Adherence to pharmacological therapy for hypertension in Portugal: a health professionals focus groups study
Arterial Hypertension (HTN) is a primary risk factor for cardiovascular disease and death worldwide. Despite the availability of efficacious hypertensive medications , blood pressure control remains suboptimal , with poor medication adherence (27–40%) being a significant contributor . Medication adherence, defined as the extent to which medication intake agrees with recommendations from healthcare providers  can be influenced by multiple factors. These factors can be categorized into five dimensions: condition-related factors, therapy-related factors, patient-related factors, healthcare system-related factors, and socio-economic factors . Forgetfulness is a common unintentional contributor to suboptimal adherence  and can be affected by specific factors such as mental comorbidities . Enhancing the effectiveness of adherence interventions could significantly increase population health . Although research into medication adherence in HTN has increased in recent years  and motivational and complex interventions are considered promising , there is a lack of high-quality studies on effective interventions for enhancing medication adherence in HTN . Strategies to improve medication adherence focused both on patient and provider factors are recommended , and current guidelines suggest that healthcare professionals should communicate the benefits of medication, mitigate side effects, and offer motivational counselling to patients . Moreover, addressing medication adherence through allied healthcare providers seems promising and cost-effective . Medication adherence in HTN is influenced by the training, knowledge, and communication skills of healthcare professionals , the quality of their relationship with patients, and the provision of positive reinforcement . A comprehensive understanding of healthcare professionals’ perspectives is crucial for developing effective strategies to enhance medication adherence as they participate in HTN management, possess unique insights into this issue, and can be a part of the solution. Although some studies have gathered the opinions of healthcare professionals on barriers to therapy adherence , no qualitative studies have been conducted in Portugal to explore the views of healthcare professionals, despite the country’s poor control rates of blood pressure (42,5–71,3%)  and medication adherence (54,6%) . Objectives This study aimed to assess the perspectives of healthcare professionals such as General Practitioners/Family Physicians (GPs/FPs), nurses, and community pharmacists, from Portugal regarding the most effective strategies for improving medication adherence in HTN and to identify factors that hinder pharmacological adherence in patients with HTN.   This study aimed to assess the perspectives of healthcare professionals such as General Practitioners/Family Physicians (GPs/FPs), nurses, and community pharmacists, from Portugal regarding the most effective strategies for improving medication adherence in HTN and to identify factors that hinder pharmacological adherence in patients with HTN.   Qualitative research using online, synchronous, focus groups, each targeting six to ten participants over one hour was conducted. This study adopted a methodology from a previously published, detailed protocol . The main moderator was BR-S, a General Practitioner/Family Physicians (GP/FP) with previous experience moderating focus groups, and the moderators’ assistants were IR, a GP/FP who also had a background in moderating focus groups, and JG, a Medical Doctor (MD) who had training from the remaining moderators. The meeting followed a script (Supplementary material ), and at the end of the focus groups, a summary of the discussion was provided, and participants were allowed to criticise it and add any information. This study used an online platform, Zoom version 5.13.10, and the focus group sessions were audio recorded and transcribed verbatim. Before the meetings, the participants signed an informed consent form for the study and a reminder was sent to all participants regarding the upcoming session. The first focus group confirmed the feasibility of the study and allowed the research team to review the script. The number of focus groups was determined by data saturation . Participants did not receive any form of compensation. This study followed the established criteria and standards for quality and transparency: the COnsolidated criteria for REporting Qualitative research ( COREQ)  and the Standards for Reporting Qualitative Research . Selection of participants Participants were GPs/FPs, family nurses, and community pharmacists in Portugal who regularly had contact with patients diagnosed with HTN in a community setting. They were selected based on predefined characteristics such as age, sex, and geographical region (north, central, and south areas of mainland Portugal and the Autonomous regions of Madeira and Azores). To ensure different opinions, each focus group included at least one physician, one nurse, and one pharmacist. The focus group inclusion criteria are presented in Table . The authors promoted the study through specific mailing lists of healthcare professionals. Healthcare professionals who replied by showing interest in participating received more details about the study. If selected to participate based on the inclusion criteria, they received a copy of the participant consent form via email. During the selection of participants for the focus groups, participants’ availability for each meeting date and time was given priority. After generating three pools of potential participants based on their profession, a random number generator was used to select them to minimise selection bias. However, because