Identifying Contextual Barriers and Potential Solutions to Improving Hypertension Management in Rural Communities in the United States: Qualitative Study From 2 North Carolina Counties

Abstract

Background

Blood pressure–related deaths from cardiovascular disease are higher in rural than in urban areas in the Unites States, especially in southeastern states. However, the barriers and potential solutions to hypertension care are inadequately understood.

Methods

We interviewed 62 local community and health systems key informants in 2 rural (Pamlico and Robeson) counties in North Carolina. Probes based on the Consolidated Framework for Implementation Research were used to identify contextual barriers and facilitators affecting existing resources and services for improving hypertension care. Data were analyzed using hybrid deductive and inductive approaches, and organized into themes and subthemes with illustrative quotations.

Results

The prominent barriers of hypertension care emerged across outer setting (economic constraints, insufficient health insurance, food insecurity, wide accessibility of processed food, lack of transportation, digital connectivity gap, limited awareness of partnership and resources, and mistrust), inner setting (provider shortage, weak communication, rural food culture, and mistrust of health systems), and individual level (low health literacy, chronic stress, and a sense of hopelessness). The most cited facilitators were codesigning task‐sharing approaches to hypertension care with community outreach that are tailored for rural settings, targeted subsidies for healthy food and health care, and trust building with the community, preferably led by faith‐based leaders.

Conclusions

Our findings based on consultations with diverse community and health systems partners show key challenges and highlight potential solutions to improve blood pressure control and cardiovascular health in rural communities in the United States. Concerted efforts to codesign hypertension care programs that are multisectoral, build on local resources, and include community outreach and trust building efforts are likely to be acceptable, effective, and sustainable.

Nonstandard Abbreviations and Acronyms

CCAB

County Coalition Advisory Board

CFIR

Consolidated Framework for Implementation Research

CHW

community health worker

CVH

cardiovascular health

IDI

in‐depth interview

PI

principal investigator

TFA

Theoretical Framework of Acceptability

Research Perspective.

What Is New?

• This qualitative study, based on consultations of multiple community and health systems partners, is among the first to highlight key challenges as well as potential solutions for improving blood pressure control and cardiovascular health in the rural United States.

• We found that alongside poverty, weak health systems, and underdeveloped environmental infrastructure, the widespread availability of sodium‐rich processed foods was a key barrier to hypertension care, and that codesigning multisectoral interventions with local community and health systems partners that are tailored for rural settings was the most cited facilitator of improving blood pressure control and cardiovascular health.

What Question Should Be Addressed Next?

• Are multisectoral interventions codesigned with local community and health systems partners feasible to implement, and are they effective in improving blood pressure and cardiovascular health of adults with hypertension in the rural United States.

Cardiovascular disease is the leading cause of preventable death in the United States, with significant rural–urban disparities. ¹ , ² High blood pressure (BP) confers the greatest attributable risk of mortality from cardiovascular disease and is responsible for substantial disability from stroke, myocardial infarction, heart failure, and kidney disease, leading to devastating consequences. ³ Almost half of all US adults have hypertension. ⁴

Since 2004, substantial rural–urban disparities have emerged in overall and cardiovascular disease mortality, with higher and increasing rates in the former, home to ≈60 million people or 20% of the US population. Hypertension prevalence is 20% higher in rural than in urban areas and, even worse, 50% higher in rural southeastern counties. ⁵

Evidence from clinical trials and systematic reviews shows unequivocal benefit of healthy behavior and pharmacologic treatment in lowering BP and preventing cardiovascular disease and other adverse vascular outcomes. ⁶ , ⁷ , ⁸ , ⁹ Despite the wide availability of hypertension treatment guidelines and the US Surgeon General's Report on multifaceted programs for hypertension management, their translation into clinical and public health practice remains suboptimal. This is especially evident in rural areas, where adverse social determinants, including poverty, low literacy, lack of transportation, food insecurity, and lack of green spaces, create substantial barriers to adopting healthy lifestyles, and contribute to multisectoral challenges in accessing care. Although public nonprofits, charities, and welfare programs serve rural communities, the effects of local environmental and access barriers on hypertension management, and how to overcome them, remain inadequately understood.

To help address this gap, our study explored key barriers and facilitators of quality hypertension care across individual, community, and health systems contexts from multiple perspectives of local health and community partners in rural North Carolina, with suggested solutions and their acceptability. ¹⁰ , ¹¹

METHODS

The study was coordinated by the Duke University Global Health Institute, in partnership with East Carolina University, and with support of collaborators from the University of North Carolina–Pembroke and University of North Carolina Health Southeastern.

Study Design

Qualitative research design used individual characteristics, with inner and outer setting components of the Consolidated Framework for Implementation Research (CFIR) as the main study construct. We also included components from the Theoretical Framework of Acceptability (TFA). Because combining theoretical frameworks is common for studies with multifaceted objectives, our study effectively elucidates how barriers potentially affect acceptability of interventions that were proposed during the in‐depth interviews (IDIs). ¹² , ¹³

Ethics

Ethical approval for the study was obtained from the institutional review board at Duke University, Durham, NC, with agreement for it to serve as an umbrella institutional review board for all partnering institutes.

The interview guide, study material, and deidentified excerpts supporting the findings are included within the article and its online supplemental material (Data S1). Because of the sensitive nature of the qualitative interviews, full interview transcripts cannot be made publicly available. Additional data may be made available from the corresponding author on reasonable request and subject to ethics approval. The study is reported in line with the Consolidated Criteria for Reporting Qualitative Research (Data S2). ¹⁴

Sampling Frame

Participants were selected from 2 underserved North Carolina counties, Pamlico (eastern region) and Robeson (southern region), where 39% and 45% of residents, respectively, resided at or below 200% of the federal poverty line in 2022. Robeson County, which has the largest indigenous population in North Carolina, also ranked last among all 100 North Carolina counties in key health indicators, including life expectancy, quality of life, smoking, and obesity. ¹⁵

Key Informant Inclusion Criteria

The inclusion criteria for the study were adults aged ≥18 years living in Pamlico and Robeson Counties at the time of the study, and belonging to the following “health systems” informants subgroup: patients (2–3) aged ≥40 years, community health workers (CHWs) (2–3), nurses (2–3), physicians (1–2), clinic managers (1–2), community pharmacists (1–2), and clinic directors (1–2), who were recruited from the local county health departments and charity clinics in each county.

