Effectiveness of Health Promotion Programs on Blood Pressure in People With Hypertension and Prehypertension in Southeast Asian Populations: Systematic Review and Meta‐Analysis

ABSTRACT

Aim

To evaluate health promotion programmes for managing hypertension in Southeast Asia.

Design

Systematic review and meta‐analysis.

Methods

A systematic search was conducted across five databases: MEDLINE, APA PsycInfo, Scopus, Web of Science, and CINAHL, covering studies conducted in Southeast Asia and published in English from January 2003 to December 2023. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) guidelines, and the protocol was registered in PROSPERO. Eligibility criteria included adults aged 18 years and older with prehypertension or hypertension, evaluating health promotion programmes focusing on exercise intervention, dietary modification, and health education compared with usual care.

Results

Eleven of the twenty‐six studies were included in meta‐analyses and showed a statistically significant effect of the interventions on blood pressure. Two studies of dietary interventions demonstrated decreased systolic blood pressure with a pooled mean difference of 8.32 mmHg (95% CI −11.29, −5.34, p ≤ 0.001). Four studies of endurance exercise reduced systolic blood pressure with a pooled mean difference of 15.95 mmHg (95% CI −19.45, −12.46, p < 0.001). Two studies of combined diet and exercise with intensive coaching decreased systolic blood pressure with a pooled mean difference of 6.41 mmHg (95% CI −7.49, −5.33, p < 0.001). Two studies of health education show a clinically significant decrease in systolic blood pressure by 5–18 mmHg.

Patient or Public Contribution

Health promotion interventions are feasible and acceptable in Southeast Asian populations and significantly reduce blood pressure, particularly systolic blood pressure. Consuming a healthy diet such as the Dietary Approaches to Stop Hypertension Diet (DASH), restricting sodium, and increasing potassium intake is feasible and effective in the Southeast Asian context. To optimise impacts on blood pressure control, endurance exercise interventions should adhere to established exercise principles. Health education programs should incorporate effective coaching strategies to enhance their impact.

1. Introduction

Hypertension is a leading cause of premature death worldwide, with a rising prevalence in low‐ and middle‐income countries (World Health Organization [WHO] 2023). Southeast Asia has a high burden of hypertension, with one in four adults affected by hypertension (WHO 2024). Only one in three of these individuals is treated, and only one in 10 has their condition under control (WHO 2024). Only 42% of individuals diagnosed with hypertension in the region receive treatment, and just 21% achieve adequate blood pressure control (WHO 2023). Cardiovascular diseases (CVDs) are a leading cause of death in the Southeast Asia Region, approximately 3.6 million per year, primarily affecting individuals under 70 years of age. Hypertension is one of the major risk factors contributing to the health burden (WHO 2024). Elevated blood pressure is a significant risk factor for cardiovascular diseases, stroke, and chronic kidney disease (Fuchs and Whelton 2020), with studies showing that a 20 mmHg increase in systolic blood pressure or a 10 mmHg rise in diastolic blood pressure doubles the risk of cardiovascular events (Fuchs and Whelton 2020).

Southeast Asia comprises 11 countries and is home to peoples with a wide diversity in religion, culture, and history: Brunei, Burma (Myanmar), Cambodia, Timor‐Leste, Indonesia, Laos, Malaysia, Philippines, Singapore, Thailand, and Vietnam (Center for Southeast Asian Studies 2025). Southeast Asian countries are rapidly modernising, with the majority of people living in urbanised communities. Rapid urbanisation has resulted in lifestyle changes such as decreased participation in rigorous exercise, high consumption of processed foods that are high in sodium, and an increased prevalence of individuals who are overweight or obese (Nawi et al. 2021). This situation is leading to an increasing prevalence of hypertension. Therefore, primary and secondary prevention of hypertension, including proper screening, health education, and motivating change in behaviour, should be encouraged by healthcare professionals such as physicians, nurses, and pharmacists who can tailor interventions to the population's culture and needs (Nawi et al. 2021; WHO 2021).

2. Background

Effective hypertension management encompasses both lifestyle changes and medication to control blood pressure. Nonpharmacological lifestyle modifications are fundamental, as they can enhance the effectiveness of pharmacological treatments (Jones et al. 2021). Such modifications include salt reduction, healthy dietary patterns, moderation of alcohol intake, weight management, smoking cessation, regular physical activity, and stress reduction (Rabi et al. 2020; Unger et al. 2020). Dietary approaches like the DASH diet advocate for nutrient‐rich foods such as whole grains, fruits, vegetables, and low‐fat dairy while limiting sodium intake to below 1500 mg/day (Whelton et al. 2018). Studies have demonstrated that sodium reduction to less than 5.8 g/day can decrease systolic blood pressure by 5 mmHg (Mancia et al. 2023). However, Southeast Asian diets traditionally include high sodium content due to the common use of salty condiments and fermented foods (Amarra and Khor 2015; Rusmevichientong et al. 2021).

Regular physical activity is similarly beneficial. For individuals with hypertension, 90–150 min of aerobic exercise per week at moderate intensity can lower systolic blood pressure by 5–8 mmHg (Mancia et al. 2023). Exercise recommendations include aerobic and resistance activities, and adherence to moderate intensity for 60 min, 3–5 days per week, with warm‐up and cool‐down periods (Liguori et al. 2021).

