Insights from patient interviews on long-term hypertension care

This article was written by Leo Rosenbaum, the founder of Heartery — a digital health company on a mission to empower people to better understand and manage their cardiovascular health. In this guest post, Leo shares insights from over 60 in-depth interviews with patients living with hypertension in Denmark. Their stories offer a window into the silent challenges of chronic disease — and what we, as innovators and healthcare providers, can do to better support them.

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A bit of context

In the past months, I did over sixty short one-on-one interviews with hypertensive patients in Holbæk Hospital. This was made possible through the support of Professor Michael Hecht Olsen, who generously introduced me to his patients.

Who are these patients?

All these patients have had hypertension for a while: some for a year, some for 20+ years. They were referred by their GP due to ongoing high readings. This matters a lot for the findings I’ll share. Given the long time they’ve been experiencing their symptoms, these people have learned to live with hypertension.

Why do these interviews?

Heartery is an international app, largely popular with the US and UK markets - but being based in Denmark, we are also building a Danish version of our app. The app offers support tools, each made for a specific challenge. One example is the challenge to avoid salt, as shown on the app screen below.

Last year, I interviewed over 150 Americans for the US version about their challenges to build support tools for them. Now, I’m learning about the Danish challenges to build support tools relevant to the Danish patients.

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How to identify the challenges?

The first thing I learned: asking Danes directly, “What challenges do you have with your blood pressure?” didn’t work. It worked well in the US. Not in Denmark.

Many interviewed have had hypertension for decades. They’ve learned to live with it. When asked about challenges - “udfordringer” in Danish,  problems, issues, things they miss -  most said, “I’m fine.” A few mentioned symptoms, but that was it.

So, I found another way. The key was empathy. The more I expressed empathy, the more people opened ‘And you know what else I have been through!’ 

I asked some navigating questions that helped them describe their journey, from diagnosis to now. They talked in detail about their daily life: food, sleep, stress, and activity.

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What types of challenges I found

After the first dozen interviews, I saw a pattern. There are two types of challenges. Some are actions, like “I still eat salt, I can’t live without it.” Others are non-actions from not knowing, like “Wait, salt is bad? No one told me in 35 years!”

So my interviews followed two paths:

1. The patient journey, with a focus on real-life difficulties, and how patients tackled them or adapted.

2. And - what they know - and very important! - they don’t know - about hypertension and heart healthy lifestyle.

I will now present the findings, but will focus on the challenges. I will omit the good and strong sides, but will be happy to talk about them if you will ask questions about it.

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What do patients know about blood pressure?

A shockingly low number of those interviewed could explain what blood pressure is - so far, under ten percent. Some tried to guess, and sometimes were even pretty close. But at least two-thirds had no idea and admitted it. 

Most know it is something about the heart. Most know that hypertension is a serious health issue. But only about half could name the dangers. Around 30–40% had never heard the term “the silent killer.”

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What do they know about blood pressure readings?

Very few patients could answer why blood pressure is measured by two numbers, not one. Very few patients knew about the blood pressure chart or terms like “grade 1” or “grade 2 hypertension.”

Almost all used terms like “high,” “quite high,” or “very high” (in Danish, tårnhøj). Only a few, usually former nurses, used more precise language.

Worryingly, even after years with hypertension, up to half did not know when to see a doctor or when to call emergency services - based on their readings.

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There are two distinct groups with regards to patient interactions with doctors

All retired interviewees reported no issues with doctors, wait times, or the system overall. They were fully satisfied.

Among those still working, about half mentioned problems. The most common were passive or burned-out GPs, and needing to push for help. The only complaint about specialists was long wait times.

The two groups see the healthcare system very differently. Retirees see it as part of the government or local government, sometimes slow but in general trustworthy. Half of people in active working age view healthcare more like a service. They expect speed, results, and feel like customers. This second view is still a minority, but I believe that it's growing.

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Knowledge about medications and medical adherence

I will now go away from my own promise to focus on the challenges and to omit the strong sides. I want to commend on the strong self-reported medical adherence. Over 90% of the patients I interviewed use weekly or monthly pill boxes or personal systems. Most take 2–10 pills daily for multiple chronic conditions. When asked, “How often do you forget?” nearly all said, proudly, “Never.” But these are long-time patients. I’d love to speak with newly diagnosed ones, likely a different story.

This is where I’d like to ask for your support: if any of you are in a position to help facilitate interviews with newly diagnosed patients, I would be truly grateful.

Despite taking many pills, few know how they work. About 30% named diuretics, because they make them pee at night. Many don’t remember pill names at all.

Is it good or bad that they know so little? I’m not sure. It’s the only area where I don’t have a firm opinion. In all other areas, I believe more knowledge helps. But let me come back to it at the end of my talk.

One more important thing: worry over side effects is very low. Much lower than among the Americans I spoke to, or what you see in social media groups.

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Now, to lifestyle.

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What they eat and what they know about food

Older patients say they eat vegetables, but also pork with potatoes and Danish brown sauce, eggs with salt, and marinated herring. Younger ones eat more pasta, with salt. 

Pretty much everybody described their food as relatively healthy. But it’s hard to tell who truly follows the healthy way. In interviews, answers were often polished.

