Effectiveness of Interventions To Enable Hypertension Medication Adherence In Low-And Middle-Income Countries: A Systematic Review And Meta-analysis

Effectiveness of Interventions To Enable Hypertension Medication Adherence In Low-And Middle-Income Countries: A Systematic Review And Meta-analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Effectiveness of Interventions To Enable Hypertension Medication Adherence In Low-And Middle-Income Countries: A Systematic Review And Meta-analysis Olivia Nakwafila, Benn Sartorius, Sphamandla Josias Nkambule, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-856012/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: In recent decades low- and middle-income countries (LMICs) are witnessing an increase in hypertension and thus becoming a significant public health issue due to associated Cardiovascular disease (CVD) outcomes. Antihypertensive medication adherence is crucial to controlling blood pressure; therefore, this systematic review aimed to evaluate the effectiveness of non-pharmacological interventions on improving blood pressure control and medication adherence in patients with hypertension in LMICs. Methods: We searched the following databases for relevant literature published between Jan 2005 – Dec 2020: PubMed, EBSCOhost included Academic Search; CINAHL and MEDLINE complete; PubMed; WEB of Science; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews and Google Scholar. Cochrane risk of bias tool (RoB 2) was used to appraise included studies critically, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to measure the quality of evidence. We conducted a meta‑analysis using DrSimonian-Laid's random-effect model at 95% confidence intervals (CIs). The secondary outcomes of interests were synthesised descriptively as changes in BP adherence outcomes. Results: We identified 14 eligible randomised controlled trials that presented blood pressure (BP) effectiveness and medication adherence among BP patients aged between 18-75 years. The overall quality of evidence with the majority of trials was moderate. Meta weighed effect (SBP) for 12/14 studies was -4.74 (95% CI:-6.07 to -3.47) and I 2 = 57%. Out of 14 eligible studies, (86%) suggested a significant improvement in the proportion of patients with controlled blood pressure (BP < 140/90mmHG) with a positive effect on secondary outcomes such as quality of life. Conclusion: Non-pharmacological interventions could be effective in managing hypertension. In recommending the need to investigate the feasibility of non-pharmacological evidence in specific LMIC settings, focus should be on an intervention strategy consisting of an educational intervention directed toward the patients, health professionals and organisation. Considering heterogeneity, randomised trials that are well-designed with larger sample sizes are encouraged in LMICs` to help policymakers make well-informed decisions on hypertension management. Systematic review Registration: PROSPERO registration number: CRD42020172954 Internal Medicine Hypertension Adherence Randomised controlled trial Effective interventions Low and middle income countries Systematic review Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Hypertension is one of the leading risk factors for CVD worldwide [ 1 – 4 ]. Low- and middle-income countries have seen an increase in hypertension in recent decades, thus, making it a significant public health issue due to the associated adverse health outcomes such as the increased incidence of CVD accounting for 75% of the global deaths in LMICs (82% attributed to coronary heart disease (CHD), stroke and heart failure) [ 5 – 8 ]. Despite some LMICs offering universal access to hypertension medication, including Namibia, adherence to chronic medication remains a problem [ 6 , 9 – 11 ]. Recent data shows that CVD in Namibia accounted for 21% of annual deaths and a reported prevalence of blood pressure (BP) among women and men aged 35–64 at between 44–57% [ 12 , 13 ]. Thus, it would appear that the prevalence of hypertension in Namibia is high compared to the global and African regional prevalence of 22% and 27%, respectively[ 14 ]. Non-adherence to antihypertensive medication is common and contributes to poor BP control and adverse health outcomes [ 15 ]. While it is substantial to understand the barriers and enablers of non-adherence, it is equally important to explore different interventions' effectiveness on improving BP control and BP medication adherence [ 15 – 17 ]. Non-pharmacological interventions to encourage BP medication adherence include educational interventions directed towards the patients, educational interventions directed towards the health professional, appointment reminder systems/models, and Organisational interventions [ 10 , 18 – 23 ]. These Interventions intentionally target non-adherence contributing factors at different levels: patients, health care workers, and the health care system[ 24 , 25 ]. Many Higher-income countries have conducted extensive research on hypertension effective interventions [ 26 , 27 ]. However, we cannot say the same about LMICs, especially in sub-Saharan Africa [ 28 ]. Due to the scarcity of evidence on effective interventions in LMIC’s, thus far has caused a rise in CVD due to non-adherence despite pharmacological efforts [ 27 , 29 ]. The contradictions around effective interventions for BP continue based on evidence conducted from several reviews such as Cochrane [ 20 ]. Henceforth it is essential to systematically review interventions that can effectively be beneficial to LMICs and help inform the feasibility of possible country-specific BP interventions that are effective. Non-adherence, which usually occurs when BP patients fail to meet treatment goals [ 20 ], causes uncontrolled high blood pressure(Systolic blood pressure/SBP; Diastolic blood pressure/DBP) ( above 120/80), which increases the risk of severe health problems, including heart attack and stroke [ 30 ]. Data regarding BP medication adherence in Namibia is minimal, with one study spanning a sample of public health facilities in the Khomas region (capital region) reporting suboptimal adherence in 2017 [ 17 ]. Effective, widely available, low-cost, and sustainable strategies are needed to prevent and manage hypertension [ 15 ]. Existing systematic reviews on interventions have recommended that adequate control of hypertension in developing countries could be achievable by community-based programs and by upgrading primary health systems [ 16 , 17 , 29 ]. A critical barrier to scaling up the literature suggests a greater need to identify the optimal and effective way to organise and deliver care to hypertensive patients in LMIC's in order to improve BP medication adherence [ 19 , 20 ]. Benefits associated with blood pressure lowering include a reduction in many complications such as stroke (35–40%), heart attack (20–25%), and heart failure (over 50%) [ 22 , 23 ]. Achieving the WHO global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025 and the SDG target of a one-third reduction in premature deaths from NCDs by 2030 requires hypertension management interventions. Therefore, this systematic review aims to evaluate the effectiveness of non-pharmacological interventions on improving blood pressure control (Primary Outcome) and medication adherence (Secondary Outcome) in patients with hypertension in LMICs. We anticipate that the results from this study will provide current evidence on effective hypertension strategies targeted at controlling hypertension and CVD in LMIC settings. Methods A study protocol was developed prior to the conduct of this review. The protocol is registered in the PROSPERO international prospective register of systematic reviews and is accessible via the link below: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172954 . The Centre for Reviews and Dissemination (CRD) guideline for systematic reviews in health care guided this study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines[ 31 , 32 ]. Completed PRISMA checklist (see Additional file 1). Identifying the research question The identifying research question was the effectiveness of interventions to enable Hypertension Medication Adherence in LMICs. Eligibility criteria A Complete inclusion and exclusion criteria form part of this review protocol, registered with (PROSPERO; CRD42020172954). We included studies published from 2005 which met the following criteria: Hypertensive patients over 18 years of age and above, regardless of sex and ethnicity with a diagnosis of primary hypertension in a specified geographically defined LMIC setting; randomised controlled trials (RCTs) of hypertensive patients which evaluated non- pharmacological effectiveness of the following interventions to improve BP medication adherence: educational interventions directed to the patient, educational interventions directed to the health professional, self-monitoring, models on appointment reminder systems, organisational interventions aimed at delivery care. We excluded RCTs` not reporting evidence from LMIC settings published before 2005 and non-randomised controlled trials. Exclusion criteria also included studies reporting on other chronic illnesses, not reporting non-pharmacological effectiveness, and BP medication adherence outcome. Search strategy for the identification of relevant studies and information sources After consulting with an information scientist at the Department of Library Services, Faculty of Health Sciences, and the University of KwaZulu-Natal on literature search approaches, search strategies were developed based on the Cochrane Handbook of Intervention Guidelines and the Cochrane Central Register of Control Trials. To find relevant literature, we used the following keywords: hypertension or blood pressure, LMICs, adherence or compliance, control or monitoring, Educational, patient, Self-monitoring, health professional, reminder systems, organizational, delivery care. The Boolean search terms (AND OR) and MeSH terms were employed. A search of the following databases was performed in March 2019 and repeated in December 2020: PubMed, EBSCOhost included Academic Search; CINAHL and MEDLINE complete; PubMed; WEB of Science; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews and Google Scholar. Additionally, we searched Grey literature from university dissertations and theses from institutional repositories to retrieve relevant articles. We searched for randomised controlled trials conducted from January 2005 - December 2020 to capture the recent evidence on the effectiveness of hypertension interventions available in LMIC's. There was no language restrictions applied to the search. The search management After a rigorous, intensive search, we exported relevant articles to the Endnote X9 library. Following the import of relevant articles by title relevance, we removed duplicates before the abstract screening stage. We then conducted a selection of abstracts and full articles using eligibility criteria utilizing abstract and full title screening forms developed in Google (see Additional file 2) for identified articles and the date of each literature searching of each database. Independent reviewers (ON and PN) did the article screening. The third screener (SN) was involved in resolving discrepancies. Subsequently, we assessed disagreement using Cohen's Kappa coefficient (κ) statistic on Stata 13.0SE (StataCorp College Station, TX, USA (Additional file 3). Data extraction and quality assessment We used a data extraction tool developed in Google form based on a checklist provided in the Cochrane handbook for systematic review for intervention. The data extracted related to main study characteristics, including author, setting, type of randomised trial, intervention and control group details, and percentage of patients enrolled in intervention and control groups(see Table 1 at the end of manuscript for full characteristics of the studies). Meta-analysis data extracted included SBP/DBP changes from different non-pharmacological interventions (Additional file 4). The methodological quality of included studies was assessed using the Cochrane risk of bias tool Current version RoB 2, which include aspects of randomisation process; deviations from intended interventions; missing outcome data; measurement of the outcome; selection of the reported result, and overall bias (reported as Low, Some concerns or High) (Figure 2 ) [33]. Data extraction and quality assessment were conducted by two reviewers’ (ON and SN), and the third author resolved discrepancies through discussions and consensus. The quality of evidence was assessed according to the domains specified in the grading of recommendation, assessment, development, and evaluation (GRADE) guidelines [34]. Data synthesis and analysis The primary outcome of this study was to determine the effectiveness of interventions to enable hypertension medication adherence in Low-and Middle-Income Countries. Based on the nature of our research question, we synthesised the data by presenting changes in mean systolic blood pressure (SBP) and mean diastolic blood pressure (DBP). Systolic and diastolic blood pressure was analysed and calculated as mean difference (MD) and pooled to produce an overall random effect size between intervention and control groups. Heterogeneity among trials was conducted using the χ2 test at 95% confidence interval and I 2 statistic value. Forest and funnel plots were presented to show the results for the primary outcome The secondary outcome aim was to determine hypertension medication adherence between intervention and control groups. We synthesized the data descriptively by showing the proportion of patients with medication adherence between intervention and control groups and effect sizes for medication adherence between the two groups. Medication adherence indicators synthesized include quality of life, and knowledge, beliefs, and retention in clinical care, number of hospitalisations, and cost-effectiveness of interventions. We adopted the definitions used by individual studies for anti-hypertension treatment and adequate control of blood pressure. [35]. Data was captured in Microsoft Excel and analysed in MetaXL version 5.3 (EpiGear International, Sunrise Beach, and Queenland, Australia). Results Literature search and study characteristics The initial database search found 162 906 potentially eligible studies, of which 161 991 were excluded during title screening. Following title screening, 915 met eligibility criteria and were included in full title screening yielding 14 definitive studies and considered for meta-analysis (see Fig. 1 for the whole screening process). The inter-rater reliability score for full-article screening showed 61.34% agreement versus 92.00% expected by chance which constitutes a moderate agreement between the screeners (Kappa statistic = 0. 