Effectiveness of nurse-led hypertension self-management interventions: A mixed-methods systematic review and meta-analysis

Abstract

Objective

This mixed-method systematic review aimed to synthesize quantitative and qualitative evidence on the effectiveness of nurse-led self-management interventions for people with hypertension.

Methods

This review, guided by the Joanna Briggs Institute (JBI) manual for evidence synthesis, was conducted by searching PubMed, CINAHL, Web of Science, Scopus, Google Scholar, and reference lists of included studies. Two reviewers independently screened, critically appraised, and extracted data from studies reporting nurse-led interventions for hypertension self-management. The JBI critical appraisal tool for randomized control trials and the mixed methods appraisal tool were used to appraise included studies. Meta-analysis was performed using Review Manager 5.4.1. The certainty of the evidence was determined using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

Results

A total of 22 studies and 2,706 participants were included. Most studies were conducted in Asia, with only one study from Africa. Most interventions employed a hybrid of face-to-face and mHealth and were delivered through a blend of individual and group-based approaches. The meta-analysis showed that nurse-led self-management interventions significantly reduced systolic blood pressure (MD = −7.60; 95 %CI: −9.83, −5.36; P ≤ 0.001; 18 studies) and diastolic blood pressure (MD = −4.12; 95 %CI: −5.83, −2.41; P ≤ 0.001; 18 studies) compared to usual care in hypertension management. The qualitative evidence revealed that peer support through shared experience enhanced self-management.

Conclusions

Nurse-led interventions focusing on self-management are effective for improving hypertension outcomes compared with usual care. Still, the high heterogeneity suggests that factors such as population characteristics and intervention components may influence effectiveness. A combination of individual and group-based approaches offers dual benefits: tailored care and patient peer support through shared experiences.

What is known?

• •The role of nurses in hypertension management is crucial for sustained blood pressure control.
• •Self-management support is essential for the effective management of hypertension.
• •Previous reviews have focused on nurse-led interventions for hypertension management and not specifically on self-management interventions to empower patients.

What is new?

• •This study shows that nurse-led self-management interventions result in sustained reduction in systolic and diastolic blood pressure beyond six months, highlighting long-term effectiveness.
• •Combining individual and group-based approaches provides a dual benefit of personalized care and peer support, enhancing self-management in patients with hypertension.
• •High heterogeneity suggests that factors such as population characteristics or intervention components may influence the effectiveness of these interventions. Further research may be needed to identify which elements contribute to the observed variability.

1. Introduction

Hypertension, a global public health problem, is the leading preventable risk factor for cardiovascular diseases, responsible for an estimated 10.8 million deaths annually [1]. Despite the availability of effective hypertension treatments, only one in five people has their condition controlled [1]. The existing gap between the number diagnosed and those with controlled blood pressure (BP) [2] highlights the need for a person-centred approach that extends beyond pharmacological treatment. Given the lifelong impact of hypertension, there is a significant emphasis on self-management as a critical component in achieving controlled BP levels and improving long-term health outcomes [3,4]. The adoption of self-management practices is increasingly recognized for its positive impact on reducing the incidence of cardiovascular diseases (CVDs) and improving the quality of life (QoL) for individuals living with chronic conditions [5]. Persons living with chronic diseases are encouraged to embrace self-management strategies to enhance their overall QoL [3,5]. However, patients’ engagement in self-management requires well-structured support from healthcare professionals, particularly nurses, to build patients’ knowledge, skills, self-efficacy, and motivation [6,7].

