Efficacy of Text Messaging and Personal Consultation by Pharmacy Students Among Adults With Hypertension: Randomized Controlled Trial

Effectiveness of digital health interventions on adherence and control of hypertension: a systematic review and meta-analysis

BACKGROUND

Hypertension, a risk factor for developing cardiovascular disease, is becoming increasingly prevalent worldwide. Digital health is now widely utilized for hypertension management, and numerous studies have assessed its effectiveness.

OBJECTIVE

The review aims to analyse the effectiveness of digital health (i.e., mobile health (mHealth), telehealth, and the combination of mHealth & telehealth) on hypertensive patients, concerning three key areas: clinical outcomes, medication adherence, and adherence to lifestyle changes, as compared to standard care.

METHODS

The review followed the PRISMA framework. Eight electronic databases were scanned for randomized control trials focusing on the effects of mHealth or telehealth on hypertensive patients, published between 2010 and 2023. All processes were conducted by the first two authors independently. A meta-analysis was conducted for quantitative data, while a narrative synthesis was conducted for qualitative data.

RESULTS

In total, 74 studies involving 92 686 participants were identified. The meta-analysis favoured the interventions, revealing a significant decrease in systolic blood pressure and diastolic blood pressure for mHealth, telehealth and mHealth & telehealth groups. Nevertheless, medication adherence showed improvement only in the mHealth group, while blood pressure control showed improvement in both mHealth and mHealth & telehealth groups, and BMI showed improvement only in the mHealth group. Evidence for adherence to physical activity and DASH diet/salt intake remained inconclusive.

CONCLUSION

In general, mHealth and telehealth have demonstrated their merits in improving the clinical outcomes of hypertensive patients.

Effectiveness of eHealth Interventions in Improving Medication Adherence Among Patients With Cardiovascular Disease: Systematic Review and Meta-Analysis

BACKGROUND

Nonadherence to medication among patients with cardiovascular diseases undermines the desired therapeutic outcomes. eHealth interventions emerge as promising strategies to effectively tackle this issue.

OBJECTIVE

The aim of this study was to conduct a network meta-analysis (NMA) to compare and rank the efficacy of various eHealth interventions in improving medication adherence among patients with cardiovascular diseases (CVDs).

METHODS

A systematic search strategy was conducted in PubMed, Embase, Web of Science, Cochrane, China National Knowledge Infrastructure Library (CNKI), China Science and Technology Journal Database (Weipu), and WanFang databases to search for randomized controlled trials (RCTs) published from their inception on January 15, 2024. We carried out a frequentist NMA to compare the efficacy of various eHealth interventions. The quality of the literature was assessed using the risk of bias tool from the Cochrane Handbook (version 2.0), and extracted data were analyzed using Stata16.0 (StataCorp LLC) and RevMan5.4 software (Cochrane Collaboration). The certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

RESULTS

A total of 21 RCTs involving 3904 patients were enrolled. The NMA revealed that combined interventions (standardized mean difference [SMD] 0.89, 95% CI 0.22-1.57), telephone support (SMD 0.68, 95% CI 0.02-1.33), telemonitoring interventions (SMD 0.70, 95% CI 0.02-1.39), and mobile phone app interventions (SMD 0.65, 95% CI 0.01-1.30) were statistically superior to usual care. However, SMS compared to usual care showed no statistical difference. Notably, the combined intervention, with a surface under the cumulative ranking curve of 79.3%, appeared to be the most effective option for patients with CVDs. Regarding systolic blood pressure and diastolic blood pressure outcomes, the combined intervention also had the highest probability of being the best intervention.

CONCLUSIONS

The research indicates that the combined intervention (SMS text messaging and telephone support) has the greatest likelihood of being the most effective eHealth intervention to improve medication adherence in patients with CVDs, followed by telemonitoring, telephone support, and app interventions. The results of these network meta-analyses can provide crucial evidence-based support for health care providers to enhance patients' medication adherence. Given the differences in the design and implementation of eHealth interventions, further large-scale, well-designed multicenter trials are needed.

TRIAL REGISTRATION

INPLASY 2023120063; https://inplasy.com/inplasy-2023-12-0063/.

Effectiveness of digital health interventions for telemedicine/telehealth for managing blood pressure in adults: a systematic review and meta-analysis

This systematic review and meta-analysis included randomized controlled trials or observational studies that compare digital health interventions (DHIs) for telemedicine/telehealth versus usual care for managing blood pressure (BP) in adults. We searched PubMed, Cochrane CENTRAL, and IchuShi-Web, and used a random-effects meta-analysis of the weighted mean difference (MD) between the comparison groups to pool data from the included studies. The outcome included the pooled MD of office BP from baseline to each follow-up period. This meta-analysis considered 117 studies with 68677 participants as eligible. The 3-month intervention period reduced office systolic BP (SBP) compared with usual care in 38 studies (MD: -3.21 mmHg [95% confidence interval: -4.51 to -1.90]), with evidence of heterogeneity. Office SBP across intervention periods demonstrated comparable effects (3-, 6- [54 studies], 12- [43 studies], and >12-month periods [9 studies]). The benefits for office diastolic BP were similar to those for office SBP. Additionally, the interventions significantly reduced the office SBP compared with the control, regardless of the mode of intervention delivery (smartphone apps [38 studies], text messages [35 studies], and websites [34 studies]) or type of facility (medical [74 studies] vs. non-medical [33 studies]). The interventions were more effective in 41 hypertension cohorts compared with 66 non-hypertension cohorts (-4.81 mmHg [-6.33, -3.29] vs. -2.17 mmHg [-3.15, -1.19], P = 0.006 for heterogeneity). In conclusion, DHIs for telemedicine/telehealth improved BP management compared with usual care. The effectiveness with heterogeneity should be considered, as prudent for implementing evidence-based medicine. This meta-analysis considered 117 studies with 68677 participants eligible. The DHIs for telemedicine/telehealth reduced office BP compared with usual care, regardless of intervention duration, intervention delivery mode, facility type, and cohort type. Additionally, the DHIs reduced the risk of uncontrolled BP compared with usual care, regardless of intervention duration, intervention delivery mode, and facility type. BP blood pressure, DHI digital health intervention, MD mean difference, RR risk ratio, SBP systolic blood pressure.

