Comparing the effects of education using telephone follow-up and smartphone-based social networking follow-up on self-management behaviors among patients with hypertension

Behavior Change Techniques Used in Self-Management Interventions Based on mHealth Apps for Adults With Hypertension: Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND

Hypertension has become an important global public health challenge. Mobile health (mHealth) intervention is a viable strategy to improve outcomes for patients with hypertension. However, evidence on the effect of mHealth app interventions on self-management in patients with hypertension is yet to be updated, and the active ingredients promoting behavior change in interventions remain unclear.

OBJECTIVE

We aimed to evaluate the effect of mHealth app self-management interventions on blood pressure (BP) management and investigate the use of behavior change techniques (BCTs) in mHealth app interventions.

METHODS

We conducted a literature search in 6 electronic databases from January 2009 to October 2023 for studies reporting the application of mHealth apps in self-management interventions. The Cochrane Risk of Bias (version 2) tool for randomized controlled trials was used to assess the quality of the studies. BCTs were coded according to the Taxonomy of BCTs (version 1). The extracted data were analyzed using RevMan5.4 software (Cochrane Collaboration).

RESULTS

We reviewed 20 studies, of which 16 were included in the meta-analysis. In total, 21 different BCTs (mean 8.7, SD 3.8 BCTs) from 12 BCT categories were reported in mHealth app interventions. The most common BCTs were self-monitoring of outcomes of behavior, feedback on outcomes of behavior, instruction on how to perform the behavior, and pharmacological support. The mHealth app interventions resulted in a -5.78 mm Hg (95% CI -7.97 mm Hg to -3.59 mm Hg; P<.001) reduction in systolic BP and a -3.28 mm Hg (95% CI -4.39 mm Hg to -2.17 mm Hg; P<.001) reduction in diastolic BP. The effect of interventions on BP reduction was associated with risk factors, such as hypertension, that were addressed by the mHealth app intervention (multiple risk factors vs a single risk factor: -6.50 mm Hg, 95% CI -9.00 mm Hg to -3.99 mm Hg vs -1.54 mm Hg, 95% CI -4.15 mm Hg to 1.06 mm Hg; P=.007); the presence of a theoretical foundation (with vs without behavior change theory: -10.06 mm Hg, 95% CI -16.42 mm Hg to -3.70 mm Hg vs -4.13 mm Hg, 95% CI -5.50 to -2.75 mm Hg; P=.07); intervention duration (3 vs ≥6 months: -8.87 mm Hg, 95% CI -10.90 mm Hg to -6.83 mm Hg vs -5.76 mm Hg, 95% CI -8.74 mm Hg to -2.77 mm Hg; P=.09); and the number of BCTs (≥11 vs <11 BCTs: -9.68 mm Hg, 95% CI -13.49 mm Hg to -5.87 mm Hg vs -2.88 mm Hg, 95% CI -3.90 mm Hg to -1.86 mm Hg; P<.001).

CONCLUSIONS

The self-management interventions based on mHealth apps were effective strategies for lowering BP in patients with hypertension. The effect of interventions was influenced by factors related to the study's intervention design and BCT.

Comparison of the effect of telephone follow-up with social network follow-up program on self-efficacy and depression in patients undergoing coronary artery bypass graft surgery: A randomized controlled trial

Introduction

Coronary artery bypass graft (CABG) surgery is a common procedure to improve blood flow to the heart muscles, but patients often face challenges during the recovery period. Self-efficacy and depression play crucial roles in patient outcomes. Telephone follow-up and social network follow-up have been introduced as interventions to enhance self-efficacy. This study aims to compare the effectiveness of telephone follow-up and social network follow-up on self-efficacy and depression in CABG patients.

Method

The study is a single-blinded, randomized controlled trial conducted at Shahid Rajaee Heart Hospital in Tehran, Iran. The sample size was determined to be 99 patients who met the inclusion criteria. Data were collected using a demographic questionnaire, Sullivan's cardiac self-efficacy questionnaire, and the Beck Depression Inventory (BDI). Participants were assigned to three groups: control, telephone follow-up, and WhatsApp follow-up using randomization. Data were analyzed using IBM SPSS Statistics for Windows, version 25 (IBM Corp., Armonk, N.Y., USA).