Ryan and Sawin’s Individual and Family Self-management Theory (IFSMT) provides a foundational understanding of self-management. They defined self-management as a “process by which individuals and families use knowledge and beliefs, self-regulation skills and abilities, and social facilitation to achieve health-related outcomes” [8]. Hypertension self-management includes strategies such as knowledge acquisition, lifestyle modification, adherence to treatment protocols, and regular BP monitoring [1,9]. To operationalize self-management interventions beyond health education interventions across chronic conditions, Jonkman et al. [10] proposed a definition that emphasizes patient empowerment and active participation. Accordingly, “self-management interventions aim to equip patients with skills to actively participate and take responsibility in the management of their chronic condition to function optimally through at least knowledge acquisition and a combination of at least two of the following: stimulation of independent sign/symptom monitoring, medication management, enhancing problem-solving and decision-making skills for medical treatment management, and changing their physical activity, dietary, and/or smoking behaviour”. This definition guides the assessment of the scope and content of self-management interventions in hypertension care.

To guide these efforts, behaviour change models, such as the Assess, Advise, Agree, Assist and Arrange (5As) Approach, provide a framework for delivering self-management support in clinical practice [11]. The 5 As Approach, although not linear or sequential, provides an all-encompassing set of activities that nurses can use to support self-management. The main goal is to collaboratively develop a personal action plan that includes specific behavioral goals and barriers, along with the strategies, problem-solving techniques, and social/environmental support available to overcome barriers and achieve the desired goals [12,13]. This review adopts the 5As model due to its patient-centred focus and well-structured approach, which enhances its practical applicability in clinical settings. The 5As supports self-management elements such as collaborative goal-setting, decision-making, and problem-solving. Integrating it with the IFSMT provides a comprehensive framework for addressing individual behaviors within a broader family context, as this review aimed to provide evidence to guide guideline development. For instance, the 5As component ‘Assess’ corresponds with IFSMT’s emphasis on understanding patients’ knowledge and beliefs. At the same time, ‘Assist’ supports self-regulation by equipping patients with problem-solving strategies and resources such as medication reminders. Likewise, ‘Arrange’ reflects IFSMT’s social facilitation by ensuring continuity of care and sustained support. This study utilized the IFSMT and the 5As model to assess the intervention components of the studies included in this review.

Although chronic disease management is interdisciplinary, nurses play a pivotal role in self-management support effective chronic disease management [14,15], by leveraging six key competencies (assess, advise, agree, assist, arrange, and partnership) as outlined by van Hooft and colleagues [16]. Unlike other healthcare professionals, such as physicians, whose interactions with patients are often episodic and focused on acute management, nurses provide continuous care, establish relationships for long-term follow-up, reinforcing behaviour change, and tailored care [17,18]. The accessibility and cost-effectiveness of nurse-led programmes [19] further strengthen the case for nurse-led models, especially in under-resourced settings.

Before this review, a preliminary search revealed a recent review where they provided evidence on the influence of nurse-led hypertension management on systolic blood pressure (SBP), diastolic blood pressure (DBP), lifestyle modification, and knowledge of hypertension and associated risk factors [20]. Although this review [20] discussed counselling and education interventions, it did not address self-management support principles, such as goal setting and decision-making, self-regulation, and social facilitation, which are vital in empowering patients as active care partners [10]. Moreover, Bulto and colleagues did not explore the perspectives and experiences of nurses or patients, which are crucial for understanding contextual barriers and facilitators to implementing such interventions. This review conceptualized nurse-led self-management interventions/support as a structured process in which nurses are responsible for designing, delivering, and coordinating interventions that equip people living with hypertension and families with the knowledge, skills, self-efficacy, and ongoing support required to manage their condition. This support includes collaborative goal setting, shared decision-making, problem-solving, self-monitoring, behaviour change facilitation, and follow-up [10], within the patient’s home or healthcare environment. While self-management support may be implemented collaboratively with other healthcare professionals, this review focuses on studies in which nurses retain the leadership role in guiding, coordinating, and sustaining these interventions.