The “nonhealth systems community” informants (1–2 per specific subgroup) were recruited from the civic and faith‐based organizations (eg, senior centers, Young Men's Christian Association, food banks, and churches), small stores, larger retailers, and county leaders within the community.

Exclusion Criteria

(1) All individuals deemed mentally incompetent or have known mental disorder (eg, psychosis, bipolar disorder, or untreated major depressive disorder) and (2) those bedridden and unable to effectively ambulate.

Sampling Process

We used purposive and snowball sampling to select at least 30 key informants in each county (thus, a total n=62 in the study) spanning a variety of backgrounds across private and public health and community non‐health sectors.

In addition, we established a County Coalition Advisory Board (CCAB) with 7 to 8 partners in each of the 2 counties to facilitate key informant selection, pretest interview questions, assist with data interpretation, and potentially collaborate to support the cocreation of a multisectoral intervention for hypertension care in the future. Site principal investigators (PIs) leveraged their relationships with the community health departments and community leaders in their respective counties to seek recommendations for CCAB members and extended invitations after consultation with the study team, and introduced the interviewer.

Conceptual Framework

To plan data collection and analysis, we used 3 major domains of CFIR focusing on outer and inner settings, as well as individual characteristics, both supplemented by relevant constructs of the TFA (affective attitude, burden, ethicality, and perceived effectiveness) of existing initiatives and services. These domains were linked with health and social services (eg, expanding CHW services, health education, and training providers), relevant to the specific community collaborators, to provide a multilevel lens for systematic evaluation of barriers and facilitators for enhancing BP and cardiovascular health (CVH) in these rural communities. ¹⁰ , ¹¹

Probes

We developed separate probes for each informant type to explore barriers, bottlenecks, and facilitators for both the nonhealth (healthy food and physical activity) and health sectors (eg, screening, referral to care, and follow‐up). Some of the questions were similar across all the groups, and some were specific to individual groups. The probes were adapted from existing CFIR and TFA templates, and finalized during the investigators' and CCAB meetings (see Appendix S1 for interview probes).

Training

The interviewers and coders were trained by qualitative experts and senior public health researchers (T.H.J., H.L., S.A., and K.D.) to conduct, code, and analyze the IDIs using the rapid framework analysis approach, which uses a structured matrix to quickly organize and interpret data according to a predefined framework for timely insights. ¹⁶ Researchers and interviewers included both women and men to ensure diverse perspectives.

Summary Templates and Code Book

The PI and coleads prepared the summary templates, debriefing documents, and the draft codebook. The initial codebook domains reflected concepts in the interview guide. The trained researchers made iterative code book modifications to better expand or define themes based on findings from the IDIs in consultation with the PI and co‐PIs.

Interviews and Data Analysis

Semistructured IDIs were conducted by 6 trained interviewers (N.D., A.Q.B., H.H., K.S., E.P., and M.L.), 3 in Pamlico County and 3 in Robeson County. The trained research staff approached the potential participants, obtained informed verbal consent, and sought preference on interview modality. All the interviews were either in person or by telephone, based on the preference of the participant, and lasted between 40 and 60 minutes. At the outset of each interview, a research team member reviewed the consent form with the participant. Interviews were conducted accordingly and audio recorded after obtaining informed consent. Information on demographics, including self‐reported ethnicity and race, was collected. Interviews explored participants' perceptions and experiences with rural challenges and strengths, and their commitment to future participation in a hypertension intervention. All the interviews were conducted between June 2023 and December 2024. Recruitment ceased once we were confident that the collected data were sufficiently comprehensive and diverse to achieve data saturation in terms of no additional major insights (themes) emerging. ¹⁷ We replaced the participants' names with pseudonyms, and quotes were deidentified to maintain data privacy.

We used the CFIR‐based deductive approach (in combination with the TFA‐based approach for acceptability), ¹³ where the primary analyst wrote detailed notes during interviews in English and “coded” notes per a codebook domain in English into an MS Excel construct of a summary matrix. A secondary analyst listened to the audio recordings and edited the notes and summary matrix, which included illustrated quotes. ¹⁸ In addition, automatic transcription of the audio recordings was performed by Zoom under a Duke license, and reviewed by a trained researcher. Each completed summary matrix was secondarily compared with the corresponding transcript for data verification. Framework analysis was used to analyze the summary matrix thematically and to organize codes using both a deductive and an inductive approach (eg, based on emerging themes from the data) focusing on barriers, facilitators, and potential solutions for improving hypertension care. Respective codes were quantified, mapping them into themes, per the CFIR domain and construct. In addition, data from the summary matrix were used to provide feedback to the CCAB and community when possible, to keep them engaged.

The summary matrix, illustrated quotes, and themes were discussed during regular weekly or biweekly meetings with the PI and co‐PIs to reduce the likelihood of interviewer bias and social desirability bias, as well as to improve reflexivity (ie, minimize the researchers' own reflections and interaction from influencing the research process and interpretation). ¹⁹ Approximately 20% of the IDIs and codes were rereviewed by site PIs and collaborators, with tasks allocated by key informant type. ²⁰ The entire research team reviewed matrices and illustrative quotes for clarity before finalizing the analysis. The reported results represent themes within and across participant groups.

RESULTS

A total of 62 interviews were conducted, with 30 from Pamlico County and 32 from Robeson County. Participants' characteristics are summarized in Table 1. Approximately 39% of the participants were aged >60 years, 74% were women, 49% belonged to racial or ethnic minority groups, 29% worked in the health sector, and 71% worked in the nonhealth sector.