09 and p-value 0.05 (Additional file 3). All studies included and considered for meta-analysis are from LMICs conducted between 2005–2020 among patients diagnosed with hypertension ranging from 18 to 75 years. Additionally, most studies included parallel randomised controlled trials (n = 13) except one study, a 3-arm randomised trial conducted in a low resource setting in Cape -Town, South Africa. Studies recruited patients mostly from rural settings and low resource settings (n = 7), and five were conducted from government hospitals, including a community pharmacy (n = 1). The main reason for exclusion was non-randomised trials (n = 8), not LMIC's = 14; evaluated other chronic diseases apart from hypertension (n = 23) non-pharmacological (n = 5) and the rest were other reasons with studies which included older patients > 75 years and unclear methodology and outcome (n = 36). All studies included were published in English. Included articles all evaluated Educational intervention towards patients, however (7/14) articles evaluated more than one intervention of which it was either Educational intervention directed towards the health professional(2/14), Appointment reminder systems/models (7/14), or Organisational interventions (2/14). Appointment reminder systems encompassed principles of reminding patients when medicines were ready for collection or about scheduled clinic appointments information (2), organizational intervention aimed at delivery care- home BP monitoring and audit (2). Models on appointment reminder systems-reminder (3) box on taking medication. The primary care providers were medical and nursing staff, community pharmacists and health workers, family support. Community interventions were delivered in community hospitals, community centres, or patients' homes (see Table 1). Quality of included studies Eleven (11) studies were graded to be Low risk, and three as having some concerns. All studies described randomisation methods; however, among the studies with some concerns, two had issues with the randomisation process where allocation sequence and concealment of participants enrolled and assigned to intervention was not indicated. The article with concerns of outcome measurement did not indicate whether the outcome assessment would have been influenced by the intervention received. The rest of the studies did not indicate any concerns with deviations from intended interventions, missing outcome data, issues with measurement of the outcome, and selection of the reported results (Fig. 2 ). Overall, the GRADE quality of evidence was moderate (Additional file 10). Effects of interventions Primary outcomes (Meta-analysis results) Data pooled from all 14 studies showed heterogeneity across studies for systolic and diastolic blood pressure. Random effects of meta-analysis results show that systolic blood pressure was reduced by -7.61(-10.47, -4.74), with four exceptions where systolic blood pressure was slightly lower in the intervention group. Heterogeneity across studies was statistically significant ( I 2 = 92%, P = 0.00) ( Fig. 3 ). The pooled mean difference for diastolic blood pressure was − 3.48(-5.52, -43). Heterogeneity for DBP was statistically significant I 2 = 89%, P = 0.00) (Fig. 4 ). When we excluded two studies (Alhalaiqa, 2012 and Mirniam, 2019) SBP random effect was − 4.74 (95% CI:-6.07 to -3.47) and I 2 = 57%. (Fig. 5 ) and DBP (-4.56–1.27) and I 2 = 78% (Fig. 6). Additional results showing funnel plots are included in the supplementary file material (Additional file 5–8). Secondary outcome Proportion (%) of patients with controlled BP (BP < 140/90mmHg Secondary outcome results indicating BP adherence outcome measures are presented as the proportion(%) of controlled hypertensive patients with corresponding effect differences between intervention and control group through OR (95% confidence interval). Additional secondary outcomes synthesised include quality of life, level of hypertension knowledge, beliefs on hypertension, retention to care, and the number of hospitalisations (Additional file 9). Out of 14 articles presented in this paper, 12 have shown a significant proportion of patients with controlled blood pressure (BP < 140/90mmHG). Other secondary outcome results In addition to the proportion of controlled hypertension reported from all 14 studies, a total number of BP medication adherence indicators from the included studies were synthesized as follows: articles that evaluated the quality of life(7); level of hypertension knowledge (2); beliefs on hypertension (2), retention to care (2); and the number of hospitalisations (2). Some studies reported more than one indicator. Results reporting on the quality of life display better overall health status in the intervention group(s) than those in the control group, similarly, with knowledge and beliefs. An increase in the knowledge level in the intervention groups was reported to modify patients’ beliefs about medicines positively. Beliefs about medication in the intervention group have moved away from the view that medications are intrinsically harmful, towards one that recognises the benefits of medication. Retention in care, as well as hospital admissions, also improved. There was no significant difference in mean health care costs per patient between groups. Discussion Our systematic review findings reveal that Non-pharmacological interventions are effective in controlling blood pressure. We included studies from the following LMICs: Jordan, South Africa low resource settings, Turkey, India, Argentina, Bangladesh, Pakistan, Sri Lanka, Iran-Isfahan, Pakistan, China, and South Korea. We observed a statistically significant reduction in SBP and DBP .among the following interventions: Educational intervention towards patients, Educational intervention directed towards the health professional, Appointment reminder systems/models, and Organisational interventions. Educational interventions directed to the patient and health professional and Organisational interventions showed the high-moderate quality of evidence. These interventions can be pilot tested in LMIC's to establish suitable country specific BP strategies in anticipation to help meet Sustainable Development Goal (SDG) target 3.4 by reducing premature mortality from non-communicable diseases (NCDs) by a third by 2030. When we restricted analysis (12/14 studies), effects remained significant with low heterogeneity for SBP and DBP. Secondary outcomes, including quality of life, level of hypertension knowledge, beliefs on hypertension, retention to care, and the number of hospitalisations, showed a significant controlled blood pressure (BP < 140/90mmHG). The aforementioned secondary outcomes are well outlined in the WHO model of hypertension medication adherence as contributing factors of BP medication adherence. We believe that this is the first study to estimate aggregate BP effects of randomised controlled trials conducted in LMICs only. Studies included in this systematic review were conducted between 2005–2020 from low resource settings providing recent evidence on the effectiveness of BP interventions and medication adherence. The variability in heterogeneity can be observed when two studies (Alhalaiqa, 2012 and Mirniam) are excluded showing a significant reduction in SBP and DBP (Fig. 5 &6)). These studies had the weakest effect in the intervention groups, which could have been caused by high heterogeneity in random-effect analysis. Overall, we attribute heterogeneity across studies to different study periods, sample sizes, and pooling of multi-component interventions between studies. Though our findings had moderate evidence on average primarily because of inconsistency and publication bias, heterogeneity was expected because it is common in behavioral research [ 36 ]. Similar results on heterogeneity have been reported in several studies in High-income countries that evaluated the effectiveness of BP interventions [ 26 , 27 ]. Considering the current burden on hypertension in LMICs, our results have heightened the need for scaling up interventions to improve hypertension outcomes and meet global SDG in achieving universal health coverage in LMICs [ 37 ]. Meta-analysis studies on the effectiveness of BP interventions have been conducted in developed countries [ 26 , 27 ]. Interventions for hypertension show a more significant effect when administered in combination[ 36 ]. In agreement with significant effects of BP interventions when administered in combination is a Cochrane systematic review of 72 randomised trial studies which stated that educational interventions alone were unlikely to be effective[ 20 ]. Authors such as Anderson LJ et al. (2020) and Ampofo AG (2020) have stated that education interventions and reminders, including regular follow-ups, were found to be effective at improving patient adherence [ 38 , 39 ]. Health care workers play an essential role in making sure that these interventions are effective. Results from our study have shown a significant controlled blood pressure among Educational interventions directed to the patient-led by health care workers, especially pharmacists or community health care workers. According to European and Canadian guidelines, Pharmacists should be the standard care of hypertension as they are valuable in team-based care (TBC) [ 40 , 41 ]. The quality of our study findings was moderate on average, showing the reliability of our results. High-quality evidence was reported in a meta-analysis that evaluated non-pharmacological interventions, which concluded that Dietary Approach to Stop Hypertension (DASH) could be the most effective in hypertension management [ 27 ]. The high-quality evidence reported from DASH intervention could have been the result of evaluating more than 20 interventions from both High income and low-income countries included. The geographical settings of HIC and LMICs might have had an influence as well, in comparison to our study, which only focused on LMICs. Our central findings that non-pharmacological interventions effectively control hypertension could positively impact non-adherence, subsequently reducing CVD's. Patients can get a better understand on hypertension management, which will eventually influence their awareness and behaviour towards BP medication adherence. More so, help clinicians make better decisions in clinical practice. The focus of this review was on RCT, which is the focused gold standard for evidence of the effectiveness of health [ 42 ]. In addition to the pooled change in systolic and diastolic blood pressure, the association between intervention and control group warrants health care workers to consider non-pharmacological interventions. Hypertension management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025 and the SDG target of one-third reductions in premature deaths from NCDs by 2030. Thus, looking at our findings, non-pharmacological interventions for hypertension adherence could avoid over half of CVD events and complications in LMICs. Future research should focus more on evaluating the feasibility of BP non-pharmacological interventions in a specific LMIC setting. Specific LMIC interventions may enable the development of public policy measures required to establish, improve and upgrade community health services to cope with the increasing burden of chronic diseases [ 43 ]. More so, helping to identify the optimal and effective way to organise and deliver care to hypertensive patients in LMIC's [ 19 , 20 ] Conclusion Our study findings conclude that non-pharmacological interventions are effective. Educational interventions directed to the patient and health professional and Organisational interventions could be the most effective in managing hypertension. There is compelling evidence that multi-component interventions delivered by pharmacists or health workers may be the most effective in hypertension management. The present and already stated interventions also positively affect outcomes of BP adherence which include quality of life, level of hypertension knowledge, beliefs, retention to care and number of hospitalisations.. Investigation of the feasibility of this evidence at a country level is necessary for LMIC to provide more reliable and effective interventions covering the country-specific needs having considered her health care system. A multi-component intervention involving patients, health professionals, and the health care system can be considered for future LMICs. Further well-designed randomised trials with larger sample sizes are encouraged to help policymakers make well-informed decisions on hypertension management. Abbreviations CVD: Cardio Vascular Diseases LMICs: low- and Middle-Income Countries HICs: Higher Income Countries SBP/DBP: Systolic Blood Pressure/Diastolic Blood Pressure WHO: World Health Organisation NCDs: Non Communicable Diseases BP: Blood Pressure CHD: Coronary Heart Disease SDG: Sustainable Development Goals RCT: Randomised Controlled Trials GRADE: Grading Of Recommendation, Assessment, Development, and Evaluation TBC: Team-Based Care DASH: Dietary Approach to Stop Hypertension UKZN: University of KwaZulu-Natal Declarations Acknowledgments The authors would like to thank the University of KwaZulu-Natal (UKZN) for providing the platform to set up and conduct this research study. Funding There was no funding source for this study. All authors had full access to all the data included in the study, and the corresponding author had final responsibility for the decision to submit for publication. Availability of data and materials All data reported and analysed in this paper was only from the published literature; hence most of the data and study materials are available in the public domain. Other datasets generated and analysed are available in the article and appendix. Authors` contributions The study has been conceptualized and designed by ON, BS and TPM-T. The initial draft of the study has been prepared by ON and PN, SN contributed to the abstract screening and full title screening. ON, BS, SJ-N and TPM-T contributed to data analysis. All authors critically reviewed the draft. All authors approved the final version of the manuscript. 