"I have to live like I'm old." Young adults' perspectives on managing hypertension: A multi-center qualitative study

Abstract

Background:
In the U.S., young adults (18-39 year-olds) have the lowest hypertension control rates among hypertensive adults. Understanding young adults' unique perceptions about hypertension and perceived barriers to hypertension control is critical to develop effective interventions for this population. This multi-center study explored young adults': 1) emotions and reactions after a hypertension diagnosis, 2) attitudes about managing hypertension (lifestyle changes, follow-up visits, antihypertensive medication use), 3) opinions about their healthcare system's hypertension education materials, and 4) opinions about using social media to manage hypertension.

Methods:
Young adults (18-39 year-olds) with a diagnosis of hypertension and regular primary care access were recruited by the Wisconsin Research and Education Network (WREN). Two focus groups (one per age range: 18-29 years, 30-39 years) were conducted in three Midwestern Family Medicine Clinics (academic, rural, and urban). Conventional content analysis was performed.

Results:
Thirty-eight young adults (mean: 26.7 [9.6] years old, 34 % male, 45 % Black, 42 % with ≥1 year of college) identified barriers to managing hypertension. Emergent themes overlapped across age groups and geographic regions. Most respondents were surprised and angry about a hypertension diagnosis; they expected to develop hypertension, but at a much older age. A hypertension diagnosis negatively altered their "young" self-identity; suggested behavior changes and antihypertensive medications made them feel "older" than their peers. Young adults missed blood pressure follow-up visits due to co-payments, transportation barriers, and longer than desired wait times for brief visits. Contrary to our hypothesis, most young adults disliked social media or text messaging to support self-management; they were most concerned that their peers would see the hypertension communication. Current hypertension education materials were described as not addressing young adults' health questions and are often discarded before leaving the clinic.

Conclusions:
Targeting interventions to young adults' unique needs is necessary to improve hypertension control and cardiovascular preventive healthcare delivery.

Full text

R E S E A R C H A R T I C L E Open Access
“I have to live like I’m old.”Young adults’
perspectives on managing hypertension:
a multi-center qualitative study
Heather M. Johnson
1,2,6*
, Ryan C. Warner
3
, Jamie N. LaMantia
1,2
and Barbara J. Bowers
4,5
Abstract
Background: In the U.S., young adults (18–39 year-olds) have the lowest hypertension control rates among
hypertensive adults. Understanding young adults’unique perceptions about hypertension and perceived barriers
to hypertension control is critical to develop effective interventions for this population. This multi-center study
explored young adults’: 1) emotions and reactions after a hypertension diagnosis, 2) attitudes about managing
hypertension (lifestyle changes, follow-up visits, antihypertensive medication use), 3) opinions about their healthcare
system’s hypertension education materials, and 4) opinions about using social media to manage hypertension.
Methods: Young adults (18–39 year-olds) with a diagnosis of hypertension and regular primary care access were
recruited by the Wisconsin Research and Education Network (WREN). Two focus groups (one per age range:
18–29 years, 30–39 years) were conducted in three Midwestern Family Medicine Clinics (academic, rural, and urban).
Conventional content analysis was performed.
Results: Thirty-eight young adults (mean: 26.7 [9.6] years old, 34 % male, 45 % Black, 42 % with ≥1 year of college)
identified barriers to managing hypertension. Emergent themes overlapped across age groups and geographic
regions. Most respondents were surprised and angry about a hypertension diagnosis; they expected to develop
hypertension, but at a much older age. A hypertension diagnosis negatively altered their “young”self-identity;
suggested behavior changes and antihypertensive medications made them feel “older”than their peers. Young
adults missed blood pressure follow-up visits due to co-payments, transportation barriers, and longer than desired
wait times for brief visits. Contrary to our hypothesis, most young adults disliked social media or text messaging to
support self-management; they were most concerned that their peers would see the hypertension communication.
Current hypertension education materials were described as not addressing young adults’health questions and are
often discarded before leaving the clinic.
Conclusions: Targeting interventions to young adults’unique needs is necessary to improve hypertension control
and cardiovascular preventive healthcare delivery.
