Understanding therapeutic inertia in the management of hypertension in primary care: examining contributing factors at the patient and provider levels in Chittoor District, Andhra Pradesh, India – a mixed methods study

Abstract Background Hypertension remains a significant global health challenge, affecting approximately 1.4 billion adults aged 30–79 worldwide. In India, the age-standardised prevalence is 28.1%, and blood pressure (BP) control remains suboptimal. Therapeutic inertia, the failure to initiate or intensify treatment when therapeutic goals are unmet, is recognised as a key contributor to uncontrolled hypertension. In this study, we aimed to understand the prevalence and factors contributing to therapeutic inertia in hypertension management within primary care settings in Chittoor, with a focus on shared decision-making (SDM). Methods A convergent parallel mixed-methods design was adopted. The quantitative strand involved 104 adults with uncontrolled hypertension attending primary care facilities. Data on sociodemographic variables, cardiovascular risk factors, consultation and treatment details, and SDM were collected through a structured questionnaire. The qualitative strand included in-depth interviews with nine patients and eight medical officers. Findings from both strands were integrated and triangulated with field observations. Results The prevalence of therapeutic inertia was 76.9%. Patients aged under 60 years (AOR = 4.36; 95% CI: 1.13–16.90) and those with borderline or mildly elevated blood pressure (AOR = 4.81; 95% CI: 1.38–16.70) had greater odds of inertia. In contrast, illiteracy (AOR = 0.23; 95% CI: 0.05–0.99), the presence of comorbidities (AOR = 0.18; 95% CI: 0.04–0.79), and higher SDM scores (AOR = 0.93; 95% CI: 0.88–0.99) were associated with lower odds. The participants with inertia had significantly lower mean SDM scores (20.36 vs. 28.4, p = 0.003). Thematic analysis highlighted seven key drivers: patient beliefs and perceptions, reluctance to adopt lifestyle changes, fragmented care and conflicting advice, provider caution and clinical judgement, poor follow-up and adherence, workforce constraints in outreach programmes, and limited SDM. Conclusions Therapeutic inertia was found to be highly prevalent within the primary healthcare system in Chittoor district, resulting from a complex interplay of factors at the patient, provider and system levels. Limited engagement in shared decision-making, particularly regarding hypertension, has been consistently associated with increased inertia. Strengthening provider capacity, enhancing patient engagement and incorporating SDM into routine clinical practice could help reduce inertia and improve hypertension management outcomes in primary care settings.