Factors affecting patient retention to hypertension treatment in a North Indian State: A mixed‐method study

Abstract

Hypertension is a global health challenge, especially in low‐to‐middle‐income countries, where awareness and control are suboptimal. Despite available treatments, poor medication adherence hampers blood pressure control, leading to adverse outcomes and increased costs. In response, the GOI has initiated national action plans to address noncommunicable diseases, including hypertension. The study aimed to analyze patient retention rates in hypertension treatment across healthcare levels and understand providers' and patients' perspectives on control factors. Using a mixed‐method concurrent design in a North Indian district, retrospective data collection covered hypertensive patients registered from January 2020 to July 2020, followed for a year (August 2020–July 2021). Quantitative data included socio‐demographic characteristics and patient follow‐up rates. Qualitative data comprised focus group discussions (FGD) and in‐depth interviews (IDI) with healthcare providers (HCPs) and patients. Findings identified challenges in patient retention and medication adherence, notably among females and at higher‐level healthcare facilities, leading to substantial loss of follow‐up. Only 63% of hypertensive outpatients maintained controlled blood pressure in the past year. Male patients exhibited more consistent attendance than females. Despite sufficient HCP knowledge, patient retention was better at Health and Wellness Centers (HWCs) levels, while blood pressure control was poorer at higher facilities. Barriers such as medication side effects, pill burden, and limited healthcare access hindered hypertension control, highlighting the need for improved primary care services, including extended clinic hours and diagnostic facilities. Improving hypertension control requires addressing medication adherence and healthcare access barriers. Strengthening primary care services and implementing patient‐centered interventions are crucial steps.

1. INTRODUCTION

The global prevalence of hypertension among adults aged 30−79 years is significant, with rates of 34% in men and 32% in women, particularly rising in low‐to‐middle‐income countries. ¹ Despite this, awareness, treatment, and control of hypertension remain low, as evidenced by recent surveys in India. ² The National Family Health Survey (NFHS‐5, 2019−2020) reported a hypertension prevalence of 29.8%, while the National Noncommunicable Disease Monitoring Survey (2017−2018) revealed low rates of awareness (29.2%), treatment (16.0%), and control (12.3%). ³ , ⁴ Despite available treatment regimens and guidelines, a substantial portion of treated patients fail to achieve adequate blood pressure control, often due to poor treatment adherence. ⁵ , ⁶ There is mounting evidence that nonadherence to prescribed treatment is associated with adverse health outcomes and higher care costs. ⁷

In response, the Government of India has implemented national action plans and initiatives to prevent and control noncommunicable diseases, including hypertension, such as the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) and the India Hypertension Control Initiative (IHCI). ⁸ , ⁹ , ¹⁰ However, various patient, provider, and health system factors continue to hinder effective blood pressure control. While studies in developed countries have identified factors influencing hypertension control, research in developing nations remains limited. ¹¹ , ¹² Another collaborative (COBRA‐BPS) study highlighted that determinants such as unhealthy lifestyles, high obesity rates and lack of adherence to antihypertensive medications contribute to poor BP control. ¹³ Despite a pretty well‐functioning health system with universal coverage, many challenges were noticed in the effective management and control of hypertension. ¹⁴ Various epidemiological studies, conducted at hospitals and managed care settings, have examined the effects of socioeconomic status, health care, and lifestyle factors on hypertension control. ¹⁵ , ¹⁶ , ¹⁷ A US‐based study suggested that access to regular health care services and necessary lifestyle alterations play a positive role in the control of hypertension among community members. ¹⁸ Data on the regularity of follow‐up visits and other provider and patient‐specific factors associated with hypertension control are sparse in low and middle‐income countries. This study aims to analyze patient retention rates in hypertension treatment at outpatient clinics across different healthcare levels and explore the perspectives of providers and patients regarding factors affecting hypertension control.