Effectiveness of a Multifaceted Mobile Health Intervention (Multi-Aid-Package) in Medication Adherence and Treatment Outcomes Among Patients With Hypertension in a Low- to Middle-Income Country: Randomized Controlled Trial

BACKGROUND

The high prevalence of uncontrolled hypertension in Pakistan is predominantly attributed to poor medication adherence. As more than 137 million people in Pakistan use cell phones, a suitable mobile health (mHealth) intervention can be an effective tool to overcome poor medication adherence.

OBJECTIVE

We sought to determine whether a novel mHealth intervention is useful in enhancing antihypertensive therapy adherence and treatment outcomes among patients with hypertension in a low- to middle-income country.

METHODS

A 6-month parallel, single-blinded, superiority randomized controlled trial recruited 439 patients with hypertension with poor adherence to antihypertensive therapy and access to smartphones. An innovative, multifaceted mHealth intervention (Multi-Aid-Package), based on the Health Belief Model and containing reminders (written, audio, visual), infographics, video clips, educational content, and 24/7 individual support, was developed for the intervention group; the control group received standard care. The primary outcome was self-reported medication adherence measured using the Self-Efficacy for Appropriate Medication Adherence Scale (SEAMS) and pill counting; the secondary outcome was systolic blood pressure (SBP) change. Both outcomes were evaluated at baseline and 6 months. Technology acceptance feedback was also assessed at the end of the study. A generalized estimating equation was used to control the covariates associated with the probability of affecting adherence to antihypertensive medication.

RESULTS

Of 439 participants, 423 (96.4%) completed the study. At 6 months post intervention, the median SEAMS score was statistically significantly higher in the intervention group compared to the controls (median 32, IQR 11 vs median 21, IQR 6; U=10,490, P<.001). Within the intervention group, there was an increase in the median SEAMS score by 12.5 points between baseline and 6 months (median 19.5, IQR 5 vs median 32, IQR 11; P<.001). Results of the pill-counting method showed an increase in adherent patients in the intervention group compared to the controls (83/220, 37.2% vs 2/219, 0.9%; P<.001), as well as within the intervention group (difference of n=83, 37.2% of patients, baseline vs 6 months; P<.001). There was a statistically significant difference in the SBP of 7 mmHg between the intervention and control groups (P<.001) at 6 months, a 4 mmHg reduction (P<.001) within the intervention group, and a 3 mmHg increase (P=.314) within the controls. Overall, the number of patients with uncontrolled hypertension decreased by 46 in the intervention group (baseline vs 6 months), but the control group remained unchanged. The variables groups (adjusted odds ratio [AOR] 1.714, 95% CI 2.387-3.825), time (AOR 1.837, 95% CI 1.625-2.754), and age (AOR 1.618, 95% CI 0.225-1.699) significantly contributed (P<.001) to medication adherence. Multi-Aid-Package received a 94.8% acceptability score.

CONCLUSIONS

The novel Multi-Aid-Package is an effective mHealth intervention for enhancing medication adherence and treatment outcomes among patients with hypertension in a low- to middle-income country.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04577157; https://clinicaltrials.gov/study/NCT04577157.

Effectiveness of digital health interventions on blood pressure control, lifestyle behaviours and adherence to medication in patients with hypertension in low-income and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Background

Digital health interventions can be effective for blood pressure (BP) control, but a comparison of the effectiveness and application of these types of interventions has not yet been systematically evaluated in low- and middle-income countries (LMICs). This study aimed to compare the effectiveness of digital health interventions according to the World Health Organisation (WHO) classifications of patients in terms of BP control, lifestyle behaviour changes, and adherence to medication in patients with hypertension in LMICs.

Methods

In this systematic review and meta-analysis, we searched the PubMed, Scopus, Web of Science, Embase, CINAHL, and Cochrane Library databases for randomised controlled trials (RCTs) published in English, comprised of adults (≥18 years old) with hypertension and the intervention consisted of digital health interventions according to WHO's classifications for patients in LMICs between January 1, 2009, and July 17, 2023. We excluded RCTs that considered patients with hypertension comorbidities such as diabetes and hypertension-mediated target organ damage (HMTOD). The references were downloaded into Mendeley Desktop and imported into the Rayyan web tool for deduplication and screening. The risk of bias was assessed using Cochrane Risk of Bias 2. Data extraction was done according to Cochrane's guidelines. The main outcome measures were mean systolic blood pressure (SBP) and BP control which were assessed using the random-effect DerSimonian-Laird and Mantel-Haenszel models. We presented the BP outcomes, lifestyle behaviour changes and medication adherence in forest plots as well as summarized them in tables. This study is registered with PROSPERO, CRD42023424227.