Keywords: Qualitative research, Hypertension, Ambulatory care, Health behavior, Young adults, Primary healthcare
* Correspondence: hm2@medicine.wisc.edu
1
Department of Medicine, School of Medicine and Public Health, University
of Wisconsin, H4/512 CSC, MC 3248, 600 Highland Avenue, Madison, WI
53792, USA
2
Health Innovation Program, University of Wisconsin School of Medicine and
Public Health, 800 University Bay Drive, Suite 210, Box 9445, Madison, WI
53705, USA
Full list of author information is available at the end of the article
© 2016 Johnson et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Johnson et al. BMC Family Practice (2016) 17:31
DOI 10.1186/s12875-016-0428-9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

Background
Uncontrolled hypertension in young adults (18–39
year-olds) is an enormous public health burden [1, 2].
In the U.S., approximately 1 in 5 young men and 1
in 6 young women have hypertension [3–6], increas-
ing their risk of future heart failure, stroke, and
chronic kidney disease [3, 7–10]. Given their longer
exposure to high blood pressures, young adults with
hypertension have a higher lifetime risk for cardiovas-
cular disease [10–16].
Multiple prior studies have assessed barriers to hyper-
tension control [17–20], highlighting patient, provider,
and healthcare system factors [21–23]. Our previous re-
search demonstrated important provider barriers in the
management of young adults with incident (new) hyper-
tension, including low rates of documented lifestyle
counseling [24] and significant delays prescribing initial
antihypertensive medication [25]. However, to identify
barriers to hypertension control specific to young adults
and develop effective interventions, we need insight
from young adults about their experiences. Prior cross-
cultural qualitative research by Morgan and Watkins
focused on barriers to hypertension control of 35–55
year-olds and primarily on antihypertensive therapy
[26]. However, the National Health and Nutrition
Examination Survey (NHANES) demonstrated that
18–39 year-olds have the lowest hypertension control
rates. Only 35 % of young adults with hypertension in
the U.S. have achieved hypertension control (blood
pressure <140/90 mmHg) [27, 28] compared to
middle-aged (40–59 year-olds; 58 %) and older adults
(≥60 year-olds; 54 %) [3]. In addition, a trial of lifestyle
modifications is commonly the initial hypertension
treatment step, rather than antihypertensive medica-
tion, among young adults [25]. An analysis by Savoca,
et al. among African-American young adults demon-
strated limited knowledge on risks of developing
hypertension, and highlighted the need for intensive
young adult education interventions [29]. Additionally,
an extensive multi-ethnic systematic review of hyper-
tension qualitative studies from 16 countries focused
on hypertension treatment adherence [30]. Across
ethnicities, patients reported disliking hypertension
treatment, intentionally stopping treatment, and iden-
tified barriers to hypertension treatment (finance, time,
memory) [30]. However, the authors concluded that to
improve hypertension interventions, a better under-
standing of patients’experiences is needed. Therefore,
we conducted a qualitative study of young adults with
hypertension, across multiple Midwest healthcare
systems, to assess their perspective of barriers to
hypertension treatment and control. In a separate
manuscript, we analyzed qualitative data from primary
care providers.
Methods
Young adult focus groups
This study was approved by the University of
Wisconsin-Madison Health Sciences Institutional Re-
view Board. Focus groups of young adults with hyper-
tension were conducted at three Family Medicine clinics
within three different counties in Wisconsin, including
an academic community clinic, urban clinic, and rural
clinic. Focus groups were the selected methodology,
rather than individual interviews, in order to maximize
interactions between the young adult participants. Our
goal was to have young adults discuss experiences and
barriers to managing hypertension, and brainstorm pos-
sible solutions to improve hypertension control and
healthcare delivery for their age group. Interactions be-
tween participants are a unique feature of focus groups,
and applicable to this young adult population. Focus
groups promote exploration and brainstorming to dis-
cuss possible solutions. Responses from the focus groups
are being used to inform the development of a young
adult hypertension intervention.
Patients were recruited by the Wisconsin Research &
Education Network (WREN), a statewide practice-based
research network. Eligible patients were identified by
electronic health record data, and were then mailed re-
search study letters, on behalf of their clinic and primary
providers, inviting them to participate in the study.
Study recruitment flyers were also placed in the waiting
areas of the selected Family Medicine Clinics, allowing
patients to directly contact the research office if inter-
ested. Inclusion criteria included young adults, 18–39
years old, with an ambulatory ICD-9 hypertension diag-
nosis code [31] within the past 12 months of the study
invitation, and awareness of their hypertension diagnosis
(determined through telephone pre-screening). One
focus group for each age group (18–29 year-olds and
30–39 year-olds) was conducted at each geographic site,
for a total of 2 focus groups at each site. The recruit-
ment goal was 6 individuals in each focus group to pro-
vide adequate variability in experiences to inform the
development of a targeted young adult hypertension
intervention [32–34]. Qualitative methods seek variation
in perspectives and experiences to promote the emer-
gence of themes [32, 35].
