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

Rethinking chronic care: how blended patient-centered care delivery and innovative financing models can contribute to achieving universal health coverage-a case study of an integrated approach in Kenya

Universal Health Coverage (UHC) aims to ensure all individuals have access to essential health services without financial hardship. Chronic diseases, like hypertension and diabetes, play a critical role in achieving UHC due to their lifelong management needs. This paper examines the implementation of a digital and mobile-based, patient-centered care model aimed at improving care for hypertensive and diabetic patients in Kenya. Between 2018 and 2019, 1626 patients from nine clinics in Nairobi, Kiambu, Nyeri and Vihiga counties were enrolled in an integrated non-communicable disease (NCD) care model including self-management devices for home monitoring, a digital health wallet (M-TIBA) for co-payment and facility-based peer support groups. Follow-up data was collected November-December 2020. Results indicated significantly improved patient outcomes, with 50% of hypertensive and 74% of diabetic patients achieving disease control, compared to 42% and 52% at baseline. Additionally, peer group participation increased adherence to self-monitoring and lifestyle modifications, contributing to better health outcomes. Despite these successes, challenges such as accessing medications and technical issues with digital tools were identified. Financial sustainability and scalability remain critical concerns, particularly in under-resourced settings. The case study highlights the potential of digital health solutions to enhance chronic care and support UHC by improving accessibility and reducing costs. A multifaceted approach, combining digital tools with face-to-face support and addressing structural barriers in healthcare systems, is essential for long-term success. The findings contribute to the broader discourse on integrated care models for NCDs in low-resource settings, underscoring the importance of sustainable financing and innovative care delivery mechanisms.

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.

Diabetes self-care intervention strategies and their effectiveness in Sub-Saharan Africa: A systematic review

BACKGROUND

Diabetes poses a significant public health challenge, predominantly affecting low-and middle-income countries (LMICs), including in Sub-Saharan Africa (SSA). The evolving landscape characterized by resource constraints, gaps in availability and functionality of healthcare system, and socio-demographic impediments has compounded these challenges. As an example, self-care interventions have played a crucial role in diabetes care. However, the effectiveness of these interventions in the SSA remains insufficiently explored. Therefore, this systematic review evaluated the effectiveness and implementation approach of diabetes self-care interventions in SSA.

METHOD

A comprehensive search was conducted across electronic databases including PubMed, Scopus, and Google Scholar, to identify studies focusing on diabetes self-care interventions in SSA from 2013 to 2023. The included studies reported interventions targeting dietary adherence, physical activity, medication adherence, blood glucose monitoring, foot care, and educational or support programs. The quality of the studies was assessed using the JBI checklist. Effectiveness was assessed through outcomes including glycemic control, adherence rate, complication reduction, and improvement in patient outcomes.

RESULT

Overall, 38.5% of interventions result showed positive changes in either primary or secondary outcomes. Studies that employed diabetes self-management education showed positive changes in approximately 28.6% of cases. However, SMS text messaging interventions did not demonstrate significant changes in the measured outcomes. Of the 13 studies reviewed, 12 used randomized controlled trial designs, whereas one study employed a quasi-experimental approach. The total of participants across intervention and control groups was 3172 adults with diabetes. The interventions employed various strategies including diabetes self-management education led by nurses and other professionals, SMS text messaging for treatment adherence, and other targeted approaches. The duration of these interventions varied from 2 to 12 months. Specific interventions, such as glucose machine provision with training, family support with culturally tailored educations, and periodontal treatment, exhibited notable improvement in adherences and reductions in HbA1c levels.

CONCLUSION

The review underscores the significance of diabetes self-care interventions in SSA, showing varying effectiveness levels across different strategies. It emphasizes the importance of tailored approaches and highlight interventions that have shown promising outcomes, providing insights for future research, policy, and healthcare strategies in the region.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

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

Community-based management of arterial hypertension and cardiovascular risk factors by lay village health workers for people with controlled and uncontrolled blood pressure in rural Lesotho: joint protocol for two cluster-randomized trials within the ComBaCaL cohort study (ComBaCaL aHT Twic 1 and ComBaCaL aHT TwiC 2)

BACKGROUND

Arterial hypertension (aHT) is a major cause for premature morbidity and mortality. Control rates remain poor, especially in low- and middle-income countries. Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems may help to overcome the current aHT care cascade gaps. However, evidence on the effectiveness of comprehensive VHW-led aHT care models, in which VHWs provide antihypertensive drug treatment and manage cardiovascular risk factors is scarce.

