Utilizing a Health Equity Framework to Explore Patient-Level Factors Impacting Effective Hypertension Management Across Two Academic Health Systems

Abstract

Social determinants of health contribute to disparities in cardiovascular outcomes, including hypertension. This study utilized a health equity framework to assess patient-level factors influencing hypertension management across two health systems in North Carolina and Kansas. We interviewed 29 providers and 25 patients with hypertension from 14 clinics, including 13 primary care clinics—six high-performing, one mid-performing, and six low-performing—and one cardiology clinic. Thematic analysis and open coding methodologies were used during analysis. Five salient patient-level themes emerged: patient resources, health literacy, lifestyle, intentionality, and patient-centered care. All providers identified health literacy as a critical barrier, however those in low-performing clinics more regularly cited literacy-related challenges, with some associating patients’ rurality with decreased understanding and intentionality. Mental health was also linked to hypertension management, as anxiety may exacerbate symptoms, while depression can reduce treatment motivation. Our findings underscore the need for individualized, equity-informed hypertension management strategies.

INTRODUCTION

Hypertension affects nearly half of U.S. adults (Chobufo et al., 2020; Ostchega et al., 2020), with recent declines in blood pressure (BP) control (i.e., BP ≤ 130/80 mmHg) (Muntner et al., 2020). Despite significant advancements in treatment, more than two-thirds of hypertension cases remain uncontrolled (CDC, 2023), contributing to an increase in cardiovascular mortality—the leading cause of death in the U.S. (Heron and Anderson, 2016; CDC, 2023). In 2021, hypertension was a contributing factor in nearly 700,000 deaths (CDC, 2023), with the age-adjusted death rate rising by 65.6% over the past decade (Martin et al., 2024). Social determinants of health, which encompass both socioeconomic and environmental structural factors, have routinely been linked with disparities in hypertension prevalence and BP control (Metlock et al., 2024; Chatuvedi et al., 2024). Prior research has observed that higher educational attainment (Egan et al., 2020), income (McDoom et al., 2018), and health insurance coverage (Huguet et al., 2023) are all associated with improved cardiovascular outcomes, including BP control and decreased hypertension prevalence. Geographic disparities are also evident, with the southern U.S. reporting persistently higher rates of hypertension and increased mortality from stroke and heart failure (Obisesan et al., 2000; Howard and Howard, 2020; He et al., 2024).

A range of patient-level variables play a significant role in hypertension management. Health literacy, for instance, is critical, as a limited understanding of hypertension and its consequences may adversely affect medication adherence, healthy lifestyle changes, and engagement in treatment (Bennett et al., 2014). Additionally, patient motivation is central to managing hypertension, as motivated individuals are more likely to adopt and maintain healthier behaviors (Artinian et al., 2010), such as improving their diet and increasing physical activity. Providers who employ a patient-centered approach—emphasizing shared decision-making and tailoring treatment to individual needs and health literacy—can significantly enhance patients’ engagement and adherence to hypertension management plans (Cooper et al., 2011; Pourat et al., 2019).

Mental health conditions, including anxiety, stress, and depression, are known to challenge hypertension management (Kretchy, 2014). These conditions can reduce patients’ ability to adhere to treatment recommendations and manage their BP effectively. Additionally, chronic stress plays a role both as a challenge to management and also as a primary driver of hypertension, exacerbating physiological responses that elevate BP (Sparrenberger et al., 2009; Roohafza et al., 2022; Vaccarino and Bremner, 2024).

In this study, we employed a health equity framework (HEF) developed by Peterson et al., (2021) to guide our analysis of hypertension management across two academic health systems (AHS) located in North Carolina (NC), a southern “Stroke Belt” state, and Kansas (KS), a Midwestern state. The HEF is a science- and justice-based model that conceptualizes health outcomes as shaped by four interconnected domains: Relationships and Networks, Individual Factors, Systems and Power, and Physiological Pathways. These domains span multiple levels of influence from personal behaviors and beliefs to institutional structures and broader sociopolitical forces. Importantly, the HEF encourages researchers to examine how these domains interact, rather than treating them as isolated variables. The HEF was selected for its ability to examine how individual, interpersonal, and structural factors influence health outcomes and specifically how these forces may differentially impact hypertension management across two geographically distinct health systems.

For this analysis, we focused primarily on the Individual Factors and Physiological Pathways domains, which include patient-level characteristics such as health literacy, motivation, lifestyle, and mental health. These domains align most closely with our aim of understanding how patient characteristics and health conditions influence hypertension management. The HEF allowed us to analyze patient and provider behaviors within the broader social and environmental contexts that shape decision-making. While our larger project addresses a broad range of factors influencing hypertension management and outcomes, including institutional processes (“Systems of Power;” Kramer et al., 2025a) and family and community relationships (“Relationships and Networks;” Kramer et al., 2025b), this particular study focuses on the role of patients’ intrapersonal influences and providers’ individual-level variations in improving hypertension management outcomes.

METHODS

Study Setting and Participants

We conducted semi-structured interviews with 25 primary care providers (PCPs), 4 cardiology providers, and 25 patients diagnosed with hypertension from thirteen primary care and one cardiology clinic across two AHS in NC and KS. All participants were English-speaking adults, with providers working in either family medicine, internal medicine, or cardiology clinics. Patient participants were all diagnosed with hypertension and either had their last BP measurement ≥ 140/90 mmHg or were engaged in an intensive, hypertension-focused telemedicine intervention via the cardiology clinic. This study was approved by the Wake Forest University School of Medicine Institutional Review Board (#IRB00087638).

