Journal of Human Hypertension (2003) 17, 397405
& 2003 Nature Publishing Group All rights reserved 0950-9240/03 $25.00
ORIGINAL ARTICLE
Using a problem detection study (PDS) to
identify and compare health care provider
and consumer views of antihypertensive
therapy
AH Wade1,2, DN Weir1, AP Cameron2 and SE Tett2
1
Australias Health Pty Ltd, Lyneham, ACT, Australia; 2School of Pharmacy, The University of Queensland,
Brisbane, QLD, Australia
The objectives of this study were to ascertain consumer
knowledge and behaviour about hypertension and
treatment and to compare these with health care
providers perceptions (of most consumers). The de-
sign for the study was a problem detection study (PDS):
focus groups and then survey. Focus groups and survey
participants were convenience samples of consumers,
doctors, nurses and pharmacists. The main outcome
measures were agreement on a 5-point Likert scale with
statements about consumers knowledge and behaviour
about high blood pressure and medication. The survey
identified areas of consensus and disagreement be-
tween consumers and health providers. While general
knowledge and concordance with antihypertensive
therapy among consumers was good, consequences
such as eye and kidney disease, interactions with herbal
medicines, and how to deal with missing a dose were
less well known. Side effects were a problem for over
one-quarter of participants, and cost was a problem in
Keywords: consumers; disease management; problem detection study
Introduction
As one of the four arms of Australias National
Medicines Policy, many existing and planned
strategies aim at improving how Australians actu-
ally use medicines.1,2 Quality use of medicines
(QUM) is high on the clinical and policy agenda in
Australia and elsewhere.14 In order to understand
what consumers know and believe about their
disease and treatment, it is essential to obtain their
views and perceptions.59 The views and percep-
tions of health care providers about these same
issues can also be sought and, ideally, interventions
Correspondence: Professor SE Tett, School of Pharmacy, The
University of Queensland, Brisbane, QLD 4072, Australia.
E-mail: s.tett@pharmacy.uq.edu.au
Received 19 November 2003; revised 4 February 2003; accepted
20 February 2003
www.nature.com/jhh
continuing therapy. Half the consumers had not re-
ceived sufficient written information. Providers overall
disagreed that most consumers have an adequate
understanding of the condition. They agreed that most
consumers adhere to therapy and can manage medi-
cines; and about their own professions role in informa-
tion provision and condition management. Consumers
confirmed positive provider behaviour, suggesting
opportunities for greater communication between pro-
viders about actions taken with their consumers. In
conclusion, the PDS methodology was useful in identi-
fying consumer opinions. Differences between consu-
mer and provider responses were marked, with
consumers generally rating their knowledge and beha-
viour above providers ratings of most consumers.
There are clear gaps to be targeted to improve the
outcomes of hypertension therapy.
Journal of Human Hypertension (2003) 17, 397405.
doi:10.1038/sj.jhh.1001565
can then be designed to bridge any gaps and match
knowledge and information needs with provision.1012
Reports, however, have described a gap between
consumer and provider perceptions of the issues
and problems faced by consumers.13 Most research
tends to ask what providers want to know and what
providers think is important.14 Consequently, there
tends to be greater emphasis on what health
providers think is important in the care of their
patients.
Although it has been found that education alone
will not significantly increase compliance, some
knowledge regarding the condition and reasons for
treatment is necessary for behaviour change.1518 It is
clear, however, that this knowledge should be
carefully matched to that already possessed by the
individual and should be designed to test or extend
that knowledge, not merely to repeat known
facts.
 PDS to investigate consumer views
AH Wade et al
398
Expert panels or focus groups conducted with
consumers have been used to ascertain specific
information and education needs of the general
community with respect to their medicine use.14
Focus groups of consumers have been used to
identify barriers to drug use in patients with
congestive heart failure, describing, for example,
the importance of closer consumerhealth provider
relationships, social support and increasing the
consumers knowledge.19 While these methods are
valuable, assessment of consumer issues using
larger samples has not been carried out.13
At least one novel method exists that attempts
to redress this discrepancy. The problem detection
study (PDS) is accepted as a tool for qualitative
health service research, and has been used in