Table 1.

Characteristics of Key Informants (Respondents) (n=62)

Characteristic	Total, N (%)	Pamlico County, N (%)	Robeson County, N (%)
Total	62	30	32
Women	46 (74)	19 (63)	27 (84)
Age range, y
18–24	0	0	0
25–39	10 (16)	4 (13)	6 (18)
40–60	28 (45)	12 (40)	16 (50)
>60	24 (39)	14 (46)	10 (31)
Race or ethnicity
White	32 (51)	23 (76)	9 (28)
Black	17 (27)	7 (23)	10 (31)
Hispanic	1 (1)	0	1 (3)
American Indians	9 (15)	0	9 (28)
Other ethnic or racial groups*	3 (5)	0	3 (9)
Health sector†	18 (29)	12 (40)	6 (18)
Physician	3 (5)	1 (3)	2 (6)
Nurse	4 (6)	4 (13)	0
Community pharmacist	2 (3)	1 (3)	1 (3)
Community workers	4 (6)	2 (6)	2 (6)
Other nonphysician health worker	2 (3)	2 (6)	0
Health administrator	3 (5)	2 (6)	1 (3)
Nonhealth sector	44 (71)	18 (60)	26 (81)
Patients or family members	6 (10)	2 (6)	4 (12)
Faith‐based organizations	8 (13)	2 (6)	6 (18)
Food business	2 (3)	2 (6)	0
Public health programs	25 (43)	10 (36)	15 (50)
Schools	3 (5)	2 (6)	1 (3)

^*Other groups were defined as individuals who were not White, Black, Hispanic, or American Indians.

^† Based on probe used as community and health systems partners often subsumed multiple roles. Each key informant was interviewed about a single role only.

Table 2 illustrates the quotes and themes related to barriers and facilitators as mentioned by participants. Although Table 2 is organized by CFIR domains and constructs, the results below are presented as an integrated thematic synthesis to emphasize cross‐cutting barriers and enablers.

Table 2.

Illustrative Quotes of Barriers to Hypertension Care in Rural US Communities in North Carolina (Robeson and Pamlico Counties)

Constructs	Themes	Key barriers	Illustrative quotes
Outer setting
Patient needs and resources at the community level	Economic constraints as barriers to hypertension care	Community poverty; low health care funding; high out‐of‐pocket expenses; prohibitive costs and lack of access to healthy food	RC IDI 18: “I think the poverty in the county gives our people a sense of hopelessness.” PC IDI 20: “People are worried about the cost of health care…By the time they decide to call an ambulance, they're super sick because they didn't want to call because they couldn't afford.”
	Transportation difficulties hindering hypertension clinical care and wellness management	Rural geographic isolation; lack of public transit; limited access to essentials (social and physical recreation, pharmacy, clinics, and emergency care)	RC IDI 18: “Robeson County is geographically one of the largest or the largest county in the state, so transportation is a problem. It's a rural community. Not everybody has…transportation to get to grocery stores.” PC IDI 21: “The biggest challenge would be getting people to the event. And when I say that I mean a lot of it is transportation. Transportation is a big challenge for I think every organization in Pamlico County.”
	Limited recreational space and digital divide limiting hypertension self‐management and care.	Limited Internet and cell service; digital divide; resistance to telehealth among some populations	RC IDI 9: “Me and my son have gone to the track, but it was dark, like no lights, and it's kind of scary.” PC IDI 7: “We're still in that generation where there's a lot of folks who would be resistant to speaking to anyone over a computer, they would much rather see that provider in person.”
Cosmopolitanism	Multilevel dimension of mistrust and stress in the communities hindering patient engagement system for hypertension care	Distrust in health care and external organizations; skepticism toward public health as a partner	RC IDI 21: “We've often came across them saying that they didn't want to be experimented on, and so that was something that I had to overcome and let them understand the importance of being a part of research.” PC IDI 19: “Changing that mindset is probably the other big challenge that you're gonna run into—to see public health as a partner to assist…everybody to make their lives better…And that's gonna take time.”
	Limited awareness of partnership and resources to leverage for hypertension care	Limited awareness of available resources; weak outreach strategies; programs not aligned with residents' everyday realities; lack of resource coordination for cost‐effective hypertension care	RC IDI 21: “Organizations spend too much time strategizing and not implementing…We need the foot soldiers to … do the actual community interaction. All of these things are … in buildings and on events that the average population does not attend since they're at work. They don't know what's going on.” PC IDI 23: “So it's really, always about do the people that need the resources know about them? And how do we connect them?”
External policies and incentives	Structural barriers to health literacy and psychosocial and cultural practices of rural communities associated with high BP	Time constraints, economic pressures, easily accessible unhealthy products, processed, calorie‐dense, sodium‐rich food, and cultural practices hindering lifestyle change	RC IDI 5: “Oh well, a $15.00 meal at McDonald's might feel a lot less burdensome when you're working 2 jobs and have to go out and shop and, you know, prepare a meal.” PC IDI 6: “[A big barrier for the] Black community is food… Because we tend to fry almost every single thing we eat…and use a lot of sugar. Only when they start getting high blood pressure … do they start thinking about changing their diet.”
Inner setting
Readiness for implementation: available resources	Provider shortages and communication breakdown hinder hypertension care	Provider shortage; limited workforce capacity; strain on health care delivery	RC IDI 9: “I know that my health care providers are overloaded, I see that on a daily basis that they are overloaded.” PC IDI 26: “We have a problem with staffing to handle all the patients. We typically have a 50 to 60 person waiting lists to get them for physical therapy.”
Readiness for implementation: access to knowledge and information		Limited patient education; lack of linguistically appropriate engagement	RC IDI 6: “Maybe a language barrier, …we have other pockets of nationalities around the county… Spanish…, Haitians, and other French speaking populations.” PC IDI 7: “So we have a lot of folks that the only physician they may encounter in a year is an emergency department physician… So the only education they may get is in the back of an ambulance or in the emergency department.”
Implementation climate: tension for change	Multilevel dimension of mistrust and stress in the communities, hindering adherence to hypertension treatment	Lack of trust in outside support; variable community readiness; skepticism about health behavior change	RC IDI 29: “Some areas are more resistant to help from outside institutions. Every community around our county has its own way of doing things… So, even though they may be in technical need of the help that doesn't mean that they're going to accept it from folks that they haven't built trust with.” PC IDI 2: “I think the biggest challenge is to convince people in the community to buy into the program…The biggest issue is, are you serious about your health?”
		Stigma in seeking help; cultural dietary preferences; distrust of health care intentions	RC IDI 20: “Native Americans tend to not trust a lot of these types of organizations. And then, if you add on the complexity of always feeling like you're being judged, it makes them harder to go seek that help … even when it's being made readily available.” PC IDI 19: “You still have individuals that kind of will dig their heels in because they associate a certain outcome because of what's happened to one of their friends. One individual said that he had a friend who had a pacemaker, and he ended up having a heart attack anyway.”
Individual characteristics
Knowledge and beliefs	Low hypertension awareness	Limited understanding of hypertension and self‐management; low nutrition literacy, including among parents	RC IDI 3: “Most people use the term ‘high blood, low blood.’ They don't truly understand what happens.” PC IDI 17: “The parents are not knowledgeable of what a well‐balanced meal is… but for most kids, they eat what they see.”
Self‐efficacy	Deliberate avoidance of antihypertensive medications	Conscious noncompliance with medication; individual attitudes toward treatment	PC IDI 7: “[Some people] make a conscious decision to not comply, conscious decision to say ‘I'm not doing it. I'm not taking that medication.’”

