Barriers to hypertension and diabetes management in primary health care in Argentina: qualitative research based on a behavioral economics approach

Abstract

Despite efforts to improve detection and treatment of adults with hypertension and diabetes in Argentina, many public healthcare system users remain undiagnosed or face barriers in managing these diseases. The purpose of this study is to identify health system, provider, and user-related factors that may hinder detection and treatment of hypertension and diabetes using a traditional and behavioral economics approach. We did qualitative research using in-depth semistructured interviews and focus groups with healthcare providers and adult users of Public Primary Care Clinics. Health system barriers included inadequate care accessibility; poor integration between primary care clinics and local hospitals; lack of resources; and gender bias and neglect of adult chronic disease. Healthcare provider–related barriers were inadequate training; lack of availability or reluctance to adopt Clinical Practice Guidelines; and lack of counseling prioritization. From a behavioral economics perspective, bottlenecks were related to inertia and a status quo, overconfidence, and optimism biases. User-related barriers for treatment adherence included lack of accurate information; resistance to adopt lifelong treatment; affordability; and medical advice mistrust. From a behavioral economics perspective, the most significant bottlenecks were overconfidence and optimism, limited attention, and present biases. Based on these findings, new interventions that aim to improve prevention and control of chronic conditions can be proposed. The study provides empirical evidence regarding the barriers and bottlenecks in managing chronic conditions in primary healthcare settings. Results may contribute to the design of behavioral interventions targeted towards healthcare provision for the affected population.

Patients with diabetes and hypertension face many challenges to controlling their chronic conditions in primary care settings.

Implications.

Practice: Continuous education for health care on managing chronic disease is mandatory yet insufficient for the adoption and maintenance of effective clinical practices. Educating patients is also imperative but does not ensure the maintenance of chronic disease self-management. Small nudges based on the behavioral economic approach, such as small changes in environment, performance standards, or incentives, should be applied for both patients and healthcare providers.

Policy: Policymakers should build capacity to improve access to primary care clinics for adults by ensuring mechanisms for timely detection and treatment of chronic diseases; focus on the providers’ education and performance standards to maintain motivation to optimize care; and implement innovative strategies such as incentive-based interventions to increase patients’ adherence to treatment and to improve quality of care.

Research: Future research should validate and scale up incentive-based interventions approaching diabetic and hypertensive patients to improve medication adherence and adoption of healthy behaviors.

INTRODUCTION

Cardiovascular diseases (CVD) continue to rise, accounting for almost 16.7 million deaths every year, out of which 80 per cent occur in low- and middle-income countries [1]. Nearly half of the deaths in those countries are individuals under 70 years old, whereas only 27 per cent of the same age group die in high-income countries [2]. In Latin America, it is estimated that between 1990 and 2020, death from CVD, including coronary heart disease (CHD) will increase by approximately 145 per cent (for both men and women), compared with a 28 per cent increase for women and a 50 per cent increase for men in developed countries over the same period [3].

In Argentina, chronic noncommunicable diseases account for more than 50 per cent of overall morbidity and mortality. Like many other Latin American countries, Argentina falls into an intermediate category (as regards mortality from CVD)—the main risk factors being hypertension, an elevated body mass index (BMI), alcohol abuse, and smoking [4]. Diabetes also represents a considerable burden. In 2009, diabetes was the seventh leading cause of death, with a mortality rate of 19.2 per 100,000 inhabitants [5].

Argentina’s healthcare system is divided into three sectors: public health, social security, and private health. The public health sector is made up of a network of public hospitals and primary healthcare centers and is funded through public sector revenue. Social security covers formal-sector workers and is funded through worker and employer contributions. Finally, the private sector relies on members’ prepayments.

In 2009, Argentina’s Department of Health (DoH) launched a program called REDES (“Redes” is the Spanish word for “Networks,” the program’s name refers to provincial networks) [6]. The program operates at the primary healthcare level within the public sector and seeks to detect, classify, and treat adults with hypertension and diabetes. REDES’s interventions strive to enhance the delivery of healthcare services on the basis of the Chronic Care Model (CCM) developed by Wagner [7]. This patient-centered model facilitates the interaction between a proactive patient and a healthcare team trained to provide high-quality evidence-based care [8, 9]. The CCM brings essential elements into primary health care, such as organizational support, clinical information systems, delivery system design, decision support, self-management support, and community resources [10]. A large body of evidence supports the effectiveness of this model [11–14].