the number of volunteers was small, snowball recruitment  was also used with participants who agreed to participate. To achieve maximum sample diversity, a purposive sampling  method was used. The focus group interviews took place in December 2023. No financial benefit was provided to the participants. Data collection Data were collected during the focus groups and recorded on the Zoom online platform. The facilitator BR-S promoted the debate using non–directive moderation with open-ended questions from the script to ensure self–containment regarding the involvement in the group . Data transcripts were not returned to participants due to their large extent and to ensure confidentiality. Additional participant sociodemographic data were collected in an online form from Google Forms at the end of the focus group. Data analysis Data analysis was performed using proper qualitative software, MAXQDA ® 2023. Two independent researchers (BR-S and JG) performed content analysis through comparative analysis and posterior consensus. Initially, they set the level of abstraction as higher and constructed a coding tree with the main themes and categories, which mainly corresponded to the script questions that were built based on prior research . First, deductive analysis was guided by these predefined themes and categories and data was labelled. Then, new categories and subcategories emerged from codes derived from meaningful units of the transcripts through inductive analyses and the level of abstraction was resettled . The categories and subcategories were revised to check category overlaps to merge or to divide into subcategories . A third researcher (IR) reviewed the analysis. The findings were displayed mainly in tables with narrative descriptions, including illustrative quotes, which omit identifying details to maintain confidentiality. When presenting the results, the barriers to medication adherence were organised according to the WHO Multidimensional Adherence Model . These results were then compared with the 15 most pertinent strategies identified from the transcript analysis. Participants did not give direct feedback on the findings.   Participants were GPs/FPs, family nurses, and community pharmacists in Portugal who regularly had contact with patients diagnosed with HTN in a community setting. They were selected based on predefined characteristics such as age, sex, and geographical region (north, central, and south areas of mainland Portugal and the Autonomous regions of Madeira and Azores). To ensure different opinions, each focus group included at least one physician, one nurse, and one pharmacist. The focus group inclusion criteria are presented in Table . The authors promoted the study through specific mailing lists of healthcare professionals. Healthcare professionals who replied by showing interest in participating received more details about the study. If selected to participate based on the inclusion criteria, they received a copy of the participant consent form via email. During the selection of participants for the focus groups, participants’ availability for each meeting date and time was given priority. After generating three pools of potential participants based on their profession, a random number generator was used to select them to minimise selection bias. However, because the number of volunteers was small, snowball recruitment  was also used with participants who agreed to participate. To achieve maximum sample diversity, a purposive sampling  method was used. The focus group interviews took place in December 2023. No financial benefit was provided to the participants.   Data were collected during the focus groups and recorded on the Zoom online platform. The facilitator BR-S promoted the debate using non–directive moderation with open-ended questions from the script to ensure self–containment regarding the involvement in the group . Data transcripts were not returned to participants due to their large extent and to ensure confidentiality. Additional participant sociodemographic data were collected in an online form from Google Forms at the end of the focus group.   Data analysis was performed using proper qualitative software, MAXQDA ® 2023. Two independent researchers (BR-S and JG) performed content analysis through comparative analysis and posterior consensus. Initially, they set the level of abstraction as higher and constructed a coding tree with the main themes and categories, which mainly corresponded to the script questions that were built based on prior research . First, deductive analysis was guided by these predefined themes and categories and data was labelled. Then, new categories and subcategories emerged from codes derived from meaningful units of the transcripts through inductive analyses and the level of abstraction was resettled . The categories and subcategories were revised to check category overlaps to merge or to divide into subcategories . A third researcher (IR) reviewed the analysis. The findings were displayed mainly in tables with narrative descriptions, including illustrative quotes, which omit identifying details to maintain confidentiality. When presenting the results, the barriers to medication adherence were organised according to the WHO Multidimensional Adherence Model . These results were then compared with the 15 most pertinent strategies identified from the transcript analysis. Participants did not give direct feedback on the findings.   