Findings

We identified 9322 articles, of which 22 RCTs from 12 countries (n = 12,892 respondents) were included in the systematic review. The quality of the 22 studies was graded as high risk (n = 7), had some concerns (n = 3) and low risk of bias (n = 12). A total of 19 RCTs (n = 12,418 respondents) were included in the meta-analysis. Overall, digital health intervention had significant reductions in SBP [mean difference (MD) = -4.43 mmHg (95% CI -6.19 to -2.67), I2 = 92%] and BP control [odds ratio (OR) = 2.20 (95% CI 1.64-2.94), I2 = 78%], respectively, compared with usual care. A subgroup analysis revealed that short message service (SMS) interventions had the greatest statistically significant reduction of SBP [MD = -5.75 mm Hg (95% Cl -7.77 to -3.73), I2 = 86%] compared to mobile phone calls [MD = 3.08 mm Hg (-6.16 to 12.32), I2 = 87%] or smartphone apps interventions [MD = -4.06 mm Hg (-6.56 to -1.55), I2 = 79%], but the difference between groups was not statistically significant (p = 0.14). The meta-analysis showed that the interventions had a significant effect in supporting changes in lifestyle behaviours related to a low salt diet [standardised mean difference (SMD) = 1.25; (95% CI 0.64-1.87), I2 = 89%], physical activity [SMD = 1.30; (95% CI 0.23-2.37), I2 = 94%] and smoking reduction [risk difference (RR) = 0.03; (95% CI 0.01-0.05), I2 = 0%] compared to the control group. In addition, improvement in medication adherence was statistically significant and higher in the intervention group than in the control group [SMD = 1.59; (95% CI 0.51-2.67), I2 = 97%].

Interpretation

Our findings suggest that digital health interventions may be effective for BP control, changes in lifestyle behaviours, and improvements in medication adherence in LMICs. However, we observed high heterogeneity between included studies, and only two studies from Africa were included. The combination of digital health interventions with clinical management is crucial to achieving optimal clinical effectiveness in BP control, changes in lifestyle behaviours and improvements in medication adherence.

Funding

None.

Community-based intervention for managing hypertension and diabetes in rural Bangladesh

BACKGROUND

Approximately 80% of non-communicable diseases (NCDs) have been reported in low- and middle-income countries (LMICs). However, studies on the usefulness of educational interventions run by non-healthcare workers in combating NCDs in resource-limited areas in rural parts of LMICs are limited. This study aimed to identify the effectiveness of a community-based simple educational program run by non-healthcare trained staff for several outcomes associated with NCDs in a resource-limited area.

METHODS

Six villages in the Narail district in Bangladesh were selected, two each in the first and second intervention and the control groups, in the Narail district in Bangladesh were selected. Pre- and post-intervention survey data were collected. The first intervention group received the "strong" educational intervention that included a checklist poster on the wall, phone call messages, personalized advice papers, seminar videos, and face-to-face seminars. The second intervention group received a "weak" intervention that included only a checklist poster on the wall in their house. The outcome was the proportion of NCDs and changes in systolic blood pressure and blood sugar level. Confidential fixed-effects logistic regression and multiple linear regression were performed to identify the effectiveness of the intervention.

RESULTS

Overall, 600 participants completed the baseline survey and the follow-up survey. The mean systolic blood pressure reduced by 7.3 mm Hg (95% confidence interval [CI] 4.6-9.9) in the first intervention group, 1.9 mm Hg (95% CI - 0.5-4.2) in the second intervention group, and 4.7 mm Hg (95% CI 2.4-7.0) in the control group. Multiple linear regression analysis showed that the between-group differences in the decline in systolic blood pressure were significant for the first intervention versus control (p = 0.001), but not for the second intervention versus control (p = 0.21). The between-group differences in the reduction in blood glucose after the intervention, were not significant on multiple linear regression analysis.

CONCLUSIONS

Community-based educational interventions for NCDs provided by non-healthcare staff improved the outcomes of hypertension and risk behaviors. Well-designed community-based educational interventions should be frequently implemented to reduce NCDs in rural areas of low- and middle-income countries. Trial registration UMIN Clinical Trials Registry (UMIN-CTR; UMIN000050171) retrospectively registered on January 29, 2023.

Research Gaps in Pediatric Heart Failure: Defining the Gaps and Then Closing Them Over the Next Decade

Given the numerous opportunities and the wide knowledge gaps in pediatric heart failure, an international group of pediatric heart failure experts with diverse backgrounds were invited and tasked with identifying research gaps in each pediatric heart failure domain that scientists and funding agencies need to focus on over the next decade.

A systematic review and meta-analysis of the effectiveness of hypertension interventions in faith-based organisation settings

Background

Hypertension is the global, leading cause of mortality and is the main risk factor for cardiovascular disease. Community-based partnerships can provide cost-saving ways of delivering effective blood pressure (BP) interventions to people in resource-poor settings. Faith-based organisations (FBOs) prove important potential health partners, given their reach and community standing. This potential is especially strong in hard-to-reach, socio-economically marginalised communities. This systematic review explores the state of the evidence of FBO-based interventions on BP management, with a focus on randomised controlled trials (RCTs) and cluster RCTs (C-RCTs).

Methods

Seven academic databases (English = 5, Chinese = 2) and grey literature were searched for C-/RCTs of community-based interventions in FBO settings. Only studies with pre- and post-intervention BP measures were kept for analysis. Random effects models were developed using restricted maximum likelihood estimation (REML) to estimate the population average mean change and 95% confidence interval (CI) of both systolic and diastolic blood pressure (SBP and DBP). The overall heterogeneity was assessed by successively adding studies and recording changes in heterogeneity. Prediction intervals were generated to capture the spread of the pooled effect across study settings.