Clinic Selection

Clinic-level performance data were reviewed for each AHS, with family medicine (FM), internal medicine (IM), and “emerging care” (EC) clinics each ranked by their respective hypertension control rates. EC clinics are a subset of primary care clinics within the NC AHS that employ community-centered approaches and generally serve more marginalized populations. Data were obtained from internal quality dashboards using a one-year lookback (7/7/2021–7/7/2022). These reports included 44 FM, 27 IM, and 10 EC clinics for the NC AHS and 6 FM and 6 IM clinics for the KS AHS. Utilizing purposive sampling methods (Campbell et al., 2020), clinics were selected based on their performance as either high-performing (top 16%) or low-performing (bottom 16%) in hypertension control when compared to other clinics within their health system. Eight primary care clinics in NC (FM: 2 high, 1 low, IM: 1 high, 2 low, EC: 1 high, 1 low) and four in KS (FM: 1 high, 1 low, 1 IM: 1 high, 1 low) were selected to participate.

Additionally, two clinics outside these thresholds were selected: one FM clinic in KS with a high proportion of racially diverse patients and one cardiology clinic in NC leading a remote hypertension monitoring intervention. This decision was made for two reasons: (1) to ensure that data collection at primary care clinics in KS included a site that served a diverse patient population, and (2) to supplement our primary care findings with the perspectives of patients and providers that are involved in intensive hypertension-focused care, which allows for increased discussion around the effectiveness of potential interventions to mitigate identified barriers.

Recruitment and Enrollment

We employed a convenience sampling frame (Etikan et al., 2016) for participant recruitment. Clinics’ quality improvement personnel assisted study team members in identifying potential PCP participants, while patients were referred by participating PCPs after completing their interview. A program director in the cardiology clinic, who led their remote hypertension monitoring intervention, assisted by referring both patient and provider participants. Beyond our eligibility criteria, which limited our sample to PCPs, cardiologists, and patients with either uncontrolled hypertension or an active involvement in a cardiology clinic telemonitoring intervention, we did not provide any additional instructions to guide participant referrals. We felt our clinic sampling strategy was sufficient to promote diverse engagement across multiple demographic variables, with our clinical recruitment sites varying substantially across geographic designation (e.g., urban, rural), racial and ethnic composition, and insurance and payer status. All recruitment outreach was conducted by a member of the study team, with interested providers and patients being scheduled for interviews. Participants were informed as to the scope of the interviews and provided verbal informed consent prior to participation (JK/JR).

Data Collection

Interviews were conducted from October 2022 to May 2023 and explored the barriers and facilitators impacting patients’ and providers’ hypertension management efforts. Our study team, which included physician experts in hypertension and qualitatively-trained research faculty, collaboratively developed two interview guides – one for providers and one for patients (Appendices 1, 2). Both guides incorporated key HEF themes (Peterson et al, 2021), while exploring the barriers and facilitators to hypertension management, specifically the impact of individual-level patient factors on BP control, such as health literacy, intentionality, patients’ access to resources, and physiological well-being. Interviews lasted between 30-45 minutes and were conducted remotely. Provider interviews typically occurred via video conferencing software and patient interviews were conducted by telephone. All interviews were facilitated by one of two graduate-level, qualitatively-trained members of the research team (JK/JR), one male and one female. Participants received a $50 prepaid debit card upon completion of their interview.

Analysis

Interviews were audio recorded, transcribed word-for-word, and analyzed using Dedoose software. Two members of the research team (JK/SE) collaboratively developed and iteratively refined a codebook, using a HEF to organize emergent codes across its four content domains (Peterson et al., 2021). Consistent with an “open coding” approach, JK/SE developed the codebook by independently reviewing two patient and two provider transcripts, with each identifying patterns in the data and developing codes (Cascio et al., 2019). JK/SE then met to reconcile their codes and finalize the initial codebook, with the agreed upon codes organized across the four HEF domains (Peterson et al., 2021), which served as parent codes, with the resulting coding tree reflected in Figure 1. JK/SE then independently applied the codebook to the previous four transcripts, meeting to resolve any coding discrepancies and revise the codebook as needed. The remaining transcripts were coded by the primary qualitative researcher (JK), with any points of confusion discussed among the research team. This process yielded analysis across all four HEF domains, however our findings relevant to this study focus on Individual Factors and Physiological Pathways.

Figure 1.

Adapted Health Equity Framework.

*First published in the Journal of General Internal Medicine, 2025, by Springer Nature (Kramer et al., 2025a). Figure adapted from Peterson et al. (2021).

Central to our analysis are the HEF domains of Individual Factors – subthemes Patient Resources, Health Literacy, Intentionality (capturing both intention and motivation), Lifestyle, and Patient-Centered – and Physiological Pathways – subthemes of Physical Health and Mental Health (Figure 1). These two HEF domains explore the impact of patient-level factors, such as behaviors, resources, and physical and mental health, on effective hypertension management. Informed by qualitative standards around thematic saturation (Hennink et al., 2017), we aimed to conduct at least 20 interviews with both patients and providers, with a minimum of 10 patient and 10 provider interviews occurring in each NC and KS. This was sufficient to reach thematic saturation, as our final round of interviews yielded no new emergent themes. After the qualitative analysis was complete, the study team collectively assessed how key themes and subthemes varied across clinics, specifically pertaining to clinic performance (i.e., hypertension control) and geographic location, which provided additional context and interpretation.

