Patient self-monitoring of blood pressure (SMBP) has shown promise in contributing towards improving ongoing management of hypertension, however it has yet to be fully integrated into guidelines or routine general practice in the UK. The aims of this thesis were to investigate the role of SMBP in the management of hypertension to better understand: patient and clinician attitudes to SMBP; what behaviour change SMBP targets in patients to bring about better BP outcomes; to what extent SMBP is utilised as part of routine hypertension management in the UK; and to understand patient preferences for hypertension management in light of effective models of care. A mixed methods approach was used including: systematic reviews of qualitative and quantitative evidence; semi-structured interviews with patients; a cross sectional survey; and a discrete choice experiment. Self-monitoring was associated with better medication adherence, which could have significant impact at a population level given the high proportion of non-adherent hypertensive patients. Use of SMBP should be seen as a continuum from being used solely to inform clinical decisions, through facilitating interaction between patients and clinicians, to empowering patients to be autonomous for example in self-management. SMBP was most effective when patients had the knowledge and skills to make improvements in their lifestyle, and this has been shown in clinical trials and through qualitative investigation. Clinicians recognise the potential benefits of SMBP, but are concerned that patients may become burdened. Clinicians should feel encouraged that patients are supportive of self-monitoring, but they must ensure that patients who wish to self-manage are equipped with the skills to do so. Lack of facility to make positive change may lead some patients to feeling disempowered and clinicians need to be cognisant of this fact.

This thesis aimed to explore whether self-management techniques, effective in essential hypertension, could be applied to women with hypertensive disorders of pregnancy postpartum (HDP). HDP affect one in ten pregnancies, remain a leading cause of maternal death worldwide and are associated with elevated long-term maternal cardiovascular risk. Hypertension often persists postpartum and complications can occur. During the puerperium, multiple stresses on new mothers and their healthcare professionals can distract from good quality blood pressure (BP) management. Transfer of responsibility, from secondary to primary care, increases scope for uncertainty. The primary objective was to develop and test the feasibility of a novel self-management intervention for postnatal antihypertensive treatment. A systematic literature review (39 studies), local audit (n=20) and regional survey (n=101) were conducted to evaluate existing evidence and clinical practice. A pilot randomised controlled trial compared self-management of postnatal antihypertensive medication with usual care (n=91). Taking patients' views of self-management into account is essential to successful implementation and these were captured through qualitative interviews (n=68). A sub-study to assess markers of vascular risk (n=16) was conducted to further evaluate the relationship between postnatal BP and elevated long-term cardiovascular risk. There is a lack of good quality evidence underpinning hypertension management postpartum and widespread inconsistencies in approaches to care. The pilot trial suggested that expanding the study would be feasible, and that self-management may be more effective than usual care in terms of BP control. Strikingly, the 4-5mmHg reduction in diastolic BP observed with self-management persisted to six months, despite the majority of women being off treatment by this stage, reinforcing the idea that BP control during the puerperium may influence cardiovascular remodelling. However, no differences were demonstrated in markers of cardiovascular risk between sub-study groups. Participants commonly preferred self-management to usual care, and reported feeling more in control through this approach.