Despite these efforts, many adults remain undiagnosed and therefore are not treated. Despite free hypertension and diabetes drug provision at Public Primary Care Clinics (PPCs), some studies estimate only 57 per cent of patients with hypertension and less than 50 per cent of patients with diabetes actually receive treatment [15, 16].

According to the traditional neoclassic economic perspective, there are several factors that likely limit patients’ access to proper care and treatment [17]: factors related to organizational aspects of the healthcare system; factors related to the provision of care and associated with health providers’ knowledge, beliefs, or practices [18, 19]; and factors related to healthcare demands, such as users’ knowledge and behavior [17, 20–23].

In addition, the behavioral economics approach offers some alternative factors regarding healthcare obstacles that are important for addressing behavioral changes. Unlike rational economics, which assumes people’s choices reflect their true preferences among the available alternatives at the time of decision-making, this novel approach focuses on the decision-making process. Behavioral economics reveals that actual behavior often systematically deviates from rational decisions, frequently in a predictable manner [24]. This approach may provide another perspective for the Chronic Care Model given that not all the barriers are rational or are easily recognizable by patients and practitioners. Major behavioral barriers to optimal health include patients’ fear of threats to health, unwillingness to think about problems when risks are known or data are ambiguous, disregard of future risks, failure to act due to lack of motivation, insufficient confidence in their ability to overcome a health problem, and inattention due to pressures of everyday life. The identification of these barriers can assist with the design of interventions based on behavioral economics, which has shown to be effective in modifying behaviors related to other health issues [25–27].

This research was proposed to provide information that would better inform healthcare stakeholders planning interventions to improve health care and promote health behaviors. The combination of both approaches may provide more knowledge of barriers that can be addressed.

We used a two-pronged approach (traditional and behavioral economics approach) to analyze the perceptions, attitudes, practices, and motivations of healthcare providers and users of the public primary healthcare system. We aimed to identify the main barriers in the prevention, detection, and control of cardiometabolic diseases in primary healthcare settings within the Argentine public healthcare sector.

CONCEPTUAL FRAMEWORK

Our study was designed to address barriers and facilitators on the basis of a conceptual and analytical framework that considers three levels: (a) the system, which includes factors related to the design and organization of healthcare services (e.g., accessibility and availability of resources); (b) the provision of health care, which includes factors related to the provision of healthcare services at PCCs (e.g., healthcare providers’ skills and attitudes or the implementation of clinical practice guidelines); and (c) users, which includes factors related to individual users of the public healthcare system.

The study explores existing traditional barriers from a neoclassic economic theory perspective (e.g., accessibility, resources, knowledge, and skills) and an additional behavioral economic approach. We use the analytic term “barriers” to distinguish the obstacles described by traditional approaches, and for irrational factors behind decision-making described by the behavioral economics approach, we use the term “bottle necks.”

According to the behavioral economics approach, people frequently make irrational choices (i.e., choices that do not maximize their lifetime utility). These irrational behaviors lead to different biases—usually acknowledged by behavioral economics—that may account for most deviations from rational behavior and attitudes: bounded rationality, bounded willpower, and bounded selfishness [28].

The concept of bounded rationality defines decision-making rationality as being limited by the available information at the time and rules of thumb or decision heuristics that are often used. Bounded willpower refers to the fact that individuals often do not make decisions that are in their best long-term interest, often due to a lack of self-control or willpower. Bounded selfishness takes place when individuals’ actions are not driven by self-interest but instead they behave altruistically (e.g., the enforcement of social norms). See Table 1 for examples of behaviors and attitudes related to these biases.

Table 1.