METHODS

Using the trials within the cohort (TwiCs) design, we are assessing the effectiveness of VHW-led aHT and cardiovascular risk management in two 1:1 cluster-randomized trials nested within the Community-Based chronic disease Care Lesotho (ComBaCaL) cohort study (NCT05596773). The ComBaCaL cohort study is maintained by trained VHWs and includes the consenting inhabitants of 103 randomly selected villages in rural Lesotho. After community-based aHT screening, adult, non-pregnant ComBaCaL cohort participants with uncontrolled aHT (blood pressure (BP) ≥ 140/90 mmHg) are enrolled in the aHT TwiC 1 and those with controlled aHT (BP < 140/90 mmHg) in the aHT TwiC 2. In intervention villages, VHWs offer lifestyle counseling, basic guideline-directed antihypertensive, lipid-lowering, and antiplatelet treatment supported by a tablet-based decision support application to eligible participants. In control villages, participants are referred to a health facility for therapeutic management. The primary endpoint for both TwiCs is the proportion of participants with controlled BP levels (< 140/90 mmHg) 12 months after enrolment. We hypothesize that the intervention is superior regarding BP control rates in participants with uncontrolled BP (aHT TwiC 1) and non-inferior in participants with controlled BP at baseline (aHT TwiC 2).

DISCUSSION

The TwiCs were launched on September 08, 2023. On May 20, 2024, 697 and 750 participants were enrolled in TwiC 1 and TwiC 2. To our knowledge, these TwiCs are the first trials to assess task-shifting of aHT care to VHWs at the community level, including the prescription of basic antihypertensive, lipid-lowering, and antiplatelet medication in Africa. The ComBaCaL cohort and nested TwiCs are operating within the routine VHW program and countries with similar community health worker programs may benefit from the findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05684055. Registered on January 04, 2023.

Development of a Health Behavioral Digital Intervention for Patients With Hypertension Based on an Intelligent Health Promotion System and WeChat: Randomized Controlled Trial

BACKGROUND

The effectiveness of timely medication, physical activity (PA), a healthy diet, and blood pressure (BP) monitoring for promoting health outcomes and behavioral changes among patients with hypertension is supported by a substantial amount of literature, with "adherence" playing a pivotal role. Nevertheless, there is a lack of consistent evidence regarding whether digital interventions can improve adherence to healthy behaviors among individuals with hypertension.

OBJECTIVE

The aim was to develop a health behavioral digital intervention for hypertensive patients (HBDIHP) based on an intelligent health promotion system and WeChat following the behavior change wheel (BCW) theory and digital micro-intervention care (DMIC) model and assess its efficacy in controlling BP and improving healthy behavior adherence.

METHODS

A 2-arm, randomized trial design was used. We randomly assigned 68 individuals aged >60 years with hypertension in a 1:1 ratio to either the control or experimental group. The digital intervention was established through the following steps: (1) developing digital health education materials focused on adherence to exercise prescriptions, Dietary Approaches to Stop Hypertension (DASH), prescribed medication, and monitoring of BP; (2) using the BCW theory to select behavior change techniques; (3) constructing the intervention's logic following the guidelines of the DMIC model; (4) creating an intervention manual including the aforementioned elements. Prior to the experiment, participants underwent physical examinations at the community health service center's intelligent health cabin and received intelligent personalized health recommendations. The experimental group underwent a 12-week behavior intervention via WeChat, while the control group received routine health education and a self-management manual. The primary outcomes included BP and adherence indicators. Data analysis was performed using SPSS, with independent sample t tests, chi-square tests, paired t tests, and McNemar tests. A P value <.05 was considered statistically significant.

RESULTS

The final analysis included 54 participants with a mean age of 67.24 (SD 4.19) years (n=23 experimental group, n=31 control group). The experimental group had improvements in systolic BP (-7.36 mm Hg, P=.002), exercise time (856.35 metabolic equivalent [MET]-min/week, P<.001), medication adherence (0.56, P=.001), BP monitoring frequency (P=.02), and learning performance (3.23, P<.001). Both groups experienced weight reduction (experimental: 1.2 kg, P=.002; control: 1.11 kg, P=.009) after the intervention. The diet types and quantities for both groups (P<.001) as well as the subendocardial viability ratio (0.16, P=.01) showed significant improvement. However, there were no statistically significant changes in other health outcomes.

CONCLUSIONS

The observations suggest our program may have enhanced specific health outcomes and adherence to health behaviors in older adults with hypertension. However, a longer-term, larger-scale trial is necessary to validate the effectiveness.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200062643; https://www.chictr.org.cn/showprojEN.html?proj=172782.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/46883.