A semi-structured interview guide was developed
based on previous literature on barriers to hypertension
control [18, 19, 36, 37] and managing cardiovascular risk
factors among adolescents/young adults (e.g., diabetes
[38, 39], hypertension [25, 40, 41]). The focus group
questions explored young adults’: 1) emotions and reac-
tions after a hypertension diagnosis, 2) attitudes about
managing hypertension (lifestyle changes, follow-up
visits, antihypertensive medication use), 3) opinions
about their healthcare system’s hypertension education
Johnson et al. BMC Family Practice (2016) 17:31 Page 2 of 9
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materials, and 4) opinions about using social media
(e.g., Facebook, Twitter, etc.) to manage hypertension. The
development of these questions were guided by our prior
research [24, 25] and input from healthcare system hyper-
tension quality improvement committees. The focus group
questions were reviewed, edited, and approved by the
Community Advisors on Research Design and Strategies
(CARDS
®
), a patient research advisory group coordinated
by the Wisconsin Network for Research Support.
All focus groups were moderated, digitally audio re-
corded, and transcribed verbatim by the University of
Wisconsin (UW) Survey Center. Prior to starting the
focus group, all participants reviewed an IRB-approved
summary sheet about the research study and provided
verbal consent; written consent (signature) was waived by
the University of Wisconsin-Madison Health Sciences In-
stitutional Review Board. Each focus group was 90 min in
length. Immediately after the focus group, each participant
completed a written, anonymous, 5-question demographic
survey (self-reported age, gender, race, ethnicity, and high-
est level of education achieved) and received a $75 cash
honorarium. All transcriptions were reviewed for accuracy
by the research staff (RW). All data was collected between
June 2014 and December 2014.
Data analysis
Following each focus group, data were analyzed by the
research team, and subsequent interview questions were
developed. Conventional content analysis was used to
code the interview transcripts [42]. Initially, transcripts
were read to achieve immersion and context. All codes
were then determined from the transcribed text, rather
than being generated a priori. Two investigators, with-
out prior clinical hypertension experience (RW and JL)
and from different disciplines (Rehabilitation Psychology;
Education), independently coded all transcripts. Investiga-
tors without clinical hypertension knowledge were selected
to avoid interpretation bias of patients’experiences [43].
Emergent codes were generated in initial readings of the
transcripts by each code. The coders then met bimonthly
to review codes, adjudicate differences by consensus, and
refine codes. When the final coding scheme was deter-
mined, following completion of all interviews, one coder
(JL) recoded all transcripts using the final coding scheme.
Data were managed by the coders with Excel. Methodo-
logical strategies undertaken to maintain rigor included the
use of a multidisciplinary research team, member checking
[44], and maintenance of memos [45].
Results
Table 1 summarizes the demographics of each focus
group by age group and Family Medicine clinic. All 38
young adults participated in focus groups and completed
demographic questionnaires (mean: 26.7 [9.6] years old,
34 % male, 45 % Black, 42 % with ≥1 year of college).
Emotions and reactions after an initial hypertension
diagnosis
The clinical term “high blood pressure”, instead of
“hypertension”, was used during the focus groups.
Table 1 Baseline demographics of young adult focus groups respondents (18–39 years old)
All Respondents
(n= 38)
Academic clinic Rural clinic Urban clinic
18–29 year-
olds (n=6)
30–39 year-
olds (n=6)
18–29 year-
olds (n=6)
30–39 year-
olds (n=6)
18–29 year-
olds (n=7)
30–39 year-
olds (n=7)
Age, years, m (SD) 26.7 (9.6) 26.2 (1.8) 34.2 (3.1) 23.3 (3.2) 34.5 (2.6) 25.3 (2.7) 34.1 (1.7)
Male gender, n (%) 13 (34) 3 (50) 0 (0) 4 (67) 3 (50) 1 (14) 2 (29)
Race, n (%)
White 20 (53) 3 (50) 4 (67) 6 (100) 6 (100) 1 (14) 0 (0)
Black 18 (47) 3 (50) 2 (33) 0 (0) 0 (0) 6 (86) 7 (100)
Other (including mixed race) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Ethnicity, n (%)
Hispanic or Latino 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Highest Level of Education, n (%)
≤8th Grade 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Some high school 3 (7.9) 0 (0) 0 (0) 1 (17) 0 (0) 1 (14) 1 (14)
Completed High School or GED equivalent
a
17 (45) 3 (50) 3 (50) 2 (33) 3 (50) 3 (43) 3 (43)
Some college or vocational school 9 (24) 1 (17) 1 (17) 1 (17) 1 (17) 3 (43) 2 (29)
Completed college or vocational school 7 (18) 1 (17) 2 (33) 1 (17) 2 (33) 0 (0) 1 (14)
Graduate or Professional School 2 (5.3) 1 (17) 0 (0) 1 (17) 0 (0) 0 (0) 0 (0)
a
GED General Education Diploma
Johnson et al. BMC Family Practice (2016) 17:31 Page 3 of 9
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Previous research by Morgan and Watkins [26] demon-
strated that many young adults do not understand the
meaning of “hypertension”and/or cannot equate it to
“high blood pressure”.