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Understanding the role of educational interventions on medication adherence in hypertension: A systematic review and meta-analysis. Heart & Lung: The Journal Of Critical Care; 2020. Anker D, Tsuyuki RT, Paradis G, Chiolero A, Santschi V. Pharmacists to improve hypertension management: Guideline concordance from North America to Europe. Can Pharm J (Ott). 2019;152(3):180–5. Carter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich). 2012;14(1):51–65. Barton S. Which clinical studies provide the best evidence? BMJ. 2000;321(7256):255. Lu Z, Cao S, Chai Y, Liang Y, Bachmann M, Suhrcke M, et al. Effectiveness of interventions for hypertension care in the community–a meta-analysis of controlled studies in China. BMC Health Serv Res. 2012;12:216-. Tables Table 1 Characteristics of included studies Author, Publication Year Country, Geographical Setting Type of RCT & Intervention type, Follow up period(months) Intervention Group Control Group Population Details, Age (y) Sample Size, Gender Population Details, Age (y) Sample Size, Gender Alhalaiqa,2012 Jordan, 3 government-run hospitals Parallel group randomised trial Educational intervention directed to the patient-adherence therapy classes; 3 months BP patients in the intervention group received Adherence Therapy (AT) in addition to Treatment As Usual (TAU). AT included seven one-to-one sessions of AT lasting 20 min over 7 weeks.AT sessions were delivered in the hospital outpatient by trained Field Assistants clinics (25% of all sessions) or at the patient’s home (75% of all sessions) depending on the patient preference, ≥ 18 years 68 M = 37% F = 63% BP patients in the control group received TAU, which consisted of monthly outpatient clinics where BP was measured, medication reviewed, laboratory investigations, and other care was delivered depending on individual needs. Consisted of a clinician-led team of medical and nursing staff based in the outpatient clinic, ≥ 18 years 68 M = 56% F = 44% Bobrow,2016(A) South Africa – Cape town, low resource setting − 3-arm randomised trial(Bobrow A & B Educational intervention directed to the patients- written information about hypertension and healthy living, motivation on collecting and taking medicine Appointment reminder system- when medicines were ready for collection or about scheduled clinic appointments information 12 months Informational SMS texting: All participants received written information about hypertension and healthy living and continued to receive care from the clinic. Personalized SMS text messages were sent to information-only. Adherence support groups were sent messages to motivate collecting and taking medicines and educating about hypertension and its treatment. Additional reminders were sent when medicines were ready for collection or about scheduled clinic appointments. ,≥ 21 years 457 M = 28% F = 72% Usual care: All participants received written information about hypertension and healthy living and continued to receive care from the clinic, ≥ 21 years 457 M = 28% F = 72% Bobrow,2016(B) South Africa-Cape town, low resource setting Educational intervention directed to the patients- written information about hypertension and healthy living, interactive texts on healthy living, motivation on collecting and taking medicine Appointment reminder system- when medicines were ready for collection or about scheduled clinic appointments information 12 months Interactive SMS texting: All BP participants received written information about hypertension and healthy living and continued to receive care from the clinic. Personalized SMS text messages were sent to interactive message group participants at weekly intervals. Messages were sent to motivate collecting and taking medicines and provide education about hypertension and its treatment. Additional reminders were sent when medicines were ready for collection or about scheduled clinic appointments. Participants allocated to the interactive adherence support received the same messages as the information-only group but could also respond to selected messages using free-to-user “Please-Call-Me” requests,≥ 21 years 458 M = 28% F = 72% Usual care: All BP participants received written information about hypertension and healthy living and continued to receive care from the clinic, ≥ 21 years 457 M = 28% F = 72% Cakir,2006 Turkey, University hospital in Istanbul - Parallel group randomised trial Educational intervention directed to the patient- comprehensive lifestyle modification including DASH diet, weight reduction, sodium intake, reducing alcohol consumption, increasing physical exercise to a moderate degree, giving up cigarette smoking, and learning stress management. Classes were given by nurses on how to control hypertension to prevent heart diseases and stroke and included core knowledge and information on the behavioural skills necessary to manage hypertension 6 months BP patients comprehensive lifestyle modification including DASH diet, reduce weight, sodium intake, reduce alcohol consumption, increase physical exercise to a moderate degree, give up cigarette smoking, Moreover, to learn stress management. Classes were given by nurses on how to control hypertension to prevent heart diseases and stroke and included core knowledge and information on the behavioural skills necessary to manage hypertension 30 M = 47% F = 63% BP patients received usual lifestyles, including dietary and exercise habits, for 6 months 30 M = 40% F = 60% Calvaho,2006 India-Mysore city, Rural community pharmacies A parallel randomised controlled trial Educational intervention directed to the patient- education on BP, medication, and lifestyle modifications 3 months BP patients without comorbidities were provided with education on BP, medication, and lifestyle modifications by a community pharmacist for 3 months,≥18years 26 M = 53.85% F = 46.15% BP patients with or without comorbidities were provided with basic education on the correct way to take medication for three months,≥ 18 years 21 M = 38.1% F = 61.9% Delavar,2019 Iran-Tehran, Fayyazbakhsh public hospital Parallel group randomised trial Educational intervention directed to the patient- patients received SME tailored Patient Health Literacy, weekly face-to-face sessions, and telephone-based educational sessions twice weekly. Given educational materials 1 month Elderly primary BP patients who received SME tailored Patient Health Literacy for 3 months (HL) face to face weekly sessions and telephone-based educational sessions twice weekly. Given educational materials by Four experts(one critical care and three health promotion specialists) Educational materials were related to hypertension definition and its risk factors, complications, medications, medication side effects, medication side effect management, medication adherence importance, and the importance of regular medical visits for blood pressure monitoring. Because of participants’ old age and their inadequate HL, the teach-back method was used to provide educational materials in both face-to-face and telephone-based educational sessions,≥60 years 54 M = 41.6% F = 57.4% Elderly primary BP patients who received routine care services, including routine medical visits, medical prescriptions, and blood pressure management. ,≥60 years 58 M = 55.2% F = 44.8% He,2017 Argentina, poor urban primary health centres Parallel group randomised trial Educational intervention directed to the patient-health coaching, physical education Educational intervention directed to the health professionals- physician training program,(online and onsite hypertension management organizational intervention aimed at delivery care- home BP monitoring and audit 18 months BP patients received an 18-month multi-component intervention program including a community health worker-led home-based intervention (health coaching and home BP monitoring and audit), physical education, BP feedback, and weekly text messaging,≥21 years. 743 M = 47.4% F = 52.6% Neither physicians nor community health workers were trained to conduct study interventions. Additionally, participants did not receive home visits, home BP monitors, or text messages. Participants were encouraged to follow the clinical visit schedule of the Remediar + Redes Program, ≥ 21 years 689 M = 46.6% F = 53.4% Jafar,2020 Bangladesh, Pakistan, and Sri Lanka, rural districts Parallel group randomised trial Educational intervention directed to the patient-home education Educational intervention directed at the health professional-physician training program on hypertension management Organizational interventions aimed at delivery care- Hypertension triage reception desk and hypertension care coordinator at the government clinics 24 months BP patients received 24 months of Multi-component intervention: blood-pressure monitoring by physicians and the use of checklists to guide monitoring and referral to physicians. Involvement of Government community health workers to measure blood pressure; home health education by government community health workers. Hypertension triage reception desk and hypertension care coordinator at the government clinics. ,≥40years 1330 M = 34.1% F = 65.9% BP patients received 24 months of Usual care consisted of existing services in the community, with routine home visits by community health workers for maternal and child care only. The clinics did not have designated triage reception desks or care coordinators for hypertension. ,≥40 years 1315 M = 37.3% F = 62.7% Mirniam,2019 Iran-Isfahan, Al Zahra hospital Parallel group randomised trial Educational intervention directed to the patient- education on consequences of not taking HTN medication, methods of controlling the disease via appropriate lifestyle changes Models on appointment reminder systems-reminder box on taking medication through family support 3 months BP patients who received Multifaceted interventions include motivational interviews and 90 minutes of training sessions, a drug reminder box, family support, and 4 phone call follow-ups. The content of the training sessions consisted of the nature and side effects of the disease, the consequences of not taking HTN medication, methods of controlling the disease via appropriate lifestyle changes, and etcetera, The content of the phone calls included question and answer sessions regarding the reinforcement of the content of the training sessions, techniques of strengthening family support, utilization of the medication reminder box, and answers to possible problems of the participants ≥ 18years 36 M = 47.2% F = 52.8% BP patients who did not receive multifaceted intervention, only usual traditional care, ≥ 18years 36 M = 50.0% F = 50.0% Ramanath,2012 India –Medicine department of Adichnchanagiri hospital and research centre-B G Nagara, rural population Parallel group randomised trial Educational intervention directed to the patients -patient counselling, patient information leaflets (PILS) Models on appointment reminder systems- frequent telephonic reminding 7 months Clinical pharmacist intervention patient counselling, patient information leaflets (PILS), and frequent telephonic reminding. patients were counselled on various aspects such as drugs, lifestyle changes, and their disease management,≥18years 26 M = 61.5% F = 38.5% Patients were not provided with any counselling and PILS at the baseline and in the first follow-up. However, They were provided with oral instruction and PIL at the end of the second follow-up. ,≥18years 26 M = 80.8% F = 19.2% Saleem,2015 Pakistan- Northwest Balochistan, Cardiac units of Sandeman Provincial Hospital (SPH) and Bolan Medical Complex Hospital (BMCH) located in Quetta Parallel group randomised trial Educational intervention directed to the patient- pocket-sized educational book on hypertension, information leaflets, and medication adherence cards 9 months BP patients Who received pharmaceutical care, consisting of follow-up by the trained hospital pharmacist during 9 months. At