developing effective QUM educational campaigns
elsewhere since 1991.1012 Its use outside Europe,
however, has not been reported and its use for
people with hypertension has not been previously
reported.
This project applied the PDS method to the major
health problem of hypertension. Hypertension,
frequently an asymptomatic disease, can lead to
many secondary causes of morbidity and mortal-
ity.20,21 Cardiovascular disease accounts for 40% of
deaths in Australia,22 creates large costs for health
care systems, and places a significant burden on
individuals and the community because of resulting
disabilities.21,23 During the period 19992000, al-
most 3 million Australians over the age of 25 years
had hypertension, or were taking medication for it.24
Of all those with hypertension (defined as diastolic
blood pressure 490 mm Hg), one Australian study
reported that 47% of men and 23% of women were
not taking any medications for their high blood
pressure.20 It is important that hypertension is
effectively treated. It is also important to discover
the reasons, from consumers, why medication is not
used optimally for this condition. Little is known
about the consumers perspectives regarding the
management of hypertension, and whether these
views align with the perspectives of the health
professionals providing treatment for the condi-
tion.2527 This project had two principal aims: to
test the PDS methodology and to use the method to
derive insights into potential gaps between consu-
mer and provider views about hypertension and its
treatment. The detection function of the PDS can
inform interventions aimed at improving the man-
agement of hypertension.
Methods
The PDS in hypertension was conducted in Brisbane
during 2001. Ethics approval for the study was
obtained from the Medical Research Ethics Commit-
tee at the University of Queensland (Approval
Number: B/460/PHARM/00). An extensive literature
review was initially conducted using MEDLINE
Journal of Human Hypertension
(1966May 2001), International Pharmaceutical
Abstracts (IPA) (1970May 2001) and the Web of
Science to provide contextual support to the PDS
survey items.
Three levels of participation from informed con-
senting health providers and consumers were
required throughout the duration of the project:
a project advisory group; participants for focus
groups who would identify and confirm issues for
subsequent investigation; and a wider sample to
complete a written survey of issues relating to the
treatment of hypertension. Consumer participants
for the focus groups and the advisory panel were
recruited through a hypertension association, and
health professionals through interest groups, perso-
nal contacts and professional associations. All
participants were volunteers, with the advisory
panel being selected for their representation of
different groups. For completion of the resulting
survey, health providers throughout Brisbane
(general practitioners, community and specialist
nurses, and pharmacists) and consumers currently
diagnosed with hypertension and taking at least
one antihypertensive medication were invited to
participate in the project. Survey responses
were anonymous and confidential. The project
advisory group met in the planning stages
of the study, and was reconvened after initial data
analysis was completed, in order to assist in
interpretation.
Four focus group meetings of 810 participants
each, separately involving pharmacists, consumers,
doctors and nurses, were held. These focus groups
were semistructured, with open questions seeded
to start the discussion. Each lasted for approxi-
mately 2 h. The discussion was recorded manually,
the issues collated and the major themes drawn out.
The focus group data indicated five principal areas
of interest: understanding the condition; under-
standing the medication therapy; information-
seeking behaviours and needs; understanding
lifestyle contributors; and adherence and review
behaviours. These broad themes, together with the
results of the critical review of the published
literature, suggested possible survey statements.
The project advisory group confirmed the final list
of 29 survey items on which the Likert-type 5-point
scale (agree/disagree) was based. The survey items
were deliberately listed on the survey in a random
order (ie no clusters around the five principal areas
of interest) and the survey order was the same for all
groups of participants, consumer or health care
provider.
Appropriately worded versions of the survey
items were produced for health providers (referring
to most consumers) and for the consumer partici-
pants (referring to the participant). All surveys were
accompanied by a prepaid addressed envelope.
Each survey requested anonymous demographic
data about the participants and their experience
with hypertension. A total of 30 community phar-