Young adults with hypertension were asked to think
about when they were first diagnosed with “high blood
pressure”(Table 2). All of the respondents, except one
(37/38), provided at least one emotion; the most com-
mon emotions (30/37; 81 %) were “surprised”,“scared”,
and “angry”. The one exception was a respondent that
was not aware that hypertension (high blood pressure) is
a chronic disease diagnosis.
6005: “Scared. Because I heard so many things about
it. If you don’t take care of it, you can really be
messed up on it, like a stroke and heart attacks and
stuff like that.”
Some young adults (7/38, 18 %) described an additional
emotion of self-blame after their initial hypertension
diagnosis; these 7 respondents identified a hyperten-
sion diagnosis as being their fault and a reflection of
poor choices. However, 26 % (10/38) were concerned
about negative stigma associated with hypertension;
these 10 respondents were concerned about experiencing
“shame”from their peers without hypertension or being
stigmatized for being unhealthy. Although additional
individuals did not voice similar responses, audiotapes
captured significant group response of “yeah”or “Iknow”
after quotes like the one below.
5006: “I think that high blood pressure is one of
those conditions that is generally seen as being one’s
own fault for getting it. So, if you have cancer,
people are going to feel bad for you, you’ll get
support. But high blood pressure, I think a lot of
people have misconceptions about it and they
wouldn’t feel bad for you or give you support. They
might, probably not publicly but privately, say ‘They
should just eat better or lose some weight, exercise.
It’s their own fault.’”
Twenty-nine of the 38 young adult respondents (76 %)
shared that they expected to develop hypertension dur-
ing their lifetime. Among those 29 young adults, none of
the respondents expected to develop hypertension at a
young age. However, 20 of the 29 (69 %) had prior expe-
rience(s) with family members managing hypertension
as a chronic disease and also experiencing complications
of hypertension (e.g., stroke, heart attack, death).
1005: “I didn't expect it that early but I knew that at
some point I would probably be diagnosed because
it runs on both sides of my family.”
Young adults’knowledge about hypertension and future
health risks
Overall, we noticed dichotomous responses to questions
related to hypertension knowledge and the delivery of
hypertension education (diagnosis, treatment, chronic
management, and complications). For hypertension know-
ledge, all (100 %) of the young adults verbally gave at least
one health complication associated with hypertension
(e.g., heart attack, stroke, death). This likely reflects the
prevalence of a family history of hypertension and its
complications discussed above. However, across both age
ranges of focus groups, none of the young adults were
aware of chronic kidney disease as a complication of
hypertension, despite the increased prevalence of chronic
kidney disease, even among young adults in the U.S. [46].
Table 2 Example focus group questions
Emotions/Reactions After Initial Hypertension Diagnosis Thinking back to when you first found out you have high blood pressure:
a) What were some of your first thoughts or questions?
b) What emotions did you feel?
Attitudes About Managing Hypertension a) If your doctor recommended that you exercise to lower your blood pressure,
what might keep you from exercising?
b) If your doctor recommended that you eat healthier to lower your blood pressure,
what might keep you from eating healthier?
c) If your doctor recommended medication for your blood pressure, what would
keep you from taking the medication?
d) What would you do if you didn’t like your doctor’s plan or recommendation
for treating your blood pressure?
Hypertension Education Materials a) How many of you have received any information, such as handouts or printouts, from
your clinic about exercise or healthy foods to help you lower your blood pressure?
b) What might keep you from using the information you received from your clinic?
Social Media to Manage Hypertension Would you use social media such as Facebook or Twitter to get support and tips
about living with high blood pressure?