each visit, the hospital pharmacist conducted a thorough interview with the patient, identified Problems leading to poor medication adherence and provided patient education. Patients in the IG were also provided with a pocket-sized educational book on hypertension, information leaflets, and medication adherence cards (all in Urdu) during the counseling process,≥18years 193 M = 64.8% F = 35.2% BP patients who were not provided with pharmaceutical care, no hospital pharmacist involvement. Control patients received the traditional service provided by the hospitals (receiving prescription orders, counselling about medication use, and information about follow-up visits). ,≥18years 192 M = 72.9% F = 27.1% Zhai,2020 China-Xi`an city Shaanxi province, 8 community health care centres (CHCs) Parallel group randomised trial Educational intervention directed to the patient- personal consultations by trained pharmacy students on BP medication adherence Models on appointment reminder systems- SMS text messages s regarding patients with poor knowledge on BP adherence and lifestyle modification 3 months BP patients who receive intervention for 3 months program comprised 2 components. Personal consultations by trained pharmacy students. The second component was SMS text messages s Regarding patients with poor knowledge were given education on BP adherence and lifestyle modification ,≥18years 192 M = 35.4% F = 64.6% BP patients who received a welcome SMS text message and an end-of-trial SMS text message but they did not receive a personal consultation. ,≥18years 192 M = 35.4% F = 64.6% Park,2011 South Korea Parallel group randomised trial Educational intervention directed to the patient- HAHA program (health education, individual counselling, and tailored exercise program delivered by trained nurses and exercise program for 12 weeks) 3 months BP patients who were given HAHA program (education counselling delivered by trained nurses and exercise program for 12 weeks) ≥ 65years 18 M = 33.3% F = 66.7% BP who received Usual care and did not receive HAHA ≥ 65years 22 M = 31.8% F = 68.2% Wang,2011 China-Guangdong province, Shenzhen Second People’s Hospital Parallel group randomised trial Educational intervention directed to the patient- Individual education was performed to inform participants about drug names, indications, strengths, adverse effects, and usage instructions. Pharmacists also introduced accurate BP measurements), medication compliance, healthy lifestyle behaviours 12 months BP patients were given pharmaceutical care for 12 months. Patients randomized to the intervention group met with clinical pharmacists every 2 months. Individual education was conducted to inform participants about drug names, indications, strengths, adverse effects, and usage instructions. Pharmacists also introduced accurate BP measurements (i.e., body position, arm position, cuff placement, and stethoscope, cuff size), medication compliance, healthy lifestyle behaviours (i.e., vegetarian diet, sodium intake, weight, and physical activity) to patients. ≥18years 29 M = 51.72% F = 48.2% BP patients were given regular medicare, ≥ 18years 30 M = 46.67% F = 53.33% Supplementary Files ONakwafilaSupplementaryfiles.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-856012","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research","associatedPublications":[],"authors":[{"id":51512800,"identity":"8da56ef0-df1f-420e-b5eb-b0fbcc6410fb","order_by":0,"name":"Olivia 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Low- and middle-income countries have seen an increase in hypertension in recent decades, thus, making it a significant public health issue due to the associated adverse health outcomes such as the increased incidence of CVD accounting for 75% of the global deaths in LMICs (82% attributed to coronary heart disease (CHD), stroke and heart failure) [\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Despite some LMICs offering universal access to hypertension medication, including Namibia, adherence to chronic medication remains a problem [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Recent data shows that CVD in Namibia accounted for 21% of annual deaths and a reported prevalence of blood pressure (BP) among women and men aged 35\u0026ndash;64 at between 44\u0026ndash;57% [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Thus, it would appear that the prevalence of hypertension in Namibia is high compared to the global and African regional prevalence of 22% and 27%, respectively[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Non-adherence to antihypertensive medication is common and contributes to poor BP control and adverse health outcomes [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. While it is substantial to understand the barriers and enablers of non-adherence, it is equally important to explore different interventions' effectiveness on improving BP control and BP medication adherence [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNon-pharmacological interventions to encourage BP medication adherence include educational interventions directed towards the patients, educational interventions directed towards the health professional, appointment reminder systems/models, and Organisational interventions [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR19 CR20 CR21 CR22\" citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. These Interventions intentionally target non-adherence contributing factors at different levels: patients, health care workers, and the health care system[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Many Higher-income countries have conducted extensive research on hypertension effective interventions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. However, we cannot say the same about LMICs, especially in sub-Saharan Africa [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDue to the scarcity of evidence on effective interventions in LMIC\u0026rsquo;s, thus far has caused a rise in CVD due to non-adherence despite pharmacological efforts [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The contradictions around effective interventions for BP continue based on evidence conducted from several reviews such as Cochrane [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Henceforth it is essential to systematically review interventions that can effectively be beneficial to LMICs and help inform the feasibility of possible country-specific BP interventions that are effective.\u003c/p\u003e \u003cp\u003eNon-adherence, which usually occurs when BP patients fail to meet treatment goals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], causes uncontrolled high blood pressure(Systolic blood pressure/SBP; Diastolic blood pressure/DBP) ( above 120/80), which increases the risk of severe health problems, including heart attack and stroke [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Data regarding BP medication adherence in Namibia is minimal, with one study spanning a sample of public health facilities in the Khomas region (capital region) reporting suboptimal adherence in 2017 [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Effective, widely available, low-cost, and sustainable strategies are needed to prevent and manage hypertension [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Existing systematic reviews on interventions have recommended that adequate control of hypertension in developing countries could be achievable by community-based programs and by upgrading primary health systems [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. A critical barrier to scaling up the literature suggests a greater need to identify the optimal and effective way to organise and deliver care to hypertensive patients in LMIC's in order to improve BP medication adherence [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBenefits associated with blood pressure lowering include a reduction in many complications such as stroke (35\u0026ndash;40%), heart attack (20\u0026ndash;25%), and heart failure (over 50%) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Achieving the WHO global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025 and the SDG target of a one-third reduction in premature deaths from NCDs by 2030 requires hypertension management interventions. Therefore, this systematic review aims to evaluate the effectiveness of non-pharmacological interventions on improving blood pressure control (Primary Outcome) and medication adherence (Secondary Outcome) in patients with hypertension in LMICs. We anticipate that the results from this study will provide current evidence on effective hypertension strategies targeted at controlling hypertension and CVD in LMIC settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e A study protocol was developed prior to the conduct of this review. The protocol is registered in the PROSPERO international prospective register of systematic reviews and is accessible via the link below: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020172954\u003c/span\u003e\u003c/span\u003e. The Centre for Reviews and Dissemination (CRD) guideline for systematic reviews in health care guided this study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Completed PRISMA checklist (see Additional file 1).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eIdentifying the research question\u003c/h2\u003e \u003cp\u003eThe identifying research question was the effectiveness of interventions to enable Hypertension Medication Adherence in LMICs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eEligibility criteria\u003c/h2\u003e \u003cp\u003e A Complete inclusion and exclusion criteria form part of this review protocol, registered with (PROSPERO; CRD42020172954).\u003c/p\u003e \u003cp\u003eWe included studies published from 2005 which met the following criteria: Hypertensive patients over 18 years of age and above, regardless of sex and ethnicity with a diagnosis of primary hypertension in a specified geographically defined LMIC setting; randomised controlled trials (RCTs) of hypertensive patients which evaluated non- pharmacological effectiveness of the following interventions to improve BP medication adherence: educational interventions directed to the patient, educational interventions directed to the health professional, self-monitoring, models on appointment reminder systems, organisational interventions aimed at delivery care.\u003c/p\u003e \u003cp\u003eWe excluded RCTs` not reporting evidence from LMIC settings published before 2005 and non-randomised controlled trials. Exclusion criteria also included studies reporting on other chronic illnesses, not reporting non-pharmacological effectiveness, and BP medication adherence outcome.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSearch strategy for the identification of relevant studies and information sources\u003c/h2\u003e \u003cp\u003eAfter consulting with an information scientist at the Department of Library Services, Faculty of Health Sciences, and the University of KwaZulu-Natal on literature search approaches, search strategies were developed based on the Cochrane Handbook of Intervention Guidelines and the Cochrane Central Register of Control Trials. To find relevant literature, we used the following keywords: hypertension or blood pressure, LMICs, adherence or compliance, control or monitoring, Educational, patient, Self-monitoring, health professional, reminder systems, organizational, delivery care. The Boolean search terms (AND OR) and MeSH terms were employed. A search of the following databases was performed in March 2019 and repeated in December 2020: PubMed, EBSCOhost included Academic Search; CINAHL and MEDLINE complete; PubMed; WEB of Science; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews and Google Scholar. Additionally, we searched Grey literature from university dissertations and theses from institutional repositories to retrieve relevant articles. We searched for randomised controlled trials conducted from January 2005 - December 2020 to capture the recent evidence on the effectiveness of hypertension interventions available in LMIC's. There was no language restrictions applied to the search.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eThe search management\u003c/h2\u003e \u003cp\u003eAfter a rigorous, intensive search, we exported relevant articles to the Endnote X9 library. Following the import of relevant articles by title relevance, we removed duplicates before the abstract screening stage. We then conducted a selection of abstracts and full articles using eligibility criteria utilizing abstract and full title screening forms developed in Google (see Additional file 2) for identified articles and the date of each literature searching of each database. Independent reviewers (ON and PN) did the article screening. The third screener (SN) was involved in resolving discrepancies. Subsequently, we assessed disagreement using Cohen's Kappa coefficient (κ) statistic on Stata 13.0SE (StataCorp College Station, TX, USA (Additional file 3).\u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eData extraction and quality assessment\u003c/h2\u003e\n\u003cp\u003eWe used a data extraction tool developed in Google form based on a checklist provided in the Cochrane handbook for systematic review for intervention. The data extracted related to main study characteristics, including author, setting, type of randomised trial, intervention and control group details, and percentage of patients enrolled in intervention and control groups(see Table 1 at the end of manuscript for full characteristics of the studies). Meta-analysis data extracted included SBP/DBP changes from different non-pharmacological interventions (Additional file 4).