Results

Of the 19 055 titles identified, only 11 studies of fair to good quality were kept for meta-analysis. Non-significant, average mean differences between baseline and follow-up for the intervention and control groups were found for both SBP (0.78 mm of mercury (mmHg) (95% CI = 2.11-0.55)) and DBP (-0.20 mm Hg (95% CI = -1.16 to 0.75)). Subgroup analysis revealed a significant reduction in SBP of -6.23 mm Hg (95% CI = -11.21 to -1.25) for populations with mean baseline SBP of ≥140 mm Hg.

Conclusions

The results support the potential of FBO-based interventions in lowering SBP in clinically hypertensive populations. However, the limited evidence was concentrated primarily in Christian communities in the US More research is needed to understand the implications of such interventions in producing clinically meaningful long-term effects in a variety of settings. Further research can illuminate factors that affect success and potential expansion to sites outside the US as well as non-Christian FBOs. Current evidence is inadequate to evaluate the potential of FBO-based interventions in preventing hypertension in non-hypertensive populations. Intervention effects in non-hypertensive population might be better reflected through intermediate outcomes.

A Randomized Controlled Trial using Brief Educational Messages Directed to Adults with Intellectual Disability and Hypertension or their Helpers Reduces Hospital Stays

PURPOSE

We assessed an educational intervention to reduce the number of emergency department (ED) and inpatient stays for cardiovascular diagnoses, among South Carolina adult Medicaid Members with intellectual and developmental disability and hypertension (Members).

DESIGN

This Randomized Controlled Trial (RCT) included Members or the person who helped them with their medications (Helpers). Participants, who included Members and/or their Helpers, were randomly assigned to an Intervention or Control group.

SETTING

South Carolina Department of Health and Human Services, which administers Medicaid, identified eligible Members.

SAMPLE

412 Medicaid Members - 214 Intervention (54 Members participating directly; 160 Helpers participating in lieu of Members) who received the messages about hypertension and surveys about knowledge and behavior and 198 Controls (62 Members; 136 Helpers) who only received surveys of knowledge and behavior.

INTERVENTION

Educational intervention about hypertension included a flyer and monthly text or phone messages for one year.

MEASURES

Input measures - characteristics of the Members; Outcome measures - hospital emergency department (ED) and inpatient visits for cardiovascular conditions.

ANALYSIS

Quantile regression tested the association of Intervention/Control group status with ED and inpatient visits. We also estimated models using Zero-inflated Poisson (ZIP) models for sensitivity analysis.

RESULTS

Participants in the Intervention group with highest baseline hospital use (top 20% ED; top 15% Inpatient) had significant reductions in Year 1 (.57 fewer ED and 2 fewer inpatient days) compared to the Control group. For ED visits, improvement continued in year two.

CONCLUSION

The intervention reduced the frequency of cardiovascular disease-related ED visits and Inpatient days for participants in the Intervention group in the highest quantiles of hospital use, and the improvement was better for those who had a Helper.

Assessing the Effectiveness of mHealth Interventions for Diabetes and Hypertension Management in Africa: Systematic Review and Meta-Analysis

Background

Mobile health (mHealth) interventions are effective in improving chronic disease management, mainly in high-income countries. However, less is known about the efficacy of mHealth interventions for the reduction of cardiovascular risk factors, including for hypertension and diabetes, which are rapidly increasing in low- and middle-income countries.

Objective

This study aimed to assess the efficacy of mHealth interventions for diabetes and hypertension management in Africa.

Methods

We searched PubMed, Cochrane Library, Google Scholar, African Journals Online, and Web of Science for relevant studies published from inception to July 2022. The main outcomes of interest were changes in hemoglobin A1c (HbA1c), systolic blood pressure, and diastolic blood pressure. The random or fixed effect model was used for the meta-analysis, and the I2 statistic was used to gauge study heterogeneity. Z tests and P values were used to evaluate the effect of mHealth interventions on HbA1c and blood pressure levels.

Results

This review included 7 studies (randomized controlled trials) with a total of 2249 participants. Two studies assessed the effect of mHealth on glycemic control, and 5 studies assessed the effect of mHealth on blood pressure control. The use of mHealth interventions was not associated with significant reductions in HbA1c levels (weighted mean difference [WMD] 0.20, 95% CI -0.40 to 0.80; P=.51) among patients with diabetes and systolic blood pressure (WMD -1.39, 95% CI -4.46 to 1.68; P=.37) and diastolic blood pressure (WMD 0.36, 95% CI -1.37 to 2.05; P=.69) among patients with hypertension. After conducting sensitivity analyses using the leave-one-out method, the Kingue et al study had an impact on the intervention, resulting in a 2 mm Hg reduction in systolic blood pressure (WMD -2.22, 95% CI -3.94 to -0.60; P=.01) but was nonsignificant for diastolic blood pressure and HbA1c levels after omitting the study.

Conclusions

Our review provided no conclusive evidence for the effectiveness of mHealth interventions in reducing blood pressure and glycemic control in Africa among persons with diabetes and hypertension. To confirm these findings, larger randomized controlled trials are required.

Efficacy of mHealth and education-led peer counseling for patients with hypertension and coronary artery disease in Pakistan: study protocol for a double-blinded pragmatic randomized-controlled trial with factorial design

BACKGROUND

Hypertension is a highly relevant public health challenge. Digital interventions may support improving adherence to anti-hypertensive medications and alter health behavior. Therefore, this protocol describes a study that aims to assess the effectiveness of mHealth and educational support through peer counseling (Ed-counselling) to control blood pressure in hypertensive patients when compared to standard care.