Results

The results revealed significant improvements in self-efficacy and reductions in depression scores for both the telephone and WhatsApp follow-up groups compared to the control group following the intervention (p < 0.001). Additionally, the mean self-efficacy score was higher and the mean depression score was lower in the WhatsApp follow-up group than in the telephone follow-up group after the intervention (p < 0.001).

Discussion

The findings provide valuable insights for healthcare professionals in choosing appropriate interventions to enhance patients' self-efficacy levels and improve mental health outcomes. Both telephone follow-up and social network follow-up interventions have their own advantages and can be effective in supporting patients' recovery after CABG surgery.

Post-Intervention Acceptability of a Multicomponent Intervention for Hypertension Management in Primary Care Clinics by Health Care Providers and Patients: A Qualitative Study of a Cluster RCT in Singapore

Background

Hypertension is a major public health challenge, globally. Recently, we reported findings from cluster randomized trial in 8 primary care clinics in Singapore and showed that a multicomponent "SingHypertension" intervention comprising 1) motivational conversation by trained nurses, 2) telephone-based follow-ups, 3) standardized algorithm with single-pill combination (SPC) antihypertensive medications, and 4) subsidy on SPC antihypertensive drugs was effective on improving BP control. This paper presents the acceptability of SingHypertension multicomponent intervention among the key stakeholders.

Methods

We conducted post-implementation interviews of 38 stakeholders, including 18 patients and 20 healthcare providers (HCPs) in 4 primary care clinics randomized to the multicomponent "SingHypertension" intervention in Singapore. We used Theoretical Framework for Acceptability (TFA) framework with a focus on affective attitude, burden, ethicality, intervention coherence, opportunity cost, perceived effectiveness and self-efficacy to assess stakeholders' acceptability of the intervention.

Results

SingHypertension multicomponent intervention had high perceived effectiveness and a good fit with the value system and ethics of patients and HCPs. Physicians appreciated the guidance from standardized training in hypertension management. Although workload was increased, the nurses felt rewarded for their positive interactions with the patients during motivational conversation sessions and the telephone follow-ups. Most patients reported high self-efficacy levels, improved lifestyles, and adherence to antihypertensive medications. The limited choice of SPC medication, lack of subsidy beyond the trial duration, and shortage of nurses were significant challenges to wide-scale implementation. All HCPs and patients supported scaling up the intervention across primary care clinics.

Conclusion

SingHypertension multicomponent intervention is acceptable to the key stakeholders in Singapore. Taken together with the effectiveness of the intervention, our findings make a compelling case for scaling-up SingHypertension in primary care clinics in Singapore and possibly other countries with similar healthcare infrastructure.

The effect of nurse-led digital health interventions on blood pressure control for people with hypertension: A systematic review and meta-analysis

PURPOSE

Nurse-led digital health interventions (DHIs) for people with chronic disease are increasing. However, the effect of nurse-led DHIs on blood pressure control and hypertension self-management remains unclear. This study aimed to identify the characteristics of nurse-led DHIs for people with hypertension and compared the effect size of nurse-led DHIs with that of usual care to establish evidence for the development of effective nursing interventions using technologies.

DESIGN

Systematic review and meta-analysis.

METHODS

This systematic review and meta-analysis followed the Preferred Reporting Items for Systematic Reviews of Intervention (PRISMA) guidelines and registered the protocol in PROSPERO. Studies published from 2000 to August 5, 2021, were searched using the international databases: PubMed; Embase; Cochrane Central Register of Controlled Trials; Web of Science; CINAHL; Korean databases: RISS, KISS, KMBASE; and NDSL. Risk of bias 2.0 was used for evaluating the quality of studies. The primary outcome was blood pressure control. The secondary outcomes were self-management, medication adherence, and diet adherence. Publication bias was assessed using the funnel plot and Egger's regression tests.

FINDINGS

The systematic review included 26 studies. A meta-analysis of 21 studies was conducted to calculate the effect size and identify heterogeneity among the included studies. In our meta-analysis, we observed that nurse-led DHIs reduced systolic blood pressure by 6.49 mmHg (95% confidence interval [CI]: -8.52 to -4.46, I2  = 75.4%, p < 0.05) and diastolic blood pressure by 3.30 mmHg (95% CI: -4.58 to -2.01, I2  = 70.3%, p < 0.05) when compared with usual care. Concerning secondary outcomes, the effect size on self-management, medication adherence, and diet adherence was 0.98 (95% CI: 0.58 to 1.37, I2  = 63.2%, p < 0.05), 1.05 (95% CI: 0.41 to 1.69, I2  = 92.5%, p < 0.05), and 0.80 (95% CI: 0.17 to 1.42, I2  = 80.5%, p < 0.05), respectively.