Three focus groups were conducted, amounting to a sample of 22 participants. Eight individuals withdrew from the study and did not attend the meetings, only two of them justified having other commitments. Participants were mainly female, with a mean age of 42.23 ± 11.11 years (range: 27–67). Among them, four (18.2%) lived in northern Portugal, 15 (68.3%) lived in the central region, one lived in Lisbon and Vale do Tejo, one lived in Algarve, and one lived in thz Autonomous Region of Madeira. The sample included nine GPs/FPs, six nurses, and seven pharmacists. Academic qualifications ranged from undergraduate to doctoral degrees, with the majority (63.6%) holding a master’s degree. Nine participants (40.9%) had previously participated in a focus group study. The characteristics of the participants are detailed in Table . Definition of adherence to pharmacological therapy Regarding the definition of adherence to therapy, participants stated that it involves patients taking the prescribed medication, in agreement with their physician while emphasizing the importance of the relationship between them. The patient takes their medicines as agreed with their physician, based on a shared decision. Healthcare professionals also believe that educating and raising awareness of patients’ chronic diseases and their therapy is crucial for medication adherence. “I would say that the first thing I value is the patient being aware that he has a chronic illness; that’s the first step. Adherence is when they are truly aware that they need to take action to control their chronic illness.” Forgetfulness in medication adherence Participants identified the main reasons young adults forget to take medicines, such as having busier routines, leaving the house in a rush, and discontinuing their medication once they achieve controlled BP levels or because they have no symptoms (Table ). Regarding older adults, healthcare professionals mentioned different reasons, such as cognitive impairment and logistical failures due to dependence on family members or caregivers. Participants also pointed out that older adults easily forget to take medication if they are in polypharmacy, particularly when there are adjustments to their medication. Irrespective of age group, lack of an established routine seems to contribute to forgetfulness to medication adherence. Side effects and strategies to mitigate side effects The most frequently mentioned side effects were increased urinary output due to diuretics and coughing due to angiotensin-converting enzyme inhibitors (ACE inhibitors). Adverse effects related to beta-blocker therapy were also discussed, such as possible changes in heart rate, reduced libido, and erectile dysfunction. Additionally, healthcare professionals mentioned dizziness, headache, and peripheral oedema, the latter being caused by calcium channel blocker (CCB) therapy (Table ). To mitigate side effects, participants recommended regular blood pressure monitoring by pharmacists and communication improvements between pharmacists and GPs/FPs. In Primary Health Care (PHC), health professionals should verify that the patient has no relative or absolute contraindications to the prescribed medication. Additionally, they should tailor the medication choice according to each patient’s characteristics and avoid making major adjustments to the medication each time it is updated. Participants also recommended improving the clinical approach by conducting more comprehensive medical histories and extending the expected length of each consultation so that health professionals can educate the patient and clarify any doubts (Table ). Furthermore, whether patients should be educated about potential side effects has been debated. One participant believed that such actions could have the opposite effect, leading to medication avoidance. Barriers to pharmacological adherence in HTN Participants identified several barriers to medication adherence (Table ). It was highlighted that the absence of symptoms in HTN often leads to a lack of concern about proper medication adherence and many patients discontinue their medication once their blood pressure improves. On the other hand, if patients experience some discomfort like lethargy due to low BP levels or medication-related side effects, they might stop taking their medication. Healthcare professionals have argued that patients on polypharmacy overlook the importance of medication adherence because they have too many pills to take; and have difficulty sharing personal misconceptions about medication at appointments. Previous medication experiences, and the influence of others when they are misadvised to stop medication, also decrease therapeutic adherence. Regarding healthcare system-related barriers, running out of medication without a new prescription, lack of effective doctor-patient communication about medication adherence, and a prescription schedule that does not align with the patient’s routine were identified as reasons for missing medication. In addition, medication costs were identified as an important barrier to medication adherence. Role of technology and family members in medication adherence Participants agreed that strategies that include technology may have a role in medication adherence (Table ), but they argued that the oldest patients resist adopting technologies like the official national service healthcare App - SNS24 - mostly because they do not know how to use them or they are not capable of using them. “(…) we encourage them to install the SNS24 app to access their prescriptions , but often they do not want to .” “Most of our oldest patients do not use apps.” It was stated that families usually assist and support patients, motivating and ensuring medication adherence. “ They even encourage each other to adhere to their therapies. ” “ They prepare the medication and organise the pillboxe s.” “ When there are difficulties in going to the health centre or pharmacy by themselves, [the family] pick up the medications and prescriptions on their behalf.” However, family members can also be absent or not physically capable of helping or acting as disruptive elements in