Johnson et al. BMC Family Practice (2016) 17:31 Page 4 of 9
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Less than half of the respondents (n= 16, 42 %) re-
ported receiving hypertension education (e.g., counsel-
ing, written materials, etc.) from their clinic and/or
healthcare team. Among the respondents that reported
receiving handouts/pamphlets from their clinic, across
clinics and geographic sites, >50 % reported discarding
the materials prior to leaving the clinic. The most com-
mon reasons for discarding materials included: 1) lack of
self-efficacy (not believing they were able to accomplish
the recommended behavior changes), 2) information
redundancy, and 3) the information did not address
their specific questions.
2004: “…so they gave me a whole bunch of pamphlets.
I left them on the side of like the waiting chair. You
know they just try to tell you you’re just going to have
to do this the rest of your life pretty much, unless you
drastically lose 100 lb and stop smoking a pack of
cigarettes and just right now I can’tdothat.”
Twenty-one respondents (55 %) shared that their pri-
mary hypertension knowledge source was family and/or
their own internet site search. Respondents most fre-
quently inquired about blood pressure medication
with family members; they were felt to be more of a
trustworthy source than their healthcare team. In addition,
young adults believed that they were more likely to toler-
ate a prescription medication if their family member was
also on the same medication. Other respondents denied
obtaining any information from their healthcare team or
independently.
2006: “Iwasn’t given any sort of information about
it really. She eventually diagnosed me and gave me
like half of a pill to take. I wasn’t like you know told
to make any particular like diet changes or anything
like that. It was just like oh, you have this, ok.”
Young adults’attitudes and barriers to hypertension
lifestyle modifications
Many young adults felt that guideline-recommended
lifestyle modifications to manage hypertension equated
to them no longer enjoying life and required them to
live as if they were older than their biological age. All
(100 %) of the young adults that were knowledgeable about
lower sodium to treat hypertension felt they were unable
to achieve the lower sodium goal (1500–2000 mg/day).
Across all audiotapes, lower sodium (i.e., lower salt) was
interpreted as lack of enjoyment with food.
6003: “I can’t eat no more, like he was saying, tacos,
cheese steaks…. You know what I’m talking about?
Like I’m only 34 but I got to live like I’m 67 and
some s***. I don’t like that.”
Approximately 30 % (n= 12) felt that achieving recom-
mended physical activity was “easier”than achieving
dietary health behavior goals. For the majority of the 12
respondents, reasons included physical activity already
being integrated into their life (e.g., work, children, family).
For the remaining, they were more confident about start-
ing a new physical activity health behavior because it is a
more independent change and not influenced as much by
social circumstances and peer influences. In contrast, hav-
ing a healthier plate/meal option may promote inquiries by
family and friends.
All of the respondents across both ages of focus groups
commented on the cost of healthy food options compared
to higher sodium and/or higher fat food options when
grocery shopping. Their responses highlighted that they
had personally investigated healthier food options because
they were able to give comparisons for specific products
(e.g., chicken breast vs. legs; fresh vs. canned vegetables).
In addition, one respondent commented on how quickly
fresh vegetables spoil prior to consumption and the effect
on her food budget.
6002: “I want to go buy us some meats and stuff and
Iain’t going to be thinking about no vegetables,
because vegetables spoil fast. I open up the lettuce, I
have to use that lettuce within 3 days. So my lettuce
done went to waste and I done spent two, three
dollars on some lettuce.”
One young male discussed difficulty selecting fast-food
options when traveling for work. Not only did he have
difficulty selecting a healthier option, but he shared ex-
periences about fast food employees’negative reactions
when he ordered a healthy item (e.g., salad). Throughout
our focus groups, our respondents had a recurring
theme of societal and peer responses when a healthy
choice does not fit the perceived “young adult”norm.
1005: “There’s no healthy food options for quick food
when you’re traveling. It’slikeatburgerjointspeople
will look at you cross eyed if you want to order a
salad. ‘Are you really going to trust our salad?’”
Time was a much more common barrier in our 30–39
year-old focus groups compared to our 18–29 year-old
groups. All of the women in the older group discussed
trying to balance being a new mom with other responsi-
bilities, with the most common being work and spending
time with their significant other. Two mothers also dis-
cussed trying to balance a full-time job with school part-
time. The combined responsibilities made it difficult for
young adults to make time for healthy behavior changes
(e.g., meal planning, preparing different meals, home
cooked meals, exercising).