CONCLUSION

Nurse-led DHIs were more effective in reducing blood pressure and enhancing self-management than usual care among people with hypertension. Therefore, as new technologies are being rapidly developed and applied in healthcare systems, further studies and policy support are needed to utilize the latest digital innovations with nursing interventions.

CLINICAL RELEVANCE

This study could be used to identify that nurse-led interventions may take advantage of real-time communication by employing digital technologies for improving blood control and self-management behaviors such as medication adherence and diet adherence. Using nurse-led DHIs allows nurses to provide patient-centered interventions such as reflecting on patients' needs and shared decision-making without space constraints and limited treatment time.

Ineffective health management in people with hypertension: Accuracy study

PURPOSE

To analyze the accuracy of the clinical indicators of the nursing diagnosis Ineffective Health Management in people with hypertension.

METHODS

This is a cross-sectional diagnostic accuracy study. The ineffective health management was investigated in 120 people with hypertension in a referral public outpatient clinic in Brazil between August and November 2020. The accuracy measures were analyzed using Rasch analysis, considering the difficulty of clinical indicator and person's ability.

RESULTS

Ineffective health management is probably present in 37.5% of people with hypertension. 'Failure to include treatment regimen in daily living' was the clinical indicator with the highest sensitivity value, and 'failure to take action to reduce risk factor' had the highest specificity value.

CONCLUSIONS

Rasch analysis demonstrated that all clinical indicators contribute significantly to estimating the presence of ineffective health management in people with hypertension in the outpatient scenario.

IMPLICATIONS FOR NURSING PRACTICE

This research contributes by providing accurate clinical indicators of ineffective health management, helping nurses prescribe and deliver the appropriate nursing interventions for people with hypertension by telenursing.

Self-care of hypertension of older adults during COVID-19 lockdown period: a randomized controlled trial

Background

COVID-19 pandemic has aggravated chronic diseases and health disparities especially hypertension because it is more common among vulnerable populations such as older adults.

Objective

This study aimed to examine the effects of a public health nursing intervention plus m-Health applications for hypertension management on enhancing the self-care, systolic and diastolic of blood pressure, and quality of life in older adults during the lockdown period in Jordan.

Methods

A randomized, controlled trial design was performed in Jordan. A total of 120 participants were randomly allocated to three groups (n = 40); interventional group (public health nursing interventions plus m.Health applications) and two control groups (m.Health applications alone group and standard care group).

Results

After 3 months, the interventional group show significantly decreased in systolic blood pressure − 14 (F = 16.74, P = 0.001), greater improvement in self-care maintenance, monitoring, and confidence (+ 30, + 17.75, + 40.27; P < 0.01, respectively) compared to the two control groups. Greater improvement in role limitations due to physical health and due to emotional problems, pain, energy/fatigue, emotional well-being, and social functioning of quality of life (P < 0.05) compared to the standard care group. No statistical significant difference was found in diastolic blood pressure (F = 3.91, P = 0.141), physical functioning (P = 0.613), and general quality of life (P = 0.060).

Conclusions

This study supports the adoption of technology with nursing intervention as a method of supporting continuity of self-management of chronic illness during the pandemic, and its potential implications for future delivery of health care, not just in Jordan, but across the world.

Trial registration

Clinical Trial.gov (ID NCT04992000). Registered August 12, 2021.

Health education interventions to promote health literacy in adults with selected non-communicable diseases living in low-to-middle income countries: A systematic review and meta-analysis

RATIONALE, AIMS AND OBJECTIVES

Health illiteracy is an important contributor to the burden of non-communicable diseases (NCDs); in particular in settings where health illiteracy is part of a perpetuating system of risk factors. Interventions that promote health literacy may provide an important tool in the primary and secondary prevention of NCDs. The objective of this systematic review was to evaluate the effectiveness of health literacy interventions on health literacy in the management of patients with selected NCDs living in low-to-middle income countries (LMIC).