I was shocked how few knew about the importance of using a limited amount of salt. Many had hypertension for decades, saw many doctors and nurses, yet I was the first to tell half of them to avoid salt.

The other half had heard of the danger, but didn’t know why salt is bad, how it works, or how much is too much. Only 1–2 people out of 60+ knew the 5g/day limit. No one checks food labels.

Then came another shock, alcohol. Working people drank moderately. But two-thirds of retirees who drink reported having two or more glasses of wine every night, and often much more on weekends.

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The Danish perception of stress

As I said, I’ve done similar interviews with Americans. They stress often, and about everything. That’s why I was very positively surprised by Danish answers to, “When was the last time you felt stressed?” 

Many said, “Three years ago,” or “I don’t work anymore, why should I stress?” In Denmark, stress is seen as job-related. Retirees reported no stress at all.

Working people linked stress to when “things at work don’t go as they should.” They get stressed by sudden changes or breaks in routine. Some had suffered major stress from loss or divorce, but those were rare.

Very few use stress coping tools. The most common method mentioned? Walking the dog.

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Walking the dog and other physical activities

Now to physical activity, another piece of good news here. Almost everyone I spoke to is active. Only about ten percent aren’t, due to disability, other chronic illness, or low energy. Even they said they know it's important.

But most don’t know why it matters, unless they’re retired nurses or married to one. Almost no one knew that sitting for hours is bad for blood pressure, or why.

About a third walk their dog daily and think that’s enough, since it’s often a 30+ minute walk. Another third are more active ]: they jog or walk, often along the coast. The final third are very active, gym workouts, sports, even marathons. I heard some truly inspiring stories. But no one does exercise specifically to lower blood pressure, because no one knows those exercises exist.

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Sleep

Over 80% reported no sleep problems. Those who did mostly used CPAP masks. 

The only repeated problems were:

1. Diuretics wake people up at night to pee, and some can’t fall back asleep.

2. Melatonin requires a prescription in Denmark.

Aside from that, most said they sleep like babies.

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Where they get to know about blood pressure

Almost every patient I interviewed knows Hjerteforeningen (Danish Heart Foundation). About 10–15% subscribe and follow its updates. Many said it was their main info source when first diagnosed. But most don’t follow it anymore. They relied on it at the start, then moved on. 

Many mentioned a popular Danish book on blood pressure-friendly food. Some also read the leaflets that come inside their medications.

About half said they ask Dr. Google often. But few rely on social media like Facebook. Danish Facebook groups on high blood pressure, there are 2–3 large ones, are surprisingly calm. They’re not filled with miracle cures or conspiracy theories like many English-speaking groups.

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3 most repeated challenges of the Danish hypertensives

To sum up, I identified three main challenge areas and zones of low awareness:‍

1. The body as a black box – Most have no basic understanding of how the body works. Very little knowledge of what blood pressure is, how to read a BP chart, or how medications work.

2. Low salt awareness and hard-to-change eating habits – Few understand the need to avoid salt or how to spot it on labels. Most eat the same foods they always have. Changing diet is hard for most, unless you’re an active-age woman. In many cases, it’s the spouse who cares more about healthy food.

3. Not enough targeted physical activity – “Walking the dog” is both the top stress relief and the most popular physical activity. Almost no one knows about or does exercises specifically aimed at lowering blood pressure.

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How we can support them 

By digital tools 

As a digital health professional, my support ideas are digital.

We can give hypertensive patients tools to check salt content, right where they are: in the supermarket, at a restaurant, or at home. I also believe we can guide people through blood pressure-lowering exercises. I’m already working on such a tool, supported by a small grant from the Danish Innovation Fund.

But tools alone aren’t enough. Most people won’t use them. How often will someone pull out their phone to scan food in a supermarket?

What we truly need are full action plans. Daily plans focused on behavior change. Gamified, rewarding, even addictive. Tools that guide people, not just offer options. That’s what we’re building next.

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By a change in provision of information

But this isn’t only about digital health. It’s also about how we share information, using many formats and reaching many groups.

We’re lucky to have Hjerteforeningen in Denmark. It’s trusted and popular. They reach about half of all hypertensives, which is very impressive with limited resources, but it still leaves the other half out. I believe that we need to give Hjerteforeningen more support for broader campaigns.

We also need more personalization. For example, campaigns aimed at spouses, often they influence diet and pill-taking.

We need to educate gym instructors. Right now, many turn hypertensive people away. Instead, let’s give them the tools and programs to help lower blood pressure safely.

We need more doctors in the media, explaining how lifestyle changes work, and how medications actually function.

Finally, about the “black box” view of the body: I usually believe more knowledge helps. But here, we must be careful. Without basic cell biology, even plain explanations of how pills work can cause confusion, or worse, misunderstandings and conspiracy theories.

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About the Author

Leo Rosenbaum is an experienced Danish digital health analyst. With experience from WHO (information officer), Copenhagen Institute for Futures Studies (digital health strategist), major Danish hospitals (Holbaek CVD), Leo is now leading Heartery, a startup in data-driven hypertension management.

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Want to see how Heartery is rethinking hypertension care? Read the case study.

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