RESULTS

Clinics and Participants

Both clinic- and patient-level demographic data have been previously reported in Kramer et al., 2025b. In total, we interviewed 34 particpants from NC (N=19 providers, N=15 patients) and 20 from Kansas (N=10 providers, N=10 patients). Patricipants in our sample were diverse across multiple variables, including sex (providers: 62% female; patients: 48% female), race (providers: 69% White, 24% Asian, 3% Black; patients: 68% White, 32% Black), and clinic location (providers: 45% urban, 48% suburban, 7% rural; patients: 28% urban, 52% suburban, 20% rural). Of our 25 patient participants, 28% had a last BP measurement (in the electronic health record) > 160/100 mmHg, 60% had a BP between 140/90 mmHg and 160/100 mmHg, and 12% had a BP ≤ 120/80 mmHg (all of whom were recruited via the NC cardiology clinic).

Participating clinics varied by geographic designation (4 urban, 8 suburban, 2 rural), specialty (6 FM, 5 IM, 2 EC, 1 cardiology), and hypertension control rates (ranging from 53% to 86%). Notable differences existed between the AHS, as KS clinics exhibited higher hypertension control rates, had lower proportions of Medicaid and uninsured/self-pay patients, and served more patients annually, both in raw numbers and patients per provider. KS clinics were either urban or suburban – 2 urban, 3 suburban, while NC clinics included 1 urban, 5 suburban, and 2 rural sites. Within NC, there were distinct clinic-level differences across high- and low-performing clinics. Of note, low-performing clinics had higher proportions of Non-Hispanic-Black patients (mean 30% vs. mean 13%), higher Medicaid payer rates (mean 13% vs. mean 8%), more providers (mean 6.25 vs. mean 4.5), and were in more densely populated areas compared to high-performing clinics. The mid-performing KS clinic, selected for its diverse patient population, had a higher Non-Hispanic-Black patient percentage (48% vs. mean 11%) and served fewer patients (5,194 vs. mean 11,142) than the other KS clinics. The participating cardiology clinic in NC was urban, employed 27 providers (22 MDs, 5 APPs), and recorded 47,974 billed visits in 2022.

Individual Factors

Participants often discussed their hypertension management efforts in terms of the Individual Factors domain, encompassing the five subthemes: Health Literacy, Lifestyle, Intentionality, Patient Resources, and Patient-Centered (Figure 1). These subthemes were reflected consistently across interviews regardless of AHS or clinic performance level.

Health Literacy

Health literacy was often discussed as a barrier to hypertension management, with patients and providers frequently linking diminished patient understanding with both a lack of uptake for potentially impactful interventions (e.g., BP telemonitoring) and medication nonadherence (Table 1). Multiple providers explained that “the biggest challenge is getting patients to understand the seriousness of hypertension” (KS/Provider 6 [PV6]/FMHigh) and due to “hypertension being a silent disease, some people just don’t put a lot of value on it until some event happens” (NC/PV10/FMLow). When discussing specific strategies for improving BP control, such as BP telemonitoring or medication initiation, patients’ health literacy was frequently identified as a barrier hindering utilization. For example, while multiple providers explained that “[BP telemonitoring] is great if you can educate patients on appropriate use” (NC/PV6/ECLow), patients often cited struggles using BP cuffs, with one patient noting that “I’ve tried learning to take it myself and I don’t know how to use my blood pressure cuff, so I don’t use it at all” (KS/Patient 6 [PT6]/IMLow). Similarly, multiple providers emphasized the importance of patients understanding their prescribed medications, which providers linked with increased adherence, otherwise “[patients] don’t really know why they’re put on certain medications, […] which results in non-compliance” (NC/PV3/FMHigh).

Table 1.

Health Literacy and Hypertension Management.

Patients’ lack of hypertension knowledge can present barriers, particularly for rural patients Most of the people with high blood pressure typically don’t have any symptoms, especially if they’re otherwise young and have no other medical issues, and they’re like, “Oh, well, this ain’t no big deal.” […] Lack of education probably is the biggest hurdle. – NC/PV4/FMHigh Just basic lack of patient education. That’s a big thing in [rural] County and in [rural town], the area out there where we are, is patient education. We are working with that. – NC/PV6/ECLow Patients’ understanding of BP medications can impact adherence Some people don’t understand the importance of blood pressure control and are just a little bit misinformed about the actual goals of blood pressure medications. […] It’s an educational mismatch. […] They’re just not realizing, “Oh, it’s important to take medicine.” – NC/PV17/Cards Some patients say, “Well, my blood pressure, it was really good or it’s under control so then I felt like I didn’t need to take it anymore.” – KS/PV4/FMLow Patients’ limited knowledge of appropriate BP measurement technique can be a barrier I’ve noticed that not all [patients] are even aware of how to check their blood pressure – resting both feet on the ground, sitting quietly not talking, not reading for five minutes while they do it. Blood pressure cuff at the level of the heart. All those sorts of things. That’s definitely a challenge. – NC/PV1/ECHigh I was walking the other day and getting out of breath. […] I thought damn, I need to take it [blood pressure] and since I didn’t know how, I tried just doing manually by feeling my pulse. […] I think it was bad. – KS/PT6/IMLow Resources can help provide patients important and useful HTN information I still do give them handouts for patient education which has lifestyle modifications, the type of blood pressure medications. Definition of what is blood pressure. What are the readings? What are good readings? What are bad readings? That helps a lot. Even, that helps for patients who have chronic hypertension and they just need a refresher. If I see their pressures are not well-controlled, then I do go ahead and give out those handouts to them. – NC/PV11/IMLow I’ve had a number of publications of stuff from Dr. [PCP] and the nurses that came to visit me that related to exercise, diet, and that kind of thing. I read that stuff. Every once in a while, I get something in the mail from [AHS] that has to do with diet or diabetes or that kind of thing. I like looking over that stuff. […] More just as a help in making decisions. I read the thing, and I maybe find a use for it later when I’m trying to make a decision as to what I’m going to have as part of my diet. – NC/PT11/FMLow