METHODS

Seven electronic databases were searched (October 29, 2020) for RCTs aimed at improving health literacy in adults with NCDs in LMICs. Eligible NCDs included those pertaining to cancer, cardiovascular disease (CVD), chronic respiratory disease (CRD) or Diabetes. Studies were included that explicitly focussed on improving health literacy, and reported comprehensive measures of health literacy, or components thereof (ie, knowledge, attitude or behaviour). Random-effect meta-analyses were conducted for continuous outcome measures (Hedges-g).

RESULTS

The completed search yielded 2573 unique results of which 53 unique studies met the inclusion criteria. Studies included patients with cancer (n = 1, 2%), CRD (n = 8, 15%), CVD (n = 11, 21%) or Diabetes (n = 33, 62%). A significant (P < .01) summary effect was found for disease knowledge (SES = 1.27 [n = 23, 95%CI = 1.05-1.49]), attitude (SES = 1.17 [n = 20, 95%CI = 0.88-1.47]), and behaviour (SES = 1.20 [n = 31, 95%CI = 0.94-1.46]).

CONCLUSIONS

These results support the conclusion that there is compelling evidence, in particular, for patients with Diabetes, that health-literacy interventions are effective in promoting disease knowledge, attitude and behaviour across four chronic conditions that drive the burden of NCDs.

The Effect of Smartphone App-Based Interventions for Patients With Hypertension: Systematic Review and Meta-Analysis

Background

Hypertension is a major cause of cardiovascular disease, which is the leading cause of premature death. People with hypertension who do not comply with recommended treatment strategies have a higher risk of heart attacks and strokes, leading to hospitalization and consequently greater health care costs. The smartphone, which is now ubiquitous, offers a convenient tool to aid in the treatment of hypertension through the use of apps targeting lifestyle management, and such app-based interventions have shown promising results. In particular, recent evidence has shown the feasibility, acceptability, and success of digital interventions in changing the behavior of people with chronic conditions.

Objective

The aim of this study was to systematically compile available evidence to determine the overall effect of smartphone apps on blood pressure control, medication adherence, and lifestyle changes for people with hypertension.

Methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines. Databases were searched to identify randomized controlled trials related to the influence of an app-based intervention in people with hypertension. Data extracted from the included studies were subjected to a meta-analysis to compare the effects of the smartphone app intervention to a control.

Results

Eight studies with a total of 1657 participants fulfilled the inclusion criteria. Pooled analysis of 6 studies assessing systolic blood pressure showed a significant overall effect in favor of the smartphone intervention (weighted mean difference –2.28, 95% CI –3.90-0.66). Pooled analysis of studies assessing medication adherence demonstrated a significant effect (P<.001) in favor of the intervention group (standard mean difference 0.38, 95% CI 0.26-0.50) with low heterogeneity (I²=0%). No difference between groups was demonstrated with respect to physical activity.

Conclusions

A smartphone intervention leads to a reduction in blood pressure and an increase in medication adherence for people with hypertension. Future research should focus on the effect of behavior coaching apps on medication adherence, lifestyle change, and blood pressure reduction.

Addition of the Electronic Educational Material to Doctor's Face-to-Face Education Has No Additive Effects on Hypertension Control: A Randomized Single Blind Study

Background

Patient education is effective for HTN treatment. There are many methods of patient education improving HTN control. Are there additive effects of combination of different educational methods for HTN treatment?

Objective

To assess the effects of addition of the electronic educational material to doctor's face-to-face education for HTN control.

Method

We designed a randomized single blind study to compare the doctor's face-to-face education alone and its combination with the electronic educational material over the cell phone. Participants were patients with a confirmed diagnosis of primary HTN. Electronic educational material over the cell phone was the intervention. Main measures were standard blood pressure measurements before and after 12 weeks of treatment.

Result

The baseline characteristics of the intervention and control groups including the age, sex, SBP, DBP, and HTN control rate were not significantly different. After 12 weeks of follow-up, the blood pressure and the HTN control rate seemed worse in the combination group; however, the differences between the intervention group and the control group were not statistically significant.

Conclusion

There were no additive effects in the combination of the doctor's face-to-face education and the electronic educational material over the cell phone.