Behavioral economics biases and examples of behaviors or attitudes

Bias	Examples of behaviors or attitudes
Bounded rationality	• Optimism and overconfidence: when people are overconfident about their own good fortune, abilities, and intuition and can display risk-taking behaviors • Availability heuristics: when the likelihood of an event is interpreted according to the vividness with which people can think of an example of that event or even the emotional reactions (affect heuristics) that guide their decisions, which, in turn, are driven by salience • Representativeness heuristics: i.e., interpreting the likelihood of an event based on its similarity to other events rather than relying on more objective criteria • Status quo bias: acting out of inertia or being reluctant to change the status quo.
Bounded willpower	• Time inconsistent preferences: when people heavily weigh short-term vs. long-term aspects when making decision (e.g., not being able to work hard today for a future reward) • Ego depletion and decision fatigue: even if they succeed at first, self-control tends to deteriorate over time • Hyperbolic discounting: when people favor immediate but smaller rewards instead of delayed but larger and highly-valued rewards • Present bias: people’s preferences depend on the timing of the decision
Bounded selfishness	• How others behave influences an individual’s choices, either by changing social norms (i.e. rules of acceptable behavior) or by providing additional information • Peer effect: when an individual’s decisions and alternative courses of action depend on what others do or think

METHODS

Study design and setting

The study used inductive inquiry consistent with the grounded theory approach [29] and was conducted in accordance with qualitative research guidelines [30, 31]. It included in-depth semistructured interviews and focus groups with health providers and users of PCCs. The study was conducted between March and December 2015.

Interviews and focus groups participants were recruited from five PPCs located in two Argentine provinces (three in Río Negro, Southern Argentina, and two in Jujuy, the Northwest). Study sites were purposively selected on the basis of geographical location, population served, and level of participation in the REDES program (three had taken part in the program for more than 2 years and two less than 1 year). The site-selection process was approved by the Ministry of Public Health, the authorities of REDES, and the International Development Bank (IDB).

Participants and sampling

Interviews and focus groups participants were purposively selected to cover two target groups: healthcare providers and public healthcare system users. During the data collection, we decided to include interviews with public health authorities. Semistructured interviews/focus group guidelines were developed based on the theoretical framework of the study.

Healthcare providers: in-depth semistructured interviews with healthcare providers that ranged from general practitioners (GPs), specialists, nurses, and administrative staff at PCCs and hospital Cardiology and Diabetology specialists.

Users: in-depth semistructured interviews and focus groups with adults over 40 years old with at least one of the following chronic conditions: type 2 diabetes, hypertension, or obesity. The study sample included both actual users and potential beneficiaries of the public healthcare system (i.e., people not receiving treatment at the clinics despite having being diagnosed with a chronic disease), henceforth referred as “users.”

Public health authorities: in-depth semistructured interviews with representatives of the REDES program at the provincial Ministry of Health, and health directors at the local level.

Procedure and data collection

Three research experts conducted the data collection. We received help and collaboration from provincial Ministries of Health to identify and invite study participants following the inclusion criteria. For the patients’ invitations, focal points used a letter of invitation explaining the project objectives and terms of participation. All health providers from the visited clinics were informed about the project and invited to be interviewed, and we finally included providers present at the moment of the visit. Interviews and focus groups lasted between 20 and 60 min, and were audiotaped and transcribed in verbatim in preparation for analysis.

Data analysis

The written transcripts were entered into ATLAS.ti version 7 (2013) qualitative data management software (Scientific Software Development, Berlin, Germany) and coded according to a codebook based on themes included in the questionnaires and supplemented by a grounded theory-based approach to capture emergent themes [15, 24].

Thematic analysis was done for each target group. Subsequently matrices were developed to facilitate comparison across the transcript materials and to retain data context (i.e., sites, clinic, and type of informant). Finally, data were abstracted and interpreted. As part of this analysis, direct quotations representative of participants’ opinions were selected and included in this paper to illustrate the findings. To protect the identity of the informants, we only provide information on informant-type (in brackets).

Qualitative data were categorized to reflect barriers for the prevention, detection, and control of cardiometabolic diseases in primary healthcare settings and grouped into three categories: (a) system-level factors; (b) health providers’ knowledge, practices, and skills; and (c) users’ knowledge and behavior.

RESULTS

Population

We interviewed 9 public health authorities and 40 healthcare providers (26 from the Northwest and 23 from the Southern provinces). Health providers interviewed belong to the primary care level (35) including GPs, nurses, community health workers, and administrative staff; and the hospital level (5) including cardiology and diabetes specialists.