Most providers linked patients’ diminished health literacy with increased barriers to hypertension control, however providers in low-performing clinics were more likely to reference these themes as challenges directly impacting their patient populations. Similarly, patients and providers in low-performing clinics more frequently discussed using patient education, with one provider explaining that “if I see their pressures are not well controlled, then I do go ahead and give out those handouts” (NC/PV11/IMLow). Although some providers in low-performing clinics noted that patient education handouts were useful, others expressed a desire for improved patient-facing education options. As one provider explained (KS/PV9/IMLow):

We really could have better education. A lot of our education on blood pressure is still like an old PDF that was scanned into the system. […] I should have multiple options to meet the patient where they’re at. Whether that is printing something out and handing it to them or sending them a PDF.

Another factor impacting discussions of health literacy was clinics’ geographic designation, with some rural NC providers contextualizing patients’ diminished health literacy by directly linking it to rurality. For example, one provider explains that “because my patient list is predominantly rural, lack of education, lack of self-awareness, noncompliance would probably be the major barriers” (NC/PV/FMHigh).

Lifestyle and Intentionality

Patients’ hypertension management efforts were frequently discussed relative to their current lifestyle behaviors (e.g., diet), with entrenched habits and competing priorities commonly cited as barriers (Table 2). Patients often attributed dietary habits to lifelong behaviors—for instance, one stated, “I like fried chicken. It’s part of my upbringing” (NC/PT1/ECHigh), while another admitted, “I don’t really know how to eat any differently than I’ve always eaten” (KS/PT7/FMMid). Expanding upon this, both patients and providers noted that competing priorities, such as family and work demands, often hinder efforts to manage hypertension. As one provider explained, “Once they leave the office, they’re just so incredibly busy with their work, life, kids, all that, that even taking a minute to sit down with a blood pressure cuff is asking a lot” (KS/PV6/IMLow).

Table 2.

Lifestyle Behaviors and Intentionality Towards Hypertension Management.

Lifestyle – Familiar foods are often unhealthy and can present challenges I like fried chicken. It is part of my bringing up, my coming up as a child. We always ate chicken, so it’s one of my favorite foods. Pizza, I like pizza. It’s like the things that I like, I know they’re not good for me, but I guess I still choose to eat them. – NC/PT1/ECHigh Lifestyle – Competing priorities can impact uptake of healthy lifestyle behaviors Being busy. It’s easy to stop in, grab something that, food-wise, isn’t good for you, but it’s convenient. I have three kids, and they all play sports. Once sport seasons start, we’re hardly ever at home. – NC/PT10/IMLow I have so much going on between the stress, the depression, the grief, and work and home. Only thing I can do is, like I say, try to remember to take my pill and that’s it. […] My work schedule is all over the place. […] Just everything is just all over the place. So, no, I can’t even do a schedule.– KS/PT10/FMMid Intentionality – Patients often have goals of getting off their anti-hypertensive medication I feel like my biggest want or worry or ask is can I get off medication at some point. Can I get my blood pressure to a good spot that I can get off medication? […] I don’t want to be in my mid-30’s and starting a daily thing I have to take every single day. – KS/PT1/IMLow Intentionality – Providers detail multiple approaches that might help with medication adherence Insisting that patients bring all their medicine every single time to visits because confusion, compliance. […] It helps make sure patients know how important it is and helps with confusion.[…] It really is more just patient perception and then sometimes polypharmacy confusion. – NC/PV16/IMHigh If their script isn’t written for 90 days, […] that impacts their compliance with the medications just because they might have multiple fills. And if they can’t get a ride to the pharmacy, or they’re not set up with mail order delivery, I think that definitely impacts it. – KS/PV8/IMLow

Consistent with themes pertaining to health literacy, providers often framed patients’ intentionality towards actively managing their hypertension in the context of understanding the severity of the disease. Multiple providers noted that “it’s hard for a patient to care about hypertension” when “in any given day it’s not causing the patient any problems or any symptoms. […] It’s just high blood pressure” (KS/PV9/IMLow). However, one cardiologist explained that patients’ prioritizations may temporarily shift after experiencing a negative cardiovascular event, during which time they may become increasingly intentional about BP management (NC/PV17/Cardiology).

If you have somebody that comes in fresh off a heart attack, they’re a little bit more scared and then they’re a little bit more motivated to get it together. Initially, I feel like I see pretty good impact, but then over time, they start going back to old habits.

While medication adherence is critical to hypertension management efforts, patients and providers routinely expressed differing perspectives pertaining to the use of medication in hypertension care. Patients consistently highlighted an aversion to taking hypertension medication, with some noting that they will do “anything I can think of that will help me stay off medicine” (KS/PT7/FMMid). For patients currently on medications, many expressed initial concerns about “starting a daily thing” and a goal of “get[ting] off medication at some point” (KS/PT1/IMLow). Multiple providers explicitly highlighted the disconnect in patient-provider expectations for medication use, which one provider associated with a lack of “patient understanding of the disease itself” (NC/PV11/IMLow). Continuing, this provider explained that PCPs’ challenge is conveying to patients the “need to be on it [medication] for a long-term basis, rather than ‘hey, my blood pressure is normal, I took the medicine, let’s stop.’” Providers also discussed medication side-effects as a barrier to adherence, particularly the “high rate of either real or perceived side effects of anti-hypertensive medications,” which can “lead to difficulty controlling blood pressure” (NC/PV2/ECHigh). One provider detailed their approach to medication adherence, which both leveraged patients’ desire to get off medications and emphasized patients’ increased uptake of lifestyle modifications (NC/PV11/IMLow).