macists were recruited to provide the surveys to any
consenting patient taking at least one antihyper-
tensive medication. Each pharmacy was requested
to hand out a maximum of 50 surveys to consumers
over a 30-day period. Most did not give out 50 in this
period.
In addition to the consumer surveys, 210 health
provider surveys were distributed to pharmacies (60
pharmacies in total received this survey, extra were
distributed as some pharmacies employ more than
one pharmacist: given an average of 1.5 pharmacists
per target pharmacy, an estimate of the available
sample size is 90); 118 health provider surveys to
nurses in hospital and community settings; and 18
health provider surveys to general practitioners
identified by the GP on the advisory group.
Returned questionnaires were examined for com-
pleteness and data were coded and entered in an
electronic database that enabled export to the SPSS
statistical analysis package.
Statistical analyses
There were two main categories of respondents to
the surveyFconsumers and health providers (phar-
macists, nurses and doctors). The survey generated
numeric and text dataFthe numeric at either the
ordinal or interval level. Ordinal data were analysed
using non-parametric statistical tests. Differences
between the groups were determined using the
KruskalWallis test. Interval data were analysed
using ANOVA. Where differences existed, post hoc
range and pairwise multiple comparisons were used
to determine which means differed (Scheffes tests).
Measures of central tendency for the numeric data
were calculated as the mean, standard error of the
mean, and median score, while measures of disper-
sion were calculated as frequency counts or percen-
tages. To enable comparability with other published
PDS, the data were also analysed by the percentage
of positive, neutral or negative scores for each
respondent group in the sample.
Statistical analyses were performed using SPSS
version 10.0, including data checking for out of
range values and for assumptions of normality
where inferential statistics were required. Normality
was tested using the KolmogorovSmirnov statistic
with a Lilliefors significance correction. By con-
vention, statistical significance (P) values for all
analyses was determined as 0.05.
Results
There were 287 consumer surveys returned. Those
incorrectly completed, for example missing data,
were excluded. This left 264 valid consumer surveys
for analysis. Gender responses by age, reported
number of medicines and their duration are illu-
strated in Table 1. There were no statistically
significant differences between the mean ages for
PDS to investigate consumer views
AH Wade et al
399
Table 1 Gender, age and medication usage by consumers of
hypertension medicines
Male Female Total
(n=154) (n=108) (n=264)a
Age (years) 59.3 (1.3) 60.8 (1.36) 59.5 (1.3)
Time taking antihypertensive 11.2 (0.75) 11.7 (1.09) 11.3 (1.02)
medication (years)
Number of antihypertensive 1.62 (1.3) 1.59 (1.01) 1.6 (0.96)
medications taken
Data are presented as group mean and standard error of the mean
( 7 SEM).
a
Two respondents did not indicate gender. In this sample, 175 (106
male, 68 female) reported taking their medicine for less than 4 years;
89 (47 male, 41 female) reported taking their medicine for more than 4
years.
males and females, the time they reported taking
hypertensive medication, nor the mean number of
medications reported as taken for hypertension. In
total, 50% of males (n 77) and 52% of females
(n 56) reported taking only one antihypertensive
medicine, 34% of males (n 53) and 32% of females
(n 34) reported two concurrent antihypertensives,
and 13% of males (n 20) and 12% of females
(n 13) reported taking three or more medicines (up
to seven in one male) concurrently for their
hypertension. In the sample, 175 (106 male and 68
female) consumers reported taking hypertensive
medicine for more than 4 years, and the remaining
(47 male and 41 female) consumers for less than 4
years.
Of all consumers 49% (n 129), reported that they
had received printed information on high blood
pressure. A low 1.0% (n 3) of the consumer
respondents (all males) reported that they currently
belonged to a high blood pressure support group.
Some respondents (2.7%, n 7) reported they were
taking herbal medicines for their high blood pres-
sure. These were more likely to be female (4.6% of
total female sample) than male (1.3% of total male
sample). In all, 13% of consumers (n 34) reported
that they were currently measuring their blood
pressure at home (14% males and 12% females).
There were 133 valid health provider surveys
completed out of an anticipated 230 (18 GPs, 118
nurses and approximately 90 pharmacists). Health
provider data by practice setting and number of
hypertensive patients seen per week are presented
in Table 2.
Pharmacists had spent less time than doctors in
practice overall. Analysis of the nurses ranked
scores by practice setting (as over a quarter practised
in hospitals) indicated that significant differences
existed only in whether they considered that most
consumers receive sufficient written information
about their antihypertensive medicines. More com-
munity- than hospital-based nurses thought this
(w2 6.54, df 1, P 0.011). Whether most consu-
mers understand that hypertension is the same as
Journal of Human Hypertension
 PDS to investigate consumer views
400
