The Role of Behavioral Friction for Patients and Clinicians in a Text-Based Home Blood Pressure Monitoring Program: A Realist Evaluation

Background Home blood pressure monitoring is a proven strategy for improving hypertension control, but implementation challenges remain. Text messaging offers a potentially low-friction, cost-effective alternative for transmitting readings, yet its effectiveness across diverse populations and settings remains underexplored. This study aimed to evaluate the implementation of a text-based home blood pressure monitoring program in a safety-net primary care setting. Methods We conducted a realist evaluation of text-based home blood pressure monitoring processes embedded in a type-2 hybrid stepped-wedge, clustered-randomized implementation trial. We developed a program theory informed by behavioral economics and recruited diverse participants using purposive sampling. Patient and clinician participants in the implementation trial were invited for interviews. 52 patients and 51 clinicians were interviewed. We conducted semi-structured interviews in person or by video. Recorded interviews were transcribed and coded to determine barriers and facilitators of the process and identify context-mechanism-outcome configurations to assess the program theory. We also coded relevant meeting notes. Results Patients reported an overall positive experience, with facilitators including perceived ease of use, minimal time burden, and practicality. Barriers to patient use, which were minor and rarely mentioned, included technical challenges, limited digital literacy, and lack of clinician response. Clinicians reported mixed experiences. Facilitators included the physical presence of a hypertension coordinator and adequate technological training. Barriers included cumbersome digital tool navigation, lack of integrated reminders, and clinician preference for familiar workflows. Findings aligned with the initial program theory and highlighted the importance of minimizing behavioral friction for both patients and clinicians. Conclusions Text-based home blood pressure monitoring is usable for patients, but clinician engagement depends heavily on workflow integration and data accessibility. Weekly multidisciplinary meetings facilitated adaptations that reduced behavioral friction and helped create a usable system for patients, clinicians, and nursing staff. These findings confirm the critical role of behavioral friction in a text-based home blood pressure monitoring program.