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe methodological quality of included studies was assessed using the Cochrane risk of bias tool Current version RoB 2, which include aspects of randomisation process; deviations from intended interventions; missing outcome data; measurement of the outcome; selection of the reported result, and overall bias (reported as Low, Some concerns or High) (Figure 2 ) [33]. \u0026nbsp;Data extraction and quality assessment were conducted by two reviewers\u0026rsquo; (ON and SN), and the third author resolved discrepancies through discussions and consensus. The quality of evidence was assessed according to the domains specified in the grading of recommendation, assessment, development, and evaluation (GRADE) guidelines [34].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003eData synthesis and analysis\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe primary outcome of this study was to determine the effectiveness of interventions to enable hypertension medication adherence in Low-and Middle-Income Countries. Based on the nature of our research question, we synthesised the data by presenting changes in mean systolic blood pressure (SBP) and mean diastolic blood pressure (DBP).\u0026nbsp;Systolic and diastolic blood pressure was analysed and calculated as mean difference (MD) and pooled to produce an overall random effect size between intervention and control groups. Heterogeneity among trials was conducted using the \u0026chi;2 test at 95% confidence interval and I\u003csup\u003e2\u003c/sup\u003e statistic value. Forest and funnel plots were presented to show the results for the primary outcome\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe secondary outcome aim was to determine hypertension medication adherence between intervention and control groups. We synthesized the data descriptively by showing the proportion of patients with medication adherence between intervention and control groups and effect sizes for medication adherence between the two groups. Medication adherence indicators synthesized include quality of life, and knowledge, beliefs, and retention in clinical care, number of hospitalisations, and cost-effectiveness of interventions. We adopted the definitions used by individual studies for anti-hypertension treatment and adequate control of blood pressure. [35].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData was captured in Microsoft Excel and analysed in MetaXL version 5.3 (EpiGear International, Sunrise Beach, and Queenland, Australia).\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eLiterature search and study characteristics\u003c/h2\u003e\n\u003cp\u003eThe initial database search found 162 906 potentially eligible studies, of which 161 991 were excluded during title screening. Following title screening, 915 met eligibility criteria and were included in full title screening yielding 14 definitive studies and considered for meta-analysis (see Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e for the whole screening process). The inter-rater reliability score for full-article screening showed 61.34% agreement versus 92.00% expected by chance which constitutes a moderate agreement between the screeners (Kappa statistic\u0026thinsp;=\u0026thinsp;0. 09 and p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05). In addition, McNemar\u0026apos;s chi-square statistic suggests that there is no statistically significant difference in the proportions of yes/no answers by reviewers with a p-value\u0026thinsp;\u0026gt;\u0026thinsp;0.05 (Additional file 3).\u003c/p\u003e\n\u003cp\u003eAll studies included and considered for meta-analysis are from LMICs conducted between 2005\u0026ndash;2020 among patients diagnosed with hypertension ranging from 18 to 75 years. Additionally, most studies included parallel randomised controlled trials (n\u0026thinsp;=\u0026thinsp;13) except one study, a 3-arm randomised trial conducted in a low resource setting in Cape -Town, South Africa. Studies recruited patients mostly from rural settings and low resource settings (n\u0026thinsp;=\u0026thinsp;7), and five were conducted from government hospitals, including a community pharmacy (n\u0026thinsp;=\u0026thinsp;1). The main reason for exclusion was non-randomised trials (n\u0026thinsp;=\u0026thinsp;8), not LMIC\u0026apos;s\u0026thinsp;=\u0026thinsp;14; evaluated other chronic diseases apart from hypertension (n\u0026thinsp;=\u0026thinsp;23) non-pharmacological (n\u0026thinsp;=\u0026thinsp;5) and the rest were other reasons with studies which included older patients\u0026thinsp;\u0026gt;\u0026thinsp;75 years and unclear methodology and outcome (n\u0026thinsp;=\u0026thinsp;36). All studies included were published in English. Included articles all evaluated Educational intervention towards patients, however (7/14) articles evaluated more than one intervention of which it was either Educational intervention directed towards the health professional(2/14), Appointment reminder systems/models (7/14), or Organisational interventions (2/14). Appointment reminder systems encompassed principles of reminding patients when medicines were ready for collection or about scheduled clinic appointments information (2), organizational intervention aimed at delivery care- home BP monitoring and audit (2). Models on appointment reminder systems-reminder (3) box on taking medication.\u003c/p\u003e\n\u003cp\u003eThe primary care providers were medical and nursing staff, community pharmacists and health workers, family support. Community interventions were delivered in community hospitals, community centres, or patients\u0026apos; homes (see Table 1).\u003c/p\u003e\n\u003cdiv class=\"Section2\" id=\"Sec10\"\u003e\n \u003ch2\u003eQuality of included studies\u003c/h2\u003e\n \u003cp\u003eEleven (11) studies were graded to be Low risk, and three as having some concerns. All studies described randomisation methods; however, among the studies with some concerns, two had issues with the randomisation process where allocation sequence and concealment of participants enrolled and assigned to intervention was not indicated. The article with concerns of outcome measurement did not indicate whether the outcome assessment would have been influenced by the intervention received. The rest of the studies did not indicate any concerns with deviations from intended interventions, missing outcome data, issues with measurement of the outcome, and selection of the reported results (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, the GRADE quality of evidence was moderate (Additional file 10).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec11\"\u003e\n \u003ch2\u003eEffects of interventions\u003c/h2\u003e\n \u003cdiv class=\"Section3\" id=\"Sec12\"\u003e\n \u003ch2\u003ePrimary outcomes (Meta-analysis results)\u003c/h2\u003e\n \u003cp\u003eData pooled from all 14 studies showed heterogeneity across studies for systolic and diastolic blood pressure. Random effects of meta-analysis results show that systolic blood pressure was reduced by -7.61(-10.47, -4.74), with four exceptions where systolic blood pressure was slightly lower in the intervention group. Heterogeneity across studies was statistically significant ( \u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;92%, P\u0026thinsp;=\u0026thinsp;0.00) ( Fig. \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). The pooled mean difference for diastolic blood pressure was \u0026minus;\u0026thinsp;3.48(-5.52, -43). Heterogeneity for DBP was statistically significant \u003cem\u003eI\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e=\u003c/sup\u003e89%, P\u0026thinsp;=\u0026thinsp;0.00) (Fig. \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). When we excluded two studies (Alhalaiqa, 2012 and Mirniam, 2019) SBP random effect was \u0026minus;\u0026thinsp;4.74 (95% CI:-6.07 to -3.47) and I\u003csup\u003e2 =\u003c/sup\u003e 57%. (Fig. \u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e) and DBP (-4.56\u0026ndash;1.27) and I\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;78% (Fig.\u0026nbsp;6). Additional results showing funnel plots are included in the supplementary file material (Additional file 5\u0026ndash;8).\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv class=\"Section2\" id=\"Sec13\"\u003e\n \u003ch2\u003eSecondary outcome\u003c/h2\u003e\n \u003cdiv class=\"Section3\" id=\"Sec14\"\u003e\n \u003ch2\u003eProportion (%) of patients with controlled BP (BP\u0026thinsp;\u0026lt;\u0026thinsp;140/90mmHg\u003c/h2\u003e\n \u003cp\u003eSecondary outcome results indicating BP adherence outcome measures are presented as the proportion(%) of controlled hypertensive patients with corresponding effect differences between intervention and control group through OR (95% confidence interval). Additional secondary outcomes synthesised include quality of life, level of hypertension knowledge, beliefs on hypertension, retention to care, and the number of hospitalisations (Additional file 9). Out of 14 articles presented in this paper, 12 have shown a significant proportion of patients with controlled blood pressure (BP\u0026thinsp;\u0026lt;\u0026thinsp;140/90mmHG).\u003c/p\u003e\n \u003c/div\u003e\n \u003cdiv class=\"Section3\" id=\"Sec15\"\u003e\n \u003ch2\u003eOther secondary outcome results\u003c/h2\u003e\n \u003cp\u003eIn addition to the proportion of controlled hypertension reported from all 14 studies, a total number of BP medication adherence indicators from the included studies were synthesized as follows: articles that evaluated the quality of life(7); level of hypertension knowledge (2); beliefs on hypertension (2), retention to care (2); and the number of hospitalisations (2). Some studies reported more than one indicator. Results reporting on the quality of life display better overall health status in the intervention group(s) than those in the control group, similarly, with knowledge and beliefs. An increase in the knowledge level in the intervention groups was reported to modify patients\u0026rsquo; beliefs about medicines positively. Beliefs about medication in the intervention group have moved away from the view that medications are intrinsically harmful, towards one that recognises the benefits of medication. Retention in care, as well as hospital admissions, also improved. There was no significant difference in mean health care costs per patient between groups.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur systematic review findings reveal that Non-pharmacological interventions are effective in controlling blood pressure. We included studies from the following LMICs: Jordan, South Africa low resource settings, Turkey, India, Argentina, Bangladesh, Pakistan, Sri Lanka, Iran-Isfahan, Pakistan, China, and South Korea. We observed a statistically significant reduction in SBP and DBP .among the following interventions: Educational intervention towards patients, Educational intervention directed towards the health professional, Appointment reminder systems/models, and Organisational interventions. Educational interventions directed to the patient and health professional and Organisational interventions showed the high-moderate quality of evidence. These interventions can be pilot tested in LMIC's to establish suitable country specific BP strategies in anticipation to help meet Sustainable Development Goal (SDG) target 3.4 by reducing premature mortality from non-communicable diseases (NCDs) by a third by 2030. When we restricted analysis (12/14 studies), effects remained significant with low heterogeneity for SBP and DBP. Secondary outcomes, including quality of life, level of hypertension knowledge, beliefs on hypertension, retention to care, and the number of hospitalisations, showed a significant controlled blood pressure (BP\u0026thinsp;\u0026lt;\u0026thinsp;140/90mmHG). The aforementioned secondary outcomes are well outlined in the WHO model of hypertension medication adherence as contributing factors of BP medication adherence.