A total of 72 healthcare users participated in interviews and focus groups. We carried out individual face-to-face interviews with 19 women and 6 men. We conducted a total of six focus groups (6–12 participants each group), including four focus groups with patients with type 2 diabetes (2 with women and 2 with men), and two focus groups with patients with hypertension (1 with women and 1 with men). The median age of users was similar in both provinces (56 years old in the Northwest province and 57 years old in Southern province). Sixty-one per cent of the participants were women.

Healthcare system barriers

As shown in Table 2, the most significant health system–level barriers are related to PCC delivery processes and the interaction with hospital healthcare delivery.

Table 2.

Barriers identified at healthcare system level to hypertension and diabetes management in primary health care in Argentina

Category	Barriers
PCC healthcare delivery for adults with chronic diseases	• Conventional care prioritizes maternal and child health, neglecting adult chronic diseases • Lack of human resources to respond to growing demand for healthcare services for adult patients • Lack of necessary equipment to control chronic diseases such as diabetes and hypertension • Shortages of free medication to treat chronic patients • Lack of functional accessibility and gender bias
Interaction between PCCs and hospitals	• Obstacles in patient hospital access • Patient’s retention by hospital specialists • Hospital specialists and clinic GPs do not agree on Clinical Practice Guidelines (CPGs)

Delivery of health care for adults with chronic diseases at PCCs

Traditionally, primary health care has focused largely on maternal and child health and preventive interventions like immunization. Despite recent attempts to incorporate chronic conditions in primary care, health policies and health providers have not adjusted their priorities. Both patients and healthcare providers highlighted the lack of time to see such patients.

“Our facilities do not provide services for those patients (chronic patients) on a regular basis... I see mostly children and adolescents at the clinic. That’s our population. The programs we implement relate to maternal and child health. On a normal day I see about 15 children, therefore, I have no time left for chronic patients” (Interview, Healthcare provider at a PCC)

PCC human resource shortages and the lack of diabetes and hypertension equipment (e.g., glucometers, test strips, blood pressure monitors, and needles) are obstacles to the growing demand for healthcare services for adult patients with chronic diseases. Although some healthcare programs, such as REDES, provide patients with hypertension and diabetes with medication free of charge, some healthcare providers and users mentioned occasional shortages. In these cases, patients have no choice but to seek medication at hospitals, pay out-of-pocket, or interrupt treatment.

“We haven’t had stock issues with some antihypertensive drugs, but sometimes we don’t have others. In these cases, for example, we need to resort to donations from other sources. Otherwise patients would have to buy them themselves.” (Interview, health provider at PCC)

Although the geographic location of PCCs was not identified as a barrier, some PCC characteristics or organizational aspects result in a lack of functional accessibility and gender bias. Lack of functional accessibility was associated with the tradition that neglects adult patients and a lack of human and material resources, which is also reflected in clinics’ distribution and interior design. Gender differences were associated with the traditional emphasis on maternal and child health (women are used to visiting the clinics during their reproductive life and to take care of their children). Men repeatedly expressed, they felt excluded from the system:

“In this clinic, Mondays and Wednesdays are exclusively for children and pregnant women. This creates a gap for us, men. We also need to have our own day of the week. If we had our own day [a day for persons with diabetes], they would see I´m right. Having our own day would be a guarantee of getting an appointment with a doctor.” (Focus groups, men with diabetes)

Interaction between clinics and hospitals

Patients with chronic diseases diagnosed and treated at PCCs often require referral to a second level of attention and joint monitoring. We identified barriers related to the interaction between clinics and hospitals. Some people faced difficulties when trying to access the second level of care due to long distances or because it is hard to make appointments for diagnostic tests or specialist care. At many hospitals, appointments are given the same day very early in the morning on a first-come, first-served basis. These issues can cause treatment delays or interruptions.

“The problem comes when you are told to make an appointment at the hospital. To get an appointment with the cardiologist I had to go to the hospital three days in a row at 4 AM” (Focus group with women with hypertension)

“Another barrier is the need for additional tests and the amount of follow up visits that are needed. people with hypertension have to go to hospital several times for an electrocardiogram or an x-ray… This back and forth takes a lot of time, patients get tired and we lose them…” (Interviews, health providers at PCC)

From some healthcare providers’ point of view, there is a patient retention by second-level clinicians, diabetologists, or cardiologists. Some hospital physicians did not show readiness to establish a joint care plan with clinic GPs.

