Evaluating the Relationship Between Patient Activation Levels and Home Blood Pressure Monitoring Adherence in the Intervention Arm of the Heart to Heart Blood Pressure Control Study

Background. Hypertension is a leading cause of morbidity and mortality in the United States, and effective management relies on sustained patient engagement in self-management behaviors. Home blood pressure monitoring (HBPM) is recommended as part of routine hypertension care, yet adherence to monitoring remains highly variable. Patient activation, defined as an individual’s knowledge, skills, and confidence in managing their health, has been associated with improved chronic disease outcomes but has not been well studied in relation to HBPM adherence. Objective. This study assessed whether patient activation is associated with adherence to home blood pressure monitoring during the initial phase of a technology-enabled hypertension intervention. Methods. This study is a retrospective, cross-sectional cohort analysis of participants in the intervention arm of the Heart to Heart Blood Pressure Control Study. Patient activation was measured at baseline using the 10-item Patient Activation Measure (PAM-10) and categorized into three levels. Adherence to HBPM was defined as the number of days with at least one transmitted blood pressure reading during the first two months and categorized into clinically meaningful levels. Associations between activation and adherence were evaluated using chi-square tests and proportional odds logistic regression, adjusting for demographic and clinical covariates. Results. Among 272 participants, 47.1% demonstrated high HBPM adherence, while 26.5% demonstrated moderate adherence and 26.5% low adherence. PAM level was not significantly associated with HBPM adherence overall (Wald χ² = 0.94, p = 0.6240). Compared with the low-activation reference group (PAM Levels 1/2), neither Level 3 (OR = 0.75, 95% CI 0.40–1.41) nor Level 4 (OR = 0.93, 95% CI 0.49–1.76) was significantly associated with HBPM adherence. Increasing age (OR = 0.95, 95% CI 0.93–0.98) and adequate medication adherence (OR = 0.40, 95% CI 0.17–0.96) were associated with lower odds of being in a lower HBPM adherence category, indicating a greater likelihood of higher adherence to home BP measurement. Although not statistically significant, higher educational attainment showed a similar pattern, whereas unmet SDOH needs were associated with higher odds of lower adherence. Conclusions. Patient activation was not significantly associated with HBPM adherence in crude or adjusted analyses. In contrast, higher age and greater medication adherence were associated with HBPM adherence, with both factors linked to lower odds of being in a lower HBPM adherence category. These findings suggest that engagement with HBPM may be shaped more by demographic and behavioral factors than by baseline patient activation alone. Interventions aiming to improve HBPM adherence should therefore prioritize structural supports and targeted strategies for patients who may be less likely to engage in home monitoring.