Initially it’s just the medications that you’re trying to control the blood pressure with. […] You tell the patient ‘Hey, you know what? We’re going to try to control it. In the meanwhile, you go ahead and work on these lifestyle changes. It’s going to take a little while. As we see the pressures coming down, then we can take you off of it [medication].’

Patient Resources and Patient-Centered Care

Access to resources emerged as a critical theme influencing hypertension management. Patients’ access to healthy foods, BP measurement devices, anti-hypertensive medication, and in-clinic visits and/or hypertension-focused interventions were all explicitly mentioned as playing key roles in hypertension management efforts (Table 3). Economic constraints were frequently cited, as many patients felt that “eating healthy is very expensive” and expressed a need for assistance to afford nutritious food (NC/PT1/ECHigh). In contrast, some providers argued that healthy eating can be affordable, pointing to options like beans, lentils, and legumes, and citing resources such as “food prescriptions” (NC/PV16/IMHigh) and detailing a need for increased diet-focused education.

Table 3.

The Impact of Patient Resources on Hypertension Management.

Patient Resources – There is a need to improve patients’ access to healthy food Eating healthy is very expensive. The grocery store prices are outrageous now. Maybe if I could get some kind of assistance with buying my food, I could probably eat a little bit better. Like right now, if you try to stick to a certain diet, it’s expensive to go on a certain diet. – NC/PT1/ECHigh Patient Resources – Cost of healthcare impacts utilization, particularly for hypertension care The hypertension program used to be complimentary and now it’s billable.[…] I do think that has created a barrier. […] When patients are told it’s going to be $300 possibly out of pocket, they’re automatically not going to do it. – NC/PV17/Cards Patient Resources – Access to BP devices present barriers to hypertension care A 24-hour blood pressure monitor would really be helpful. Do they dip with sleep? Those would really help me. It has really become, because of insurance and lack of coverage, I don’t have a good way to get that for patients. – NC/PV16/IMHigh For my patients who do not have means to even buy a blood pressure cuff, and I know they’re fairly inexpensive, but it’s still a big ask for some of them. Getting the durable medical equipment is a huge headache. – NC/PV5/ECHigh Patient Resources – Competing priorities and resource limitations can present barriers When your blood pressure is not under control, you may have to come in for multiple doctor’s appointments. And that requires transportation, and it requires taking a half day off of work […] where then you’re losing money. You may require someone to watch the kids while you go to your doctors’ appointments, all these kinds of issues, just to control blood pressure, which in many ways the patient perceives is not causing me any problems. The cost ratio for that patient is kind of difficult to get past. And so, all of those are large barriers to care. – KS/PV9/IMLow Patient-Centered - Providers’ trust in patients can yield increased opportunities for access The other thing that then determines whether I do even a quick touchpoint is really the patients that it really is a one-and-done. It’s patients that everything else we’ve got a good plan for that’s on autopilot. Really, it’s blood pressure that we’re working on, and I know they are the kind of person that is going to come in and focus and not hit me with ten other complaints. There are certain patients that you just know it’s never going to be five or ten minutes ever. Trying to bring those patients in as a double-booked visit is setting yourself up for failure. – NC/PV16/IMHigh

Providers generally agreed that anti-hypertensive medications were affordable, noting that “financial is less of a concern given that most common anti-hypertensives are generic” (KS/PV6/FMHigh). However, although many providers cited the importance of patients’ home BP telemonitoring on effective hypertension management, the high cost of home BP monitors remained a barrier. As one patient noted (NC/PT2/ECHigh):

I’d like to be able to afford all the machines and gadgets that I need to keep my blood pressure under control, but a blood pressure monitor, they’re over $100 if you get a good one. The insurance won’t pay that.

Further, cost of healthcare was another commonly cited barrier, with providers noting that economic limitations often hinder patients’ engagement with both hypertension-focused interventions and BP recheck appointments, stating that “if they know it’s a billable thing, they oftentimes will not come back to have that done” (NC/PV17/Cardiology). Although pharmacist-led BP monitoring interventions were positively received, rising program costs for patients have reduced participation, with one cardiologist stating that “for a while it was no cost, which patients loved,” but “now with additional cost […] they’re unwilling to pay for extra visits” (NC/PV19/Cardiology).

Providers frequently discussed hypertension care delivery by detailing how specific patient-level considerations may impact their treatment decisions. In most cases, this centered on tailored prescribing practices and the importance of considering patient-level factors when initiating medications, such as patients’ age, comorbidities, lifestyle, and economic resources. However, some providers also referenced considering patient-level factors when using non-traditional appointments (e.g., double-booked appointments, nurse visits) to assist patients in navigating barriers associated with clinic access. While providers in both high- and low-performing clinics indicated using double-booked appointments and nurse-led BP recheck visits, providers in high-performing clinics were more likely to explicitly state that they reserved these resources for patients that they “trusted.” Pertaining to double-booked appointments, one provider explained that these spots were reserved for patients that will “come in and focus [on hypertension] and not hit me with ten other complaints” (NC/PV16/IMHigh). Similarly, a different provider detailed their use of BP recheck nurse visits, which they recommended only for patients “that I trust who will come back,” explaining that “the other patients who are just in and out of care, I know it won’t happen” (KS/PV6/FMHigh).