\u003c/p\u003e \u003cp\u003eWe believe that this is the first study to estimate aggregate BP effects of randomised controlled trials conducted in LMICs only. Studies included in this systematic review were conducted between 2005\u0026ndash;2020 from low resource settings providing recent evidence on the effectiveness of BP interventions and medication adherence. The variability in heterogeneity can be observed when two studies (Alhalaiqa, 2012 and Mirniam) are excluded showing a significant reduction in SBP and DBP (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e \u0026amp;6)). These studies had the weakest effect in the intervention groups, which could have been caused by high heterogeneity in random-effect analysis. Overall, we attribute heterogeneity across studies to different study periods, sample sizes, and pooling of multi-component interventions between studies. Though our findings had moderate evidence on average primarily because of inconsistency and publication bias, heterogeneity was expected because it is common in behavioral research [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Similar results on heterogeneity have been reported in several studies in High-income countries that evaluated the effectiveness of BP interventions [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Considering the current burden on hypertension in LMICs, our results have heightened the need for scaling up interventions to improve hypertension outcomes and meet global SDG in achieving universal health coverage in LMICs [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMeta-analysis studies on the effectiveness of BP interventions have been conducted in developed countries [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Interventions for hypertension show a more significant effect when administered in combination[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. In agreement with significant effects of BP interventions when administered in combination is a Cochrane systematic review of 72 randomised trial studies which stated that educational interventions alone were unlikely to be effective[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Authors such as Anderson LJ et al. (2020) and Ampofo AG (2020) have stated that education interventions and reminders, including regular follow-ups, were found to be effective at improving patient adherence [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Health care workers play an essential role in making sure that these interventions are effective. Results from our study have shown a significant controlled blood pressure among Educational interventions directed to the patient-led by health care workers, especially pharmacists or community health care workers. According to European and Canadian guidelines, Pharmacists should be the standard care of hypertension as they are valuable in team-based care (TBC) [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. The quality of our study findings was moderate on average, showing the reliability of our results. High-quality evidence was reported in a meta-analysis that evaluated non-pharmacological interventions, which concluded that Dietary Approach to Stop Hypertension (DASH) could be the most effective in hypertension management [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The high-quality evidence reported from DASH intervention could have been the result of evaluating more than 20 interventions from both High income and low-income countries included. The geographical settings of HIC and LMICs might have had an influence as well, in comparison to our study, which only focused on LMICs.\u003c/p\u003e \u003cp\u003eOur central findings that non-pharmacological interventions effectively control hypertension could positively impact non-adherence, subsequently reducing CVD's. Patients can get a better understand on hypertension management, which will eventually influence their awareness and behaviour towards BP medication adherence. More so, help clinicians make better decisions in clinical practice. The focus of this review was on RCT, which is the focused gold standard for evidence of the effectiveness of health [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. In addition to the pooled change in systolic and diastolic blood pressure, the association between intervention and control group warrants health care workers to consider non-pharmacological interventions.\u003c/p\u003e \u003cp\u003eHypertension management interventions are essential for achieving the global target of a 25% relative reduction in the risk of premature mortality from NCDs by 2025 and the SDG target of one-third reductions in premature deaths from NCDs by 2030. Thus, looking at our findings, non-pharmacological interventions for hypertension adherence could avoid over half of CVD events and complications in LMICs. Future research should focus more on evaluating the feasibility of BP non-pharmacological interventions in a specific LMIC setting. Specific LMIC interventions may enable the development of public policy measures required to establish, improve and upgrade community health services to cope with the increasing burden of chronic diseases [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. More so, helping to identify the optimal and effective way to organise and deliver care to hypertensive patients in LMIC's [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study findings conclude that non-pharmacological interventions are effective. Educational interventions directed to the patient and health professional and Organisational interventions could be the most effective in managing hypertension. There is compelling evidence that multi-component interventions delivered by pharmacists or health workers may be the most effective in hypertension management. The present and already stated interventions also positively affect outcomes of BP adherence which include quality of life, level of hypertension knowledge, beliefs, retention to care and number of hospitalisations.. Investigation of the feasibility of this evidence at a country level is necessary for LMIC to provide more reliable and effective interventions covering the country-specific needs having considered her health care system. A multi-component intervention involving patients, health professionals, and the health care system can be considered for future LMICs. Further well-designed randomised trials with larger sample sizes are encouraged to help policymakers make well-informed decisions on hypertension management.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCVD: Cardio Vascular Diseases\u003c/p\u003e\n\u003cp\u003eLMICs: low- and Middle-Income Countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHICs:\u0026nbsp;Higher Income Countries\u003c/p\u003e\n\u003cp\u003eSBP/DBP: Systolic Blood Pressure/Diastolic Blood Pressure\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organisation\u003c/p\u003e\n\u003cp\u003eNCDs: Non Communicable Diseases\u003c/p\u003e\n\u003cp\u003eBP: Blood Pressure\u003c/p\u003e\n\u003cp\u003eCHD: Coronary Heart Disease\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSDG: Sustainable Development Goals RCT: Randomised Controlled Trials\u003c/p\u003e\n\u003cp\u003eGRADE: Grading Of Recommendation, Assessment, Development, and Evaluation\u003c/p\u003e\n\u003cp\u003eTBC: Team-Based Care\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDASH: Dietary Approach to Stop Hypertension\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eUKZN: University of KwaZulu-Natal\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the University of KwaZulu-Natal (UKZN) for providing the platform to set up and conduct this research study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere was no funding source for this study.\u0026nbsp;All authors had full access to all the data included in the study, and the\u0026nbsp;corresponding author had final responsibility for the decision to submit for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data reported and analysed in this paper was only from the published literature; hence most of the data and study materials are available in the public domain. Other datasets generated and analysed are available in the article and appendix.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors` contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study has been conceptualized and designed by ON, BS and TPM-T. \u0026nbsp;The initial draft of the study has been prepared by ON and PN, SN contributed to the abstract screening and full title screening. ON, BS, SJ-N and TPM-T contributed to data analysis. All authors critically reviewed the draft. All authors approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003eThe were no human participants\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe declare no interest\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990\u0026ndash;2010: a systematic analysis for the Global Burden of Disease Study 2010. 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BMJ Open. 2015;5(3):e006583.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAntonakoudis G, Poulimenos L, Kifnidis K, Zouras C, Antonakoudis H. Blood pressure control and cardiovascular risk reduction. Hippokratia. 2007;11(3):114\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026lt;WHO. 2003 theories.pdf\u0026amp;gt.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlsolami FJA. Factors Affecting Antihypertensive Medications Adherence among Hypertensive Patients Attending a General Hospital in Jeddah City [Doctor of philosophy]. Saudi Arabia: Qeensland University of Technology; 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalsh J, McDonald KM, Shojania KG, Sundaram V, Nayak S, Davies S, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. 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Global heart. 2014;9(4):431\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWhelton Paul K, Carey Robert M, Aronow Wilbert S, Casey Donald E, Collins Karen J, Dennison Himmelfarb C, et al 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. Journal of the American College of Cardiology. 2018;71(19):e127-e248.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSystematic Reviews. CRD`s guidedance for undertaking reviews in health care. Centre for Reviews and Dissemination; 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoher D, Liberati A, Tetzlaff J, Altman DG, Group atP. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Ann Intern Med. 2009;151(4):264\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSterne JACSJ, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng H-Y, Corbett MS, Eldridge SM, Hern\u0026aacute;n MA, Hopewell S, Hr\u0026oacute;bjartsson A, Junqueira DR, J\u0026uuml;ni P, Kirkham JJ, Lasserson T, Li T, McAleenan A, Reeves BC, Shepperd S, Shrier I, Stewart LA, Tilling K, White IR, Whiting PF, Higgins JPT. RoB 2: a revised tool for assessing risk of bias in randomised trials. 366: l4898BMJ 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGRADE handbook for grading quality of evidence and strength of recommendations. Updated October 2013. The GRADE Working Group. Sch\u0026uuml;nemann H BJ, Guyatt G, Oxman A, editors2013.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u0026lt;cochrane-handbook-\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003efor-systematic-reviews-of-interventions.pdf\u0026gt;\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eConn VS, Ruppar TM, Chase J-AD, Enriquez M, Cooper PS. Interventions to Improve Medication Adherence in Hypertensive Patients: Systematic Review and Meta-analysis. Curr Hypertens Rep. 2015;17(12):94-.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health O. Health workforce requirements for universal health coverage and the Sustainable Development Goals. (Human Resources for Health Observer, 17). Geneva: World Health Organization; 2016 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson LJ, Nuckols TK, Coles C, Le MM, Schnipper JL, Shane R, et al. A systematic overview of systematic reviews evaluating medication adherence interventions. American Journal of Health-System Pharmacy. 2020;77(2):138\u0026ndash;47.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAmpofo AG, Khan E, Ibitoye MB. Understanding the role of educational interventions on medication adherence in hypertension: A systematic review and meta-analysis. Heart \u0026amp; Lung: The Journal Of Critical Care; 2020.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnker D, Tsuyuki RT, Paradis G, Chiolero A, Santschi V. Pharmacists to improve hypertension management: Guideline concordance from North America to Europe. Can Pharm J (Ott). 2019;152(3):180\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarter BL, Bosworth HB, Green BB. The hypertension team: the role of the pharmacist, nurse, and teamwork in hypertension therapy. J Clin Hypertens (Greenwich). 2012;14(1):51\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBarton S. Which clinical studies provide the best evidence? BMJ. 2000;321(7256):255.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLu Z, Cao S, Chai Y, Liang Y, Bachmann M, Suhrcke M, et al. Effectiveness of interventions for hypertension care in the community\u0026ndash;a meta-analysis of controlled studies in China. BMC Health Serv Res. 2012;12:216-.