Table 2 Practice setting, time spent (years) in practice and
number of hypertensive patients seen per week (also expressed as
the percentage for all respondents) for health providers
Pharmacist Nurse
(n=51) (n=64)a
Practice setting
Hospital 4 17
Community 46 44
Other 1 2
No. of hypertensive patients per week (% total responses for each
professional category)
o10 1 (2) 27 (44) 1 (6)
1050 27 (54) 34 (55) 15 (84)
>50 22 (44) 1 (1) 2 (10)
a
One did not state a practice setting.
high blood pressure, more hospital than commu-
nity-based nurses thought this (w2 4.26, df 1,
P 0.039). There were no other differences based
on site of practice.
To enable comparability with other PDS, the data
are reported by the total percentage of consumers
and combined health providers marking agree (4)
and strongly agree (5) on the 5-point Likert scale
(Table 3). The KruskalWallis statistic on ranked
median scores for consumers and categories of
health professionals revealed many significant dif-
ferences between groups. This reflects the wide
disparity in percentage agreement between consu-
mers and the provider group seen on many
of the survey items, for example knowledge of target
blood pressure or kidney and eye disease conse-
quences.
Table 3 includes all the general data obtained from
the groups; however, there were also some notable
differences within subgroups. For example, for
consumers, significantly more females than males
agreed that they understood that hypertension is the
same as high blood pressure (w2 8.24, df 1,
P 0.004), and more males than females disagreed
with the statement that they understood high blood
pressure can cause kidney disease (w2 4.05, df 1,
P 0.044). Most consumers report they understand
that over-the-counter (OTC) medicines can interact
with their blood pressure medicines, but gender
differences reached statistical significance
(w2 5.04, df 1, P 0.025) with more females than
males agreeing with this statement. Only 49% of
consumers reported agreement with the possible
interaction with herbal preparations, with more
females agreeing than males (w2 8.64, df 1,
P 0.003). Most consumers agreed that they have
enough assistance to remember to take their medi-
cines. Slightly fewer felt confident in managing their
medicinesFgender differences reaching statistical
significance (w2 5.58, df 1, P 0.018)Fwith more
females than males reporting agreement with this
statement.
Journal of Human Hypertension
AH Wade et al
Only 5% of consumers (n 14) agreed that they
are sometimes influenced by friends or family to
stop taking their blood pressure medicines, and in
Doctor this group, females were significantly more likely to
(n=18) be influenced than males (w2 8.39, df 1,
P 0.004). This is contrasted with 48% of providers
(n 64) who agreed that most consumers are some-
F times influenced to stop in this way.
18 Most consumers agreed that they regularly review
F
their blood pressure medicines with their doctor,
and significantly more females than males (w2 4.33,
df 1, P 0.037) agreed with this. Only 35% of
providers (n 47) agreed that this occurs for most
consumers, but there were differences between the
provider categories in this regard, with 67% of
doctors (n 12) agreeing, and 25% of the pharma-
cists (n 13) and 34% of the nurses (n 22)
disagreeing that consumers regularly reviewed their
antihypertensives with their doctor.
Nearly 80% of consumers (n 221) agree that
their doctor takes a planned approach to their blood
pressure medicines; however, this number declines
in relation to whether medicine changes and brand
substitution are adequately explained. While 50% of
providers (n 67) agree that therapy is planned,
there are differences between provider categories,
with pharmacists and nurses not agreeing as
strongly as doctors, that doctors take a planned
approach to antihypertensive medicines. In relation
to brand substitution, pharmacists agreed, while
nurses and doctors disagreed, that this was ade-
quately explained to consumers.
The consumer group was further examined to
determine if there were differences in survey scores
for those in treatment for hypertension for different
time periods: 175 (106 male and 68 female)
consumers reported taking hypertensive medicine
for longer than 4 years, and 89 (47 male and 41
female) consumers for less than 4 years. The longer
treatment time group reported a significantly stron-
ger agreement (w2 3.56, df 1, P 0.001) than the
group treated for less than 4 years in their under-
standing that hypertension is synonymous with the
term high blood pressure, in understanding what
their target blood pressure is, and in understanding
that high blood pressure can cause kidney disease.
The subgroup receiving treatment for less than 4
years was significantly less certain than the longer
treatment group (w2 4.12, df 1, P 0.001) that
changes in their blood pressure medicines are
adequately explained to them, and that their health
care providers have helped them achieve lifestyle
changes.
Confidence in knowing what to do if a dose is
missed is significantly less in the under 4 years
subgroup than their more experienced counterparts
(w2 8.47, df 1, P 0.001), while both groups dis-
agree that friends or family experiences influence
their continued use of hypertensive medicines, and
the over 4 years subgroup is significantly more
certain of this.
 PDS to investigate consumer views
AH Wade et al