METHODS

We chose a double-blinded pragmatic randomized-controlled with factorial design for this investigation. The trial is going to recruit 1648 hypertensive patients with coronary artery disease at the age of 21 to 70 years. All participants will already be on anti-hypertensive medication and own a smartphone. They will be randomized into four groups with each having 412 participants. The first group will only receive standard care; while the second group, in addition to standard care, will receive monthly Ed-counselling (educational booklets with animated infographics and peer counseling); the third group will receive daily written and voice reminders and an education-led video once weekly together with standard care; while the fourth one gets both interventions given to second and third groups respectively. All groups will be followed-up for 1 year (0, 6, and 12 months). The primary outcome will be the change in systolic blood pressure while secondary outcomes include health-related quality of life and changes in medication adherence. For measuring changes in systolic blood pressure (SBP) and adherence scores difference at 0, 6, and 12 months between and within the group, parametric (ANOVA/repeated measure ANOVA) and non-parametric tests (Kruskal-Wallis test/Friedman test) will be used. By using the general estimating equation (GEE) with negative binomial regression, at 12 months, the covariates affecting primary and secondary outcomes will be determined and controlled. The analysis will be intention-to-treat. All the outcomes will be analyzed at 0, 6, and 12 months; however, the final analysis will be at 12 months from baseline.

DISCUSSION

Besides adding up to existing evidence in the literature on the subject, our designed modules using mHealth technology can help in reducing hypertension-related morbidity and mortality in developing countries.

Effectiveness of mHealth Interventions in Medication Adherence among Patients with Cardiovascular Diseases: A Systematic Review

mHealth interventions have been reported to improve adherence to long-term therapies in chronic conditions. Therefore, this study aimed at determining the effectiveness of mHealth interventions in medication adherence among patients with cardiovascular diseases (CVDs), a leading cause of mortality globally. Relying on our inclusion criteria and the PRISMA recommendations, a literature search was carried out in the PubMed, Medline, and ProQuest databases for primary studies that investigated the impact of mHealth on medication adherence for cardiovascular disease (CVD) between 2000–2021. A total of 23 randomized controlled trials with 34,915 participants matched the selection criteria. The mHealth interventions used included text messages, mobile phone applications, and voice calls, which were used either as a single intervention or combined. Additionally, studies on enhancing drug adherence had contradictory findings: most of the studies elaborated positive results; however, six studies were unable to reveal any significant effect. Finally, a risk bias analysis revealed varying outcomes across all studies. This review, as a whole, supported the notion that mHealth interventions can be effective in improving adherence to CVD medication even though they could not improve adherence to all CVD medications when compared with controls. Further trials with more refined designs integrated with comprehensive interventions are needed to produce better health outcomes.

Effectiveness, reach, uptake, and feasibility of digital health interventions for adults with hypertension: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Digital health interventions are effective for hypertension self-management, but a comparison of the effectiveness and implementation of the different modes of interventions is not currently available. This study aimed to compare the effectiveness of SMS, smartphone application, and website interventions on improving blood pressure in adults with hypertension, and to report on their reach, uptake, and feasibility.

METHODS

In this systematic review and meta-analysis we searched CINAHL Complete, Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid MEDLINE, and APA PsycInfo on May 25, 2022, for randomised controlled trials (RCTs) published in English from Jan 1, 2009, that examined the effectiveness of digital health interventions on reducing blood pressure in adults with hypertension. Screening was carried out using Covidence, and data were extracted following Cochrane's guidelines. The primary endpoint was change in the mean of systolic blood pressure. Risk of bias was assessed with Cochrane Risk of Bias 2. Data on systolic and diastolic blood pressure reduction were synthesised in a meta-analysis, and data on reach, uptake and feasibility were summarised narratively. Grading of Recommendations, Assessment, Development, and Evaluation criteria were used to evaluate the level of evidence. The study was registered with PROSPERO CRD42021247845.

FINDINGS

Of the 3235 records identified, 29 RCTs from 13 regions (n=7592 participants) were included in the systematic review, and 28 of these RCTs (n=7092 participants) were included in the meta-analysis. 11 studies used SMS as the primary mode of delivery of the digital health intervention, 13 used smartphone applications, and five used websites. Overall, digital health intervention group participants had a -3·62 mm Hg (95% CI -5·22 to -2·02) greater reduction in systolic blood pressure, and a -2·45 mm Hg (-3·83 to -1·07) greater reduction in diastolic blood pressure, compared with control group participants. No statistically significant differences between the three different modes of delivery were observed for both the systolic (p=0·73) and the diastolic blood pressure (p=0·80) outcomes. Smartphone application interventions had a statistically significant reduction in diastolic blood pressure (-2·45 mm Hg [-4·15 to -0·74]); however, there were no statistically significant reductions for SMS interventions (-1·80 mm Hg [-4·60 to 1·00]) or website interventions (-3·43 mm Hg [-7·24 to 0·38]). Due to the considerable heterogeneity between included studies and the high risk of bias in some, the level of evidence was assigned a low overall score. Interventions were more effective among people with greater severity of hypertension at baseline. SMS interventions reported higher reach and smartphone application studies reported higher uptake, but differences were not statistically significant.

INTERPRETATION

SMS, smartphone application, and website interventions were associated with statistically and clinically significant systolic and diastolic blood pressure reductions, compared with usual care, regardless of the mode of delivery of the intervention. This conclusion is tempered by the considerable heterogeneity of included studies and the high risk of bias in most. Future studies need to describe in detail the mediators and moderators of the effectiveness and implementation of these interventions, to both further improve their effectiveness as well as increase their reach, uptake, and feasibility.

FUNDING

European Union's Horizon 2020 Research and Innovation Programme.