treatment adherence, particularly when more than one family member has HTN, potentially leading to confusion regarding the appropriate therapeutic regimen. “ Often, families are not present .” “ Nowadays, older adults are taking care of other older adults, isn’t it? Sometimes it’s a mother who is 90 years old, and the daughter is already 70 or 60 .” “ (…) others are completely the opposite and should take different medications because if not, they completely confuse each other .” It was also noted that patients sometimes refuse help from their families and that patients should be included in the decision regarding whether family support should be involved in medication management. “ When the family tries to help, (…) the older adult reacts poorly because they feel that they are being told they are not capable of managing their medication .” “(…) it must be done with the agreement of the older adult or the more dependent individual that this is necessary and that they accept that this person [family member] assumes the role [of medication management] , in order to avoid conflicts of interest.” Strategies to improve adherence to antihypertensive medication According to the participants of the focus groups, the key strategy was to improve the coordination and communication between health services among themselves and caregivers as they should be a team and share information about medication adherence. Engaging caregivers or family members to come to appointments and help manage medication and providing access to the national electronic prescription platform called Prescrição Electrónica Médica (PEM) to pharmacists would enhance the quality of communication. Developing home visits to patients to ensure medication adherence and promoting health literacy through public health education in schools and on television were also proposed as coordinated measures to improve medication adherence in HTN. Regarding technology, participants highlighted the need to incorporate technology into patients’ daily lives, like using mobile phones to set alarms to remind them to take their medication and renew their prescriptions. The development of watches to measure blood pressure was also suggested. Healthcare professionals acknowledged the value of mobile applications (apps) designed to remind users to take their medication and to measure and record their blood pressure and argued that health systems could play a more active role in promoting these applications. In this context, the participants stated that it would be beneficial to develop an app or platform that connects the patient with the GP/FP, community pharmacist, and family nurse (Table ). The idea of patients wearing watches that enable blood pressure measurements was seen as promising. At the HPC Centres, participants suggested extending the appointments for managing HTN to provide more time for educating patients and addressing their concerns. They also recommended updating the PEM to simplify the process of medication adjustments and that GPs/FPs reduce therapy complexity by decreasing the number of pills the patient should take. In addition, the participants proposed that the PEM system allows detailed prescriptions to be sent through patients’ mobile phones or that a therapeutic guide with the purpose of each drug in an understandable language should be provided when delivering the prescription. At the pharmacies, it was mentioned that it would be useful to involve pharmacists in medication management and allow them to check if a patient has the necessary number of pill boxes and allow pharmacists to renew their chronic medications in collaboration with the GP/FP. Healthcare professionals spoke about the need to create a “family pharmacy” and have alerts to pharmacists when medication adjustments are made. To assist patients in adhering to their medication regimen, participants recommended placing the medication in a visible and accessible location linked to a morning routine to prevent forgetfulness. They emphasised the importance of patients being aware of their chronic disease, the need for chronic medication, the consequences of missing medication, and involving them in disease management, such as selecting the most suitable schedule for taking the medication. The use of a preprepared pillbox with distinct compartments for each day of the week to reduce the risk of missing medication doses was also proposed.   Regarding the definition of adherence to therapy, participants stated that it involves patients taking the prescribed medication, in agreement with their physician while emphasizing the importance of the relationship between them. The patient takes their medicines as agreed with their physician, based on a shared decision. Healthcare professionals also believe that educating and raising awareness of patients’ chronic diseases and their therapy is crucial for medication adherence. “I would say that the first thing I value is the patient being aware that he has a chronic illness; that’s the first step. Adherence is when they are truly aware that they need to take action to control their chronic illness.”   Participants identified the main reasons young adults forget to take medicines, such as having busier routines, leaving the house in a rush, and discontinuing their medication once they achieve controlled BP levels or because they have no symptoms (Table ). Regarding older adults, healthcare professionals mentioned different reasons, such as cognitive impairment and logistical failures due to dependence on family members or caregivers. Participants also pointed out that older adults easily forget to take medication if they are in polypharmacy, particularly when there are adjustments to their medication. Irrespective of age group, lack of an established routine seems to contribute to forgetfulness to medication adherence.   