Physiological Pathways

The impact of patients’ physical and mental health on BP control was mentioned by both patients and providers (Table 4). Regarding physical health, participants noted that comorbidities—such as heart disease and diabetes—increase a patient’s adherence to treatment protocols. For example, providers observed that patients with “known heart disease” or “diabetes” were “more likely to stick to the recommended regimen or treatment strategy as compared to just high blood pressure being an isolated problem” (NC/PV4/FMHigh). One patient illustrated this point, stating, “I have a blocked artery – the one they call the ‘widow-maker’ – that has kept me trying to be good as far as routines and diet and trying to lose weight” (KS/PT5/IMLow). Additionally, some providers highlighted that the complexity of a patient’s condition often necessitated additional support, noting that “pharmacists in the clinic help us manage these patients” (KS/PV5/IMLow).

Table 4.

Physiological Factors and Hypertension Control.

Physical Health - Patient age and complexity can impact providers’ care goals I have selected a patient population that is very old and very frail. So, the truth is, my top priority is not hypertension. My priority is quality of life and things like that. […] I don’t want to push it [BP] down too much, because they already fell three times last month. So, it’s hard to be real protocol driven in geriatrics because of that. – KS/PV3/IMLow There is certainly a risk of overtreatment with the older patients with many comorbidities. Sometimes, I have to adjust my realistic goal for blood pressure goals and that can involve a lot of subjectivity, […] causing me to adjust goals probably upwards to prevent falls. – NC/PV1/ECHigh Blood pressure management changes with age. Elderly patients, it’s a much more complex interplay with managing blood pressure safely without running into side effects. […] The risk of having an adverse effect from a blood pressure medicine, whether that’s a fall, whether that’s orthostatic hypotension, dizziness, fatigue, poor quality life, is much heavier weighed. You got to change your blood pressure targets. – NC/PV2/ECHigh Mental Health – Providers link patients’ depression, anxiety, and past trauma with elevated BP Often times there’s other things going on. […] They truly do have trauma or anxiety or depression. A lot of them, blood pressure is not the first concern, but a secondary side effect of addressing the depression or whatever. – KS/PV1/FMLow Mental Health – Anxiety can impact patients’ self-monitoring of BP As far as doing my blood pressure every day? That’s – no. I think that would be unhealthy for me. I think I would make myself sick if it didn’t read right. […] I’m not a nutcase, I just overthink things whenever it comes to my health. – KS/PT2/IMLow You have to be very careful with that [BP monitoring] though, because you can overdo that. There are a lot of patients who overdo that. There’s a huge overlap between the diagnosis of hypertension and the diagnosis of anxiety about hypertension. – NC/PV2/ECHigh My more anxious patients, it doesn’t really help to track it at home because it just makes them more anxious. – KS/PV4/FMLow Mental Health – Providers may leverage additional support to address mental health concerns If I feel like anxiety is to a level that just doing relaxation techniques and things to relieve their anxiety by themselves is not a good idea, then I do say, “Hey, you know what? I think you should at least see a psychotherapist. I can go ahead and place a referral for it or maybe through work and see if that’s going to help you. It has helped a lot of people.” – NC/PV11/IMLow

Patient age was also mentioned as an important factor, both as it related to age being associated with increased intentionality to address hypertension, and as it pertained to elderly patients often having more complex health needs. Multiple providers noted that “blood pressure management changes with age” and that with elderly patients it can be more challenging “managing blood pressure safely without running into side effects” (NC/PV2/ECHigh). Some providers discussed the need to augment BP targets for elderly patients, explaining that the “risk of overtreatment” can necessitate providers “adjusting realistic goals for blood pressure” (NC/PV1/ECHigh). Explaining this, one provider noted (KS/PV2/IMHigh):

Not every old person is going to benefit from 115 over 75 blood pressure. For some people 140 is perfectly acceptable, because they need that for brain perfusion. […] We might fall out of those treatment guidelines on certain patients, but for good reason.

Providers frequently linked patients’ physiological well-being with management of their hypertension, explaining that factors such as “stressors or pain […] could artificially be increasing somebody’s blood pressure and would throw off what you’re seeing” (NC/PV12/IMLow). Hypertension management was commonly contextualized vis-à-vis patients’ mental health, with one provider explaining that “if they are actually depressed or stressed, you’re going to say, ‘well, your blood pressure is probably up because you’re depressed and stressed” (NC/PV14/FMLow). As one cardiologist explains (NC/PV17/Cardiology):

Several patients come in and they’re super hypertensive because they have anxiety. […] I don’t want to treat anxiety with a blood pressure medicine. The underlying cause of the high blood pressure is the anxiety, so that’s what needs to be treated.

While the impact of mental health on blood pressure control was mentioned by multiple participants, the challenges associated with patients’ anxiety and depression were often very different. Depression was usually referenced relative to patients’ decreased motivation and intentionality, with one provider explaining that “there’s also a challenge of our patients with depression that they stop taking all their medications,” and that depressed patients may not be “motivated to take care of their physical health because of their mental health” (KS/PV6/FMHigh). Conversely, patients with anxiety were often cited as being “more aware of their blood pressure” and “willing to take medication for it” (KS/PV2/IMHigh). However, providers cautioned that patients with anxiety were also more likely to over-monitor their BP, with elevated measurements potentially exacerbating their existing anxiety. Highlighting this, a patient explained that “if I had that monitor to check my blood pressure every time I thought it was high, I think I would go off the deep end” (NC/PT2/ECHigh).