2. METHODOLOGY

2.1. Study design and setting

The current retrospective follow‐up concurrent mixed‐method study was conducted in various health facilities of one district of a North Indian state of India. The data collection for the hypertensive patients registered between January 2020 and July 2020 who had followed for 1 year (i.e., August 2020–July 2021) was done in months of July and October 2021. The selected district has a population of 0.68 million, primarily living in urban (75%) area. There are four administrative blocks in the selected district. Each block has Community Health Centers (CHCs), a few Primary Health Centers (PHCs), and subcenters (SCs) with population coverage ranging from 80,000 to 1,25,700, 20,000 to 35,560, 3000 to 5600, respectively. ¹⁹ A national‐level government initiative upgraded many PHCs and SCs to Health and Wellness Centers (HWCs) under the Ayushman Bharat Scheme, which has a dedicated paramedical health staff with advanced training, namely Community Health Officers (CHOs) to enhance its capacity to offer an expanded range of services. ²⁰ They are involved in screening of adults >30 years for hypertension and diabetes under the nation's population‐based screening program.

2.2. Sample size and sampling procedure

Two blocks in the selected district were selected randomly out of four blocks. One CHC, two PHCs, and four HWCs were chosen randomly from each of these two blocks. A total of two CHCs, four PHCs, and eight HWCs were covered under the study. All adult hypertensive patients (>18 years of age) who were on outpatient follow‐up for at least 1 year before the data collection period and had documented BP measurement results were eligible for the study. The details of health facilities and data collection are given in Annexure 1.

ANNEXURE 1.

Details of data collection in district Roopnagar.

S.No.	Date	Block	HWC/PHC/CHC	Patient records	FGD	IDI	Drug logistic questionnaire	Patient questionnaire
1	August 5, 2021	Kiratpur Sahib	HWC Agampur	20	1	3 (2 ANM. 1 CHO)	1
			HWC Bhalri	20	1	2 (1 ANM, 1CHO)	1	3
2	August 6, 2021	Bharatgarh	HWC Nangal sarsa	9	1	2 (1 ANM,1CHO)	1
			HWC Gardale	17	1	1 (CHO)	1
			CHC Bharatgarh	19	–	3 (1 DPM, 1 STAFF NURSE, 1 MO)	–
3	August 11, 2021	Kiratpur Sahib	PHC Kiratpur	14	1	3 (1 SMO, 1 Nursing officer, 1 Pharmacist)	2
		Nurpur bedi	HWC Dhumewal	13	1	1 (CHO)
			HWC Jhajh	32	1	1 (CHO)	1
			HWC Mukari	15			1	1
4	August 18, 2021	Nurpur bedi	HWC Dhamana	10				1
		Chamkor sahib	HWC Chtamali	18	1	1 (CHO)	1
			HWC Chalaki	20	1	1 (CHO)	1
			PHC Amrali	12		2 (Staff nurses)
5	August 25, 2021	Chamkor sahib	CHC Singhpura		1	1 (MO)
			HWC Dhnana			1 (CHO)
			PHC Abiana kalan			1 (Pharmacist)	1	1

For qualitative component, sixteen (16) focus group discussions (FGD) (two each in two CHCs, two PHCs, and four HWCs) were conducted with the patients registered and seeking treatment during the last 1 year. In addition, 20 in‐depth interviews (IDI) were conducted with the Senior Medical Officers (2), CHOs (8), Staff Nurses (5), and Auxilliary Nurse–Midwives (5), from various levels of healthcare facilities to study the provider and health system factors about BP control.

The questions during FGD and IDI revolved around medication adherence and its importance, common barriers and facilitators reported for hypertension control, availability of antihypertensive medication.

2.2.1. Study tools and data variables

A semistructured questionnaire recorded patient information regarding registration and follow‐up of hypertension diagnosis, treatment, and adherence. Hypertension control was taken as a dependent variable, whereas the independent variables included a number of follow‐up visits, availability of healthcare providers (HCPs), availability of the prescribed medicines, counseling services, behavior of the HCPs, treatment compliance, patient comorbidities/obesity, patient travel time/distance/waiting time, and awareness related to blood pressure.

2.3. Inclusion and exclusion criteria

Patients older than 18 years of age, regardless of sex, and having a diagnosis of hypertension according to the 2020 ISH global practice guidelines were considered for enrollment in the study. Additionally, they needed to be on a pharmacotherapy regimen for their blood pressure for a minimum of 1 year before entry into the study. Patients whose data were registered before January 2020 and those who were unable to provide informed consent were excluded from participation.

