizziness and light-headedness (19%), water

 

retention (19%), and numbness (8%). Thirty-one percent of

 


 

the respondents felt that these symptoms were associated

 

with fluctuations in their BP levels and appeared when their

 

BP was not controlled. Participants used these symptoms as

 

an indication of whether or not a BP measurement should

 

be taken or a care provider seen. Others...

 


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DATE ANSWERED

Sep 18, 2020

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