Hypertension management in Southeast Asia faces unique challenges. Factors such as cultural relevance, environmental influences, and available resources impact the effectiveness of interventions (Irwan et al. 2022). While many randomised controlled trials have assessed blood pressure management strategies, a systematic review and meta‐analysis specifically examining health promotion interventions for individuals with hypertension and prehypertension in Southeast Asia has not been conducted.

3. Aim

The aim of this review is to evaluate dietary, exercise, and health education interventions to identify the most effective methods for managing blood pressure in Southeast Asian populations and provide recommendations for designing regionally appropriate health promotion programmes.

4. Methods

4.1. Design

This study is a systematic review and meta‐analysis.

4.2. Search Methods

This study is presented according to the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses (PRISMA) statement, an updated guideline for reporting systematic reviews of healthcare interventions. This study protocol is registered in PROSPERO (ID CRD42023437518) and can be accessed online (https://www.crd.york.ac.uk/prospero/#recordDetails).

4.3. Inclusion Criteria

The study inclusion criteria were as follows: Participants: This systematic review included studies of adults 18 years and older with hypertension or prehypertension, whether adults have metabolic syndrome that blood pressure met criteria. According to The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7), prehypertension was defined as a mean SBP ≥ 120 mmHg and/or DBP ≥ 80 mmHg and hypertension was defined as a mean SBP ≥ 140 mmHg and/or DBP ≥ 90 mmHg. Participants diagnosed with stroke, heart failure, or chronic kidney disease were excluded. Intervention: The interventions were categorised based on clinical practice guidelines and a literature review on hypertension management, which suggested reducing risk factors such as decreasing salt intake, increasing fruit and vegetable consumption, promoting exercise, and obtaining health education. Studies that evaluated health promotion programmes focusing on exercise intervention, increasing physical activity, dietary modification, and health education were considered. Comparator: Studies that compared health promotion programmes to usual care or control groups were considered. Context: All studies were conducted in primary healthcare settings or communities in Southeast Asia. Outcome: The primary outcomes were defined as degree of change in systolic blood pressure and diastolic blood pressure. Study Design: All studies are primary research conducted as randomised controlled trials and published in English from January 2003 to December 2023.

4.4. Search Outcome

After registering the protocol in PROSPERO, the researcher searched five databases, MEDLINE via PubMed, APA PsycInfo, Scopus, Web of Science, and CINAHL, in July 2023 to identify eligible studies. Searching strategies used keywords and Booleans, for example, hypertension OR high blood pressure OR prehypertension AND health education OR health promotion OR dietary modification OR low salt diet OR physical activity OR exercise AND blood pressure OR systolic blood pressure OR diastolic blood pressure (Table S1). All studies were exported to Endnote version 20.2.1 and categorised by database. Additionally, the researcher included 17 studies from a previously conducted narrative review, which were part of the 1030 studies. The summary of the search process and the final systematic review are presented in the PRISMA flow diagram (Figure S1). PB exported all studies to the Covidence program to screen titles and abstracts. PB and AFH independently reviewed the titles and abstracts of all studies that met the inclusion criteria for systematic reviews. Two independent reviewers (PB and AFH) evaluated the full text of selected citations and provided reasons for inclusion or exclusion. Any disagreements between the reviewers at each stage of the selection process were resolved through discussion with an additional reviewer.

4.5. Quality Apprasial

The Joanna Briggs Institute (JBI) critical appraisal tool was used to assess bias for randomised controlled trials (Barker et al. 2023) (Table S2). PB and AFH independently reviewed and completed the quality appraisal for each included study and discussed any disagreements.

4.6. Data Abstraction

Data were abstracted by two independent reviewers (PB and AFH) into a Microsoft Excel document, including the first author's name, publication year, country, sample size, participant characteristics (hypertension or prehypertension, aged range), antihypertensive treatment, and type of interventions (dietary, exercise, combined diet and exercise, and educational programs).

4.6.1. Dietary Interventions

Data were extracted on participants, the type of food, duration and follow‐up, the strategy used to deliver the content, and the comparator intervention.

4.6.2. Exercise Interventions

Data were extracted on participants, duration of intervention, type of exercise, intensity, frequency, duration, and comparator intervention. Details of the exercise types are as follows:

4.6.3. Endurance Exercise

Prolonged and rhythmic activities that use large muscle groups, for example, walking, cycling, swimming, and arm swings.

4.6.4. Intensive Aerobic Exercise

Moderate‐intensity exercise performed for 30–60 min, maintaining a heart rate reserve at 40%–59%, or calculating maximum heart rate as 220 minus age.

4.6.5. Strength Exercise

Stretching exercises targeting the lower and upper extremities and trunk muscles, stretching to the point of feeling tightness or slight discomfort.

4.6.6. Resistance Exercise

Muscular fitness optimised through resistance training includes the use of free weights, machines, body weight, bands, or any other objects that require exertion of force against resistance.

4.6.7. Combined Diet and Exercise Interventions

Data were extracted on participants, duration, diet and exercise content, teaching strategy, and comparator intervention.

4.6.8. Health Education Programs

Data were extracted on participants, duration, presented content, material, theory, person who provides health education, and comparator intervention.

For all interventions, systolic and diastolic blood pressure were extracted pre‐intervention and post‐intervention. The extracted statistics included mean, mean difference, standard deviation, and standard deviation difference. The researcher emailed the corresponding authors for studies that did not present a standard deviation. Two of the seven studies' corresponding authors provided the data.

