Identifying barriers to the acceptability and adoption of ambulatory blood pressure monitoring and proposed strategies in Bangladesh, Pakistan, and Sri Lanka: a qualitative study

In South Asia, hypertension is a leading modifiable risk factor for premature death. Ambulatory blood pressure monitoring (ABPM) is an internationally recommended method for hypertension diagnosis, but remains underutilized in South Asia, with little evidence on users’ perspectives. This study aims to identify barriers and proposed strategies related to the acceptability and adoption of ABPM for hypertension management from the perspectives of patients with hypertension and healthcare professionals in Bangladesh, Pakistan, and Sri Lanka. Across government and private facilities in Bangladesh, Pakistan, and Sri Lanka, we performed semi-structured interviews with 35 patients with hypertension who had previous experience of using ABPM. We also interviewed 29 healthcare professionals involved in hypertension management who had knowledge on ABPM use, including 11 technicians, 15 specialist physicians, 2 primary care physicians, and 1 administrative head. Guided by a combined framework of the Theoretical Framework of Acceptability and the Consolidated Framework of Implementation Research, we used framework analysis to identify barriers and proposed strategies. While patients with hypertension and healthcare professionals generally supported expanding ABPM use across all three countries, social stigma around ABPM emerged as a common cultural barrier for patients in South Asia. Other key barriers included low public awareness, limited public availability and insurance coverage, lack of organizational alignment and readiness, and patient burden and inconvenience. Participants proposed strategies to address these barriers, including public awareness campaigns to promote and normalize ABPM use, expanding public access through government and donor support, improving ABPM integration by standardizing clinical pathways and strengthening the workforce, and developing more user-friendly ABPM device. In resource-constrained South Asian settings, our findings highlight the need for public education and stronger government support to improve ABPM adoption and acceptability. We provide actionable and context-sensitive insights to inform interventions aimed at reducing social stigma and expanding equitable ABPM access, and to support local guidelines and policies for improving hypertension management through acceptable approaches.