The most frequently mentioned side effects were increased urinary output due to diuretics and coughing due to angiotensin-converting enzyme inhibitors (ACE inhibitors). Adverse effects related to beta-blocker therapy were also discussed, such as possible changes in heart rate, reduced libido, and erectile dysfunction. Additionally, healthcare professionals mentioned dizziness, headache, and peripheral oedema, the latter being caused by calcium channel blocker (CCB) therapy (Table ). To mitigate side effects, participants recommended regular blood pressure monitoring by pharmacists and communication improvements between pharmacists and GPs/FPs. In Primary Health Care (PHC), health professionals should verify that the patient has no relative or absolute contraindications to the prescribed medication. Additionally, they should tailor the medication choice according to each patient’s characteristics and avoid making major adjustments to the medication each time it is updated. Participants also recommended improving the clinical approach by conducting more comprehensive medical histories and extending the expected length of each consultation so that health professionals can educate the patient and clarify any doubts (Table ). Furthermore, whether patients should be educated about potential side effects has been debated. One participant believed that such actions could have the opposite effect, leading to medication avoidance.   Participants identified several barriers to medication adherence (Table ). It was highlighted that the absence of symptoms in HTN often leads to a lack of concern about proper medication adherence and many patients discontinue their medication once their blood pressure improves. On the other hand, if patients experience some discomfort like lethargy due to low BP levels or medication-related side effects, they might stop taking their medication. Healthcare professionals have argued that patients on polypharmacy overlook the importance of medication adherence because they have too many pills to take; and have difficulty sharing personal misconceptions about medication at appointments. Previous medication experiences, and the influence of others when they are misadvised to stop medication, also decrease therapeutic adherence. Regarding healthcare system-related barriers, running out of medication without a new prescription, lack of effective doctor-patient communication about medication adherence, and a prescription schedule that does not align with the patient’s routine were identified as reasons for missing medication. In addition, medication costs were identified as an important barrier to medication adherence.   Participants agreed that strategies that include technology may have a role in medication adherence (Table ), but they argued that the oldest patients resist adopting technologies like the official national service healthcare App - SNS24 - mostly because they do not know how to use them or they are not capable of using them. “(…) we encourage them to install the SNS24 app to access their prescriptions , but often they do not want to .” “Most of our oldest patients do not use apps.” It was stated that families usually assist and support patients, motivating and ensuring medication adherence. “ They even encourage each other to adhere to their therapies. ” “ They prepare the medication and organise the pillboxe s.” “ When there are difficulties in going to the health centre or pharmacy by themselves, [the family] pick up the medications and prescriptions on their behalf.” However, family members can also be absent or not physically capable of helping or acting as disruptive elements in treatment adherence, particularly when more than one family member has HTN, potentially leading to confusion regarding the appropriate therapeutic regimen. “ Often, families are not present .” “ Nowadays, older adults are taking care of other older adults, isn’t it? Sometimes it’s a mother who is 90 years old, and the daughter is already 70 or 60 .” “ (…) others are completely the opposite and should take different medications because if not, they completely confuse each other .” It was also noted that patients sometimes refuse help from their families and that patients should be included in the decision regarding whether family support should be involved in medication management. “ When the family tries to help, (…) the older adult reacts poorly because they feel that they are being told they are not capable of managing their medication .” “(…) it must be done with the agreement of the older adult or the more dependent individual that this is necessary and that they accept that this person [family member] assumes the role [of medication management] , in order to avoid conflicts of interest.”   According to the participants of the focus groups, the key strategy was to improve the coordination and communication between health services among themselves and caregivers as they should be a team and share information about medication adherence. Engaging caregivers or family members to come to appointments and help manage medication and providing access to the national electronic prescription platform called Prescrição Electrónica Médica (PEM) to pharmacists would enhance the quality of communication. Developing home visits to patients to ensure medication adherence and promoting health literacy through public health education in schools and on television were also proposed as coordinated measures to improve medication adherence in HTN. Regarding technology, participants highlighted the need to incorporate technology into patients’ daily lives, like using mobile phones to set alarms to remind them to take their medication and renew their prescriptions. The development of watches to measure blood pressure was