BP indicates blood pressure; IDI, in‐depth interview; PC, Pamlico County; and RC, Robeson County.

Key Barriers

We identified key barriers to hypertension management in rural counties related to economic constraints, lack of transportation, limited recreational space, the digital divide, increased availability of processed food, provider shortages, as well as social barriers rooted in mistrust and stress, and limited awareness of partnership and resources, as delineated below with illustrative quotes (Figure1; Table 2).

Figure 1. Contextual barriers and facilitators for improving blood pressure and cardiovascular health in rural counties in North Carolina, United States.

CHW indicates community health worker; EBT, electronic benefit transfer; EMT, emergency medical technician; NPHW, nonphysician health care worker; and SNAP, Supplemental Nutrition Assistance Program.

Economic Constraints as Barriers to Care

Participants in both counties consistently described economic constraints as impacting dietary, medication, and health care decisions. In Robeson County, the respondents often highlighted daily trade‐offs, such as balancing medical costs with utility bills. In Pamlico County, participants emphasized competing priorities, insurance gaps, and how catastrophic plans left patients underinsured or uninsured, creating a barrier to accessing preventive or timely services.

“It's just a lot of combinations, you know, not just the food…Get to the doctors. Get your medicine. Get your light bill paid.” (Robeson Country [RC] IDI 2)

“People have jobs, but not enough. I mean jobs, in a sense plural, is still not enough to cover their needs.” (Pamlico Country [PC] IDI 17)

Insufficient Health Insurance

Many participants reported health insurance gaps, and public programs running out of funds, limited opportunities for screening BP and appropriate preventive care, along with high out‐of‐pocket expenses as major barriers to regularly taking antihypertensive medications, which are considered “preventive care.”

“People are worried about the cost of health care…By the time they decide to call an ambulance. You know they're super sick. Because they didn't want to call cause they couldn't afford.” (PC IDI 20)

“I don't get Medicare on my medicine… I have to pay off all my medicine, and it makes me be careful about what I take and what I don't take.” (RC IDI 24)

Food Deserts, Food Insecurity, and Widely Accessible Processed Foods

Many respondents emphasized that limited access to fresh fruits and vegetables in their rural communities was a significant issue both in terms of limited availability of healthy food options and their prohibitive cost. In contrast, processed foods were more affordable, widely accessible, and frequently the only viable option for most residents.

“We don't have a food bank or food pantry system like a lot of larger communities do… We don't have any pantry of choice, where people get to select the foods they want… If you've got a chronic disease and they're giving you canned soup, it's very high in sodium. You know that doesn't help your high blood pressure.” (RC IDI 1)

“We are not selective (about food in food pantry). We are not in a position to be selective (about healthy food). So it is a lot of processed food.” (PC IDI 17)

Participants reported that they primarily purchased groceries from discount general stores, such as Family Dollar and Dollar Tree, rather than traditional grocery stores. These stores stocked processed and shelf‐stable foods, further reinforcing unhealthy dietary patterns. The food pantries also distributed processed food albeit on a restricted schedule.

“And as far as the food banks go, there's no real food bank in Pamlico County. There's a couple of food pantries… Many of our patients, they get their groceries at Dollar General or Family Dollar and they're eating whatever they can find that's quick and easy.” (PC IDI 8)

Travel Difficulties Hindering Hypertension Care

Lack of Transportation

Scarcity of public transport options, along with long distances to clinics, pharmacies for refills of antihypertensive medications, and grocery stores were identified as major challenges. Participants noted that local transport services (eg, Craven Area Rural Transit System in Pamlico County and South East Area Transit System in Robeson County) were significantly limited because of restricted schedules and routes, sometimes requiring an entire day just to visit the clinic. Across both sites, these limitations not only lead to delayed treatment of acute conditions but routinely led to postponing visits to health facilities, especially for preventive services for asymptomatic conditions like hypertension.

“There is a bus that if you have Medicaid or Medicare maybe that you can call them to try to get scheduled for them to pick you up. But even that is challenging…they may drop you off…2 hours before your appointment. You're sitting there for another 2 hours after your appointment waiting for them to pick you back up.” (RC IDI 27)

“There is no urgent care facility. There are no specialists in the county. The average time to travel to outside county for specialist visit is 1 to 4 hours…VA hospital it's about 2.5 hours.” (PC IDI 1)

Limited Recreational Space and Digital Divide

Suboptimal Infrastructure for Physical Activity

Both counties reported few safe or accessible spaces for physical activity because of scarcity of sidewalks, walking trails, parks, fitness centers, or inexpensive spaces for exercise. These limitations further decrease one's ability to follow recommendations for lifestyle or behavioral change.