4.7. Data Synthesis

The included studies were categorised into different interventions: diet interventions, exercise interventions (endurance exercise, endurance exercise in hypertensive people, endurance exercise in prehypertensive and hypertensive people, exercise with moderate intensity), coaching to promote behaviour change (combined diet and exercise, brief behaviour change coaching interventions, intensive behaviour change coaching interventions), and health education intervention. The data on changes in systolic and diastolic blood pressure before and after the intervention were summarised by the first author (P.B.), and data accuracy was checked by a second and third author (AFH and AD).

Meta‐analyses were conducted using Stata version 18.0 (StataCrop 2025), utilising the ‘meta’ command to compute and declare effect sizes for two‐group comparisons of continuous outcomes when at least two studies involved similar interventions or participants. The mean difference and standard deviation difference were used for the comparison of studies. If studies did not present standard deviations, the researcher imputed the missing standard deviation change values following the Cochrane guidelines (Higgins et al. 2023):

1. Estimate the correlation coefficient value derived from Tran's study (Tran et al. 2017) using the following formula.

$${\text{Corr}}_{\mathrm{E}}=\frac{{\mathrm{SD}}_{\mathrm{E},\text{baseline}}^2+{\mathrm{SD}}_{\mathrm{E},\text{final}}^2-{\mathrm{SD}}_{\mathrm{E},\text{change}}^2}{2\times {\mathrm{SD}}_{\mathrm{E},\text{baseline}}\times {\mathrm{SD}}_{\mathrm{E},\text{final}}}$$

• 2Calculate the missing standard deviation change values using the following formula:

$${\mathrm{SD}}_{\mathrm{E},\text{change}}=\sqrt{{\mathrm{SD}}_{\mathrm{E},\text{baseline}}^2+{\mathrm{SD}}_{\mathrm{E},\text{final}}^2-\left(2\times \text{Corr}\times {\mathrm{SD}}_{\mathrm{E},\text{baseline}}\times {\mathrm{SD}}_{\mathrm{E},\text{final}}\right)}$$

where SD_E,baseline is the standard deviation before the intervention, SD_E,final is the standard deviation after the intervention, SD_E,change is the standard deviation difference between the final and before the intervention, and Corr is the correlation value. The experimental group and control group use similar formulas to impute missing values.

All meta‐analyses used the 95% confidence interval. The random effects analysis model was utilised due to the heterogeneity of the studies (Alavi et al. 2021). Heterogeneity was assessed with I ², using the rule‐of‐thumb where 0%–40% might not be important, 30%–60% may represent moderate heterogeneity, 50%–90% may represent substantial heterogeneity, and 75%–100% indicates considerable heterogeneity (Alavi et al. 2021; Higgins et al. 2023).

Researchers conducted sensitivity analyses by grouping studies with similar interventions and comparing them between participant types. For example, in the exercise category, we categorised studies into: Endurance Exercise, Endurance Exercise in Hypertensive People, Endurance Exercise in Prehypertensive and Hypertensive People, and Exercise with Moderate Intensity. Additionally, outliers were removed to reduce heterogeneity in the estimates.

5. Results

5.1. Characteristics of Studies

A total of 1030 studies were identified using the above search strategy. After removing duplicates, 915 articles were screened by abstract and title. A total of 848 citations were deemed to be irrelevant and were screened out of the review. Sixty‐seven full‐text studies were assessed for eligibility, and 41 were excluded for the following reasons: wrong study design, wrong research setting, no blood pressure measurement in the outcomes, irrelevant population, or intervention not including dietary modification, exercise, or education. Finally, 26 studies were included in the review (Figure S1). Of these, 13 (50.0%) were conducted in Thailand, 5 (19.2%) in Malaysia, 3 (11.5%) in Vietnam, 3 (11.5%) in Indonesia, and 2 (7.7%) in Singapore (see Table 1).

TABLE 1.

Overview characteristics of included studies.