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1002: “Being a new mom too. It’s tough to balance
work and spending time with the baby and spending
time with my spouse. It’s hard to balance all that,
and then rationalize, like well I could go, you know,
by myself and workout but I haven’t seen anybody
all day, so I’d rather just play on the floor here.”
Cost-benefit analysis of adhering to blood pressure
medication
Multiple themes emerged about young adults weighing
the risks and benefits of high blood pressure medication
adherence. The most common recurring theme 31 %
(12/38) was that hypertension is commonly asymptomatic.
There are usually no negative health repercussions on a
day-to-day basis for skipping blood pressure medication.
Of these 12 respondents, 6 shared that the complications
of hypertension are usually long-term, which promotes a
young adult population to take more of a risk.
5006: “I think, specifically with things like high blood
pressure, you can’t tell if you missed a pill. It’s not like,
‘l missed my pill today but oh, this is going to happen.’
It’s such a long-term thing…don’t take it that seriously
if I miss one day. It’s a long-term thing. But then, one
day. One day. A week. It all adds up.”
Overall, approximately 55 % (21/38) of young adults
were prescribed antihypertensive medication(s). The ma-
jority of these young adults felt that medication cost was
no longer a barrier to blood pressure medication, with
the primary reason being the United States’Affordable
Care Act [47, 48]. Over 30 % of the 21 young adults
shared stories of financial barriers prior to obtaining pre-
scription insurance. Remembering to take medication(s)
and side effects were the most common active barriers
across all ages of our focus groups. Although our modera-
tors did not ask, some young adults volunteered methods
that they found effective to remember medications
(e.g., take when brushing teeth, put next to morning
coffee, set alarm, etc.) within our interactive focus groups.
Medication side effects was a concern among all 21
young adults prescribed blood pressure medication. Re-
spondents shared concerns about long-term side effects.
Also, since many had experience with hypertension
through other family members, there was concern about
being prescribed medication that another family member
may not have tolerated. Lastly, approximately 5 patients
(13 %) did not believe they needed medication and
instead felt that stress management would be the most
effective treatment. All of the themes about medication
non-adherence merged back to the cost-benefit analysis.
Young adult respondents shared that many times patients
will gamble when immediate negative repercussions are
not expected.
6001: “I think most people just gamble. You know? I
mean, when I say a gamble, is that you figure ain’t
nothing going to happen to you until it happens.
And once it happens to you, you say ‘I’m gonna, I
wish I would of’and sometimes it’s too late, because
you dead.”
Social media use among young adults for hypertension
self-management
The latter part of our focus group addressed possible so-
cial media solutions to improve hypertension education,
self-management, and control among young adults. Con-
trary to our hypothesis, the majority of respondents dis-
liked any social media (e.g., Facebook, Twitter, etc.) or
text messaging communication for hypertension self-
management. Young adults could not recommend a pre-
ferred alternative social media platform. They were con-
cerned about peers finding out about their hypertension
diagnosis. Some young adults felt that it would be an in-
vasion of their personal space or result in harassment. In
addition, for many respondents, social media was a place
to avoid life stressors and they did not want their health-
care issues overlapping with recreational activities. Both
ages preferred readings directly from internet websites –
which allowed privacy, portability, and flexibility with
their schedules.
Discussion
This is the first multi-center qualitative study to assess
barriers to hypertension control among U.S. young
adults (18–39 year-olds) with regular primary care access.
Our research adds to current knowledge gaps by addressing
both behavior modification and pharmacologic treatment
for hypertension. In contrast to prior hypertension qualita-
tive studies in other age groups, our young adult focus
group respondents highlighted a change in self-identity
upon receiving a diagnosis of hypertension. This chronic
disease diagnosis and the recommended lifestyle modifica-
tions cause many young adults to feel “older”than their
biological age. Our focus groups respondents also shared
ongoing adverse psychological effects of having a hyperten-
sion diagnosis, including self-blame and shame. These find-
ings help fill an important research gap in understanding
young adults’experiences as identified by Marshall, et al
[30]. We have highlighted the need for healthcare teams to
understand the negative emotional and mental health
effects a hypertension diagnosis has on young adults
[49, 50]. Similar results have been obtained for other
chronic diseases (e.g., asthma [50], diabetes); however,
additional research and resources are needed to address
this critical barrier, specifically among young adults.
Another important emergent theme was the cost-
benefit analysis performed by young adults when deter-
mining the necessity of a recommended blood pressure
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treatment plan (e.g., lifestyle modifications, medication).