Operational Definitions used in the study

• Hypertension diagnosis‐ Systolic blood pressure of ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least two occasions on different days, or prior treatment with antihypertensive medications at the time of registration irrespective of their BP reading, or ≥160 mmHg or ≥100 mmHg on a single day with two readings over the 1 year study period. ²¹

• Lost to Follow‐up‐The patients who were registered under NPCDCS/IHCI and followed up until the previous quarter did not return for a follow‐up visit consecutively for 3 months or more over the 1 year study period. ²²

• Patient retention in care: A patient's regular engagement (at least one visit every quarter over the 1 year study period) with medical care at a healthcare facility after initial entry into the system. ¹⁶

• Hypertension Control: If the systolic BP and diastolic BP of hypertensive adult patients come out to be <140 mmHg and <90 mmHg, respectively, during the patient's visit to the health facility over 1 year study period. ²³

2.3.1. Data analysis

IBM SPSS version 16.0 was used for data analysis. We computed proportion and test of significance using McNemar's chi‐square for hypertensive patient characteristics according to age group, facility type, and sex separately for those who were retained on treatment and missed the follow‐up visits.

For qualitative analysis, two investigators made transcripts on the same day based on the verbatim notes and audio or video recordings of the FGD and IDI. Transcripts were analyzed using the manual descriptive content analysis. The third investigator reviewed the transcripts to reduce bias and interpretive credibility. The decision on coding rules and theme generation was done by using standard procedures and in consensus of the investigators. Any differences between the two were resolved by discussion. Some codes were combined into themes. The codes/themes were related to the original data to ensure that the results reflected the data. According to “Consolidated Criteria for Reporting Qualitative Research,” the findings were reported. ²⁴

2.4. Ethical approval and consent for participation

The patient records data were collected after getting approval from the Department of Health and Family Welfare, Government of Punjab. Informed consent was taken from the participants before conducting FGDs and IDIs. Ethical Clearance was obtained from the Institute Ethics Committee, PGIMER, Chandigarh (No. PGI/IEC/2019/002357).

3. RESULTS

3.1. Quantitative component

A total of 1169 hypertensive patients were registered in the selected healthcare facilities between January and July 2020. The socio‐demographic characteristics of the registered hypertensive patients are given in Table 1. Almost two‐thirds of the patients were females (64.5%), and over half (52.2%) belonged to the age group of >60 years. Most of the respondents were married (80.3%), and few had attained tertiary education (7.3%), while nearly half (43.7%) had a monthly income from 25,000 to 50,000 (INR).

TABLE 1.

Socio‐demographic characteristics of the registered hypertensive patients (January–July 2020).

Characteristics	Frequency (n = 1169)	Percentage (%)
Age
Mean age (± SD)	62.9 (± 0.57)
<40 years	23 (1.96)	1.96
40–60 years	510 (43.6)	43.6
>60 years	636 (54.4)	54.4
Sex
Male	467	39.9
Female	702 (60.1)	60.1
Marital status
Single	23	2.0
Married	939	80.3
Divorced	04	0.3
Widowed	203	17.4
Educational statusa
No formal education	165	14.1
Primary	320	27.3
Junior high	303	26.0
Secondary	296	25.3
Tertiary	85	7.3
Monthly family income (INR)
<25,000	403	34.5
25000‐50,000	511	43.7
>50,000	255	21.8
Health facility
CHC	330	28.2
PHC	323	27.6
HWC	516	44.1

^aPrimary‐ Up to 5th class, Junior High‐ Up to 8th class, Secondary‐ up to 12th class, Tertiary‐graduation and post‐graduation.

Among all hypertensive patients registered between January and July 2020 (n = 1169), the lost to follow‐up (LFU) rate from point of registration to visit at 3rd and 12th‐month visits ranged from 80% and 85% among females and 82% to 85% among males. LFU rate was highest among the patients visiting the CHC which ranged from 92% to 94% from 3rd to 12th month. The LFU rate was lowest at the HWCs which was 74% at the last follow‐up visit as compared to 92.8% and 94.2 % in PHCs and CHCs, respectively. In terms of age group, the LFU rate at the last follow‐up visit was highest in the patients belonging to the age group of 40−60 years each at 3rd (81.3%), 6th and 9th (84.1%), and 12th (86.1%) month as compared to >60 years of age group (Table 2).

TABLE 2.

Lost to follow‐up rate of the hypertensive patients January 2020–July 2021.