“Once a patient has a confirmed diagnosis, I practically lose him or her. They do not come back to the clinic and continue the follow up at the hospital. Honestly, I cannot think of any patient who returned to the PCC for his or her follow up.” (Interview, health provider at PCC)

For some patients, it was more convenient to continue with follow-up at the hospital. They often need to visit the hospital for additional tests (e.g., lab tests or imaging tests), to see a specialist (e.g., cardiologists, diabetologists, and nutritionists), and in some cases to receive medication.

“The problem is that our patients at the PCC also need to go to hospital many times a month and, therefore, they end up choosing the hospital over the PCC because they perceive PCCs don’t have an adequate supply of the drugs they need, or just out of convenience, to avoid duplicate visits.” (Interviews, health provider specialist at PCC)

Specialists at the hospital level follow different Clinical Practice Guidelines (CPGs) from GPs at the primary care level. They sometimes prescribe medications not covered by the national Free Essential Drugs Supply Program. This poses a barrier to medication adherence.

“Patients with hypertension who don’t receive proper care at the clinic go to see a cardiologist at the hospital. The cardiologist then changes their medication and we have a hard time trying to provide them with [drugs not included in REMEDIAR] for example” (Interview, health provider at PCC)

Barriers identified at the level of healthcare providers

The most significant factors hindering hypertension and diabetes management at the healthcare providers’ level are described in Table 3. Under each category, we identified traditional barriers and some bottlenecks described by the behavioral economics approach.

Table 3.

Barriers identified at healthcare providers level to hypertension and diabetes management in primary health care in Argentina

Category	Barriers related to traditional approaches	Bottlenecks identified through the behavioral economics approach
Knowledge and skills training	• Lack of knowledge and skills in chronic disease care • Lack of GP training in following up with hypertension and type 2 diabetes patients	• Overconfidence regarding their skills and optimism bias
Care provision	• Lack of availability and/or use of Clinical Practice Guidelines • Effective counseling activities are not prioritized • Lack of availability of educational material for patients	• Status quo bias and inertia • Overconfidence regarding their skills and Optimism bias

Knowledge and skills

Healthcare teams working at primary healthcare clinics frequently lack the skills needed to manage common adult chronic diseases like type 2 diabetes and hypertension. Interviewers mentioned a lack of systematic and proper training and experience as obstacles to providing routine care for these patients.

“Training sessions are always the same. We are trained to measure blood pressure and we receive information on the risks of hypertension. We are not trained on long term follow-up. So far, and at least during the last three years, my training sessions have not included recommendations on the frequency of routine tests like electrocardiograms or fundoscopies. We are not trained on how to provide proper long-term care and follow-up which is actually what patients need from us…” (Interviews, health providers at PCCs) II)

National and provincial health training relies on select few providers at each clinic, who are then responsible for retraining other staff members. Furthermore, working conditions hinder the proper dissemination of this training within the PCCs.

“Actually I am not allowed to attend all training sessions. The clinic director selects only two doctors or other staff members. My continued education opportunities are quite limited.” (Interviews, health providers at PCC)

Obstacles for follow-up training are not only related to the availability of training programs but also to bounded rationality of the healthcare providers. Some healthcare providers considered that they did not need additional training to provide effective counseling. They were optimistic and overconfident about their knowledge, experience, skills, or intuition.

“In my case, I advise patients based on my own knowledge and experience. Other healthcare providers read or study but that’s not my case. I think my patients will be OK” (Interviews, health providers at PCC)

Care provision

The lack of availability of national health CPGs for the management of diabetes and hypertension was identified as a barrier to the implementation of evidence-based interventions at some PCCs with less experience in the REDES program. Even though REDES has delivered CPGs to primary care facilities, several healthcare providers seemed unaware of their existence. In addition, despite being aware of guideline availability, some health providers failed to recognize their usefulness or appeared reluctant to follow them.

“We have some old-school GPs with no formal training in family medicine. They learned along the way, through practice. They don’t use guidelines. They assess patients based on their intuition only” (Interview, health providers)

Reticence in the use of CPGs reveals providers’ bounded rationality or inertia regarding routines, and lessons and practices learned academically. Following routine practices leads to status quo bias.