Against this backdrop, the present mixed-method systematic review aimed to synthesize the available evidence on the effectiveness of nurse-led hypertension self-management interventions and nurses’ and patients’ experiences with these interventions. By integrating quantitative effectiveness data with qualitative findings, this review will generate comprehensive evidence to inform the development of evidence-based guidelines for nurses to provide self-management support for patients with hypertension. Specifically, the review questions guiding this study are: a) How effective are nurse-led hypertension self-management interventions? b) What are the delivery methods of hypertension self-management interventions? c) What is the content of hypertension self-management interventions? d) What are nurses’ and patients’ experiences of nurse-led hypertension self-management and implementation barriers/enablers?

2. Methods

2.1. Design

This review followed the Joanna Briggs Institute (JBI) methodology for mixed-method systematic reviews (MMSR) [21], using a priori protocol registered in PROSPERO (CRD42024573010). MMSR integrates diverse evidence to generate practical and evidence-based recommendations. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) format was used to guide the reporting of the review [22].

2.2. Search strategy

An initial limited search of PubMed and CINAHL was conducted to identify relevant studies and inform the development of key search terms and index headings. The initial search strategy used was: “((Effectiveness) OR (Efficacy) OR (impact)) OR (benefits) AND ((nurse-led interventions) OR (nurse-facilitated interventions) OR (nurse-delivered) OR (Self-management interventions) OR (self-management support interventions) OR (self-management support strategies) OR (self-management strategies) OR (self-care interventions) OR (self-care support interventions)) AND ((hypertension) OR (high blood pressure) OR (high BP) OR (cardiovascular diseases) OR (CVD) OR (chronic diseases))”. A comprehensive search strategy was developed from the preliminary search results and applied to the included databases, with adaptations made as required for each information source. As combining search terms for both patients’ and nurses’ experiences of nurse-led interventions yielded no results, searches relating to patients’ experiences were conducted separately to enhance sensitivity. The databases searched were PubMed, CINAHL, Web of Science, Google Scholar, Scopus, and the Cochrane Central Register of Controlled Trials. The reference lists of all included studies were also screened to identify additional eligible studies. The detailed search strategy is provided in Appendix A. Only studies published between January 2014 and June 2024 were included.

2.3. Inclusion and exclusion criteria

Eligibility criteria were defined using the PICO questions [21]. The review included studies involving these criteria. a) adults (≥18 years) with primary hypertension (SBP ≥140 mmHg [1 mmHg = 0.133 kPa] and/or DBP ≥90 mmHg, or on anti-hypertensive medication) [1] and nurses delivering self-management interventions. b) Quantitative studies evaluated the effectiveness of nurse-delivered hypertension self-management interventions, defined as interventions facilitated by nurses working independently or within interdisciplinary teams, and addressing hypertension-related knowledge and either self-efficacy or practical self-management skills. Interventions were delivered by facility-based nurses or nurse researchers and were compared with usual care or no intervention. c) Usual care typically comprised medical follow-up, including BP monitoring, medication refill, and general lifestyle advice. d) Primary outcomes were systolic and diastolic BP, with secondary outcomes including hypertension knowledge, self-management behaviors, self-efficacy, medication adherence, and lifestyle behaviors. e) The qualitative component included studies exploring patients’ and nurses’ experiences of nurse-delivered hypertension self-management support, specifically perceptions of benefits, barriers, and enablers. f) Peer reviewed studies conducted across all healthcare levels (primary, community, and other settings) and resource contexts (high-, middle-, and low-income) were eligible. Studies were excluded if: a) participants had comorbidities (e.g., hypertension with diabetes); b) interventions were not nurse-facilitated; c) primary BP outcomes were not reported; d) qualitative findings did not address perceived benefits, effectiveness, barriers, or enablers of nurse-led self-management support; or e) not published in the English language only.