also suggested. Healthcare professionals acknowledged the value of mobile applications (apps) designed to remind users to take their medication and to measure and record their blood pressure and argued that health systems could play a more active role in promoting these applications. In this context, the participants stated that it would be beneficial to develop an app or platform that connects the patient with the GP/FP, community pharmacist, and family nurse (Table ). The idea of patients wearing watches that enable blood pressure measurements was seen as promising. At the HPC Centres, participants suggested extending the appointments for managing HTN to provide more time for educating patients and addressing their concerns. They also recommended updating the PEM to simplify the process of medication adjustments and that GPs/FPs reduce therapy complexity by decreasing the number of pills the patient should take. In addition, the participants proposed that the PEM system allows detailed prescriptions to be sent through patients’ mobile phones or that a therapeutic guide with the purpose of each drug in an understandable language should be provided when delivering the prescription. At the pharmacies, it was mentioned that it would be useful to involve pharmacists in medication management and allow them to check if a patient has the necessary number of pill boxes and allow pharmacists to renew their chronic medications in collaboration with the GP/FP. Healthcare professionals spoke about the need to create a “family pharmacy” and have alerts to pharmacists when medication adjustments are made. To assist patients in adhering to their medication regimen, participants recommended placing the medication in a visible and accessible location linked to a morning routine to prevent forgetfulness. They emphasised the importance of patients being aware of their chronic disease, the need for chronic medication, the consequences of missing medication, and involving them in disease management, such as selecting the most suitable schedule for taking the medication. The use of a preprepared pillbox with distinct compartments for each day of the week to reduce the risk of missing medication doses was also proposed.   Main findings The focus group discussions revealed a multifaceted approach to improving medication adherence in HTN in Portugal. The primary emphasis centred on enhancing coordination and communication among healthcare professionals, patients, and caregivers, recognising the importance of information sharing through integrated informatics software between GPs/FPs, family nurses, and community pharmacists. Participants advocated for family member’s involvement in consultations, the development of a mobile app to connect patients or caregivers with their healthcare providers, and the promotion of health literacy through public education initiatives. The integration of technology into patients’ daily routines, such as mobile phone reminders to take and purchase medication alongside remote blood pressure monitoring, was highlighted as a promising approach. Several important recommendations emerged from this qualitative study: patient empowerment, provision of a comprehensible therapeutic guide with a simplified regimen, preprepared medication in pillboxes, reduced medication costs, and a “family pharmacist” to help in medication management. Regarding barriers to medication adherence, participants identified diverse categories: condition-related and therapy-related barriers, the influence of others and patients’ beliefs, and the lack of communication with patients concerning issues like medication adherence. Strengths and limitations of this study This focus group study explored insights and views from Portuguese healthcare professionals, which were shaped by social interaction and facilitated a more authentic collection of their ideas on an understudied subject . The moderators’ expertise in qualitative research enabled attentive listening and allowed them to remain reflexive throughout the meetings. Furthermore, a validated script was used to ensure the meeting’s quality. Participants had experience in the research topic, enhancing their willingness to share their insights, and they had a broad age range (27–67 years), which facilitated a diverse range of opinions. Although there was at least one healthcare professional from each region of the country, most participants belonged to the central area of Portugal. Despite having the chance to provide feedback at the end of each meeting summary, participants did not have access to the final analysis and two participants were known to the main facilitator, which may have introduced desirability bias. The verbatim translation into English may have resulted in cultural nuances or loss of meaning. The findings from these focus groups are specific to the Portuguese healthcare system, as intended, and may have limited generalisability to other contexts. Discussion of results and comparison with existing literature Our study found that improving the care coordination between family nurses, community pharmacists, and GPs/FPs in Portugal can improve medication adherence among patients with HTN. This should include enhancing communication between these healthcare professionals through shared informatics software, enabling them to verify dispensed prescriptions, access current medication modifications, and monitor if the medication is being correctly taken. These specific measures have not been identified in other studies, potentially due to their unique relevance to Portugal’s healthcare system. Including a caregiver or family member in HTN consultations to help with medication management aligns with the existing research, suggests medication counselling  or update on regularly medication  for caregivers and