Even though the REDES program includes risk classification requirements, some interviewees mentioned that some healthcare providers do not follow the guidelines and continue to classify their patients based on their own criteria or clinical experience. This behavior reflects healthcare providers overconfidence in their own experience. The following quote illustrates routine practice inertia and status-quo bias, and overconfidence on own abilities.

“Our staff includes GPs that have practiced medicine for many years. They have their own ways to provide care. They don’t use guidelines. They have their own way of assessing patients’ CVD risk.” (PCC authority)

Despite the obstacles illustrated above, generally healthcare providers acknowledge patients’ need for information and support, though this may not be prioritized due to the lack of time during a medical consultation.

“Chronic patients are very demanding patients. Most of them are elderly people. They have many questions about their condition and they need a lot of information… Therefore, they need longer visits. It’s not just about prescribing drugs. They need help to learn to live with their disease. We don’t have time for that. All we can do is address the most urgent matters. That is the first barrier. If we allocated good human resources to prevention and patient education, we wouldn’t have such a heavy workload in the first place. (Interviews, health providers) REDES)

The REDES program recommends providing patients with counseling, while providing PCCs with material to facilitate this activity. However, many GPs are unaware of the existence of this material. Furthermore, printed material was not available at some PCCs, and even when available, some health providers were reluctant to use it. Health providers also showed inertia and stuck to routine practices instead of following REDES counseling recommendations.

Barriers identified at the level of users

Table 4 summarizes the barriers that users face to achieve a chronic disease diagnosis, such as diabetes and hypertension, and stick to the recommended treatment. The table also summarizes the identified bottlenecks described from the behavioral economics’ approach.

Table 4.

Barriers identified at the level of users in hypertension and diabetes management in primary health care in Argentina

Category	Barriers related to traditional approaches	Bottleneck identified through the behavioral economics approach
Visiting the clinic for diagnosis and to start treatment	• Lack of Knowledge • Misconceptions • Fear of getting bad news	• Optimism • Overconfidence bias
Treatment management and follow-up Medical checkups Medication adherence Diet Physical activity	• Lack of knowledge • Misconceptions • Needs for accurate information not met • Mistrust of therapeutic interventions • Overestimation of drugs adverse effects • Lack of affordability for healthy diet • Lack of time for preparing healthy meals or engaging physical activities • Lack of access to places for physical activities • Lack of family support	• Optimism and overconfidence bias • Representativeness heuristics • Availability heuristics • Affect heuristics • Decision fatigue and ego-depletion

Diagnosis and treatment barriers

Limited knowledge regarding chronic conditions like diabetes and hypertension is an obstacle for early consultation and diagnosis. Some users said that their reluctance to attend medical checkups and follow-up visits was a way to avoid disease confirmation, whereas others mentioned anxiety regarding a potentially negative diagnosis.

“During my routine checkups they [the doctors] always found something different. Eventually I decided to skip my routine checkups. They found I had hypertension when I visited hospital due to an inguinal hernia.” (Focus groups, man with hypertension)

Many users delayed medical treatment due to an assumption that medication use would create dependency.

“Once you start with insulin, there is no way out. That is why I decided not to start, and thank God I feel good” (Female user)

Resistance in learning about one’s health condition and acknowledging diabetes as a chronic condition that requires life-long treatment is related to a bounded rationality, showing optimism and overconfidence bias. People over-rely on their own good fortune, and intuition and, therefore, engage in risk-taking behaviors like missing scheduled appointments or delaying treatment.

Treatment management and follow-up of chronic diseases

Healthcare providers mentioned patients’ lack of knowledge and misconceptions regarding chronic diseases, high-risk behaviors, and the importance of continued treatment as barriers to treatment adherence. Lack of proper information contributes to users’ misconceptions, with some discontinuing treatment and follow-up appointments when asymptomatic.

“I interrupted the drug as soon as I felt better. I didn´t need it then. Later I had to take it up again because my blood pressure went up (Focus groups, women with hypertension)

“Then I stopped going to the clinic because they told me I did not have hypertension anymore” (Interviews, women with hypertension)

Users expressed various concerns regarding treatment, including lack of information from health providers.