No.	Author and year	Country	Setting	No. of participants (intervention/control)	Inclusion criteria	Anti hypertensive treatment	Duration	Type of intervention
								Diet	Exercise	Both diet and exercise	Education
1	Aminuddin et al. (2011)	Malaysia	Outpatient Physiotherapy Department (University Hospital)	6, 7	1. People with prehypertension or hypertension 2. Aged 35 to 60 years	Nil	8 weeks		x
2	Rujiwatthanakorn et al. (2011)	Thailand	Community hospital	50, 46	1. People with hypertension 2. Aged 33 to 82 years	Antihypertensive treatments	10 weeks				x
3	Jafar et al. (2016)	Singapore	Polyclinics	50, 50	1. People with hypertension 2. Aged 40 years and older	Antihypertensive treatments	12 weeks				x
4	Nguyen et al. (2017)	Vietnam	Community	80, 80	1. People with hypertension 2. Aged 50 years and older	Antihypertensive treatments maintained at stable doses	3 months			x	x
5	Phing et al. 2017	Malaysia	Community	70, 85	1. People with prehypertension/metabolic syndrome 2. Aged 18 to 59 years	Nil	24 weeks		x
6	Sabilu et al. 2017	Indonesia	Public health center	14, 14	1. People with hypertension 2. Aged 60 years and older	Nil (stop medication before commencing intervention)	7 days	x			x
7	Tran et al. (2017)	Vietnam	Community	175, 162	1. People with prehypertension/metabolic syndrome 2. Aged 50 to 65 years	Nil	6 months			x
8	Chaiyasoot et al. (2018)	Thailand	Research centre of nutrition support	48, 45	1. People with prehypertension/metabolic syndrome 2. Aged 18 years and older	Unknown	12 weeks			x	x
9	Chongthawonsatid and Chinjenpradit (2018)	Thailand	The golden jubilee medical center	30, 26	1. People with prehypertension or hypertension 2. Aged 30 to 65 years	Nil	6 months		x		x
10	Nur et al. (2018)	Malaysia	Primary care clinic	31, 31	1. People with prehypertension or hypertension 2. Aged 35 to 45 50 years	Unknown	12 weeks		x
11	Nguyen et al. (2018)	Vietnam	Community	80, 80	1. People with hypertension 2. Aged 50 years and older	Antihypertensive treatments maintained at stable doses	12 months			x	x
12	Sutipan et al. (2018)	Thailand	Rural community	20, 20	1. People with hypertension 2. Aged 60 to 75 years	Unknown	12 weeks				x
13	Thiabpho et al. (2018)	Thailand	Primary health care center	30, 30	1. People with normotensive or prehypertension 2. Age 30 to 50 years	Nil	16 weeks			x	x
14	Pengpid et al. (2019)	Thailand	Community	188, 206	1. People with prehypertension 2. Age 35 to 65 years	Nil	12 months			x	x
15	Prasertsri et al. (2019)	Thailand	Community	25, 25	1. People with prehypertension 2. Aged 60 to 80 years	Nil	3 months		x
16	Ruangthai and Phoemsapthawee (2019)	Thailand	Community	42, 12	1. People with hypertension 2. Aged 60 years and older	Antihypertensive treatments maintained at stable doses	12 weeks		x
17	Ruangthai et al. (2020)	Thailand	Community	29, 12	1. People with hypertension 2. Aged 60 years and older	Antihypertensive treatments maintained at stable doses	12 weeks		x
18	Thatthong et al. (2020)	Thailand	Community	25, 25	1. People with prehypertension 2. Aged 19 to 59 years	Unknown	10 weeks	x			x
19	Intarakamhang and Macaskill (2022)	Thailand	Community	100, 100	1. People with prehypertension 2. Aged 40 to 59 years	Nil	8 weeks			x	x
20	Mir et al. (2021)	Malaysia	Community	15, 15	1. People with prehypertension 2. Aged 18 to 25 years	Nil	4 weeks	x			x
21	Phoemsapthawee and Sriton (2021)	Thailand	Community	10, 10	1. People with prehypertension 2. Aged 19 to 22 years	Nil	12 weeks		x
22	Susanto et al. (2021)	Indonesia	Community	60, 30	1. People with normotensive or prehypertension or hypertension 2. Aged 18 to 50 years	Antihypertensive treatments maintained at stable doses	3 months			x	x
23	Jafar et al. (2022)	Singapore	Primary care clinic	447, 469	1. People with hypertension 2. Aged 40 years and older	Antihypertensive treatments maintained at stable doses	24 months			x	x
24	John et al. (2022)	Malaysia	Health center	22, 10	1. People with prehypertension 2. Aged 18 to 25 years	Nil	4 weeks		x
25	Rizka et al. (2022)	Indonesia	Community	17, 17	1. People with hypertension 2. Aged 60 years and older	Antihypertensive treatments maintained at stable doses	3 weeks		x
26	Sarinukul et al. (2023)	Thailand	Community	17, 17	1. People with hypertension 2. Aged 60 to 75 years	Antihypertensive treatments maintained at stable doses	8 weeks		x

The interventions evaluated were: 10 (38.5%) exercise interventions, 10 (38.5%) combined diet and exercise, 3 (11.5%) education programmes, and 3 (11.5%) dietary interventions. The studies included participants with a diagnosis of hypertension, 11 (42.3%) with hypertension; of these, in 10 (38.5%) studies, the participants were taking stable doses of antihypertensives and in one study the participants stopped their antihypertensive treatment for the 7 days of the trial (Sabilu et al. 2017). There were 10 (38.5%) studies of participants with prehypertension, and 3 (11.6%) studies of participants with both hypertension and prehypertension. There were 2 (7.6%) studies that included participants with normal blood pressure, prehypertension, and hypertension. In the five studies that included participants with mixed diagnoses, the use of antihypertensive medications was not reported (Aminuddin et al. 2011; Chongthawonsatid and Chinjenpradit 2018; Nur et al. 2018; Phing et al. 2017; Sutipan et al. 2018). The study designs included 20 (76.92%) randomised controlled trials and 6 (23.08%) cluster randomised controlled trials.

5.2. Effectiveness of Interventions

The effectiveness of health promotion interventions is presented in four groups: diet, exercise, combined diet and exercise, and health education interventions.

5.3. Diet Interventions

Three studies of dietary intervention (Table S3.1) showed significant decreases in systolic blood pressure by 8–9 mmHg, but only one study showed a reduction in diastolic blood pressure by 6 mmHg within 7 days to 10 weeks (Mir et al. 2021; Sabilu et al. 2017; Thatthong et al. 2020). The dietary intervention that reduced blood pressure encouraged participants to consume tomato juice (which enriches potassium) (Sabilu et al. 2017). Another study provides a DASH diet and restricts sodium to less than 100 mmol/day plus music therapy (Table S3.2) (Mir et al. 2021). Two studies evaluated systolic and diastolic blood pressure as primary outcomes, allowing for meta‐analysis to be conducted and found a statistically significant reduction in systolic blood pressure (−8.32 mmHg, 95% CI −11.29, −5.34; p < 0.001, I ² = 0.00%) (see Figure 1) (Mir et al. 2021; Sabilu et al. 2017).