Educating Patients by Providing Timely Information Using Smartphone and Tablet Apps: Systematic Review

Background

Patient education is a crucial element within health care. It is a known predictor for increased engagement in shared decision making, improved medication and treatment adherence, higher levels of satisfaction, and even better treatment outcomes. Unfortunately, often patients only remember a very limited amount of medical information. An important reason is that most patients are simply not capable of processing large amounts of new medical information in a short time. Apps for smartphones and tablets have the potential to actively educate patients by providing them with timely information through the use of push notifications.

Objective

The objective of this systematic review is to provide an overview of the effects of using smartphone and tablet apps to educate patients with timely education. Within this review, we focused on patients that receive their care in a hospital setting. We assessed the effects of the interventions on outcomes, such as patients’ knowledge about their illness and treatment, adherence to treatment instructions and to medication usage, and satisfaction with the care they received.

Methods

A comprehensive search of MEDLINE (Medical Literature Analysis and Retrieval System Online), Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Web of Science was conducted. Randomized controlled trials (RCTs) published between January 2015 and November 2019 were eligible for inclusion. Two reviewers independently searched and screened articles, assessed study quality and risk of bias, and extracted the data. Due to the heterogeneity of populations, interventions, and outcomes, a meta-analysis was not deemed appropriate. Instead, a narrative synthesis is presented.

Results

A total of 21 RCTs with 4106 participants were included. Compared to usual care, overall effectiveness of the interventions was demonstrated in 69% of the outcomes. Effectiveness increased to 82% when the intervention had a duration shorter than one month and increased to 78% when the intervention provided at least one push notification per week. The interventions showed the highest effects on satisfaction with information, adherence to treatment instructions and to medication usage, clinical outcomes, and knowledge.

Conclusions

This review demonstrates that educating patients with timely medical information through their smartphones or tablets improves their levels of knowledge, medication or treatment adherence, satisfaction, and clinical outcomes, as well as having a positive effect on health care economics. These effects are most pronounced in interventions with a short duration (ie, less than a month) and with a high frequency of messages to patients (ie, once per week or more). With the knowledge that patient education is a predictor for improved outcomes and the fact that patients have obvious difficulties processing large amounts of new medical information, we suggest incorporating the delivery of timely information through smartphone and tablet apps within current medical practices.

How Behavior Change Strategies are Used to Design Digital Interventions to Improve Medication Adherence and Blood Pressure Among Patients With Hypertension: Systematic Review

BACKGROUND

Information on how behavior change strategies have been used to design digital interventions (DIs) to improve blood pressure (BP) control or medication adherence (MA) for patients with hypertension is currently limited.

OBJECTIVE

Hypertension is a major modifiable risk factor for cardiovascular diseases and can be controlled with appropriate medication. Many interventions that target MA to improve BP are increasingly using modern digital technologies. This systematic review was conducted to discover how DIs have been designed to improve MA and BP control among patients with hypertension in the recent 10 years. Results were mapped into a matrix of change objectives using the Intervention Mapping framework to guide future development of technologies to improve MA and BP control.

METHODS

We included all the studies regarding DI development to improve MA or BP control for patients with hypertension published in PubMed from 2008 to 2018. All the DI components were mapped into a matrix of change objectives using the Intervention Mapping technique by eliciting the key determinant factors (from patient and health care team and system levels) and targeted patient behaviors.

RESULTS

The analysis included 54 eligible studies. The determinants were considered at two levels: patient and health care team and system. The most commonly described determinants at the patient level were lack of education, lack of self-awareness, lack of self-efficacy, and forgetfulness. Clinical inertia and an inadequate health workforce were the most commonly targeted determinants at the health care team and system level. Taking medication, interactive patient-provider communication, self-measurement, and lifestyle management were the most cited patient behaviors at both levels. Most of the DIs did not include support from peers or family members, despite its reported effectiveness and the rate of social media penetration.

CONCLUSIONS

This review highlights the need to design a multifaceted DI that can be personalized according to patient behavior(s) that need to be changed to overcome the key determinant(s) of low adherence to medication or uncontrolled BP among patients with hypertension, considering different levels including patient and healthcare team and system involvement.