401
Table 3 Percentages of total providers and consumers scoring disagree (D), neutral (N) or agree (A), sorted by highest consumer
agreement within survey item categories

Cat. Item Consumer survey item/provider survey item Providers Consumers

D N A D N A

A 14 I understand that high blood pressure can cause a stroke. 28 16 56 3 3 94

Most consumers understand that hypertension can cause a stroke.
A 16 I understand that hypertension is the same as high blood pressure. 24 20 56 5 13 82
Most consumers understand that hypertension is the same as
high blood pressure.
A 2 I understand what my target blood pressure is. 56 14 29 14 10 76
Most consumers understand what their target blood pressure is.
A 6 I understand that high blood pressure can cause kidney disease. 84 14 2 17 24 59
Most consumers understand that hypertension can cause kidney
disease.
A 23 I understand that high blood pressure can cause eye disease. 86 13 1 16 32 51
Most consumers understand that hypertension can cause eye disease.
B 3 I understand that blood pressure medicine can interact with over-the-counter 62 14 24 5 10 85
preparations.
Most consumers understand that antihypertensive medicine can interact with
over-the-counter preparations
B 18 I feel my doctor takes a planned approach to my blood pressure medicines. 20 28 52 9 13 79
Doctors take a planned approach to most consumers antihypertensive medicines.
B 15 I feel that brand substitution of my medicines is adequately explained to me. 37 22 41 17 19 65
Brand substitution of medicines is adequately explained to most consumers.
B 27 I feel that changes in my blood pressure medicines are adequately explained to me. 47 20 33 12 25 63
Changes in antihypertensive medicines are adequately explained to most consumers.
B 29 I understand that blood pressure medicine can interact with herbal preparations. 82 14 4 13 38 49
Most consumers understand that antihypertensive medicine can interact with
herbal preparations.
B 1 Side effects of my blood pressure medicines are a problem for me. 4 3 93 57 18 26
Side effects of antihypertensive medicines can cause problems.
C 24 My doctor has explained my high blood pressure to me in plain language that I 27 42 31 11 8 81
could understand.
Doctors explain hypertension to most consumers in plain language that they can
understand.
C 25 Information for my family about high blood pressure would be useful in managing 6 7 87 12 36 53
my condition.
Information for the consumers family regarding hypertension would be useful in
managing their condition.
C 9 I have received sufficient written information about my blood pressure medicines. 56 20 23 35 13 52
Most consumers receive sufficient written information about their antihypertensive
medicines.
C 17 Information from the media about high blood pressure has been useful to me. 33 28 39 23 40 37
Information from the media about hypertension is useful for most consumers.
C 4 Seeking information myself was easier than waiting for the health provider to 45 35 20 47 27 26
supply it.
Most consumers find that seeking information themselves is easier than waiting
for the health provider to supply it.
C 13 Information from blood pressure support groups is useful to me. 13 35 52 20 62 19
Information from hypertension support groups is useful for most consumers.
D 19 I understand how my weight affects my blood pressure. 31 20 49 6 8 86
Most consumers understand how their weight affects their blood pressure.
D 26 I understand how my diet affects my blood pressure. 43 23 34 7 12 81
Most consumers understand how their diet affects their hypertension.
D 10 I believe that changing my lifestyle has an effect on my blood pressure. 28 14 58 12 12 76
Most consumers believe that changing their lifestyle can have an effect on
their hypertension.
D 12 It is helpful to me when health providers continually reinforce the need to 21 29 50 15 33 52
change my lifestyle.
Most consumers find it helpful for health providers to continually reinforce the
need to change their lifestyle.
D 28 My health providers have helped me achieve lifestyle changes. 29 33 38 21 34 45
Health providers help most consumers achieve lifestyle changes.
E 7 Even when I dont feel any symptoms, I continue to take my blood 11 15 74 3 2 96
pressure medicines.
Even when consumers dont feel any symptoms, most continue to take their
antihypertensive medicines.
E 22 I feel I have enough assistance to remember to take my medicines. 19 24 57 3 6 91
Most consumers have enough assistance to remember to take their medicines.
E 21 I feel confident in managing my own medicines. 17 24 59 8 7 85