This implicit cost-benefit analysis has been demon-
strated among other chronic diseases and has been
shown to be associated with medication adherence [51].
We have demonstrated that this cost-benefit analysis is
an important barrier to hypertension control in young
adults. Our U.S. data supports prior qualitative studies,
which demonstrated that medication non-adherence is
influenced by concerns about long-term harmful effects
[52], and difficulty balancing other life responsibilities
with finding time to take medication and follow-up with
their healthcare team [30]. These findings also support
prior research demonstrating a significant decrease in
clinic visit attendance during transition to young adulthood
[53] and young adults’goal of having treatment plans com-
ply with their lifestyle, not with their doctor’swishes[54].
We also demonstrated that young adults perform a
cost-benefit analysis when selecting healthy food op-
tions. Young adults are a unique population, usually with
newer jobs and, for many, new budgeting responsibil-
ities. Their observation of the higher cost of many
healthy foods in the U.S. compared to higher sodium
foods is a critical barrier to health behavior adoption.
These findings highlight the need for ongoing policy
changes. Finally, young adults’concerns about experien-
cing negative social stigma based upon their behavior
choices, especially among males, results in a cost-benefit
analysis for behavior modification (e.g., ordering high so-
dium foods, rather than a salad). Unfortunately, young
adults shared that negative stigma in response to behavior
change expands beyond their daily activities in society and
also effects their behaviors and choices at home among
family. Effective, team-based young adult-healthcare team
communication is needed to discuss patients’beliefs
and concerns, and jointly develop a treatment plan
that individually addresses other competing demands
in young adulthood.
Our research also underscores the need for hyperten-
sion education materials tailored specifically to young
adults’questions and concerns. Similar to prior findings
by other researchers [29, 52], our young adult respon-
dents were aware of the importance of controlling their
blood pressure, with many having unfortunate cardiovas-
cular events in their family. However, additional research
is needed to improve the delivery of hypertension educa-
tion materials to young adults to promote necessary be-
havioral changes to achieve and maintain hypertension
control. Many young adults reported discarding hyper-
tension education materials prior to leaving the clinic.
Since providers use printed education materials to sup-
plement limited counseling time, discarded materials re-
sult in young adults receiving suboptimal education
about hypertension as a diagnosis, its contributors, and
ongoing chronic disease management. We also identified
that overall, current hypertension materials are not
beneficial in helping young adults initiate or maintain
lifestyle modifications. Broad healthcare system changes
are needed to improve the delivery of tailored hyperten-
sion education materials and integrate effective resources
to support the maintenance of lifestyle modifications. Ac-
cording to previous studies, behavior change is more likely
to be maintained when lifestyle changes are integrated
into one’s identity and are internally motivated [55, 56],
key factors lacking in the current delivery of hypertension
education to young adults. Some of our identified hyper-
tension control barriers (e.g., co-payments, medication
side effects) overlapped with previous studies in other age
groups [19, 30, 36], but demonstrate ongoing needs to im-
prove hypertension control across populations.
In contrast to our hypothesis, young adults did not like
social media or text messaging to assist with hypertension
chronic disease management. These mobile health options
were considered an intrusion on their recreational activ-
ities and increased their concerns of peers being aware of
their diagnosis. Social networks using group interactions
in middle-aged and older adults have been beneficial in
managing hypertension [57]. However, further research is
needed to understand the support resources that meet the
needs and protect the self-identity of young adults.
In summary, our findings expand prior research in
hypertension treatment adherence by studying both
medication and lifestyle modification adherence. Prior
frameworks focused on adherence [58, 59] and often ad-
dressed patients’health beliefs about an illness. However,
we demonstrated that among 18–39 year-olds, patients’
belief in their own self-identity as a “young”adult is
negatively altered. Additionally, solely focusing on social
support outside of the clinic may not be a successful
intervention, since many young adults often consider
hypertension a “private”issue among their peers and even
among family members without hypertension. These find-
ings highlight the need for expanded team-based care to
increase patient-provider communication and to increase
perceived autonomy support and self-management re-
sources for young adults with hypertension [60, 61].
