TABLE 4.

Challenges to and potential solutions for optimizing clinic blood pressure measurement in the low-to-middle-income setting

Challenges	Proposed solution
Lack of prioritization of and funding for hypertension care and proper BP measurement, including provider reimbursement, programmatic funding, and equipment.	Increased advocacy and recognition of the importance and scope of the problem.
Limited observer education and training in standardized BP measurement.	Training that is easily accessible and affordable. Eliminate the need for expertise in auscultation, and errors resulting from poorly performed auscultation, by using semi-automated or fully automated devices.
High provider workload and limited time to perform proper measurement, including between-patient cuff changes. Lack of dedicated clinic space to perform BP measurements.	Simplify measurement practices by modifying workplace ergonomics to facilitate best measurement practices (e.g. have a dedicated BP measurement station including a chair with arm-rest, even if not in a segregated clinical space, and arrange furniture to optimize patient and observer position).
Lack of availability of inexpensive, easily operable, clinically validated automated BP devices necessitating use of auscultation.	Increased advocacy and awareness of the need for clinical validation and low-cost devices. Encourage manufacturers to market low-cost clinic, home, and ambulatory devices.
Lack of availability of BP device accessories, including batteries and additional cuffs. Lack of proper environmentally responsible battery disposal mechanisms. Limited and/or lack of access to electrical power.	Choose validated semi-automated or solar-charged device overcome requirements for batteries or electrical power. A reasonable compromise if only one cuff size is available is to choose the cuff size that is considered optimal for most of the patients seen in that clinical setting.
Extremely high environmental temperatures in some regions that may theoretically affect the performance of BP devices.	Requires further study.

BP, blood pressure.