Journal of Human Hypertension

 PDS to investigate consumer views
AH Wade et al

402 Table 3 (continued)

Cat. Item Consumer survey item/provider survey item Providers Consumers

D N A D N A

Most consumers feel confident in managing their own medicines.

E 11 I regularly review my blood pressure medicines with my doctor. 39 25 35 7 9 84
Most consumers regularly review their antihypertensive medicines
with their doctor.
E 5 I feel confident in knowing what to do if I miss a dose of my blood 75 15 10 16 8 76
pressure medicine.
Most consumers feel confident in knowing what to do if they miss a dose of
their antihypertensive medicine.
E 20 The cost of my blood pressure medicines is a problem in continuing them. 39 23 38 50 18 32
The cost of antihypertensive medicines can cause a problem for most consumers
in continuing them.
E 8 I am sometimes influenced by my friends or family to stop taking medicines due to 21 30 49 89 6 5
their experiences.
Most consumers are sometimes influenced by friends or family to stop taking
medicines due to their experiences.

Categories: AFknowledge/understanding of the condition of hypertension, BFunderstanding of the medicine therapy, CFinformation-seeking
behaviour/needs, DFunderstanding of lifestyle contributors, EFadherence and review behaviours.

Discussion alone will produce behaviour change,29 leading to

A significant message of this study is that in almost
all the items (Table 3), consumers ranked the issue
differently to health professionals. This finding is
consistent with earlier applications of the PDS and
highlights that if interventions to assist consumers
were developed solely from a health professional
perspective, important issues to consumers could be
missed.912,27,28 The PDS methodology was success-
fully conducted in the Australian environment and
would be a transportable method for other groups
and for other countries to consider when seeking
valuable insights into consumer perceptions and
behaviour.
Care should be taken, however, with extrapolation
of these specific data. This was a convenience
sample of voluntary participants, with an average
length of time taking medicine for hypertension of
11 years: a sample well experienced in the condition
and its treatment. Given that surveys were distrib-
uted through pharmacies to people receiving anti-
hypertensive medicine, the sampling technique will
also be biased to those who adhere to their medicine
treatment. It would be interesting to sample a group
more recently diagnosed, as this study showed that
those with less experience tended to be less certain
of some aspects of hypertension and its treatment.
However, any educational intervention would need
to be designed so as not to talk down to those who
had knowledge about the condition and its con-
sequences, as health professionals thought that
consumers had substantially less knowledge than
they actually reported.
Patient education can sometimes have little im-
pact on individuals owing to commonly held beliefs
of, and activities carried out by, health care
providers. Assumptions include that education
over-reliance on one or two education strategies
only (eg a brief lecture), efforts too short to achieve
long-term behaviour change, and failure to under-
take a behavioural diagnosis to select appropriate
educational strategies for particular indivi-
duals.18,30,31 To achieve long-lasting behavioural
modifications, educational activities lasting for
prolonged periods and of a diverse nature are
required.17,18 Although it has been found that
education alone will not significantly increase
compliance, some knowledge regarding the condi-
tion and reasons for treatment is necessary for
behaviour change.15,16 However, this knowledge
should be carefully matched to that already pos-
sessed by the individual and should be designed to
test or extend that knowledge, not merely to repeat
known facts.
It is interesting that consumers tended to agree
more that their therapy is planned and explained
than health providers do. Consumers supported the
relevant health providers perceptions more than the
other health providers do. For example, consumers
agreed with pharmacists that brand substitution is
explained (nurses and doctors did not agree) and
agreed with doctors that a planned approach to
medicines is undertaken and changes are adequately
explained (nurses and pharmacists did not agree).
These results suggest some interesting insights.
Among each of the provider groups, there is less
confidence that others have performed these tasks.
This may demonstrate that there is relatively little
information exchange between the provider groups
about planned approaches, including explanation
to the consumer of changes to therapy. It may
also indicate that the health providers do not take
account of the services provided to consumers by
the other providers. Perhaps better interdisciplinary