FIGURE 1.

Forest plots generated from the meta‐analysis present the mean difference (95% CI) of the effect of dietary interventions on (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP).

5.4. Exercise Interventions

Eleven studies evaluated the effect of exercise interventions. Two studies were excluded from the meta‐analysis as standard deviation or confidence interval data were not available (Rizka et al. 2022; Ruangthai et al. 2020). The results are divided into four groups based on the type of exercise and the characteristics of the participants, as detailed below:

5.4.1. Endurance Exercise

Six studies explored the effect of endurance exercise, including walking at least 10,000 steps/day, stepping exercise for 60 min/day, arm swinging for 30 min/day, strength exercise, and combined endurance and strength exercise for 60 min/day, with a frequency of 3 times/week. Additionally, Ruangthai and Phoemsapthawee conducted a study with three groups: (1) Endurance Training Group: this group followed a walking program that included walking with arms up, heel hits behind, tiptoeing, arm adduction/abduction, and knee lifts. (2) Strength Training Group: participants in this group performed exercises targeting the lower and upper extremities and trunk muscles. (3) Combined Endurance and Strength Training Group: this group engaged in both walking and strength exercises. Two studies comparing endurance exercise to a control group found a statistically significant reduction in systolic blood pressure by 10–15 mmHg (Table S3.3) (Ruangthai and Phoemsapthawee 2019; Sarinukul et al. 2023). All six studies were included in the meta‐analysis and found a statistically significant reduction in systolic blood pressure (−9.45 mmHg, 95% CI −16.28, −2.62; p = 0.01, I ² = 76.09%). Only one study showed a statistically significant decrease in diastolic blood pressure by 8 mmHg (Figure S2.1) (Ruangthai and Phoemsapthawee 2019).

5.4.2. Endurance Exercise in Hypertensive People

Six studies of endurance exercise showed high levels of heterogeneity (I ² = 76.09%). Researchers conducted a sensitivity analysis of sub‐groups by selecting interventions in the same participants as follows. Four studies assessed the effect of endurance exercise in people with hypertension and were included in a meta‐analysis (see Figure 2). Endurance exercise resulted in significantly decreasing systolic blood pressure (−15.95 mmHg, 95% CI −19.45, −12.46; p < 0.001, I ² = 0.00%). Three of four studies show significant decreases in systolic blood pressure by 7–15 mmHg (Table S3.3) (Ruangthai and Phoemsapthawee 2019; Sarinukul et al. 2023). One intervention (Group 1) involving walking and strength exercises for 60 min/day, with a frequency of 3 days/week, found a significant reduction in systolic and diastolic blood pressure by 10 and 8 mmHg, respectively (Ruangthai and Phoemsapthawee 2019).

FIGURE 2.

Forest plots generated from the meta‐analysis present the mean difference (95% CI) of the effect of endurance exercise in hypertensive people on (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP).

5.4.3. Endurance Exercise in Prehypertensive and Hypertensive People

Two studies encouraged participants to walk 10,000 steps/day and perform arm swing exercises for 30 min/day, with a frequency of 3 days/week for 12 weeks (Table S3.4) (Nur et al. 2018; Prasertsri et al. 2019). These two studies were included in a meta‐analysis to explore the effect of endurance exercise in people with prehypertension and hypertension. The results show a non‐statistically significant decrease in both systolic and diastolic blood pressure (p = 0.55, p = 0.35) (Figure S2.2).

5.4.4. Exercise With Moderate Intensity

Four studies were included in the meta‐analysis to evaluate the effect of moderate‐intensity exercise on people with prehypertension and hypertension (Aminuddin et al. 2011; Phing et al. 2017; Phoemsapthawee and Sriton 2021). In Phing's study, two groups of interventions were conducted: (1) Participants received a point‐of‐decision prompt, which consisted of a standing banner encouraging participants to walk 10,000 steps per day. (2) Participants involved in aerobic exercise attended a 60‐min moderate‐intensity aerobics class weekly and had meetings every fortnight to monitor their progress (Phing et al. 2017).

The results show a nonsignificant reduction in blood pressure (p = 0.54, p = 0.16) (see Figure 3). The interventions allow for treadmill exercise for 30 min, with 50%–70% of heart rate reserved for 8 weeks, moderate‐intensity aerobics class for 60 min, prompt walking 10,000 steps/day, and combined aerobic, resistance, and stretching exercise for 60 min, with 50%–60% of heart rate reserved for 12 weeks.

FIGURE 3.

Forest plots generated from the meta‐analysis present the mean difference (95% CI) of the effect of exercise with moderate intensity on (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP).

5.5. Coaching to Promote Behavioural Change

Ten studies explored the effect of combined diet and exercise interventions, and six of these studies provided statistics suitable for a meta‐analysis. One study showed a significant decrease in both systolic and diastolic blood pressure by 10 mmHg (Table S3.5). This intervention included progressive muscular relaxation and stretching exercises, as well as information on diet, exercise, sleep, and work‐related problems (Susanto et al. 2021). The results are divided into three groups based on the intensity of coaching to promote behaviour change, as detailed below:

5.5.1. Combined Diet and Exercise

Six studies evaluated the effect of combined diet and exercise and were included in a meta‐analysis (Chongthawonsatid and Chinjenpradit 2018; Intarakamhang and Macaskill 2022; Jafar et al. (2022); Pengpid et al. 2019; Thiabpho et al. 2018; Tran et al. 2017). The result presented no statistically significant decrease in systolic blood pressure (p = 0.23). There were high levels of heterogeneity across the included studies (I ² = 94.25%). However, diastolic blood pressure shows a significant reduction (−1.89 mmHg, 95% CI −2.84, −0.48; p = 0.01, I ² = 19.08%) (Figure S2.3).

