JMIR Publications

ABSTRACT

Background:

Self-measured blood pressure (SMBP) monitoring is a low-cost, scalable approach to hypertension management, yet adoption remains limited in rural, low-resource settings. Moving monitoring from clinics into homes redistributes tasks previously supported by healthcare professionals, clinical routines, infrastructure, and information systems. However, little is known about whether home settings provide the conditions needed to support these redistributed roles.

Objective:

This study examined how monitoring roles and responsibilities are redistributed as SMBP moves into homes and how their alignment with the home setting shapes adoption and continuation, taking rural Ghana as a case study.

Methods:

We conducted a 6-month longitudinal qualitative field study in two rural Ghanaian communities involving 42 participants: 29 patients, 10 health care professionals, and 3 community leaders. Data were generated through semi-structured interviews, in-situ observations, SMBP training, situated monitoring enactments, and longitudinal follow-up of 16 households at 1-2 weeks and approximately six months of home monitoring. Guided by Behaviour Settings Theory, we compared how roles, competencies, routines, materials, infrastructure, and care relationships were configured across clinical, community, and household settings and across six interdependent monitoring stages: initiation, measurement, logging, interpretation, sharing, and feedback.

Results:

Blood pressure monitoring was organised differently across settings. In clinical settings, monitoring was sustained by coordinated professional roles, established procedures, infrastructure, documentation systems, and direct pathways to interpretation and clinical response, while community settings retained partial support through local intermediaries. When SMBP moved into homes, these functions remained necessary, but responsibility for performing them became redistributed across patients, caregivers, household members, community actors, and health care professionals. Competencies were frequently distributed across multiple people rather than residing in one individual. Participants adapted monitoring through domestic routines, material improvisation, and informal collaboration, but these adaptations did not always compensate for missing competencies, infrastructure, or clinical connections. We conceptualise this mismatch between required monitoring roles and available setting conditions as Role–Setting Misalignment (RSM). Because monitoring stages were interdependent, misalignment at one stage could constrain subsequent stages, making the overall monitoring pathway fragile.

Conclusions:

Moving blood pressure monitoring into homes redistributes health care work into settings that may not provide the conditions needed to perform it. Sustainable SMBP therefore requires moving beyond individual behaviour, device usability, and isolated contextual barriers to ensuring that redistributed monitoring roles are adequately supported and coordinated by the social, material, informational, procedural, and clinical conditions available across settings.