Category	Registration (N = 1169)	1st FU visit (N = 219)	LFU (%)	2nd FU visit (N = 193)	LFU (%)	3rd FU visit (N = 193)	LFU (%)	4th FU visit (N = 172)	LFU (%)
Sex
Female	702	136	80.6	119	83.1	115	83.6	104	85.1
Male	467	83	82.2	74	84.1	78	83.2	68	85.4
Age group
<40 years	23	2	0	2	0	2	0	2	0
40‐60 years	510	95	81.3	81	84.1	81	84.1	71	86.1
>60 years	636	122	80.8	110	82.7	110	82.7	99	84.4
Health facility
CHC	330	24	92.7	19	94.2	19	94.2	19	94.2
PHC	323	26	91.9	24	92.6	24	92.6	23	92.8
HWC	516	169	67.2	150	70.9	150	70.9	130	74.8

Among all patients registered between January and July 2020, 219 (18.7%) returned for all four quarterly follow‐up visits over the period of 1 year, the majority (n = 138, 63%) had BP under control during all visits (Table 3). The follow‐up visits were highest at the level of HWCs (32.8%) followed by PHCs (8.04%) and CHCs (5.7%). More females (19.3%) and patients >60 years (19.2%) had all recorded quarterly follow‐up visits for seeking BP treatment. Achieved BP control on the 4th follow‐up visit was highest in males (63.8%) as compared to females (62.5%); and in PHCs (88.4%) as compared to CHCs (79.1) and HWCs (56.8%).

TABLE 3.

Hypertension control at follow‐up visits, (August 2020–July 2021).

Categories	Registrations b/w January–July, 2020 (N = 1169)	People who followed up between August 2020 to July 2021 (N = 219)	HTN control at 1st FU visit (N = 182)	HTN control at 2nd FU visit (N = 168)	HTN control at 3rd FU visit (N = 161)	HTN control at 4th FU visit (N = 138)
Age group*
<40 years	23 (1.96)	2 (8.7)	1 (50.0)	0	0	0
40‐60 years	510 (43.6)	95 (18.6)	77 (81.0)	69 (72.6)	67 (70.5)	57 (60.0)
>60 years	636 (54.4)	122 (19.2)	104 (85.2)	99 (81.1)	94 (90.3)	81 (77.8)
Sex
Male	467 (39.9)	83 (17.8)	64 (77.1)	61 (73.4)	60 (72.2)	53 (63.8)
Female	702 (60.1)	136 (19.3)	118 (86.7)	107 (78.6)	101 (74.2)	85 (62.5)
Health facility
CHCs	330 (28.2)	24 (7.3)	19 (79.1)	19 (79.1)	19 (79.1)	19 (79.1)
PHCs	323 (27.6)	26 (8.04)	25 (96.1)	25 (96.1)	24 (92.3)	23 (88.4)
HWCs	516 (44.1)	169 (32.8)	138 (815.6)	124 (73.3)	118 (69.8)	96 (56.8)

*p< .05.

3.2. Qualitative component

A descriptive content analysis was done. Theme generation was based on standard procedures and the findings were reported as per the “Consolidated Criteria for Reporting Qualitative Research.” ²⁵

3.2.1. Theme 1: Adequate knowledge facilitates the hypertension control

Almost all health professionals (service providers) have adequate knowledge regarding the hypertension control rate, medication adherence, and treatment protocol. All CHOs mentioned using the IHCI Treatment Protocol to screen, diagnose, and manage hypertension after receiving training from IHCI and the IHCI protocol was found to be displayed in the health centers. 70% of the CHOs correctly explained that if the patient's BP is ≥140/90 on three consecutive readings, it is considered as “hypertension” and the patient is put on treatment. BP is considered controlled when the patient is adhering to the treatment, making the scheduled follow‐up visits, and BP reading is <140/90.

The patients were aware of the causes, symptoms and consequences of hypertension. Half of the patients mentioned that hypertension is caused due to lack of physical activity, stress, and high‐fat or fried food. Two‐thirds of the patients reported headaches, heaviness, numbness, changes in heart rate, convulsions, etc. as symptoms of high blood pressure.

