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

Abstract

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 have 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 Organization (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 PubMed, Scopus, Web of Science, Embase, CINAHL and Cochrane Library databases for randomised controlled trials (RCTs) published in English comprise 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 organs 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)], I 2 = 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 statistical 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, improvements 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.