Strengths of this qualitative analysis include a multisite
design of academic, rural, and urban healthcare systems,
which represents a diverse sample of young adults with
hypertension. Although young adults were from the
Midwestern U.S., clinics across diverse geographic regions
were represented. Overall, 45 % of the focus group re-
spondents were Black; however, there was a lack of Latino
representation. Therefore, this data may not encompass
some barriers encountered in managing hypertension
across other minority races/ethnicities. Our focus group
design may not have allowed respondents to provide in-
depth answers to all of their individual experiences with
hypertension [62]. Yet, our goal was to foster interactions
Johnson et al. BMC Family Practice (2016) 17:31 Page 7 of 9
Content courtesy of Springer Nature, terms of use apply. Rights reserved.

between young adults to move the discussion beyond
individual experiences and brainstorm about possible
interventions for young adults. There is always a concern
that some participants do not actively participate in group
discussions. However, our trained moderators from the
University of Wisconsin Survey Center provided an envir-
onment for each individual to participate with every ques-
tion, as reviewed on the audiotape files, and to reduce the
likelihood of solely dominant personalities responding.
Additionally, there is a concern that young adults may be
uneasy discussing a chronic medical issue in public. As ex-
pected, almost 30 % of the respondents shared that a diag-
nosis of hypertension is a private issue when around peers
or family without hypertension. To address this concern a
priori, we ensured that each focus group was held within
the patients’normal primary care clinic in a closed confer-
ence room. Finally, all young adults in this study had regu-
lar primary care access (i.e., a medical home) and the
identified barriers in this manuscript may have a different
priority and/or may not reflect young adults without pri-
mary care access. However, these results will help inform
the adaptation of effective hypertension interventions to
young adult populations and likely improve the low and
stagnant hypertension control rates in this population.
Conclusions
This qualitative analysis identifies important intervention
target areas for young adults with hypertension. Develop-
ing interventions to address young adults’unique needs
are important next steps to improve hypertension control
and cardiovascular preventive healthcare delivery.
Abbreviations
CARDS: community advisors on research design and strategies;
IRB: institutional review board; UW: University of Wisconsin; WREN: Wisconsin
research and education network.
Competing interests
HJ has clinical appointments with the academic group practice that has a
financial interest in delivering care to the general population from which study
subjects were drawn. For the remaining authors, no conflicts were declared.
Authors’contributions
HJ conceptualized the project, analyzed all data, wrote the manuscript, and
critically edited the manuscript. RW and JL analyzed all data and critically
edited the manuscript. BB contributed to conceptualization of the project,
analyzed all data, and critically edited the manuscript. All authors read and
approved the final manuscript.
Authors’information
HJ is a clinician-researcher in health services research. During this project, RW
was a project assistant at the Health Innovation Program, a multidisciplinary
health services research center. JL is a research specialist at the Health
Innovation Program. BB is a Professor of Nursing.
Acknowledgments
The authors would like to acknowledge Colleen Brown, Health Innovation
Program, for assistance with preparing the manuscript.
HJ is supported by the National Heart, Lung, and Blood Institute of the NIH
(K23HL112907), and also by the University of Wisconsin (UW) Centennial
Scholars Program of the UW School of Medicine and Public Health. This
content is solely the responsibility of the authors and does not necessarily
represent the official views of the NIH. Additional funding for this project
was provided by the UW Health Innovation Program and the UW School of
Medicine and Public Health from The Wisconsin Partnership Program.
Parts of this manuscript were presented as an abstract at the American Heart
Association 2015 Scientific Sessions (November 7–11, 2015; Orlando, FL).
Author details
1
Department of Medicine, School of Medicine and Public Health, University
of Wisconsin, H4/512 CSC, MC 3248, 600 Highland Avenue, Madison, WI
53792, USA.
2
Health Innovation Program, University of Wisconsin School of
Medicine and Public Health, 800 University Bay Drive, Suite 210, Box 9445,
Madison, WI 53705, USA.
3
Department of Counselor Education and
Counseling Psychology, Marquette University, Schroeder Health & Education
Complex, 561 N 15th Street, Room 151A, Milwaukee, WI 53233, USA.
4
Department of Research, School of Nursing, University of Wisconsin, 5130
Cooper Hall, Signe Skott, 701 Highland Avenue, Madison, WI 53705, USA.
5
Department of Academic & Student Services, School of Nursing, University
of Wisconsin, Cooper Hall, Suite 1100, 701 Highland Avenue, Madison, WI
53705, USA.
6
Division of Cardiovascular Medicine, University of
Wisconsin-Madison, School of Medicine and Public Health, UW Health
Advanced Hypertension Program, H4/512 CSC, MC 3248, 600 Highland
Avenue, Madison, WI 53792, USA.
Received: 29 December 2015 Accepted: 3 March 2016
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