Effects of community family doctors-led intervention for self-management and medication adherence in type 2 diabetes mellitus patients: study protocol of a cluster randomised controlled trial

INTRODUCTION

The management of diabetes has become a critical public health issue in China. The development of community-based type 2 diabetes management in China has not yet reached an ideal state, and the most suitable management methods for diabetic patients are still being explored. Few studies have used community-based family doctors to perform interventions of appropriate intensity. This protocol describes a planned randomised controlled trial to evaluate the effectiveness of a family doctor-led intervention model for diabetes self-management and medication adherence in type 2 diabetes mellitus patients.

METHODS AND ANALYSIS

This is a Standard Protocol Items: Recommendations for Interventional Trials-compliant cluster randomised controlled trial. The study will be conducted at four CHCs (community health centers). The control group will receive conventional medical services and health education. The intervention group will receive an intervention led by community family doctors based on the conventional medical services and health education. It will include five parts: usual care, a medication reminder, a 4-week plan, a weekly phone interview and a monthly interview. The primary outcomes are changes in fasting blood glucose, glycosylated haemoglobin, self-management knowledge and behaviour, and medication adherence from baseline to the 3rd and 6th months. The secondary outcome is the proportion of people whose blood sugar and glycosylated haemoglobin are under control in the 3rd and 6th months.

ETHICS AND DISSEMINATION

The study proposal was approved by the Biomedical Ethics Committee of the Medical Department of Xi'an Jiaotong University (no. 2021-1371). The findings will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry, ChiCTR2100051685.

Determining the frequency and level of task-sharing for hypertension management in LMICs: A systematic review and meta-analysis

BACKGROUND

Low- and middle-income countries (LMICs) bear a disproportionately higher burden of Cardiovascular Disease (CVD). Team-based care approach adds capacity to improve blood pressure (BP) control. This updated review aimed to test team-based care efficacy at different levels of hypertension team-based care complexity.

METHODS

We searched PubMed, Embase, Cochrane, and CINAHL for newer articles on task-sharing interventions to manage hypertension in LMICs. Levels of tasks complexity performed by healthcare workers added to the clinical team in hypertension control programs were categorized as administrative tasks (level 1), basic clinical tasks (level 2), and/or advanced clinical tasks (level 3). Meta-analysis using an inverse variance weighted random-effects model summarized trial-based evidence on the efficacy of team-based care on BP control, compared with usual care.

FINDINGS

Forty-three RCT articles were included in the meta-analysis: 31 studies from the previous systematic review, 12 articles from the updated search. The pooled mean effect for team-based care was a -4.6 mm Hg (95% CI: -5.8, -3.4, I²  = 80.2%) decrease in systolic BP compared with usual care. We found similar comparative reduction among different levels of team-based care complexity, i.e., administrative and basic clinical tasks (-4.7 mm Hg, 95% CI: -6.8, -2.2; I²  = 79.8%); and advanced clinical tasks (-4.5 mmHg, 95%CI: -6.1, -3.3; I²  = 81%). Systolic BP was reduced most by team-based care involving pharmacists (-7.3 mm Hg, 95% CI: -9.2, -5.4; I²  = 67.2%); followed by nurses (-5.1 mm Hg, 95% CI: -8.0, -2.2; I²  = 72.7%), dieticians (-4.7 mmHg, 95%CI: -7.1, -2.3; I²  = 0.0%), then community health workers (-3.3 mm Hg, 95% CI: -4.8, -1.8; I²  = 77.3%).

INTERPRETATION

Overall, team-based hypertension care interventions consistently contributed to lower systolic BP compared to usual care; the effect size varies by the clinical training of the healthcare team members.

FUNDING

Resolve To Save Lives (RTSL) Vital Strategies, Danielle Cazabon, Andrew E. Moran, Yvonne Commodore-Mensah receive salary support from Resolve to Save Lives, an initiative of Vital Strategies. Resolve to Save Lives is jointly supported by grants from Bloomberg Philanthropies, the Bill & Melinda Gates Foundation, and Gates Philanthropy Partners, which is funded with support from the Chan Zuckerberg Foundation.

Tulane STAR (Sending Texts, Advancing Results): impact of text messaging on bariatric post-operative protocol compliance

BACKGROUND

Text messaging is frequently employed in the outpatient setting to communicate with or send reminders to patients. However, there is a paucity of literature on the impact of text messaging on inpatient care. In this study, the use of text messaging in hospitalized patients is evaluated by assessing patient compliance to a post-operative bariatric protocol.

METHODS

This was a randomized controlled trial that studied compliance to a post-operative bariatric protocol in patients who underwent bariatric surgery at a tertiary, academic medical center between February and May 2021. Patients were randomized to either the control group, in which they received standard post-operative education alone or the Tulane Sending Texts, Advancing Results (STAR) intervention arm, in which participants received the same post-operative education along with two text message reminders to drink water, use their incentive spirometers, and ambulate (per post-operative instructions) on post-operative day (POD) # 0 and POD # 1. The primary outcome was compliance with the protocol, defined as the number of 1-oz cups of water consumed, incentive spirometry usage, and ambulation frequency and distance. Secondary outcomes include length of stay and complications.

RESULTS

A total of 35 patients were enrolled in the study (17 control, 18 STAR intervention). There was no significant difference in age, BMI, or type of surgery performed between the two groups. Clear liquid consumption was significantly higher in the STAR intervention group with an average of 27.7 ± 3.5 cups as compared to 18.2 ± 8.9 in the control group (p < 0.001). Similarly, statistically significant increases in incentive spirometry usage (p < 0.01) and ambulation distance and frequency (p < 0.02) were observed in the STAR intervention group.

CONCLUSIONS

While patients are in the hospital, text messaging can improve compliance to post-operative protocols. Peri-operative text messaging can enhance patient education and communication.