“Hypertension, if not treated in time, may lead to cardiovascular diseases and other chronic heart diseases, including stroke.” [IDI_6, Senior Medical Officer]

“We do not have a regular doctor posted in the HWC, but we are trained by IHCI and give treatment according to IHCI protocol.” [IDI_4, CHO]

“Usually, when I have high blood pressure, I start having headaches and fast breathing. These symptoms are the indicators for me to assess that I am having hypertension” [FGD_2, patient]

3.2.2. Theme 2: Treatment compliance/medication adherence is vital in hypertension control

Medication adherence was reported as the most crucial factor in hypertension control by the medical officers (n = 2) and CHOs (n = 6) whereas ANMs (n = 3) and staff nurses (n = 3) highlighted that the lifestyle factors such as physical activity and diet are essential in the regulation of hypertension. Nearly two‐thirds of the HCPs reported that the common problems faced by the registered high BP patients in its control are the perception of side effects of the medicine, lifelong/long‐term medication, poor compliance to treatment, and dietary counseling. Regular BP monitoring is less practiced, whereas many patients take the medicine depending on their health situation.

Majority of the patients (109; 85%) reported that medication adherence and appropriate lifestyle modification are key strategies for controlling hypertension. More than half (74; 58%) of the patients reported forgetfulness and high pill burden (>4 pills) as major reasons for missed medication. Few patients (35; 27%) reported skipping medicines in between without doctors' consultation, when they found their BP in control or believed it was cured. Majority of the patients (101; 79%) reported the availability of antihypertensive drugs, including amlodipine, atenolol, telmisartan and chlorthalidone at all levels of health facilities (PHCs, CHCs, HWCs). More than half of the respondents mentioned that the dispensing of drugs varied from 10 to 15 days and depended on the availability of medicine stock.

One‐third of the patients were of the opinion that the drugs available at government health centers are less effective. Less than half of the respondents (54; 42%) mentioned that they lack awareness about the HWC and its services, including noncommunicable diseases monitoring blood pressure and diabetes and free drug dispensing. The patients also emphasized that the absence of CHOs in the center during the COVID duties affected treatment compliance and also, the centers do not have a regular doctor.

“If the patient does not come for a follow‐up visit, we make home visits to give a reminder to the patient for the follow‐up visit and if in case the patient is not able to come, we deliver the medicines at homes” [IDI_6, ANM]

“Sometimes, the patient is enrolled in our center but does not continue the treatment for various reasons. This affects the hypertension control rate” [IDI_7, CHO]

“Although sufficient stock of medicines is available in the HWCs, however, during COVID times, the HWCs were either locked or without the CHOs as they were rolled in the COVID duties, which we could do not procure medicines. Most of times, they provide us antihypertensive drugs for a period of 10−15 days” [FGD_2, patient]

“Although we organize regular health awareness sessions at the community level, various myths related to hypertension are still prevalent among the general public. Hypertension is generally considered a disease of an entire life. The patients get bored of taking regular medicines of hypertension and skip on their own without the consultation of doctors” [IDI_5, ANM]

3.2.3. Theme 3: People prefer to visit a convenient place for seeking treatment

It was reported that two‐thirds of the patients that they find it challenging to travel a long distance from their respective residences to the health centers. The majority of the patients (102; 79.8%) preferred to visit those health facilities where the waiting time was less and medicines and service providers were available. Besides, the lack of diagnostic and screening facilities at the HWC was also a significant reason for losing follow‐ups.

“Since all family members are working, we prefer the health facilities near our homes. It is not possible to pay regular follow‐up visits to the health centers farther from our homes.” [FGD_3,Patient]

“Sometimes, the patient is enrolled in our center but does not continue the treatment due to various reasons such as inadequate availability of medicines, unavailability of doctors, lack of monitoring and diagnostic facilities, etc. Resultingly, the hypertension control rate is affected.” [IDI_7, CHO]

3.2.4. Theme 4: There is a need to strengthen the primary care services

Three‐fourths of the CHOs expressed a need to have a Medical Officer/Doctor at the screening camp for better patient sensitization and compliance. Other factors important for hypertension control include a regular supply of medicines, BP monitoring at home, and family support, as reported by ANMs (4) and staff nurses (2). The staff nurses also expressed a need for a separate counselor to guide the patients in lifestyle modification. Two‐thirds of the patients suggested that the HWCs should be opened till 5 pm along with the provision of all diagnostic and screening facilities and also expressed a desire that health centers organize frequent and regular health awareness sessions at the community level.

