Table 2 Key feedback from feasibility study focus groups and interviews (patients and health professionals) and how this informed intervention design in HOME BP

Patients did not regard hypertension as a serious problem requiring active management.

A motivational quiz was added to the first website session to highlight the potential serious consequences of uncontrolled hypertension.

Patients were happy to self-monitor their blood pressure, but most felt they had already made sufficient healthy behaviour changes and were not highly motivated to undertake further behaviour changes to manage hypertension.

Since medication titration is more effective than behavioural management of hypertension, the HOME BP intervention was designed so that all patients undertook titration as their primary aim but were encouraged to also undertake behaviour changes to avoid future medication increases.

The medication titration procedures were not implemented as planned, because:

a) receptionists were unaware of the automated procedure and so booked patients for a GP appointment when they contacted the practice with raised blood pressure;

b) prescribers forgot or had missed out on the training and were not picking up their reminder emails, so just proceeded with usual care rather than following the titration protocol.

The HOME BP intervention was designed so that:

a) the prescriber was emailed directly to make required titrations by issuing a prescription (avoiding the need for a consultation);

b) the online and offline procedures were re-designed (with central monitoring) and a practice lead designated to ensure that prescribers were aware of the intervention, had completed training and were accessing emails from the intervention.

Some patients were not receiving nurse support. Some nurses did not recall their training and were unaware that they needed to check the study email account, hence were not picking up reminder emails from the automated intervention or emails from patients requesting support.

The study procedures were re-designed so that nurses had to complete online training before they could recruit patients and could re-access this training at any point during the intervention. Emails prompting nurses to provide support were sent to their personal email account and to a general study account which the practice manager took responsibility for overseeing.