Multiple providers discussed leveraging additional care team support when they felt patients’ mental health was hindering hypertension control, with referrals to therapists being a commonly cited next step. For patients with anxiety and depression, providers routinely linked improved mental health with increased motivation and intentionality towards hypertension management. As one provider explains, “in chronic diseases like hypertension, once patients start feeling better mentally, they’re more motivated to take care of their own blood pressure” (KS/PV6/FMHigh).

DISCUSSION

This study offers a novel contribution to the existing hypertension management literature by employing a health equity framework (Peterson et al., 2021) specifically adapted to examine patient-level and physiological factors influencing hypertension control across diverse clinical environments, a perspective that has been underutilized in prior equity-focused research on hypertension.

The application of the HEF in our analysis represents a methodological advancement by facilitating simultaneous examination of individual behaviors, clinical practices, and contextual determinants through a unified theoretical lens. Previous investigations have typically employed fragmented approaches, focusing either on medication adherence (Hossain et al., 2025), provider practices (Chukwuka et al., 2024), or social determinants (Memon et al., 2025) in isolation. Our integrated analytical framework revealed interactions between patient and clinic-level factors, demonstrating that the impact of health literacy on blood pressure control may be influenced by the quality of patient-centered care delivery, and in turn patient-centered care delivery may be shaped by a patient’s demonstrated health literacy. This finding advances the conceptual understanding of hypertension management by illustrating how individual and systemic factors operate synergistically rather than independently, an important refinement to existing models that frequently treat these dimensions as separate domains of influence.

Our findings also suggest meaningful differences in intervention strategies between high- and low-performing clinics. Providers in high-performing clinics described selectively deploying resources—such as double-booked appointments, nurse-led BP rechecks, and patient education materials—based on patient engagement indicators like appointment adherence and self-management capacity. In contrast, providers in low-performing clinics reported more frequent use of broad educational efforts and expressed a need for improved patient-facing materials. These clinics also appeared to rely more heavily on standardized interventions, such as printed handouts, due to limited infrastructure or staffing flexibility (Kramer et al., 2025a). This contrast may reflect differences in organizational capacity, provider discretion, or patient population needs. While high-performing clinics emphasized tailoring interventions to individual patients, low-performing clinics often focused on overcoming foundational barriers to engagement. These distinctions underscore the importance of context-sensitive implementation strategies and suggest that intervention effectiveness may be shaped not only by content, but also by how and to whom it is delivered.

Our analysis revealed distinct patterns between high- and low-performing clinics, particularly highlighting differences in perceptions of health literacy and provider resource allocation. Providers in low-performing clinics frequently cited challenges due to patients’ limited understanding of hypertension, requiring extensive educational efforts. Conversely, high-performing clinics adopted more targeted approaches, strategically allocating resources based on patient engagement metrics such as appointment attendance and self-management capabilities. While this pattern suggests a potential link between tailored interventions and improved hypertension management, the direction of causality remains unclear—whether targeted solutions drive better outcomes, or whether effective management enables more strategic tailoring. These findings align with Bodenheimer et al. (2014), which emphasize elements such as data-driven improvement, team-based care, and patient engagement as critical to clinic performance. Our results suggest that high-performing clinics may be better equipped to implement these principles, particularly in tailoring interventions to patient needs and engagement levels. This presents an important consideration for future research. Economic constraints further complicated hypertension management, limiting patients’ ability to access low-sodium foods and cost-effective interventions, such as home blood pressure monitoring and nurse-led support programs—particularly in clinics serving a high proportion of patients who are uninsured or enrolled in Medicaid. These constraints may lead individuals to rely on inexpensive, shelf-stable foods high in sodium, further hindering blood pressure control.

Additionally, our findings illustrate the complex relationships between psychological factors, comorbidities, and blood pressure control. Participants generally described comorbid conditions as influencing patient motivation for treatment adherence. Mental health conditions were noted to have varied effects: for example, anxiety was often associated with increased vigilance regarding blood pressure, though it sometimes led to over-monitoring, while depression was frequently linked to reduced engagement and intentionality in care. Provider responses to these psychological factors differed substantially across clinic settings, often shaped by the availability of mental health resources, staffing, and screening infrastructure. These findings emphasize the critical need for routine psychological screening within hypertension management strategies and reinforce the value of integrated behavioral health services within primary care settings.

We demonstrate strong alignment with existing literature on hypertension management and health disparities, while extending current understanding through novel applications of the HEF. Our findings on the role of health literacy in treatment adherence are consistent with prior work by Algabbani and Algabbani (2020), which identified significant links between disease comprehension and medication self-management. Differences in health literacy across clinic performance levels reflect earlier research and suggest that literacy-related challenges may be more prevalent in certain clinical settings. While this pattern may be influenced by structural factors such as clinics serving higher proportions of patients with lower socioeconomic status, including Medicaid beneficiaries or self-pay individuals, further research is needed to confirm this association. Rather than attributing outcomes solely to individual literacy, our findings point to the potential influence of systemic factors, including organizational culture, provider communication strategies, and access to educational resources (Kramer et al., 2025a; Kramer et al., 2025b). These insights support the development of tailored, clinic-level interventions for populations with lower health literacy.