Predictors of Smartphone and Tablet Use Among Patients With Hypertension: Secondary Analysis of Health Information National Trends Survey Data

BACKGROUND

Uncontrolled hypertension leads to significant morbidity and mortality. The use of mobile health technology, such as smartphones, for remote blood pressure (BP) monitoring has improved BP control. An increase in BP control is more significant when patients can remotely communicate with their health care providers through technologies and receive feedback. Little is known about the predictors of remote BP monitoring among hypertensive populations.

OBJECTIVE

The objective of this study is to quantify the predictors of smartphone and tablet use in achieving health goals and communicating with health care providers via SMS text messaging among hypertensive patients in the United States.

METHODS

This study was a cross-sectional, secondary analysis of the 2017 and 2018 Health Information National Trends Survey 5, cycles 1 and 2 data. A total of 3045 respondents answered "Yes" to the question "Has a doctor or other healthcare provider ever told you that you had high blood pressure or hypertension?", which defined the subpopulation used in this study. We applied the Health Information National Trends Survey full sample weight to calculate the population estimates and 50 replicate weights to calculate the SEs of the estimates. We used design-adjusted descriptive statistics to describe the characteristics of respondents who are hypertensive based on relevant survey items. Design-adjusted multivariable logistic regression models were fitted to estimate predictors of achieving health goals with the help of smartphone or tablet and sending or receiving an SMS text message to or from a health care provider in the last 12 months.

RESULTS

An estimated 36.9%, SE 0.9% (183,285,150/497,278,883) of the weighted adult population in the United States had hypertension. The mean age of the hypertensive population was 58.3 (SE 0.48) years. Electronic communication with the doctor or doctor's office through email or internet (odds ratio 2.93, 95% CI 1.85-4.63; P<.001) and having a wellness app (odds ratio 1.82, 95% CI 1.16-2.86; P=.02) were significant predictors of using SMS text message communication with a health care professional, adjusting for other demographic and technology-related variables. The odds of achieving health-related goals with the help of a tablet or smartphone declined significantly with older age (P<.001) and ownership of basic cellphones (P=.04). However, they increased significantly with being a woman (P=.045) or with being married (P=.03), having a wellness app (P<.001), using devices other than smartphones or tablets to monitor health (P=.008), making health treatment decisions (P=.048), and discussing with a provider (P=.02) with the help of a tablet or smartphone.

CONCLUSIONS

Intervention measures accounting for age, gender, marital status, and the patient's technology-related health behaviors are required to increase smartphone and tablet use in self-care and SMS text message communication with health care providers.

Integration of text messaging intervention into hypertension management among older adults: A systematic review and meta-analysis

BACKGROUND

An aging population and required hypertension control are global concerns that burden the healthcare system. Text messaging interventions have been developed to support hypertension management, but their effects on the older population are unknown.

OBJECTIVES

This review aimed to identify the effects of a text messaging intervention on hypertension management among older adults.

METHODS

Four English and two Chinese databases with randomized controlled trials published between January 2010 and December 2020 were searched. The mean age of the participants was 60 years or above. Participants were also diagnosed with hypertension. The Cochrane risk-of-bias tool was used for the critical appraisal. Data in each study were extracted, and a meta-analysis was presented in terms of mean difference (MD) and standardized mean difference (SMD).

RESULTS

A total of 1670 records were screened, of which six were included in the final review. The intervention of the included studies lasted up to 6 months, and one-way text messaging was commonly used. Meta-analysis showed that a text messaging intervention significantly reduced systolic blood pressure (MD = -6.11, p < .01) but not diastolic blood pressure. Regarding medication adherence, a moderate effect was noted with the use of text messaging among older adults with hypertension (SMD = 0.65, p = .01).

LINKING EVIDENCE TO ACTION

A text messaging intervention can improve hypertension management among older adults. The standardized content of one-way text messaging is suggested to be delivered weekly.

Effectiveness of Text Messaging Interventions on Blood Pressure Control Among Patients With Hypertension: Systematic Review of Randomized Controlled Trials

Background

Controlling blood pressure (BP) is an international health concern, and high BP is a major contributor to cardiovascular disease mortality. Evidence has shown that educational interventions directed at patients potentially improve BP control and adherence to medications and lifestyle modifications. In addition, a text messaging intervention has a potential effect on BP control; however, the dosage of a text messaging intervention has not been determined in previous reviews, resulting in difficult application in practice.

Objective

This review aimed to identify the effectiveness of a text messaging intervention on hypertension management with a specific focus on the dosage of text messaging and the type of additional interventions with text messaging.

Methods

A systematic review was conducted and reported on in accordance with PRISMA guideline. Participants were aged 18 years and older and diagnosed with primary hypertension. The included studies used text messaging as a component of the intervention. We searched for randomized controlled trials published until June 30, 2020, from the following health-related electronic databases: Embase, Medline, CINAHL Complete, PsycINFO, and Scopus. Data were extracted for qualitative synthesis and meta-analysis. The Physiotherapy Evidence Database Scale was used to assess the methodological quality of each study, and the quality of the included studies was assessed independently by two authors.

Results

Twelve studies met the inclusion criteria. The overall methodological quality was fair (mean score 5.75). The frequency of text message delivery varied from daily to biweekly. Health education was identified in 4 studies as an additional intervention with text messaging. The overall results showed that the text messaging intervention significantly reduced systolic BP (SBP) but not diastolic BP (DBP). There was no significant difference in BP reduction between studies that lasted 6 months or less and those that lasted more than 7 months. Seven studies that lasted 6 months or less involving 1428 patients with hypertension were pooled for further meta-analysis. Text messages delivered at a lower frequency (once per week or less) had a small effect on SBP reduction (effect size 0.35, P<.01) and DBP reduction (effect size 0.28, P=.01). In addition, the use of a text messaging intervention halved the odds of uncontrolled BP among patients with hypertension in 6 months (odds ratio 0.46, P=.02).