states that the family’s role in medication adherence is fundamental in encouraging medication adherence . Although not universally accessible, technology has been previously proposed as a tool to improve medication adherence . Some interventions utilising apps have been tested in RCTs, though the predominant focus was to improve health literacy through educational content . Our study highlighted the need for coordinated health literacy. We identified some studies featuring apps that included patient reminders to take medication, BP recording capabilities; healthcare providers or caregiver notifications for abnormal BP readings, and enabled healthcare providers to check the uploaded data and give feedback to their patients . Our participants added that technological reminders should include medication purchase alerts and that apps should facilitate communication with healthcare teams. The proposal of wearables like a watch to monitor BP remotely corroborates previous findings on remote patient monitoring improving HTN care . The recommendation to extend the length of appointments to allow healthcare professionals sufficient time for patient empowerment in HTN management may reflect the perceived barrier that physicians do not discuss issues like medication adherence  This is consistent with other Portuguese studies indicating patients feel that doctors conduct consultations at a fast pace . Additionally, this aligns with literature supporting self-management interventions’ beneficial effects on older adults with HTN . Consistent with other studies reporting therapeutic complexity as a barrier to medication adherence in cardiovascular patients , our participants advocated for simplified therapeutic regimens – a crucial consideration for health professionals. Other strategies to improve adherence to antihypertensive medication were pharmacists’ active involvement in medication management, particularly addressing side effects and establishing a “family pharmacist” role to be coordinated with PHC care. Although strategies addressing community pharmacists have been developed with some of them in collaboration with GP/FP , only one randomised controlled trial (RCT) with a multi-collaborative initiative has been conducted in Portugal  which did not show effectiveness and did not apply this specific concept. This study indicated that medication preparation services can be valuable for improving medication adherence among older adults with HTN. Similar ideas have been suggested  although evidence for such interventions remains limited . Regarding barriers to medication adherence in HTN, although they were mainly described in a recent systematic review , our findings present a specific selection reflecting Portuguese healthcare providers’ perspectives. Implications for research and clinical practice A larger number of GPs/FPs, community pharmacists, and family nurses from PT will, in a subsequent phase, be surveyed about the best strategies for improving medication adherence using a questionnaire developed from these findings as a framework. This qualitative study is part of a broader research that also examines the perspectives of Portuguese patients with HTN. Following the triangulation of these perspectives, the best strategies to enhance medication adherence in HTN should be evaluated through an RCT in Portugal. This qualitative study recommends several strategies to improve medication adherence in HTN focusing on healthcare professionals’ perspectives and addressing barriers to medication adherence in HTN within the Portuguese context. This study was conducted with a local population and offers practical recommendations to the healthcare system and providers that may enhance the quality of HTN care and help address suboptimal rates of medication adherence and HTN control in Portugal.   The focus group discussions revealed a multifaceted approach to improving medication adherence in HTN in Portugal. The primary emphasis centred on enhancing coordination and communication among healthcare professionals, patients, and caregivers, recognising the importance of information sharing through integrated informatics software between GPs/FPs, family nurses, and community pharmacists. Participants advocated for family member’s involvement in consultations, the development of a mobile app to connect patients or caregivers with their healthcare providers, and the promotion of health literacy through public education initiatives. The integration of technology into patients’ daily routines, such as mobile phone reminders to take and purchase medication alongside remote blood pressure monitoring, was highlighted as a promising approach. Several important recommendations emerged from this qualitative study: patient empowerment, provision of a comprehensible therapeutic guide with a simplified regimen, preprepared medication in pillboxes, reduced medication costs, and a “family pharmacist” to help in medication management. Regarding barriers to medication adherence, participants identified diverse categories: condition-related and therapy-related barriers, the influence of others and patients’ beliefs, and the lack of communication with patients concerning issues like medication adherence.   