“I think the patients with uncontrolled hypertension require regular BP monitoring at home. They should monitor their BP daily twice a day to keep a regular track of their BP readings and control.” [FGD_1, Patient]

“Like other health facilities, the HWCs should also be opened till 5 pm, and medical officers should also be appointed at the HWC along with all screening and diagnostic facilities.” [FGD_5, Patient]

4. DISCUSSION

This study revealed that 63% of hypertensive patients on outpatient follow‐up controlled their BP over the last year. This finding was higher than those of studies conducted in Ethiopia (50.4%), ²⁶ Turkey (31.7%), ²⁷ Malaysia (48.3%), ²⁸ Tanzania (47.7%), ²⁹ Zimbabwe (32.8%), ³⁰ Kenya (33.4%), ³¹ Uganda (35.9), ³² and a similar study in India (59.8%). ¹⁶ This difference is probably due to a change in the criteria used to classify hypertensive patients with uncontrolled and controlled BP. Most of the literature used JNC7 (which was used as a cutoff point > 140/90 for nondiabetic patients and > 130/80 for diabetic patients to say uncontrolled BP), whereas the current study was conducted using the International Society of Hypertension (ISH guidelines). IHCI, a multi‐partner initiative, launched in 2017, supported the Govt. of India's NPCDCS program by strengthening the management of diagnosed hypertension in primary healthcare settings using ISH guidelines. ¹⁰ The knowledge level of the health care providers regarding BP control, treatment protocol was found to be adequate in the current study. The medical officers at the health facilities and CHOs at HWCs received training on IHCI protocol. ³¹ Most prescriptions for BP control were issued according to these protocols and the same were displayed in the health center. This protocol implementation experience was consistent with a study from Cuba and China, which showed that an algorithm‐based approach and capacity building of doctors improved prescriber compliance to the use of protocol drugs ³³ and improved BP control from 10% to 15%. ³⁴

It was observed that male patients were more regular in attending treatment follow‐up appointments than female patients. Sex differences in attending follow‐up appointments have been reported for other disease conditions. ³⁵ , ³⁶ However, studies conducted in the United Kingdom and Canada have reported that female patients were more likely to attend treatment follow‐up visits than their male counterparts. ³⁷ Females often require a male counterpart or any other family member to accompany them to the health center, and this may lead to irregularity in the follow‐up visits for the continuation of treatment. Follow‐up visits were more common among the older age group (>60 years) than younger ones and the difference was found to be statistically significant. Increased disease severity or other comorbidities among old‐age patients may encourage elderly patients to attend treatment follow‐up appointments regularly. However, some studies found a negative correlation between age and regularity in treatment follow‐up. ³⁸ This negative correlation may be due to memory loss, nonavailability of any caregiver, or deteriorated health condition of the patient. ²¹

The study results suggest that patient retention was better at HWC level but BP control was poorer among those who followed up compared to the higher facilities. These findings suggest that people's accessibility to health care services has been enhanced with the up‐gradation of SCs into HWCs. These centers are closer to patients' homes and provide services at the doorstep of patients. The Govt. of India's initiative of converting the SCs into HWCs has expanded the reach and access to comprehensive primary health care in India. ³⁹ The effectiveness of primary care interventions in improving hypertension control has been documented in various settings. ⁴⁰ In an intervention program in Cuba, patients with BP control increased from 59% to 68% among 2000 + patients after implementing WHO HEARTS strategies at primary‐level health centers. ¹¹ Regular monitoring and adequate availability of medicines at HWCs are also the likely reasons for the patients' sustained follow‐up visits, thus ensuring a better hypertension control rate. However, at the same time poor BP control at the HWCs paves the argument for upskilling of the CHOs, provision of screening and diagnostic facilities along with uninterrupted supply of antihypertensive drugs at the HWC level. For patients with hypertension, treatment follow‐up provides an opportunity for healthcare practitioners to adjust the patient's treatment regimen, assess the patient's adherence to the therapy, monitor any adverse effects, and improve the patient's understanding of disease management. ⁴¹ , ⁴² , ⁴³

The study revealed that the patients who reported taking over four antihypertensive pills per day, were less likely to have their hypertension under control than those taking up to two pills. Similar results from developed nations have shown that patients on three or more antihypertensive drugs were more likely to miss their medication due to forgetfulness or have a treatment gap than those treated on two pills. ⁴⁴ In addition, the high cost of medicines and the high pill burden were cited as other reasons for nonadherence among patients on more pills. ⁴⁵ However, in some settings, patients are educated to appreciate the severity of their condition to mitigate these treatment gaps. ⁴⁶ Hypertension control among patients with high pill burden could be improved using fixed‐dose combination (FDC) polypills to simplify treatment. ⁴⁷ , ⁴⁸ These reasons are similar to those identified in a Nigerian study on hypertension medication adherence ⁴⁹ and an Indian study conducted at a tertiary sector hospital. ⁵⁰