“My father has hypertension. However, I don´t know much about hypertension. I know salt is bad for him, but is it possible for hypertension to derive from anxiety? I’ve coped with great anxiety and stress in the past, but my blood pressure was always normal and I didn´t get sick. I got sick after a very stressful situation once, but just that once. The truth is I don’t understand the disease very well.” (Focus groups, men with hypertension)

The level of existing knowledge varies greatly between patients with different chronic conditions. In general, patients with diabetes are more aware of the risks and complications of their disease than those with hypertension because their symptoms are more readily perceived. On the other hand, hypertension has been called the silent killer and patients are more prone to deny or ignore their condition.

“Sometimes I feel dizzy, buy only rarely. If it happens I just rest for a while until it is over. I have never felt the dangerous symptoms of high blood pressure, unlike my neighbor, who has been hospitalized several times for this condition…” (Focus groups, men with hypertension)

Some patients expressed a need for tailored information and recommendations regarding healthier habits (information adapted to their actual financial situation).

“Talking about healthy habits is very difficult here... These are working-class people, they need to work and they don’t have time to jog for 30 minutes every day.... You may recommend healthy snacks but they’ll eat what’s available... I must be very cautious when making recommendations. I don’t want to hurt their feelings by suggesting changes they cannot make” (Interviews, health providers)

Some patients are fully aware of the problems they may face in the future, but their decisions are not in their best long-term interest. Sometimes this is due to a lack of self-control or willpower. Hyperbolic discounting leads to present bias: people favor immediate satisfaction over future benefits.

Mistrust of medical treatments was also identified as an adherence barrier. Some patients overestimate the adverse effects of medications based on the experiences of their relatives or friends. Mistrust of therapeutic indications and overestimation of drugs’ adverse effects affect heuristics such as representativeness and availability biases.

“I do have a friend with advanced diabetes. He needs a kidney transplant and the doctor told him that it was caused by metformin”. (Focus group, men with diabetes)

Many participants mentioned that they could not afford a healthy diet. Recommended diets, rich in fruits and vegetables or products with less sodium or sugar, are expensive and not easily available. Those who eat their meals outside their homes, during working hours, for example, find it easier and cheaper to eat less healthy food. Moreover, from participants’ point of view, preparing healthy meals at home is more time consuming and difficult.

“I´m supposed to eat grilled skinless chicken and fish, but you need a lot of money to buy these products.” (Interviews, women with diabetes)

“Following a balanced diet is very expensive. I followed the one the doctor recommended for two months but I had to give it up, I didn’t have enough money. Plus I had to cook a meal for myself and another one for the rest of the family, which was even more expensive”. (Focus group, men with hypertension)

Although most participants acknowledged the importance and benefit of physical activity, very few reported exercising due to the lack of time or safe environment and fatigue.

“It depends a lot on what you do for a living. If you finish your working day feeling very tired it’s difficult to get in the mood to work out.” (Focus group, men with hypertension)

Patients’ families and the community may play either a positive or negative role in patients’ ability to maintain healthy habits. Family support is crucial to develop and maintain healthier habits.

“It is always the same… you start with a strict diet but you are not able to follow it for more than two or three months. There’s always a birthday party and plenty of reasons to eat too much… Such is life.” (Focus groups, women with diabetes)

Sticking to a healthy diet is perceived as a big challenge. Patients’ failure to change their lifestyles is related to decision fatigue and ego-depletion. Users mentioned that they were only able to make changes for short periods, as self-control deteriorated over time. Local traditions, peers’ habits, and financial issues push people back to their usual and less healthier habits.

DISCUSSION

The qualitative approach allowed us to better understand key factors that likely hinder the healthcare management of patients with hypertension and diabetes in primary care settings within the public health sector in Argentina. This study sheds light on how typical barriers relate to the bottlenecks identified from a BE perspective.

Several obstacles operate at the health system level. Primary healthcare clinics have traditionally prioritized maternal and child health, so the recent addition of adult populations and chronic conditions has been met with a lack of human and material resources to respond to the new demand. Accessibility is not only a matter of geographical location, but rather a functional issue, since facilities are not designed and organized to provide healthcare services for adults with chronic diseases, especially in the case of male patients. Moreover, there is no integration between primary care clinics and hospitals at the local care level hindering patients’ timely access to the second level of care (e.g., for further tests or appointments with specialists). Deficiencies in the referral and counter-referral system impede the implementation of a comprehensive model of primary care. These factors also favor heuristics, as status quo biases and inertia.