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable border=\"1\" id=\"Tab1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCharacteristics of included studies\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"10\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAuthor, Publication Year\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCountry, Geographical Setting\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" rowspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eType of RCT \u0026amp; Intervention type, Follow up period(months)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIntervention Group\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eControl Group\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\" name=\"Emphasis\" type=\"Bold\"\u003ePopulation Details, Age (y)\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\" name=\"Emphasis\" type=\"Bold\"\u003eSample Size, Gender\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\" name=\"Emphasis\" type=\"Bold\"\u003ePopulation Details, Age (y)\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u003cspan class=\"Bold\" name=\"Emphasis\" type=\"Bold\"\u003eSample Size, Gender\u003c/span\u003e\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAlhalaiqa,2012\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eJordan, 3 government-run hospitals\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient-adherence therapy classes;\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients in the intervention group received Adherence Therapy (AT) in addition to Treatment As Usual (TAU). AT included seven one-to-one sessions of AT lasting 20 min over 7 weeks.AT\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003esessions were delivered in the hospital outpatient by trained Field Assistants\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eclinics (25% of all sessions) or at the patient\u0026rsquo;s\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ehome (75% of all sessions) depending on the patient\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003epreference, \u0026ge;\u0026thinsp;18 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e68\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;37%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;63%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients in the control group received TAU, which consisted of monthly outpatient clinics where BP was measured, medication reviewed, laboratory investigations, and other care was delivered depending on individual needs. Consisted of a clinician-led team of medical and nursing staff based in the outpatient clinic, \u0026ge;\u0026thinsp;18 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e68\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;56%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;44%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBobrow,2016(A)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSouth Africa \u0026ndash; Cape town, low resource setting\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;3-arm randomised trial(Bobrow A \u0026amp; B\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patients- written information about hypertension and healthy living, motivation on collecting and taking medicine\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eAppointment reminder system- when medicines were ready for collection or about scheduled clinic appointments information\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eInformational SMS texting: All participants received written information about hypertension and healthy living and continued to receive care from the clinic. Personalized SMS text messages were sent to information-only. Adherence support groups were sent messages to motivate collecting and taking medicines and educating about hypertension and its treatment. Additional reminders were sent when medicines were ready for collection or about scheduled clinic appointments.\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u0026ge; 21 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e457\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;28%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;72%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUsual care: All participants received written information about hypertension and healthy living and continued to receive care from the clinic, \u0026ge; 21 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e457\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;28%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;72%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBobrow,2016(B)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSouth Africa-Cape town, low resource setting\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patients- written information about hypertension and healthy living, interactive texts on healthy living, motivation on collecting and taking medicine\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eAppointment reminder system- when medicines were ready for collection or about scheduled clinic appointments information\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eInteractive SMS texting: All BP participants received written information about hypertension and healthy living and continued to receive care from the clinic. Personalized SMS text messages were sent to interactive message group participants at weekly intervals. Messages were sent to motivate collecting and taking medicines and provide education about hypertension and its treatment. Additional reminders were sent when medicines were ready for collection or about scheduled clinic appointments.\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipants allocated to the interactive adherence support received the same messages as the information-only group but could also respond to selected messages using free-to-user \u0026ldquo;Please-Call-Me\u0026rdquo; requests,\u0026ge; 21 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e458\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;28%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;72%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eUsual care: All BP participants received written information about hypertension and healthy living and continued to receive care from the clinic, \u0026ge; 21 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e457\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;28%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;72%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCakir,2006\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eTurkey, University hospital in Istanbul\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e- Parallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- comprehensive lifestyle modification including DASH diet, weight reduction, sodium intake, reducing alcohol consumption, increasing physical exercise to a moderate degree, giving up cigarette smoking, and learning stress management. Classes were given by nurses on how to control hypertension to prevent heart diseases and stroke and included core knowledge and information on the behavioural skills necessary to manage hypertension\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e6 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients comprehensive lifestyle modification including DASH diet, reduce weight, sodium intake, reduce alcohol consumption, increase physical exercise to a moderate degree, give up cigarette smoking,\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eMoreover, to learn stress management. Classes were given by nurses on how to control hypertension to prevent heart diseases and stroke and included core knowledge and information on the behavioural skills necessary to manage hypertension\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;47%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;63%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients received usual lifestyles, including dietary and exercise habits, for 6 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;40%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;60%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCalvaho,2006\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIndia-Mysore city, Rural community pharmacies\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eA parallel randomised controlled trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- education on BP, medication, and lifestyle modifications\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients without comorbidities were provided with education on BP, medication, and lifestyle modifications by a community pharmacist for 3 months,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;53.85%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;46.15%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients with or without comorbidities were provided with basic education on the correct way to take medication for three months,\u0026ge; 18 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;38.1%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;61.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eDelavar,2019\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIran-Tehran, Fayyazbakhsh public hospital\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- patients received SME tailored Patient Health Literacy, weekly face-to-face sessions, and telephone-based educational sessions twice weekly. Given educational materials\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e1 month\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eElderly primary BP patients who received SME tailored Patient Health Literacy for 3 months (HL) face to face weekly sessions and telephone-based educational sessions twice weekly. Given educational materials by\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eFour experts(one critical care and three health promotion specialists) Educational materials were related to hypertension definition and its risk factors, complications, medications, medication side effects, medication side effect management, medication adherence importance, and the importance of regular medical visits for blood pressure monitoring. Because of participants\u0026rsquo; old age and their inadequate HL, the teach-back method was used to provide educational materials in both face-to-face and telephone-based educational sessions,\u0026ge;60 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e54\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;41.6%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;57.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eElderly primary BP patients who received routine care services, including routine medical visits, medical prescriptions, and blood pressure management. ,\u0026ge;60 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e58\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;55.2%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;44.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHe,2017\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eArgentina, poor urban primary health centres\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient-health coaching, physical education\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the health professionals- physician training program,(online and onsite hypertension management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eorganizational intervention aimed at delivery care- home BP monitoring and audit\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e18 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients received an 18-month multi-component intervention program including a community health worker-led home-based intervention (health coaching and home BP monitoring and audit), physical education, BP feedback, and weekly text messaging,\u0026ge;21 years.\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e743\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;47.4%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;52.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNeither physicians\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003enor community health workers were trained to conduct\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003estudy interventions. Additionally, participants did not receive\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ehome visits, home BP monitors, or text messages.\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eParticipants were encouraged to follow the clinical visit schedule\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eof the Remediar\u0026thinsp;+\u0026thinsp;Redes Program, \u0026ge;\u0026thinsp;21 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e689\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;46.6%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;53.4%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eJafar,2020\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBangladesh, Pakistan, and Sri Lanka, rural districts\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient-home education\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed at the health professional-physician training program on hypertension management\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eOrganizational interventions aimed at delivery care- Hypertension triage reception desk and hypertension care coordinator at the government clinics\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e24 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients received 24 months of Multi-component intervention: blood-pressure monitoring by physicians and the use of checklists to guide monitoring and referral to physicians. Involvement of Government community health workers to measure blood pressure; home health education\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eby government community health workers. Hypertension\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003etriage reception desk and hypertension\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ecare coordinator at the government clinics. ,\u0026ge;40years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1330\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;34.1%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;65.9%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients received 24 months of Usual care consisted of existing services in the community, with routine home visits by community\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ehealth workers for maternal and child\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ecare only. The clinics did not have designated\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003etriage reception desks or care coordinators for\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ehypertension. ,\u0026ge;40 years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1315\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;37.3%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;62.