“In my neighborhood, there's really no walk in the grass or on the road, and I don't want to come around that curve. And there's no telling. So it is kind of dangerous out there trying to just get your walk in.” (PC IDI 6)

“A lot of our community don't have so many places to exercise.” (RC IDI 1)

Limited Internet Connectivity

Access to the internet and cell service was also a barrier across both counties. Although internet access was available in central areas, remote parts of the rural counties experienced weaker connectivity, limited digital literacy, or lack of ownership of a computer, which were mentioned by a few as a significant barrier to virtual medical consultations and remote counseling for hypertension management.

“The problem is that there's a significant lack of digital equity and literacy in our county.” (RC IDI 5)

“A lot of these people don't even have Internet. Even if they have Internet, maybe there's grandkids that use it or something. But they don't use it.” (PC IDI 24)

Provider Shortages and Communication Breakdown

Provider Shortages

A critical concern expressed by most participants in both counties was the shortage of health care providers, including specialists, primary care physicians, nurses, and pharmacists, with high staff turnover further exacerbating the issue. The health care infrastructure is inadequate for most patients with hypertension. Although a few federally qualified health centers exist in both counties (1 in Pamlico County and 6 in Robeson County), they are understaffed and overburdened. A few private clinics offer hypertension care mainly for commercially insured or Medicare‐covered seniors. Nonprofit or charitable clinics do provide some preventive services and make referrals for uninsured patients, but they also face staffing and outreach constraints.

In Robeson County, participants stressed that providers often avoided taking Medicaid or Medicare patients, whereas in Pamlico County, the challenge was framed around long wait times and limited facilities.

Although the pharmacies commonly dispense antihypertensive medications and statins, access is a challenge as subsidized programs require the medications to be picked up in person from the pharmacy at frequent intervals.

“There aren't enough providers for the number of people that we have, and then the folks that do have insurance. Many of them are on subsidized programs like Medicaid, Medicare, and doctors and providers don't prefer to see those individuals, because it's so cumbersome with the paperwork.” (RC IDI 29)

“I know that X clinic …. people would show up they would wait for many hours to be seen or for their medications.” (PC IDI 16)

Inconsistent Provider‐Patient Communication

Respondents, both patients and providers, expressed frustrations with communication, citing inadequate time and dialogue. For example, participants reported inadequate counseling on condition or their management, and others noted a lack of enough involvement in prescribed management plans which contribute to medication nonadherence. In Robeson County, the concern centered on patients not being adequately educated about their condition, whereas in Pamlico County, participants stressed patient resistance to programs imposed without sufficient explanation.

“I think a major missing piece is just the educational component… If you don't sit me down and explain to me what can happen and let me actually see it…and discuss the risk factors…to fully understand and know how serious this is and how important it is for me take care of my health. So that piece is a lot of times is missing.” (RC IDI 6)

“They'll bring bags of medication or baskets, plastic containers full of medication, and a lot of those are the same medications. It'll be like 9 bottles of the same medication. They've never been opened… They just don't trust things being forced on them without proper explanation.” (PC IDI 7)

Multilevel Dimension of Mistrust and Stress in the Communities

Mistrust of Systems

Participants across both counties described a sense of mistrust toward health care systems, alongside personal experiences of discrimination, highlighting the sociocultural burden and systemic barriers they face in accessing care.

Government and nongovernmental organization–led initiatives were sometimes perceived as disconnected from rural realities, with some perceptions that they were benefiting those with relatively more resources, rather than those in greatest need. Participants recounted that negative perceptions stemmed from concerns such as the lack of engagement of health planners with community partners, and perceived exploitation of benefits by wealthier groups, as well as disrespect for rural and tribal cultures by some providers and external partners, all of which contributed to feelings of resentment and distrust.

A few key informant narratives appeared to reflect elements of othering, particularly when discussing mistrust, with community perspectives sometimes framed as external to the health system rather than as responses shaped by lived experience.

“I think that whole population, certainly people in that poverty‐stricken area, are somewhat of a different culture in the way, you know, that they look at things and be—they're somewhat distrusting of the establishment.” (PC IDI 14)

“Sometimes people don't feel comfortable coming to a clinic. They feel like it's a setup.” (RC 26)

Perceived Classism, Racism, and Chronic Stress

A few participants expressed concerns about perceived disparities in care of delayed or inadequate treatment for those who were economically challenged (primarily in Pamlico County), Black, and American Indian patients (in Robeson County) at local clinics or hospitals. Additionally, some viewed medical providers with skepticism, citing experiences of impersonal treatment, feeling unheard, or sensing negative judgment. In addition, many participants also mentioned that chronic stress attributable to perceived stigma, anxiety, and economic hardships leads to the adoption of unhealthy behaviors (eg, smoking) and feelings of hopelessness.

“I do not go to X hospital when something is wrong with me. There's that prejudice there, you know.” (RC IDI 4)

“There was a story someone shared with our board member. A local farmer had gotten injured while working on farm equipment. They went to some of the local clinics around here, and hopes to get helped but was turned away.” (PC IDI 22)

Rural Culture and Beliefs, Stigma With Seeking Help

Insufficient health literacy and social factors (eg, community‐level poverty and unemployment) in rural setting were considered to be a major challenge to BP control by many respondents. Participants described strong food‐related cultural habits and a preference for traditional local diets that can be high in sodium and unhealthy fats. Additionally, many rural residents who are struggling financially are reluctant to use public benefits, like Supplemental Nutrition Assistance Program, and food subsidies because of perceived stigma, which further limits their access to healthy food.

