Intern Alessandro Chincotta, MSc, conducted in-depth interviews with Holly Health users with hypertension as part of our government-funded UKRI Future Economy project. His aim? To capture users' firsthand experiences and challenges, providing insights to shape a service that truly supports their needs.
Introduction
Hypertension is a leading cause of premature death, accounting for approximately 8.5 million deaths globally each year (Zhou et al., 2021). The World Health Organisation (WHO, 2013), emphasises that self-management (defined as the ability of individuals to control their health conditions independently Grady & Gough, 2014), is essential in reducing this global health burden. However, despite its importance, many individuals struggle with self-management, often failing to adhere to prescribed medications and lifestyle changes (Natale et al., 2023). Educational interventions present a promising solution, as they have been found to improve hypertensive patients' self-efficacy, enhancing their ability to self-manage and control their blood pressure (BP; Foroumandi, Kheirouri, & Alizadeh, 2020).
In the context of BP self-management, the interaction between mental health and hypertension is critical. Storer et al. (2023) and Sundarrajan et al. (2022), revealed the prevalence of mental health in those with hypertension, finding that 43.6% of hypertensive patients experienced anxiety, and 53.4% suffered from depression. As evidenced in Busotti’s (2018) literature review, the prevalence of anxiety and depression can adversely affect an individual's ability to self-manage their BP, highlighting the need for holistic interventions that address both mental and physical health concerns. Innovative applications such as Holly Health offer an example of this holistic approach, by integrating evidence-based mental wellness tools with BP management resources, and educational intervention, providing a more comprehensive approach to health management than traditional BP-tracking apps.
In recent years, mobile health (mHealth) interventions have emerged as effective tools for enhancing BP self-management and increasing patient knowledge (Xu & Long, 2020; Gazit et al., 2021). These interventions provide educational content, as well as resources for health data tracking, and behaviour change support. Li et al.’s (2020) literature review demonstrated the effectiveness of mHealth tools for hypertensive patients, finding that these interventions led to improving self-management behaviours, and medication adherence. Specifically, it was found that mHealth tools that incorporated tailored messages, interactive communication, and multifaceted functions were most effective in promoting self-management behaviours and improving BP control. However, the success of mHealth tools is often hindered by usability challenges, inconsistent patient engagement, and insufficient user involvement in app development (Rowland et al., 2020). To tackle these challenges, studies, such as Saparamadu et al. (2021) emphasise the value of incorporating user feedback in developing mHealth interventions, enhancing functionality and engagement.
Therefore, this study aimed to explore the efficacy of the Holly Health app in supporting hypertension self-management, employing a user-centred approach to gain insights that may improve this mHealth intervention.
Method
Design
The present study employed a qualitative design to explore user experiences with the Holly Health app.
Participants
Participants were recruited through purposive sampling, targeting users with self-reported hypertension and comorbid anxiety and/or depression. The sample consisted of nine participants, with 66.7% (n = 6) identifying as female and 33.3% (n = 3) identifying as male. Participants were distributed across age groups as follows: 11.1% (n = 1) were aged 25–34 years, 11.1% (n = 1) were aged 45–54 years, 33.3% (n = 3) were aged 55–64 years, and 44.4% (n = 4) were aged 65–74 years.
Data Collection
Data was collected through semi-structured interviews conducted remotely via Zoom. The interviews followed an interview guide and lasted approximately 30 minutes. All interviews were audio recorded and transcribed with the participant’s consent. Data collection took place between 14th June 2024 and 3rd September 2024.
Data analysis
The interview data were analysed using thematic analysis, following Braun and Clarke’s (2006) framework.
Results
From the analysis five themes were identified: 1) User behaviours in BP tracking, 2) Positive aspects of BP tracking using mHealth, 3) Wider benefits of mHealth in BP management, 4) User suggestions for enhancing BP management, and 5) The interaction between mental health and hypertension.
1. User Behaviours in BP Tracking
Users demonstrated varying levels of engagement with BP tracking. While some were confident about monitoring their BP at home, others admitted to not checking it as regularly as they should.
“I do keep a check on it at home fairly regularly, yeah, just to make sure, you know, things are not getting out of hand.”
“I've got the monitor at home, and I don't take it as regularly as I should do. So, if there's an app or something to help me do that? That'd be brilliant.”
A notable number of users were unaware of the Holly Health BP tracking feature and expressed their desire for this feature to be more accessible. However, users expressed openness to tracking their BP using the Holly Health app.
"I need to have a look at this blood pressure thing… Once I find it, obviously I have looked through quite a wee bit of the app and use several sections. But it could be maybe if it was a wee bit easier to find."
Interviewer:
“So, were you aware that you can track and record your blood pressure in the app?”
User:
“No, I wasn't actually no.”
Interviewer:
“Is this something that you'd be willing to do or willing to try?”
User:
“Yeah, absolutely yes.”
2. Positive Aspects of BP Tracking Using mHealth
The BP tracking feature proved beneficial, with users appreciating the ease and convenience of digital recording over traditional paper-based methods.