5.5.2. Brief Behaviour Change Coaching Interventions

Three studies explored the effect of brief behavioural change intervention by coaching and were presented in a meta‐analysis that found a significant decrease in both systolic and diastolic blood pressure (−1.44 mmHg, 95% CI −2.75, −0.13; p = 0.03, I ² = 00.00%, −1.79 mmHg, 95% CI −3.38, −0.20; p = 0.03, I ² = 32.22%) (see Figure 4) (Jafar et al. (2022); Pengpid et al. 2019; Tran et al. 2017). Pengpid et al. showed a significant decrease in blood pressure through interventions that included increasing moderate‐intensity physical activity to 30 min per day and modifying a healthy diet. This diet involved restricting energy from fat, reducing sodium intake to less than 2400 mg/day, and limiting alcohol intake to less than 2 drinks per day for men and 1 drink per day for women (Table S3.6) (Pengpid et al. 2019). Two studies by Jafar and Tran showed no statistically significant decrease in diastolic and systolic blood pressure (Jafar et al. (2022); Tran et al. 2017). Jafar's intervention included physician training on risk management, a motivational conversation curriculum for hypertension management, and telephone follow‐up for people with hypertension (Jafar et al. (2022)). Tran's intervention promoted physical activity and a healthy diet based on the WHO's recommendations for physical activity and the food‐based dietary guidelines in Vietnam (Tran et al. 2017).

FIGURE 4.

Forest plots generated from the meta‐analysis present the mean difference (95% CI) of the effect of brief behaviour change coaching interventions on (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP).

5.5.3. Intensive Behaviour Change Coaching Interventions

A meta‐analysis included two studies presenting significantly decreasing systolic blood pressure (−6.41 mmHg, 95% CI −7.49, −5.33; p < 0.001, I ² = 00.00%), but no statistically significant decrease in diastolic blood pressure (p = 0.25) (see Figure 5). The interventions are group intensive coaching in 8–16 weeks to motivate participants to change their lifestyle based on their experience, discover barriers, encourage critical assessment, and empower them to change unhealthy behaviour (Table S3.6).

FIGURE 5.

Forest plots generated from the meta‐analysis present the mean difference (95% CI) of the effect of intensive behaviour change coaching interventions on (a) systolic blood pressure (SBP) and (b) diastolic blood pressure (DBP).

5.6. Health Education

Three studies focus on health educational programs underpinning self‐care management (Jafar et al. 2016; Rujiwatthanakorn et al. 2011; Sutipan et al. 2018). Self‐care management utilises motivational conversation to help people with hypertension set priorities for self‐care and respond to their health. The intervention lasts 10–12 weeks and provides knowledge of hypertension, hypertension management, healthy diet, exercise, and medical adherence (Table S3.7) (Jafar et al. 2016; Rujiwatthanakorn et al. 2011; Sutipan et al. 2018). Two studies showed a clinically significant decrease in blood pressure, with systolic blood pressure declining by 5 to 18 mmHg and diastolic blood pressure reducing by 4 to 5 mmHg (Table S3.8) (Jafar et al. 2016; Rujiwatthanakorn et al. 2011). The intervention that showed the greatest decrease in systolic blood pressure focuses on specific knowledge and skills and promotes active participant involvement in identifying problems through sharing self‐care experiences, finding possible solutions, changing lifestyles, and self‐evaluating by recording self‐care activities and blood pressure (Rujiwatthanakorn et al. 2011). Additionally, this intervention includes motivation and support from family members and healthcare providers.

6. Discussion

This systematic review and meta‐analysis of diet interventions, endurance exercise, and intensive behaviour change coaching interventions showed significant decreases in systolic blood pressure for programs focusing on lowering sodium intake and participating in intensive endurance exercise (Intarakamhang and Macaskill 2022; Mir et al. 2021; Pengpid et al. 2019; Ruangthai and Phoemsapthawee 2019; Sabilu et al. 2017; Sarinukul et al. 2023; Thiabpho et al. 2018). Some interventions show a decrease in both systolic and diastolic blood pressure, while other interventions only reduced either systolic or diastolic blood pressure. According to Kouremeti et al., a 6‐year prospective study of predictors of cardiovascular events among hypertensive patients showed that systolic blood pressure is a significant predictor of adverse cardiovascular events, in contrast to diastolic blood pressure (Kouremeti et al. 2022). Providing an indication that interventions that result in clinically important decreases in systolic blood pressure should be adapted for local implementation.