“I'm including myself because I have bad habits when it comes to eating. I like the country food… That's just the way it is. And I'm gonna say it for as far as the Native Americans, the African Americans here in our area, it's just not healthy… We need to do better at how we prepare foods.” (RC IDI 2)

“I will also say that a lot of times it is a cultural thing. I would assume that most of the local grocery stores in the county probably sell higher numbers of the same types of processed foods… And that's typically what folks go for… But it's also that's what they're familiar with and more comfortable with.” (PC IDI 7)

Limited Awareness of Partnership and Resources

Lack of awareness, coordination, and partnerships across community resources: A recurring concern in both counties was a limited awareness of existing community resources and a lack of systematic collaboration among organizations. Participants emphasized that residents, particularly in more remote areas, often did not access information about available services. Outreach efforts were also described as ineffective in reaching the populations most in need. In Robeson County, participants highlighted that organizational planning happens without meaningful community engagement. In Pamlico County, participants pointed to a broader absence of coordination among agencies and organizations, with efforts described as fragmented rather than part of a cohesive system.

“Many times they do not get the information in your rural areas that they get in the small towns.” (RC IDI 22)

“I'm not sure that we have a systematic network that links the different groups that are doing that and lays it against the population to know (which are the populations in need).” (PC IDI 13)

Key Enablers and Potential Solutions

Despite the barriers, participants across both counties highlighted facilitators that would support hypertension care, including codesigning task‐sharing approaches of hypertension care that are tailored for rural settings, targeted subsidies for healthy food and health care, and trust building with the community, preferably led by faith‐based leaders (Figure; Table 3).

Table 3.

Illustrative Quotes of Facilitators to Hypertension Care in Rural US Communities in North Carolina (Robeson and Pamlico Counties)

Construct	Themes	Key facilitator	Illustrative quotes
Outer setting
Cosmopolitanism	Cocreating multisectoral interventions for hypertension management, community participation, trust building, and potential role of faith‐based organization	Trust in community organizations (such as churches and schools); reliance on institutions as anchors for outreach and engagement	RC IDI 25: “It would have to be brought by local leaders, and the best place to bring it would be through churches. Churches are the backbone.” PC IDI 6: “The best thing … is get something together and present it to the churches because 9 times out of 10 these clients go to church… And the New Bern Eastern Missionary Baptist Association… That would be a good start to get out some literature to that union and pass it out to all those churches that are there.”
	Cocreating multisectoral interventions for hypertension management, community participation, trust building, and potential role of faith‐based organization	Partnerships with schools and community organizations; reducing duplication of services; expanding county‐wide presence and trust	RC IDI 1: “And then as a part of Healthy Robeson, we would go out and make those partnerships with the community and try to construct, say, a walking trail or try to help have a park built using some of our money from the grant to do that.” PC IDI 8: “I am very excited about partnering with other organizations. I think it's necessary to be successful to partner with other organizations and stop duplicating services. Let's combine our efforts and let's do a really good job.”
Patient needs and resources	Alternative service models for hypertension care and targeted subsidies	Youth acceptance of telehealth; successful provider use of telehealth to reach patients unable to travel	RC IDI 11: “Teenagers are like already wired to do this, and so I think they've had some success in doing telehealth therapy appointments with youth.” PC IDI 16: “We did have our first telehealth on the opposite end for a patient recently who could not get to us because he was in rehabilitation service… It worked out really well with our providers here.”
	Alternative service models for coordinated hypertension care and targeted subsidies	Access to healthy food supports; meal kits and recipes promoting healthy cooking at home; mobile food pantries; access to physical activity spaces (eg, walking trails)	RC IDI 1: “We've been doing healthy meal kits and we usually do that with the church when we do our mobile community resource hub. We'll pick a healthy recipe and we'll have an insulated bag with everything that they need to make that healthy recipe in that bag.” PC IDI 16: “We do have a diabetes program with ECU's Fresh Start program, and that is a healthy eating, prescription produce, and health coaching–based program. That is 9 visits, every other week, starting in January. And right now they were also granted a mobile food pantry and teaching kitchen that should start in the rural communities in April.”
Inner setting
Readiness for implementation: available resources	Alternative service models for coordinated hypertension care and targeted subsidies	Strong interest in integration of community health workers model; expanded navigation and resource support coordination	RC IDI 1: “Several community colleges offer…a new class for community health worker… There are several hospitals that have actually started hiring [community health workers]. They find that it's better to spend the money for community health workers to help people navigate the system than it is to continually have people readmitted to the hospital.” PC IDI 5: “We had about 86 community health workers in different counties all over eastern North Carolina. And we went out into the community and provided resources for people in need, anywhere from housing to … medical needs, therapists, referrals.”
Networks and communications	Social networks and close‐knit communities as buffers for stress and systemic hypertension care engagement.	Social support networks, peer‐to‐peer encouragement, and building collective community resilience	RC IDI 11: “Social connections being a way to support others to lift them up out of stress and trauma and to build that individual and collective community resilience.” PC IDI 23: “I have, you know, a huge believe that will help make our community healthier if we can meet the people where they are, but also bring them together to meet the other people in their smaller concentric spheres, if you will.”
Individual characteristics
Knowledge and beliefs	Culturally tailored health education programs for hypertension care.	Improved health literacy on chronic disease, exercise, and nutrition; community interest in health education; past experiences with health coaching	RC IDI 6: “We did it for 6 months. People are still asking, When are you gonna bring that program back? Because I learned so much. We had somebody to come in and talk about heart disease, some of the risk factors, what you need to do differently. Someone to talk about exercise and healthy eating.” PC IDI 23: “At Wild Health you get as many meetings with your health coach as you want. You could schedule twice a week if you want, most people don't… the health coach is the person that will translate that health report into action.”
		Reframing culture as a celebration; teaching younger generations healthier cooking and food practices while maintaining cultural relevance	RC IDI 21: “Instead of coming in as a problem, come in as a celebration. Take some of their culture and possibly not change it but reenact it in a more positive way, where they can create an understanding of how better living can be implemented.” PC IDI 19: “Especially the younger generation had no idea whether it was squash or zucchini, so I saw that as an example of …having individuals and folks come in and teach them how to cook and use the food that is available to them and try to get them away from processed food.”