The current study identified various reasons for poor patient retention of hypertension treatment. Making frequent visits to health centers to get medicines, long waiting times and lack of appropriate screening and diagnostic facilities hinder the retention of the treatment. Although the patients reported an adequate supply of antihypertensive drugs, but the drug dispensing was limited to 10−15 days. They were left with no other choice but to revisit the health center every 2 weeks. These findings were similar to a study which reported that frequent follow‐up visits, long waiting times, lack of physician continuity, and diagnostic facilities explained the lack of follow‐up care. ⁵¹ Patients’ lacked awareness regarding the available services and prognosis of the disease which affected the continuation of the treatment at one health facility. The role of extended prescriptions to patients with BP under control and community health workers in enhancing awareness regarding BP control services and treatment could be explored. Studies from India and Thailand reported improved awareness or control involving lay health workers and community volunteers to improve hypertension management. ⁵² , ⁵³

Our study is not without limitations. First, the information concerning knowledge and management of hypertension was self‐reported, lending itself to recall and information bias. However, most of this information was corroborated from patient records, thus eliminating such biases. Secondly, this study also did not control for the different treatment types (drugs, frequency, duration, etc.) used by participants during treatment. Therefore, it is difficult to generalize the control rate. Thirdly, many CHOs were additionally assigned responsibilities for COVID‐related activities which could have affected the overall performance and patient follow‐up at HWCs. Moreover, as noted above, some patients may have continued treatment at facilities other than those we monitored, so the actual control rates may be higher than those we documented. However, the study has several strengths. The study portrays the patients' retention level of hypertension management over 1 year. The findings of this study could be helpful for physicians and program managers involved in the evidence‐based management of hypertensive patients. The selected study sites represented all types of health facilities providing primary to tertiary health care services. A mixed‐method approach was used to get an answer for the “why” of BP control and LFU. The study could gauge the factors responsible for LFU, which could be addressed to improve patient retention.

5. CONCLUSIONS AND RECOMMENDATIONS

Regular follow‐up visits may be pivotal in attaining sustained BP control. More females, patients >60 years of age, were regularly following up the hypertension treatment. Hypertension was better managed at the SCs level (upgraded to HWCs). Therefore, we recommend strengthening the primary health facilities to provide adequate diagnostic services and ensure the unbroken delivery of medicines at patients' doorstep. The physician‐patient communication should also be assured regarding the importance of regular treatment for controlling blood pressure. There is also a need to ensure the effective implementation of treatment guidelines as per NPCDCS, emphasizing the use of polypills to reduce pill burden and improve hypertension control. Evidence‐based targeted interventions should be developed and implemented to enhance attendance at treatment follow‐up appointments, considering local needs.

AUTHOR CONTRIBUTIONS

Conceptualization: Sonu Goel, Om Prakash Bera. Methodology: Nidhi Jaswal, Kritika Upadhyay, Anupam Khungar Pathni. Formal analysis: Nidhi Jaswal, Kritika Upadhyay, Anupam Khungar Pathni. Investigation: Nidhi Jaswal, Kritika Upadhyay. Writing—original draft preparation: Nidhi Jaswal, Kritika Upadhyay. Writing—review and editing: Sonu Goel, Om Prakash Bera. Visualization, supervision: Sonu Goel, Vandana Shah, Om Prakash Bera.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflicts of interest.

PATIENT CONSENT STATEMENT

Informed consent was obtained from all individual participants included in the study.

PERMISSION TO REPRODUCE MATERIAL FROM OTHER SOURCES

Material from other sources has been acknowledged in the manuscript.

CLINICAL TRIAL REGISTRATION

None.

Jaswal N, Goel S, Upadhyay K, Pathni AK, Bera OP, Shah V. Factors affecting patient retention to hypertension treatment in a North Indian State: A mixed‐method study. J Clin Hypertens. 2024;26:1073–1081. 10.1111/jch.14866

DATA AVAILABILITY STATEMENT

We confirm that all data supporting the findings of this study are available in the manuscript.