This focus group study explored insights and views from Portuguese healthcare professionals, which were shaped by social interaction and facilitated a more authentic collection of their ideas on an understudied subject . The moderators’ expertise in qualitative research enabled attentive listening and allowed them to remain reflexive throughout the meetings. Furthermore, a validated script was used to ensure the meeting’s quality. Participants had experience in the research topic, enhancing their willingness to share their insights, and they had a broad age range (27–67 years), which facilitated a diverse range of opinions. Although there was at least one healthcare professional from each region of the country, most participants belonged to the central area of Portugal. Despite having the chance to provide feedback at the end of each meeting summary, participants did not have access to the final analysis and two participants were known to the main facilitator, which may have introduced desirability bias. The verbatim translation into English may have resulted in cultural nuances or loss of meaning. The findings from these focus groups are specific to the Portuguese healthcare system, as intended, and may have limited generalisability to other contexts.   Our study found that improving the care coordination between family nurses, community pharmacists, and GPs/FPs in Portugal can improve medication adherence among patients with HTN. This should include enhancing communication between these healthcare professionals through shared informatics software, enabling them to verify dispensed prescriptions, access current medication modifications, and monitor if the medication is being correctly taken. These specific measures have not been identified in other studies, potentially due to their unique relevance to Portugal’s healthcare system. Including a caregiver or family member in HTN consultations to help with medication management aligns with the existing research, suggests medication counselling  or update on regularly medication  for caregivers and states that the family’s role in medication adherence is fundamental in encouraging medication adherence . Although not universally accessible, technology has been previously proposed as a tool to improve medication adherence . Some interventions utilising apps have been tested in RCTs, though the predominant focus was to improve health literacy through educational content . Our study highlighted the need for coordinated health literacy. We identified some studies featuring apps that included patient reminders to take medication, BP recording capabilities; healthcare providers or caregiver notifications for abnormal BP readings, and enabled healthcare providers to check the uploaded data and give feedback to their patients . Our participants added that technological reminders should include medication purchase alerts and that apps should facilitate communication with healthcare teams. The proposal of wearables like a watch to monitor BP remotely corroborates previous findings on remote patient monitoring improving HTN care . The recommendation to extend the length of appointments to allow healthcare professionals sufficient time for patient empowerment in HTN management may reflect the perceived barrier that physicians do not discuss issues like medication adherence  This is consistent with other Portuguese studies indicating patients feel that doctors conduct consultations at a fast pace . Additionally, this aligns with literature supporting self-management interventions’ beneficial effects on older adults with HTN . Consistent with other studies reporting therapeutic complexity as a barrier to medication adherence in cardiovascular patients , our participants advocated for simplified therapeutic regimens – a crucial consideration for health professionals. Other strategies to improve adherence to antihypertensive medication were pharmacists’ active involvement in medication management, particularly addressing side effects and establishing a “family pharmacist” role to be coordinated with PHC care. Although strategies addressing community pharmacists have been developed with some of them in collaboration with GP/FP , only one randomised controlled trial (RCT) with a multi-collaborative initiative has been conducted in Portugal  which did not show effectiveness and did not apply this specific concept. This study indicated that medication preparation services can be valuable for improving medication adherence among older adults with HTN. Similar ideas have been suggested  although evidence for such interventions remains limited . Regarding barriers to medication adherence in HTN, although they were mainly described in a recent systematic review , our findings present a specific selection reflecting Portuguese healthcare providers’ perspectives.   A larger number of GPs/FPs, community pharmacists, and family nurses from PT will, in a subsequent phase, be surveyed about the best strategies for improving medication adherence using a questionnaire developed from these findings as a framework. This qualitative study is part of a broader research that also examines the perspectives of Portuguese patients with HTN. Following the triangulation of these perspectives, the best strategies to enhance medication adherence in HTN should be evaluated through an RCT in Portugal. This qualitative study recommends several strategies to improve medication adherence in HTN focusing on healthcare professionals’ perspectives and addressing barriers to medication adherence in HTN within the Portuguese context. This study was conducted with a local population and offers practical recommendations to the healthcare system and providers that may enhance the quality of HTN care and help address suboptimal rates of medication adherence and HTN control in Portugal.   This qualitative study addresses a significant gap in patient care by outlining strategies to improve medication adherence among patients with Hypertension in Portugal. These strategies involve improving healthcare coordination and communication, patient empowerment, and involving family and “family pharmacists” in supporting adherence. They are based on the insights of healthcare professionals and could be implemented following robust intervention studies.   Below is the link to the electronic supplementary material. Supplementary Material 1   