Conclusions

This review found that a text messaging intervention was effective in BP control. One-way text messaging delivered in a weekly manner was suggested to be effective and required fewer resources. Future studies should use different forms of text message and be integrated into other interventions to improve adherence behaviors and BP control among patients with hypertension.

I text for I COUGH: A clinical pilot study to evaluate the impact of text messaging upon postoperative ambulation in the hospital

BACKGROUND

The "I COUGH" protocol is associated with improved postoperative pulmonary outcomes, and ambulation is an essential component. I COUGH is an acronym for Incentive spirometry, Coughing, Oral care, Understanding (patient and staff education), Getting-out-of-bed, and Head-of-bed elevation. This trial sought to enhance one component, specifically ambulation after operations.

METHODS

Randomized trial of inpatients in a safety-net, academic medical center. The intervention group received standard I COUGH education along with text message reminders to ambulate postoperatively, whereas the control group received standard education alone. Postoperative walking frequency was compared to each participant's ambulation on the day prior to enrollment.

RESULTS

The intervention group had an average improvement of 1.8 ± 1.8 walks per day per patient, while the average change for the control group was 0.2 ± 1.0 walks per day per patient. This represents a 9-fold increase in ambulation for the intervention group (p = 0.03).

CONCLUSIONS

Implementation of text message reminders increased ambulation and improved adherence to the I COUGH protocol following operations. This system should be further investigated as an adjunct to postoperative care.

Clinical outcomes of pharmaceutical care intervention in HIV positive patients with hypertension: A randomized controlled study

WHAT IS KNOWN AND OBJECTIVE

Pharmaceutical care (PC) has been shown to improve clinical outcomes in hypertensive patients as well as in people living with HIV (PLWHV). The objective of this study was to evaluate the impact of PC on blood pressure (BP) control, viral load and adherence to medications in hypertensive PLWHV.

METHODS

This was a prospective, randomized controlled study conducted in the University of Uyo Teaching Hospital, Uyo, Akwa Ibom State, Nigeria. Eligible ambulatory patients were randomized equally to two study arms. The control arm (CA) received the traditional care offered at the HIV clinic; the intervention arm (IA) received the traditional care in addition to PC by the research pharmacist, which included structured education/counselling. BP and self-reported medication adherence were measured at baseline, 6 months and 12 months. Viral load was obtained at baseline and after 12 months. Data were analysed with spss, version 25.0.

RESULTS AND DISCUSSION

Of the 206 participants initially randomized, 182 (91 in each study arm) completed the 12-month follow-up. No significant differences existed in both arms concerning socio-demographic/clinical characteristics of participants at baseline (p > 0.05). After 12 months, BP control was significantly higher in the IA (53.4% vs. 25.2%; p < 0.001, adjusted odds ratio, aOR = 3.20 (95% CI 1.59-6.44). Systolic BP reduced by 0.9 mmHg from baseline in the CA (p = 0.668) and by 16.67 mmHg from baseline value in the IA (p < 0.001). Diastolic BP increased by 1.9 mmHg in the CA (p = 0.444), but reduced by 7.0 mmHg in the IA (p < 0.001). No significant differences were observed in the change from baseline in the proportion with undetectable plasma viral load (UPVL) in both groups (p > 0.05). PC led to an increase in mean adherence to antiretroviral drugs (Δ = 0.55; p = 0.015), and an increase in mean adherence to antihypertensive drugs (Δ = 2.32; p < 0.001) in the IA.

WHAT IS NEW AND CONCLUSION

To our knowledge, this is the first prospective randomized controlled study evaluating the impacts of PC on clinical outcomes in hypertensive PLWHV with a 12-month follow-up. Our results show that PC significantly improved BP control and adherence to antiretroviral and antihypertensive medications, but had no significant effect on viral load in HIV positive patients with hypertension. Providers of care for PLWHV should leverage the established HIV treatment successes for promoting adherence to treatment for common comorbidities like hypertension in PLWHV in order to improve clinical outcomes.

Strategies to Improve Adherence to Anti-Hypertensive Medications: a Narrative Review

PURPOSE OF REVIEW

Medication adherence is critical for effective management of hypertension, yet half of patients with hypertension are non-adherent to medications. In this review, we describe and critically evaluate medication adherence interventions published in the past 3 years for patients with hypertension.

RECENT FINDINGS

We identified 1593 articles and 163 underwent full review, of which 42 studies met the inclusion criteria. Studies were classified into eight categories: simplification of medication regimen (e.g., fixed dose combination pills); electronic Health (eHealth) tools (e.g., text messaging reminders); behavioral counseling (e.g., motivational interviewing); healthcare system changes (e.g., patient-centered medical home); patient education; multicomponent chronic disease management program; home blood pressure monitoring; and financial incentives. Studies utilizing strategies to simplify medication regimens, eHealth tools, patient education, and behavioral counseling were most likely to report positive findings. Interventions targeting patient behavior were more likely to be associated with improvements in medication adherence compared to those targeting providers or the healthcare system. eHealth tools show promise for augmenting behavioral interventions. A major limitation of included trials was short study duration and use of self-report measures of medication adherence. Future research should explore how complex interventions that utilize a combination of evidence-based strategies and target multiple adherence behaviors (e.g., both day-to-day medication taking and long-term persistence) may be efficacious in improving medication adherence.