Use of a dietary approach, focused on decreasing sodium intake, showed a significant decrease in systolic blood pressure. All three studies involved participants with prehypertension or hypertension who were not receiving medication. Effective interventions included consuming tomato juice to increase potassium levels, maintaining a balanced diet, following a DASH diet, restricting sodium to less than 100 mmol/day, and applying an innovative nutrition education tool (LINE application) (Mir et al. 2021; Sabilu et al. 2017; Thatthong et al. 2020). According to hypertension management guidelines and previous studies, it is recommended to take 75–125 mmol of potassium per day, restrict sodium intake to 100 mmol per day, and follow the DASH diet (Fu et al. 2020; Mancia et al. 2023; Thai Hypertension Society 2019). Researchers should carefully manage the content related to sodium restriction to avoid spreading misinformation and promoting unhealthy practices (Terada et al. 2024). Only one study of a dietary intervention by Sabilu et al. showed a statistically significant decrease in systolic and diastolic blood pressure. This was because the participants, who had hypertension, followed an intensive balanced diet and consumed one glass of tomato juice every day to increase their potassium intake. The intervention lasted 7 days, making dietary behaviour modification straightforward. Additionally, the support from the researcher, including providing tomato juice, was a reinforcing enabling factor that helped participants maintain a healthy diet (Sabilu et al. 2017). Similarly, a systematic review shows that social, cultural, and economic factors, especially food prices and affordability, are barriers to achieving healthy diets in Southeast Asia (Gaupholm et al. 2023). It seems that policymakers, healthcare providers, family members, and stakeholders should identify barriers impacting nutrition in communities and promote equitable access to healthy diets by improving individual lifestyle choices and the food environment.

Two studies involving people with prehypertension did not show significant results because the baseline diastolic blood pressure before the intervention was normal (Mir et al. 2021; Thatthong et al. 2020). One study used innovative technology to promote adherence to sodium restriction, by sending key messages via the LINE application to participants' smartphones and demonstrated a significant decrease in systolic blood pressure (Thatthong et al. 2020). According to previous studies in India, information technology—including short message service (SMS), email, social networking applications, and the distribution of a ‘SMART Eating’ kit, which includes a kitchen calendar, dining table mat, and measuring spoons—was found to be effective in managing blood pressure and promoting a healthy diet (Kaur et al. 2020). In addition, it seems that individuals with prehypertension who are not taking antihypertensive medication can improve blood pressure control through dietary modifications.

Endurance exercise enhances cardiorespiratory fitness by improving the functional capabilities of the heart, lungs, blood vessels, and skeletal muscles to transport and utilise oxygen for physical work (Liguori et al. 2021). The current meta‐analysis demonstrates that participation in regular endurance exercise resulted in a statistically significant decrease in systolic blood pressure, especially in people with hypertension. Three exercise interventions were tested, with participants engaging in walking, walking combined with strength exercises, and stepping exercises for 60 min per day, 3 times per week, over 8–12 weeks (Ruangthai and Phoemsapthawee 2019; Sarinukul et al. 2023). Similarly, World Health Organisation and the American College of Sports Medicine recommend endurance exercises for people with hypertension, such as walking, leisurely cycling, aqua aerobics, and slow dancing, with a frequency of 3 days per week for 50 min or 5 days per week for 30 min at moderate intensity, or at least 150–300 min of moderate‐intensity aerobic physical activity (Bull et al. 2020; Liguori et al. 2021; Mancia et al. 2023). Additionally, resistance and flexibility exercises are recommended 2–3 days per week to improve muscle power, muscular endurance, and range of motion of the joints (Liguori et al. 2021). Moreover, endurance exercise combined with medication may help reduce blood pressure in individuals with hypertension or prehypertension.

Previous studies show that 14.7% of the Southeast Asian population has insufficient physical activity (WHO 2018). Many people are employed in low‐paid jobs and work extended hours, limiting their time to incorporate exercise into their daily routine (WHO 2018). It can be said that encouraging people with hypertension and prehypertension to exercise according to guidelines and in ways that suit their lifestyles, even with limited resources, is essential. For individuals not meeting exercise recommendations, it is advisable to start with small physical activities and gradually increase the frequency, intensity, and duration over time (Bull et al. 2020). Two studies of exercise interventions involving participants diagnosed with prehypertension and hypertension did not show statistically significant results, possibly due to inadequate frequency and duration (Nur et al. 2018; Prasertsri et al. 2019). These studies involved walking 10,000 steps per day and arm swing exercises for 30 min, 3 days per week. These interventions do not align with the ACSM guidelines, which recommend 150 min of aerobic exercise per week (Liguori et al. 2021). Moreover, different modes of exercise affect blood pressure differently. A previous systematic review and meta‐analysis showed that heated pool exercises significantly decreased systolic blood pressure by 14.76 mmHg (Xi et al. 2024). Performing two to three types of aerobic exercise simultaneously significantly decreased diastolic blood pressure by 5.61 mmHg, and hand grip training reduced diastolic blood pressure by 5.57 mmHg (Xi et al. 2024).

Four interventions involving moderate‐intensity aerobic exercise were included in the meta‐analysis but did not significantly reduce either systolic or diastolic blood pressure. This outcome could be due to inadequate frequency, duration, and number of participants (Aminuddin et al. 2011; Phing et al. 2017; Phoemsapthawee and Sriton 2021). Furthermore, two studies were conducted with small sample sizes in randomised controlled trials (6–10 participants per group), which may have affected the statistical power of the studies to demonstrate an impact on the primary outcome (Aminuddin et al. 2011; Phing et al. 2017; Valojerdi et al. 2017).