ECU indicates East Carolina University; IDI, in‐depth interview; PC, Pamlico County; and RC, Robeson County.

Cocreating Multisectoral Interventions for Hypertension Care, Community Participation, Trust Building, and Potential Role of Faith‐Based Organization

Many participants felt that cocreating a hypertension care program with local partners would build trust, enhance feasibility and effectiveness, strengthen partnerships, and support program sustainability.

Most participants acknowledged that a multisectoral approach was needed, which would include churches, faith‐based institutions, and community support groups to facilitate broad engagement and integrate wellness behaviors within hypertension management, along with clinical care. This approach could also contribute to addressing food insecurity through involvement of local fast food chains and dollar store groceries and incentivizing healthier menu options, food pantries, and even meal delivery.

Although most participants emphasized food insecurity as a major barrier, a few offered contrasting perspectives, suggesting that additional community resources do exist but are underused because of limited coordination and integration across services.

“I really don't see a lot of challenges on trying to access food because we do have a couple of food banks here and there's some churches, some local churches who give out boxes of food, and if they can't and get it, then they'll take it to them.” (PC IDI 6)

Additionally, participants suggested that involving faith leaders could encourage greater participation and engagement.

“The Lord wants us to take care of our bodies … when we're healthy, you can be more, we can, our spiritual life can be healthier too.” (RC IDI 4)

Culturally Tailored Hypertension Health Education Programs

Most participants emphasized the need for hypertension awareness campaigns and education programs to improve health literacy, especially about the impact of traditional southern diets. They also stressed that communication should be culturally sensitive and delivered in a respectful manner. Robeson County participants pointed to programs that reframed cultural foods in healthier ways, whereas Pamlico County participants stressed teaching practical cooking skills for lasting change.

“It is about education, making more county, South, rural food choices that is a little healthier and showing people they can do that, No, you don't have to give up the foods you love but you can make them a different way.” (RC IDI 18)

“The benefit is education… teach people how to cook, (teach) about their bodies. That's something they can use for the rest of their life and give to their family and quote.” (PC IDI 22)

Alternative Service Models for Hypertension Care With Targeted Subsidies

Many participants acknowledged the positive role of CHWs in referrals for social and health services during the COVID‐19 pandemic and wondered why the program was not offered after the pandemic. Some participants suggested task sharing hypertension care with nurse practitioners, pharmacists, and community health workers as a potential strategy to improve care quality. They emphasized that reimbursement for these services, through Medicare, Medicaid, or targeted subsidies, would be essential for sustainability.

Several participants suggested that health care providers must be trained in rural culture, enhancing their communication skills, and promoting dignified, respectful care practices. The respondents from the health department cited an example of the tuberculosis program where provider refresher trainings included case studies from the local rural clinics and suggested that the same be done with hypertension training programs.

“So we don't have a lot of direct services within our organization, we actually fund services that are out in the community at that.” (RC IDI 11)

“I think we need someone with ability to educate patients, meet patients where they are in community. This can be done easily within their community with the community health worker or other health care worker. Access to health is important.” (PC IDI 8)

Some participants emphasized the need to bring health care closer to residents through mobile clinics and alternative care models. These models could involve task shifting and increased engagement of community health workers, who would visit patients at home or nearby locations for hypertension monitoring. This could be supported by telehealth or remote monitoring systems, along with prescription services.

“The first and third Wednesdays of the month, we are doing our mobile outreach clinics, which consists of transporting supplies and staff to community centers or churches in order to see patients in those area.” (PC IDI 16)

Additionally, some participants suggested initiatives to improve access to healthy food, such as mobile farmers' markets and subsidies or incentives for low‐income families. Another proposed facilitator was partnering with local emergency medical services and fire departments to transport high‐risk patients to clinics, leveraging existing infrastructure for improved health care access.

“American Heart Association is trying to get us a blood pressure monitor in here so we are able to have kiosk folks can actually check and record their progress or know when they're signs and symptoms that need to be aware of should be concerned of.” (RC IDI 5)

Social Networks and Close‐Knit Communities as Buffers for Stress and Hypertension Care Engagement

Many participants underscored that their small rural towns are resilient, with community members often relying on strong social networks, such as churches, faith‐based groups, extended family, neighbors, local civic organizations, and informal support groups, to collectively navigate and overcome health challenges, including those related to hypertension.

“This is a county where everyone takes care of everyone.” (PC IDI 24)

DISCUSSION

Our qualitative study highlights the contextual barriers and practical solutions for improving BP and CVH in 2 rural counties in North Carolina based on insights from multiple key informants across community and health systems settings. Previous studies on barriers to BP control were primarily conducted in urban areas and focused on individual behaviors, such medication nonadherence. ²¹ Our study adds to the knowledge by exploring the broad community and health systems determinants of uncontrolled BP in rural environments that are highly relevant from an implementation perspective.

We found that in addition to the common contextual socioeconomic and infrastructural challenges in rural areas, such as limited transportation, long distances to care, economic constraints, and shortages of health care providers, hypertension care is further hindered by several factors, such as the widespread availability of processed foods and a sense of hopelessness within communities. The limited access to digital health technologies along with low digital literacy posed challenges for remote BP monitoring and teleconsultation services, especially in remote areas. In addition, mistrust was identified as a recurring barrier at multiple levels. These barriers are especially consequential for chronic conditions, like hypertension, which depend on continuous care, regular engagement with health services, long‐term behavioral change, and a supportive health promotive environment. ²²

The roots of medical and health care mistrust have a long history, especially for populations experiencing systemic inequities. The broadening of widespread institutional health care mistrust has been documented in the context of COVID‐19. ²³ , ²⁴ , ²⁵ Our study illustrated examples of mistrust in relation to hypertension that encompassed new health programs and the existing health care systems, and extended to certain subgroups of populations (eg, those with limited economic resources and lower educational attainment) within the community. Our findings underscore the importance of trust‐building efforts within the community as a core component of hypertension care interventions. ²³ , ²⁴ , ²⁵ , ²⁶ , ²⁷ Our key recommendations based on the rural community–informed enablers are listed in Table 4.