At the level of providers, we found that those working at clinics (especially GPs) lack training and skills to manage chronic diseases. CPG unavailability and the disparity between the protocols used by GPs and second-level specialists affect the quality of care and the implementation of evidence-based interventions. Resistance to adopt CPGs or to update their knowledge about chronic conditions may be explained as heuristics related to inertia and a tendency to stick to the status quo bias, as well as overconfidence and optimism bias regarding their skills and the tools they use (instead of using CPGs or counseling).

At the level of the community, barriers to controlling chronic diseases include limited knowledge about diseases and negative attitudes regarding available treatments. Weak treatment adherence and difficulty in adopting or maintaining healthy habits relate to lack of knowledge and skills, lack of accurate information, and lack of resources [32], as described in another study conducted in a similar context in our country. Resistance to know one’s health status or to accept hypertension or diabetes as a chronic condition that requires life-long treatment are related to overconfidence and optimism bias [33]. In addition, some user’s appeared reluctant to initiate or continue treatment or mistrust of therapeutic indication due to affect or representativeness heuristic (limited attention, present bias, and availability bias). Families and social environments may play either a positive or a negative role in patients’ ability to maintain healthy habits. Patients’ failure to adhere to lifelong treatments and to maintain healthy habits likely stem from decision fatigue and ego depletion.

These results may contribute to the design of hypothesis-driven interventions that aim to improve the prevention and control of cardiometabolic conditions. Some of these interventions may be focused on providing resources or improving functional accessibility. Providers’ lack of knowledge on adult chronic conditions is still a major gap that needs to be addressed through adequate formal training. Potential interventions aimed at health providers may focus on improving continuous education and training by accessible modalities like online training [34, 35]. Some innovative intervention or nudges that have proved to be successful in the past are the promotion of the achievement of goals [36] generating “priming,” committing, and being consistent now for a future gain (intending to reduce bounded willpower) and competition among PCCs to achieve set goals (addressed individuals’ “over-confidence and optimism”). Additionally, decision making supports at the point of care and feedback compared with their peers to achieve set goals [37]. Potential interventions directed towards the patient that have been successful are peer mentoring [25,38] by counteracting the patient’s bounded willpower and providing blood pressure monitors and glucometers for self-monitoring [39] to provide salient and counter the limited attention bias.

Study strength and limitations: As generally with qualitative research studies, findings helped researchers discover and explore themes, generated informative and illustrative personal narratives but may not be generalizable to larger population of health care providers and communities living in other regions of the country. Nevertheless, our findings were consistent across study sites and our sample reached data saturation. Findings were based on opinions and self-reports rather than observation of actual practices.

CONCLUSION

Study findings provide empirical evidence about the multiple barriers to controlling chronic conditions in primary care settings. Evaluating health system barriers from a BE approach may provide more effective interventions and support improvements in the diagnosis and treatment of chronic illnesses. The knowledge gained through this study may assist in the formulation of interventions aimed to overcome the revealed bottlenecks, both on the side of care provision and the community, so as to improve the effectiveness and quality of care for chronic conditions in the public primary healthcare sector. Further strategies that aim to achieve patient engagement and to empower them are recommended.

Compliance with Ethical Standards

Funding: This study was funded by Inter-American Development Bank, No. 20150109.

Authors’ Contributions: A.R. and V.I. conceived the study and developed the protocol with the participation of M.S., M.B. and J.C. M.B., J.P.A. and A.N. curried out the data collection and conducted the analysis. All authors contributed to the interpretation of data. M.B. and J.P.A. drafted the manuscript with the collaboration of V.I. and A.N. All the authors read and approved final manuscript.

Conflict of Interest: Authors Maria Belizan, Juan P. Alonso, Analía Nejamis, Joaquín Caporale, Mariano G. Copo, Mario Sánchez, Adolfo Rubinstein, and Vilma Irazola have no conflict of interest to report.

Ethical Approval: All procedures performed in the study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards2343. The study protocol was approved by the Research Ethics Committee (Comité de Etica de Protocolos de Investigación) of the Hospital Italiano, Buenos Aires, Argentina (Protocol number 2343). This article does not contain any studies with animals performed by any of the authors.

Informed Consent: All participants provided written informed consent.