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMirniam,2019\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIran-Isfahan, Al Zahra hospital\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- education on consequences of not taking HTN medication, methods of controlling the disease via appropriate lifestyle changes\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eModels on appointment reminder systems-reminder box on taking medication through family support\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who received Multifaceted interventions include motivational interviews and 90 minutes of training sessions, a drug reminder box, family support, and 4 phone call follow-ups. The content of\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ethe training sessions consisted of the nature and side effects of the disease, the consequences of not\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003etaking HTN medication, methods of controlling the disease via appropriate lifestyle changes, and\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eetcetera, The content of\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ethe phone calls included question and answer\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003esessions regarding the reinforcement of the content\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eof the training sessions, techniques of strengthening\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003efamily support, utilization of the medication\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ereminder box, and answers to possible problems of\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ethe participants\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026ge;\u0026thinsp;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;47.2%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;52.8%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who did not receive multifaceted intervention, only usual traditional care, \u0026ge;\u0026thinsp;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e36\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;50.0%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;50.0%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRamanath,2012\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eIndia \u0026ndash;Medicine department of Adichnchanagiri hospital and research centre-B G Nagara, rural population\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patients -patient counselling, patient information leaflets (PILS)\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eModels on appointment reminder systems- frequent telephonic reminding\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e7 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eClinical pharmacist intervention patient counselling, patient information leaflets (PILS), and frequent telephonic reminding.\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003epatients were counselled on various aspects such as drugs, lifestyle changes, and their disease management,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;61.5%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;38.5%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePatients were not provided\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ewith any counselling and PILS at the baseline and in the first follow-up. However,\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eThey were provided with oral instruction and PIL at the end of the second follow-up. ,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e26\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;80.8%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;19.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSaleem,2015\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePakistan- Northwest Balochistan, Cardiac units of Sandeman Provincial Hospital (SPH) and Bolan Medical Complex Hospital (BMCH) located in Quetta\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- pocket-sized educational book on hypertension, information leaflets, and medication adherence cards\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e9 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients Who received pharmaceutical care, consisting of follow-up by the trained hospital pharmacist during 9 months. At each visit, the hospital pharmacist conducted a thorough interview with the patient, identified\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eProblems leading to poor medication adherence and provided patient education. Patients in the IG were also provided with a pocket-sized educational\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ebook on hypertension, information leaflets, and medication adherence cards (all in Urdu) during the counseling process,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e193\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;64.8%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;35.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who were not provided with pharmaceutical care, no hospital pharmacist involvement. Control patients received the traditional service\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eprovided by the hospitals (receiving prescription\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eorders, counselling about medication use, and information about follow-up visits). ,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e192\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;72.9%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;27.1%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eZhai,2020\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChina-Xi`an city Shaanxi province, 8 community health care centres (CHCs)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- personal consultations by trained pharmacy students on BP medication adherence\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eModels on appointment reminder systems- SMS text messages s regarding patients with poor knowledge on BP adherence and lifestyle modification\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who receive intervention for 3 months program comprised 2 components. Personal consultations by trained pharmacy students. The second component was SMS text messages s Regarding\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003epatients with poor knowledge were given education on BP adherence and lifestyle modification\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e192\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;35.4%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;64.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who received a welcome SMS text\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003emessage and an end-of-trial SMS text message but they did not\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ereceive a personal consultation.\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e,\u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e192\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;35.4%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;64.6%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePark,2011\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSouth Korea\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- HAHA program (health education, individual counselling, and tailored exercise program delivered by trained nurses and exercise program for 12 weeks)\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e3 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients who were given HAHA program (education counselling delivered by trained nurses and exercise program for 12 weeks)\u0026thinsp;\u0026ge;\u0026thinsp;65years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e18\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;33.3%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;66.7%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP who received Usual care and did not receive HAHA\u0026thinsp;\u0026ge;\u0026thinsp;65years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;31.8%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;68.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eWang,2011\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChina-Guangdong province, Shenzhen Second People\u0026rsquo;s Hospital\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eParallel group randomised trial\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eEducational intervention directed to the patient- Individual education was performed to inform participants about drug names, indications, strengths, adverse effects, and usage instructions. Pharmacists also introduced accurate BP measurements), medication compliance, healthy lifestyle behaviours\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003e12 months\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients were given pharmaceutical care for 12 months. Patients randomized to the intervention group met with clinical pharmacists every 2\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003emonths. Individual education was conducted to inform participants about drug names, indications, strengths, adverse effects, and usage instructions. Pharmacists\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ealso introduced accurate BP measurements (i.e., body\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eposition, arm position, cuff placement, and stethoscope,\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ecuff size), medication compliance, healthy lifestyle\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003ebehaviours (i.e., vegetarian diet, sodium intake, weight,\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eand physical activity) to patients. \u0026ge;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e29\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;51.72%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;48.2%\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eBP patients were given regular medicare, \u0026ge;\u0026thinsp;18years\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e30\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eM\u0026thinsp;=\u0026thinsp;46.67%\u003c/div\u003e\n \u003cdiv class=\"SimplePara\"\u003eF\u0026thinsp;=\u0026thinsp;53.33%\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Adherence, Randomised controlled trial, Effective interventions, Low and middle income countries, Systematic review","lastPublishedDoi":"10.21203/rs.3.rs-856012/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-856012/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eIn recent decades low- and middle-income countries (LMICs) are witnessing an increase in hypertension and thus becoming a significant public health issue due to associated Cardiovascular disease (CVD) outcomes. Antihypertensive medication adherence is crucial to controlling blood pressure; therefore, this systematic review aimed to evaluate the effectiveness of non-pharmacological interventions on improving blood pressure control and medication adherence in patients with hypertension in LMICs.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eWe searched the following databases for relevant literature published between Jan 2005 – Dec 2020: PubMed, EBSCOhost included Academic Search; CINAHL and MEDLINE complete; PubMed; WEB of Science; Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews and Google Scholar. Cochrane risk of bias tool (RoB 2) was used to appraise included studies critically, and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used to measure the quality of evidence. We conducted a meta‑analysis using DrSimonian-Laid's random-effect model at 95% confidence intervals (CIs). The secondary outcomes of interests were synthesised descriptively as changes in BP adherence outcomes. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eWe identified 14 eligible randomised controlled trials that presented blood pressure (BP) effectiveness and medication adherence among BP patients aged between 18-75 years. The overall quality of evidence with the majority of trials was moderate. Meta weighed effect (SBP) for 12/14 studies was -4.74 (95% CI:-6.07 to -3.47) and I\u003csup\u003e2\u0026nbsp;\u003c/sup\u003e= 57%. Out of 14 eligible studies, (86%) suggested a significant improvement in the proportion of patients with controlled blood pressure (BP \u0026lt; 140/90mmHG) with a positive effect on secondary outcomes such as quality of life.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eNon-pharmacological interventions could be effective in managing hypertension. In recommending the need to investigate the feasibility of non-pharmacological evidence in specific LMIC settings, focus should be on an intervention strategy consisting of an educational intervention directed toward the patients, health professionals and organisation. Considering heterogeneity, randomised trials that are well-designed with larger sample sizes are encouraged in LMICs` to help policymakers make well-informed decisions on hypertension management.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSystematic review Registration: \u003c/strong\u003ePROSPERO registration number: CRD42020172954\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Effectiveness of Interventions To Enable Hypertension Medication Adherence In Low-And Middle-Income Countries: A Systematic Review And Meta-analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-09-15 22:03:43","doi":"10.21203/rs.3.rs-856012/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1795a82d-c377-4a04-911d-df80c9403bf9","owner":[],"postedDate":"September 15th, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":7206641,"name":"Internal Medicine"}],"tags":[],"updatedAt":"2022-04-18T14:43:17+00:00","versionOfRecord":[],"versionCreatedAt":"2021-09-15 22:03:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-856012","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-856012","identity":"rs-856012","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}