The Effectiveness of Self-Management of Hypertension in Adults Using Mobile Health: Systematic Review and Meta-Analysis

Background

Effective treatment of hypertension requires careful self-management. With the ongoing development of mobile technologies and the scarcity of health care resources, mobile health (mHealth)–based self-management has become a useful treatment for hypertension, and its effectiveness has been assessed in many trials. However, there is a paucity of comprehensive summaries of the studies using both qualitative and quantitative methods.

Objective

This systematic review aimed to measure the effectiveness of mHealth in improving the self-management of hypertension for adults. The outcome measures were blood pressure (BP), BP control, medication adherence, self-management behavior, and costs.

Methods

A systematic search was conducted using 5 electronic databases. The snowballing method was used to scan the reference lists of relevant studies. Only peer-reviewed randomized controlled trials (RCTs) published between January 2010 and September 2019 were included. Data extraction and quality assessment were performed by 3 researchers independently, adhering to the validation guideline and checklist. Both a meta-analysis and a narrative synthesis were carried out.

Results

A total of 24 studies with 8933 participants were included. Of these, 23 studies reported the clinical outcome of BP, 12 of these provided systolic blood pressure (SBP) and diastolic blood pressure (DBP) data, and 16 articles focused on change in self-management behavior and medication adherence. All 24 studies were included in the narrative synthesis. According to the meta-analysis, a greater reduction in both SBP and DBP was observed in the mHealth intervention groups compared with control groups, −3.78 mm Hg (P<.001; 95% CI −4.67 to −2.89) and −1.57 mm Hg (P<.001; 95% CI −2.28 to −0.86), respectively. Subgroup analyses showed consistent reductions in SBP and DBP across different frequencies of reminders, interactive patterns, intervention functions, and study duration subgroups. A total of 16 studies reported better medication adherence and behavioral change in the intervention groups, while 8 showed no significant change. Six studies included an economic evaluation, which drew inconsistent conclusions. However, potentially long-term financial benefits were mentioned in all economic evaluations. All studies were assessed to be at high risk of bias.

Conclusions

This review found that mHealth self-management interventions were effective in BP control. The outcomes of this review showed improvements in self-management behavior and medication adherence. The most successful mHealth intervention combined the feature of tailored messages, interactive communication, and multifaceted functions. Further research with longer duration and cultural adaptation is necessary. With increasing disease burden from hypertension globally, mHealth offers a potentially effective method for self-management and control of BP. mHealth can be easily integrated into existing health care systems.

Trial Registration

PROSPERO CRD42019152062; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=152062

The Potential of mHealth Applications in Improving Resistant Hypertension Self-Assessment, Treatment and Control

PURPOSE OF REVIEW

To review the evidence supporting the use of mobile health (mHealth) apps to improve resistant hypertension self-assessment, treatment and control.

RECENT FINDINGS

mHealth apps have been used to directly measure blood pressure (BP) levels, either using the oscillometric method with automated inflatable cuffs or using pulse wave signals detected by smartphone technology without the need for cuffs. These app-based BP monitors tend to over or underestimate BP levels when compared to a gold standard aneroid sphygmomanometer. However, the differences in BP measurements are within the acceptable range of 5 mmHg pre-defined by the European Society of Hypertension International Protocol Revision 2010. mHealth apps are also used as tools to support physicians in improving hypertension treatment. App-based clinical decision support systems are innovative solutions, in which patient information is entered in the app and management algorithms provide recommendations for hypertension treatment. The use of these apps has been shown to be feasible and easily integrated into the workflow of healthcare professionals, and, therefore particularly useful in resource-limited settings. In addition, apps can be used to improve hypertension control by facilitating regular BP monitoring, communication between patients and health professionals, and patient education; as well as by reinforcing behaviours through reminders, including medication-taking and appointment reminders. Several studies provided evidence supporting the use of apps for hypertension control. Although some of the results are promising, there is still limited evidence on the benefits of using such mHealth tools, as these studies are relatively small and with a short-term duration. Recent research has shown that mHealth apps can be beneficial in terms of improving hypertension self-assessment, treatment and control, being especially useful to help differentiate and manage true and pseudo-resistant hypertension. However, future research, including large-scale randomised clinical trials with user-centred design, is crucial to further evaluate the potential scalability and effectiveness of such mHealth apps in the resistant hypertension context.