Based on our findings, several intervention strategies may be effective in improving hypertension management, particularly in low-performing clinics. These include enhanced patient education materials tailored to varying literacy levels, expanded access to home BP monitors through subsidized programs, and integration of behavioral health screening into routine hypertension care. Additionally, leveraging nurse-led BP recheck visits and pharmacist-supported medication management may help offload provider burden and improve continuity (Kramer et al., 2025a). However, implementation challenges remain. Clinics with limited staffing, high patient volumes, or constrained budgets may struggle to adopt these strategies without external support. Further, tailoring interventions to patient engagement levels as seen in high-performing clinics requires robust data infrastructure and provider discretion, which may not be feasible in all settings. These challenges highlight the need for scalable, context-sensitive implementation models that account for clinic capacity, patient population needs, and systemic resource constraints.

A unifying thread across the five themes (Individual Factors domain) identified in this study is the influence of structural factors, those foundational, system-level conditions that shape both access to care and the context in which patients and providers operate. Whether examining variability in health literacy, clinic-level resource allocation, economic barriers, or mental health integration, structural inequities emerged as underlying forces that affect individual behaviors and provider decision-making alike. These conditions manifest in how care is delivered (e.g., availability of educational resources or mental health screening), how patients are able to engage (e.g., food insecurity or limited insurance coverage), and how systems respond (e.g., through quality improvement [QI] infrastructure of tailored interventions), which was explored by our prior study examining the HEF domain Systems of Power (Kramer et al., 2025a). Recognizing these structural origins not only clarifies the interconnectedness of the identified themes, but also offers direction for targeted, system-level interventions where the potential for impact may be greatest.

The geographic and demographic variations documented in our multi-site sample contribute empirical evidence to the evolving literature on regional health disparities and implementation science. Rather than reflecting differences in hypertension control rates alone, our findings highlight how individual-level factors, particularly health literacy and rurality, shape patient engagement and response to interventions. These results align with analyses by Lind et al. (2025), who also observed significant contextual variability in hypertension outcomes across clinical environments. Our study extends these insights by demonstrating that comparable interventions, such as home BP monitoring programs or health education workshops, may require adaptation based on rural-urban classification, insurance coverage patterns, or provider-to-patient ratios. From an implementation science perspective, tailoring discrete strategies to the specific needs and capacities of the patient population served will be essential for scaling evidence-based hypertension management across diverse settings.

Limitations and Future Directions

This study has several methodological constraints that merit consideration when interpreting its findings. While our approach yielded rich contextual data, the qualitative nature of the study limits generalizability; however, our intent was to support transferability of insights to similar settings rather than statistical representativeness. The purposive sampling strategy, designed to capture diverse perspectives from clinics within two AHS, is a recognized strength in qualitative evaluation. However, the inclusion of AHS with established quality improvement infrastructure may introduce selection bias, as clinics with robust QI practices may have been more likely to participate. As such, findings may be less transferable to healthcare contexts with limited infrastructure or less emphasis on QI initiatives.

Although efforts were made to capture a range of perspectives, provider interviews may be subject to social desirability bias, particularly when discussing clinic performance or patient behaviors. Furthermore, conclusions regarding clinic-level practices, particularly distinctions between high- and low-performing clinics, are based on interviews with one or two providers per site, which may not fully reflect the broader organizational culture or practice patterns. If future research aims to draw clinic-level conclusions, additional recruitment strategies or triangulation with other data sources would strengthen those interpretations.

Our patient sample, while demographically diverse in several respects, showed underrepresentation of some racial and ethnic groups, including Hispanic/Latino and Asian individuals, relative to national hypertension prevalence statistics. Our patient recruitment strategy, which leveraged participating PCPs to refer patients, may also have introduced bias, particularly insofar as referred patients may have been more engaged in care than those who were not referred. Additionally, the use of self-reported medication adherence data introduces the possibility of recall and response bias. Future studies should incorporate objective measures of adherence and use validated instruments to assess patient activation and engagement over time.

Our adaptation of the HEF for hypertension management is a novel application that warrants further exploration across diverse clinical contexts. Importantly, the two AHS included in this study differed significantly in their structure, resources, and patient populations, which enhances the transferability of our findings across varied healthcare environments.

Future efforts should focus on delivering contextually informed, patient-centered, and equity-focused hypertension management programs that address the individual and systemic factors identified in this study. Implementation science methodologies, including hybrid effectiveness-implementation designs, should be used to systematically identify contextual factors that support or hinder the integration of HEF-informed strategies into routine care. Multi-site randomized controlled trials comparing interventions to address health literacy disparities, resource constraints, and psychological barriers would further strengthen the evidence base and guide equitable clinical practice.

CONCLUSION

Our study underscores the imperative of adopting a comprehensive, patient-centered approach to hypertension management that integrates both individual and systemic factors. By leveraging the HEF, we have illuminated how health literacy, intentionality, and mental health, coupled with socioeconomic and geographic determinants, collectively influence BP control. These findings carry meaningful implications across clinical, research, and policy domains. Clinically, our results advocate for tailored, equity-informed hypertension care that integrates behavioral health screening and reinforces the importance of patient education, resource alignment, and individualized care strategies. From a research standpoint, the study supports further application of implementation science and health equity frameworks to understand how context shapes intervention effectiveness. Policy makers should consider these insights when designing scalable, community-responsive programs to reduce disparities in chronic disease outcomes particularly as health systems shift toward value-based care models that risk deprioritizing equity initiatives. Ultimately, our findings provide a foundation for advancing high-quality, equitable hypertension care across diverse patient populations and practice settings.

DATA AVAILABILITY

The de-identified datasets analyzed for this study can be made available upon request.