Combined healthy diet and exercise with coaching interventions illustrate statistically significant systolic and diastolic blood pressure reduction (Jafar et al. (2022); Pengpid et al. 2019; Tran et al. 2017). Combined lifestyle modifications can effectively impact blood pressure when researchers coach participants to motivate behaviour change. This systematic review highlighted the effectiveness of combined interventions with coaching strategies in reducing systolic and diastolic blood pressure. Specifically, intensive coaching was associated with a significant reduction in systolic blood pressure by 6.41 mmHg, while brief coaching decreased diastolic blood pressure by 1.44 mmHg, indicating that more intensive and sustained behaviour change coaching is required to achieve clinically important changes in systolic blood pressure. According to previous systematic analyses, a healthy diet and physical activity are the most important combination of lifestyle modifications for individuals with prehypertension and hypertension, decreasing systolic blood pressure by 9.88 mmHg and diastolic blood pressure by 6.28 mmHg (Krishnamoorthy et al. 2023). These modifications are best achieved through education, counselling, and support (Krishnamoorthy et al. 2023). Furthermore, integrating antihypertensive treatment with regular exercise and a healthy diet may help reduce blood pressure in individuals with hypertension or prehypertension.

Health education programs show a significant decrease in both diastolic and systolic blood pressure. The educational interventions integrate self‐management concepts, motivational interviewing, problem‐solving skills, structured follow‐up, social support, and multidisciplinary teams (physician and nurse practitioner) for hypertension management (Jafar et al. 2016; Rujiwatthanakorn et al. 2011; Sutipan et al. 2018). Similarly, a previous systematic review on preventing hypertension in Southeast Asian communities explored essential health components, such as educational activities, telehealth, peer support, empowerment, lifestyle advice, storytelling, family support, and comprehensive interventions (Pardoel et al. 2021). Contextual factors that may affect the intervention outcome include implementation challenges, group cooperation, cultural sensitivity, accessibility, social support, gender dynamics, stakeholder participation, and educational strategies for providing lifestyle advice (Pardoel et al. 2021). According to Gabiola et al., the effect of lifestyle intervention including diet and physical activity education in people with hypertension and prehypertension showed a significant decrease in systolic blood pressure in the intervention group (−12 mmHg, 95% CI −14.5 to −10.9, p < 0.001) (Gabiola et al. 2020).

6.1. Strengths and Limitations

This systematic review has several strengths in demonstrating the effectiveness of lifestyle modifications for controlling blood pressure in specific regions. Additionally, this is the first systematic review and meta‐analysis to evaluate the effectiveness of health promotion interventions for controlling blood pressure in Southeast Asian populations.

This review has several limitations. First, the study participants included people with both prehypertension and hypertension, which may have impacted the power of the studies to demonstrate a clinically important decrease in blood pressure. Second, the outcome evaluated was a change in systolic and diastolic blood pressure immediately following intervention program completion. The included studies did not provide data on the sustainability of the intervention and potential benefits over the intermediate to long term. Measuring the impact of improved blood pressure control on the rate of cardiovascular events, cardiovascular, and cerebrovascular mortality was beyond the scope of this study. Third, this review included only primary research published in English; interventional studies published in languages other than English are excluded, decreasing the generalizability of the results. Fourth, the evidence on these interventions remains limited, with only a few small clinical trials available, necessitating further research to establish their effectiveness in hypertension management.

6.2. Recommendations for Research

In the future, healthcare providers, stakeholders, family members, and patients should collaborate to co‐design interventions that are tailored to the specific needs of the target population group, considering cultural lifestyles and environmental factors. Further research is needed to conduct randomised controlled trials with a sufficient sample size to effectively impact the primary outcome in Southeast Asian populations.

7. Conclusion

The health promotion program for controlling blood pressure, which includes a healthy diet, aerobic endurance exercise, combined healthy diet and exercise with coaching, and health education, has shown significant effects on blood pressure, particularly systolic blood pressure, a critical predictor of cardiovascular events. The endurance exercise, following the principles of frequency, time, and intensity, shows the best results in decreasing systolic blood pressure. Dietary interventions recommended for individuals with high blood pressure include the DASH approach, maintaining energy balance, reducing fat intake, limiting sodium—particularly from traditional salted and fermented foods—and increasing potassium intake daily. The use of health education with coaching techniques is recommended to empower individuals to actively manage their health, leading to sustainable behaviour changes, improved health outcomes, and a better quality of life. The duration of the health promotion intervention should be between 10 and 12 weeks. Digital technology is a useful tool to integrate into health promotion programs for educating and motivating people to change behaviours. Additionally, health promotion programmes are fundamental as a first‐line approach to controlling blood pressure alongside antihypertensive medication, as they can enhance the effectiveness of pharmacological treatments.

Author Contributions

P.B. conducted database searches, screened studies for inclusion, extracted and analysed data, created forest plots, and prepared the draft manuscript. D.K analysed data and created forest plots. AFH and A.D conceptualised the study, screened studies for inclusion, performed data extraction and analysis, and edited the manuscript.

Ethics Statement

The authors have nothing to report.

Conflicts of Interest

The authors declare no conflicts of interest.

Supporting information

Figure S1.

Figure S2.

Table S1.

Table S2.

Table S3.

Bawornthip, P. , Driscoll A., Khaw D., and Hutchinson A.. 2025. “Effectiveness of Health Promotion Programs on Blood Pressure in People With Hypertension and Prehypertension in Southeast Asian Populations: Systematic Review and Meta‐Analysis.” Nursing Open 12, no. 6: e70252. 10.1002/nop2.70252.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.