Journal of Human Hypertension


communication and collaboration about the actions
and plans implemented for individual consumers
might help to bridge this difference in perceptions.
Using the general practitioner as a principal
health provider and utilizing the skills of other
health providers (eg pharmacists and nurses), a
comprehensive approach to treating and educating
the consumer can be achieved.3234 Pharmacists can
monitor patients, work together with general practi-
tioners to review all aspects of pharmacotherapy,
and help the consumer individually by tailoring
regimens and educating on all components of
therapy including lifestyle changes.3538 Nurses can
contribute to the health team by providing support
to the general practitioner, monitoring of blood
pressure and other aspects of therapy, providing
education to consumers individually, and forming
valuable links with social support networks in
families, workplaces and the greater community.39,40
These results suggest opportunities for targeted
information about interactions between blood pres-
sure medicines, OTC and especially herbal prepara-
tions. In addition, a clear explanation of changes
to therapy, including OTC and complementary
medicines, is needed, including information ex-
change between providers. Consumers commencing
therapy for hypertension may benefit from ap-
propriately targeted information about the risk/
benefits and potential interactions of antihypertensive
medication.
While over half of the consumers reported that
side effects are not a problem to them, 26% say they
are. Providers are almost universally in agreement
with the statement that side effects can cause
problems; however, their question may have been
too generic as it is hard to disagree that side effects
can cause problems per se. The lower consumer
score may indicate experienced consumers who
have perhaps sorted out any adverse effects through
changes and adaptations. This analysis gains some
support by examining the subsample of consumers
with 4 years or less time on hypertension medica-
tion. For this group, side effects are more of a
problem than for their more experienced peers. It
could also be that adverse effects are not being
recognized as such. It would be an ineffective use of
resources, however, to base a whole campaign
around the perception by health providers of side
effects as a major issue. There are more important
issues that consumers are concerned about. The
highest median score in the survey by providers was
that side effects can cause problems; however, the
ranking as a problem rated second lowest for
consumers. The consumer results are consistent
with the literature on the relations between side
effects and adherence. For example, two separate
studies found that only 7% of consumers indicated
that side effects were enough of a problem to
discontinue therapy.41,42
With respect to information seeking, only half of
the consumers felt they had received sufficient
PDS to investigate consumer views
AH Wade et al
403
written information and a similar number thought
that information for their family would be useful.
These results suggest that there are substantial
opportunities for providing further information to
consumers and their families about hypertension
and medicines. Extensive social support and educa-
tion (usually given to the spouse) has been demon-
strated to improve the compliance behaviours and
blood pressure control of hypertensive patients.4345
The media was not perceived by many as a useful
source of information, while only one-quarter of
consumers agreed that it was easier to get informa-
tion themselves rather than waiting for providers to
supply it. This suggests that, despite the multiple
information sources now available to consumers,
there is clearly still a primary role for health
providers to supply information. Unfortunately,
support groups were not recognized by consumers
as useful information resources. This could indicate
the low penetration of awareness of these groups
(only 1% of the consumers belonged to one),
although the health providers agreed (50%) that
these would be useful. This suggests that providers
are supportive of such information, but may have
little knowledge of the extent of consumer involve-
ment in support groups. It could be helpful to
consumers if health providers could distribute
information about these support groups.
For understanding lifestyle contributors, most
consumers agreed that they understand how weight
and diet affects their blood pressure, but while half
of the providers agree that consumers understand
the relation between weight and blood pressure,
only one-third agree on consumer understanding of
the relation between diet and blood pressure. Half of