“Being able to put online if it's much easier for me, and plus, that means if I did lose the paper, it would still be recorded in the app.”
The app's visual representation of health data was especially effective, offering users a clear and accessible view of their BP trends.
“You didn't have to go through pages of your different results, but at least with the chart, it can show you if whether it's increased or decreased on a weekly basis.”
Additionally, users found that having all of their BP-related data in one place was beneficial, enabling them to track their progress and motivate them to improve their BP and health behaviours.
“I personally am results driven, marks and so on. I didn't know that you could see charts and you know the numbers, that kind of thing. That might help me. I'll do that. Look into it again.”
3. Wider benefits of mHealth in BP management
Users valued the Holly Health app for the daily support and accountability it provided. The app’s goal-setting features were particularly appreciated as it provided a sense of achievement and motivation to achieve health goals.
"I think it's really cool. It's really good. Yeah, it's nice to have something sort of there that you can just check in with to help you. No, I think it's brilliant."
"I suppose it's a wee bit of I feel that there's a sense of achievement. I've achieved my goals and things I've set myself, you know."
Additionally, users found that completing daily tasks and goals led to small, incremental changes, which ultimately helped them to make a larger impact on their lives.
"That's the other thing about Holly health, instead of changing my life completely, to change it incrementally, bit by bit, that's helped."
4. User Suggestions for Enhancing BP Management
Users offered valuable insights to enhance the BP management feature. One suggestion was to include more granular data views, such as daily summaries, in addition to weekly trends.
“Being able to see the data, data daily, rather than weekly… So if I could have it day to day, then that would be good for me for recording purposes, especially when showing my diabetic nurse.”
Users also expressed interest in receiving automated feedback, to help them interpret their BP data in real-time. This feature would provide users with immediate feedback and tailored advice based on their BP readings.
“If it could tell me whether I'm in range or out of range or just so then that gives me more peace of mind, like, is my results a good result or a bad about me having to go to the nurse or just to tell me that themselves, if it had a feature like that.”
Medication tracking and reminders were also suggested as potential additions to improve the app's functionality.
“When the other thing, I suppose, is making sure you take your medication. So, so, like, you know the times that you supposed to take it… And then you click the reminder to go, yes, I've taken it. So that records and you know that you've taken it.”
Additionally, users expressed a desire for supplemental information related to their health, including dietary recommendations and condition-specific, advice.
“I think there should be if it was information around menopause, post-menopause, there's an argument we should all be taking HRT, and that might if I went on HRT, that could improve my blood pressure, etc.”
“Or yeah, so which one is a little bit more age, age-related. So, for example, for a woman over 50, it's maybe high, recommended to take more collagen, or if you do fasting, take more protein.”
Users also stated that this additional information would be most accessible through short videos, which could offer practical advice for managing their condition.
“I guess it was just like the video I think I mentioned before, to have more videos based around diabetes, maybe like a recipe video with like managing the condition, or just to add further support for people who have that condition.”
“Videos are something I prefer. I find with the video. It's visual, and you sit watch it and hear it, and it's quite easy. If it's something to read, might start reading something and then get halfway through it, and then I give up. It's like an effort to read, whereas videos are much, much easier.”
5. The interaction between mental health and hypertension
Many users discussed the connection between mental health and BP, suggesting that Holly Health could be enhanced with stress-relief techniques and mental health support to better assist with BP management.
“I think blood pressure is also connected about stress level, all of these kind of things, like the brain activities and switch off things which will help you to switch up can help with the reduce the stress. So that's of course, then it's a reduce your blood pressure as well.”
Common suggestions for supporting both mental health and BP management included gratitude journaling and meditation.
“I did it before, Holly health, gratitude you know, writing I actually isn't that's one of my acts that I do use, where I write down every day and a prompted kind of thing. And the act of putting writing it down makes it kind of concrete, you know.”
“Yeah, I mean, maybe I do like meditation, you know, I don't know if they do any meditation apps on there, you know, just to talk through, you down or whatever.”
Some users also mentioned activities that would encourage mental relaxation and stimulation.
“It doesn't include in the Holly health app, but when, when it's asking, for example, about brain activity, then I can connect it with, for example, playing like sudoku or something like crossword. Which one is helps to a little bit switched off, okay, but also keep your brain fresh.”
Conclusion
This research explored user behaviours and preferences for managing their blood pressure and mental health, as well as their experiences with the Holly Health app. Users valued the app’s BP tracking features but suggested improvements, such as more detailed data views and personalised feedback, demonstrating openness to using mHealth tools for BP management. The strong link highlighted by users between their mental and physical health stressed the need for mHealth applications that address both areas. Holly Health’s holistic approach spanning sleep, mental health, physical health and condition management, nutrition and exercise, shows promise in tackling these interconnected challenges rather than focusing on a single condition or challenge. Insights from this research will guide product enhancements, including new tailored coaching content and the development of a tutorial video to improve awareness of the app’s BP features and navigation. This research provides valuable user-driven insights that not only enhance the Holly Health app but also contribute to the broader understanding of integrated mHealth solutions for managing both physical and mental health challenges.
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