Table 4.

Community‐Informed Recommendations for Quality Hypertension Care in Rural US Counties: Pamlico and Robeson Counties, North Carolina, United States

Cocreating interventions based on community participation Rationale: promotes trust building by engaging community partners and incorporating local knowledge and perspectives, which will enhance the relevance, acceptability, and equity of hypertension care services.

2 Trained community health worker–led task‐sharing models of hypertension care Rationale: enhances access of hypertension care services in underserved communities, addresses health care worker shortage, and enables earlier diagnosis and management.

3 Culturally tailored health education programs on BP and cardiovascular health Rationale: improves understanding of hypertension care by aligning health messages to the local beliefs, diets, and culture.

4 Targeted subsidies for heart‐healthy diet (low in sodium and rich in fruits, vegetables, and whole grains) Rationale: enhances accessibility to diet shown to be effective for BP lowering.

5 Wider access to digital health technology Rationale: enables remote BP monitoring, health education, and teleconsultations, especially in remote areas.

6 Leverage existing social networks and resources for hypertension care Rationale: enhances feasibility, cost‐effectiveness, sustainability, and scalability of interventions.

BP indicates blood pressure.

We identified several potential facilitators of quality hypertension care, among which engagement of local community partners, including community members, faith‐based leaders, and health care providers, in cocreation and implementation was particularly important. Community‐engaged and participatory approaches have become central to designing public health interventions. ²⁸ , ²⁹ By incorporating local knowledge and perspectives, such approaches aim to enhance the relevance, acceptability, and equity of health interventions. ²⁸ , ³⁰ Our findings are of tremendous clinical and public health significance in terms of guidance for tackling the increasing rates of hypertension in rural communities in the United States.

We found strong enthusiasm for BP screening and health promotion efforts at locations that were close to homes of rural residents and could potentially leverage the existing community infrastructure resources, such community centers, churches, or even door‐door service by CHWs, emergency medical technicians, or mobile clinics staffed by primarily nonphysician health care workers. Such task‐sharing models of CHW‐led BP monitoring, coaching, and care coordination have been shown to be effective and cost‐effective in low‐ and middle‐income countries with critical health care worker shortages. ³¹ , ³² Several counties across the United States initiated or expanded the CHW program for the outreach of health services in many rural areas during the COVID‐19 pandemic, albeit continued funding is needed in many states, including North Carolina. ³³ Our findings advocate strongly for expanding and evaluating the role of CHWs in hypertension care programs in rural settings in the United States with a sustainable funding model to ensure outreach to most of the population with hypertension.

It is important to underscore that the cultural adaptation of health education on BP and CVH for rural settings was emphasized as a strong enabler, which is consistent with feedback and efforts in other racial and ethnic minority groups. ³⁴ , ³⁵ Such adaptations consider local traditions and beliefs, cuisines, socioeconomic realities, and preferred communication methods, and can be delivered by diverse cadres of community health workers, thereby enhancing feasibility, acceptability, and effectiveness. ³⁶ , ³⁷ , ³⁸ In addition, wider Internet coverage is expected to enhance access, and participants underscored the value of direct face‐to‐face interaction with health care workers, which they perceived as a major facilitator of engagement and hypertension care.

Our findings that community members expressed concerns about the role of processed and fast foods on worsening uncontrolled BP in rural communities suggest potential for behavior change if healthy food options were available. ³⁹ Targeted subsidies for fresh produce in existing programs (eg, Supplemental Nutrition Assistance Program), rural food banks offering healthy food options, and expansion of mobile grocery stores in rural areas were suggested as possible solutions, which could potentially be effective. ⁴⁰ , ⁴¹ , ⁴² Emerging evidence based on studies conducted in rural settings outside the United States combining financial incentives and education with culturally tailored messengers can effectively promote healthier food purchases and intake. ⁴³ Pilot studies in rural settings in the United States indicate that fresh produce prescriptions might be feasible. ⁴⁴ , ⁴⁵ Such social prescribing approaches should be integrated as part of a rural hypertension care program and formally evaluated for their effectiveness.

The main limitation of our study was the relatively small number of informants in each specific group, which may have prevented us from achieving data saturation on certain barriers and facilitators. However, the use of data triangulation and the identification of common factors across different informant groups strengthened the validity and reliability of our findings.

Major strengths of our study include community voices from multiple key informants, reflecting the real‐world experiences of patients, families, civil society, community organizations, and local health systems representatives from 2 different counties, including 1 of the largest counties with the worst health indicators in North Carolina; and a robust study design using partner‐specific probes based on CFIR and TFA constructs, and rigorous framework analysis. The involvement of cultural insiders and discussions with CCAB in each county further enhanced the validity of our findings.

Hypertension is a major public health challenge in rural areas with worsening trends. Our findings based on feedback from multiple key informants from 2 counties, including the largest in North Carolina, show that hypertension care in rural North Carolina is shaped by common persistent structural barriers, policy‐level neglect, and limited community engagement in planning with skepticism around new initiatives that cut across counties. We also identified facilitators that are deeply rooted in the strengths of rural communities that can be used to improve the management of hypertension in rural settings. Rural residents face overlapping challenges in access and resources for hypertension care, while also relying on similar forms of faith, and social networks to support CVH.

Our findings underscore that hypertension interventions cocreated across health and nonhealth sectors and including community outreach and trust‐building efforts are likely to be both successful and scalable for improving BP control and CVH in rural counties in North Carolina and possibly across the United States.

Sources of Funding

This study was supported by the Duke Global Health Institute Pilot award.

Disclosures

None.

Supporting information

Data S1. Key informant probes

Data S2. COREG checklist