the consumers agreed that it is helpful for providers
to reinforce the need for lifestyle change, but less
than half agree that providers have helped them
achieve these changes. This indicates an opportu-
nity for providers to help with these factors in a
strategic manner, with individualized behaviour
change approaches.
The literature shows that information, education
and reinforcement can all contribute to effective
change, but these need to be delivered in targeted
and coordinated ways, based on the individual.46,47
Care needs to be taken in utilizing social support
through fear tactics, for example, by emphasizing
catastrophic consequences of inadequate dietary
compliance. There is often miniscule benefit and
occasional backfires for the patient, resulting in
excess fault-finding and nagging.15,4850
Importantly for adherence and review behaviours,
consumers overwhelmingly agreed that they have
enough assistance to remember to take, and feel
confident in managing, their medicines. However,
this significantly declines for the less experienced
group (see Results). Interestingly, provider agree-
ment with these items is lower in all cases.
Almost all consumers agree that they continue
to take their medicines when asymptomatic, and
Journal of Human Hypertension
 PDS to investigate consumer views
AH Wade et al
404
three-quarters of the providers agree that most
consumers do so. This is reassuring as this has been
identified as one of the main reasons for stopping
therapy. However, this is a very different finding to
that reported in the literature. For example, one
study found that almost 40% of all patients who had
dropped out of therapy did so because they felt
good without using antihypertensive medications.41
Several studies reviewed by Garfield and Caro51
demonstrated that the asymptomatic nature of
hypertension is still one of the most significant
causes of noncompliance. A possible explanation
for the consumer results is the sample bias towards
long-term medicine users recruited though pharma-
cies. However, the provider result suggests either a
very different adherence pattern in the community,
or a low understanding of how the asymptomatic
nature of hypertension influences adherence.
Consumers and providers disagree that consumers
are confident in knowing what to do if they miss a
hypertension medicine dose, with three-quarters of
consumers saying they are confident and only 10%
of providers agreeing. Almost 20% of this ex-
perienced sample of consumers say they do not
know what to do if they miss a doseFa potential
problem in the trend to single daily dose regimens,
and a demonstrated need for better medicines
information.
Over 30% of consumers agree that medicine cost
is a problem in continuing therapy; a similar
number of providers agree. This is a concern as this
could be another reason for stopping therapy.
Previous research has found that 12% of people
discontinued antihypertensive medications because
of cost, and another group found this figure to be
2%.41,42 Again, this needs further investigation in a
group of patients commencing antihypertensive
therapy.
Consumers do not agree that they are sometimes
influenced by the experiences of friends or family to
discontinue their medicines. They are very clear
about this, and this is significantly different from the
view of the health providers, who agree that
consumers are influenced by friends/family experi-
ences and stop taking their medicines. This was the
item with which consumers agreed least and may
again reflect aspects of sample bias toward experi-
enced, adherent medicine users. It may be that for
these consumers their family and friends are
supportive of therapy, and this social support would
be consistent with the overall reported adherence of
the group.
Conclusions
In this PDS, a questionnaire was successfully
developed to compare consumer attitudes and
knowledge about hypertension to those of health
providers. The survey was developed from focus
group information as well as from data in the
Journal of Human Hypertension
literature. The results from administration of the
survey revealed significant differences in percep-
tions between experienced hypertensive consumers
and health care providers (doctors, pharmacists and
nurses). Interventions need to be developed that are
based on identified consumer opinions and issues,
together with the different perceptions of health care
providers.
Acknowledgement
We thank the consumers and health professionals
who participated in the Advisory Panel and con-
tributed to the Focus Groups. The financial assis-
tance of a grant (AUD$ 30,000) from Queensland
Health (Public Health Services) for this Quality Use
of Medicines project is also appreciated.
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