2.4. Study selection

All identified citations were imported into Covidence (https://app.covidence.org/), and duplicates were removed. Two independent reviewers (S.P. Adzitey and M. Mohammed) screened the titles and abstracts. The full text of potentially relevant studies was retrieved. When the full texts were inaccessible, the authors were contacted to share the full texts of the studies. Some studies were excluded because the authors did not respond or did not provide additional information. Two reviewers (S.P. Adzitey and M. Mohammed) independently screened the full text to determine their eligibility for inclusion. The reasons for excluding studies were documented. All conflicts at each stage of the selection process were resolved through discussion with the third reviewer (T. Crowley). Data search, screening, selection process, and reasons for exclusion of some studies are presented in the PRISMA diagram (Fig. 1).

Fig. 1.

PRISMA flowchart of included studies in systematic review.

2.5. Assessment of methodological quality

Two appraisal tools were used: 18 randomized controlled trials (RCTs) were assessed using the JBI Critical Appraisal Checklist for RCTs [23], while four non-RCT studies (three quasi-experimental and one mixed-method) were appraised using the Mixed-Method Appraisal Tool (MMAT) [24]. Both assessments were conducted independently by two reviewers (S.P. Adzitey and E.I. Ilhan). All disagreements between the two reviewers were resolved through discussion or by the third reviewer (T. Crowley). The JBI Critical Appraisal Tool for randomized controlled trials has 13 items, and each item was rated as “Yes,” “No,” or “Unclear”, with “Yes” scored as “1” and all other responses scored as “0”. The Mixed Methods Appraisal Tool (MMAT) also has 5 items, each rated as “Yes,” “No,” or “Can’t tell”, with “Yes” scored as “1” and all other responses scored as “0”. For both tools, the total quality scores were calculated as the proportion of items rated “Yes” divided by the maximum possible score.

2.6. Data extraction

The quantitative data were extracted from the included studies by two independent reviewers (S.P. Adzitey and E.I. Ilhan) using the Template for Intervention Description and Replication (TIDieR) template [25]. The template was piloted on two studies and amended before complete data extraction. For quantitative studies and the quantitative component of the mixed-methods study, specific details on populations, interventions, self-management components, duration, interventionists, theoretical underpinnings, materials used/methods of delivery, study methods, and outcomes of significance to the review question were extracted. For the qualitative component of the mixed-methods study, specific details about the population and the nurses’ and patients’ experience of nurse-led self-management support were extracted. All disagreements during data extraction were resolved through discussion and/or with the third reviewer (T. Crowley).

2.7. Data analysis

The meta-analysis included 18 eligible studies reporting the primary outcome (SBP and DBP). Review Manager (RevMan) version 5.4.1 was utilized for meta-analysis, which computed the pooled effectiveness of nurse-facilitated self-management interventions on SBP and DBP, with a 95 %CI on forest plots. A P < 0.05 was considered statistically significant. A random effects model was used, and the effect measure was the mean difference. Effect sizes were expressed as weighted post-intervention mean differences (MD) with their 95 % confidence intervals (CI) [26]. Heterogeneity was evaluated statistically using the standard I² test. Although the I² values indicated substantial heterogeneity, the included interventions were conceptually similar in terms of nurses’ delivery and the components of self-management addressed. Therefore, a meta-analysis was deemed appropriate using a random-effects model. A sensitivity analysis was done to explore the impact of individual studies on overall heterogeneity. Additionally, subgroup analyses were conducted for studies that reported SBP and DBP at different follow-up times, grouping studies under < 6 months and ≥6 months. This approach allowed for the evaluation of intervention efficacy in both the short term and longer term, thereby providing insight into the sustainability and duration of intervention effects. Bulto and colleagues [20] performed the same subgroup analysis. Forest and Funnel plots were generated, and Egger’s test was performed to assess publication bias and small-study effect. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) was used to assess the certainty of evidence [27]. The GRADE considers factors such as risk of bias, inconsistency, publication bias, imprecision, plausible confounding factors, and indirectness; this rates the evidence as high, moderate, low, or very low. Studies were downgraded 1 level due to risk of bias or high heterogeneity. All secondary outcomes assessed were described narratively and in tabular format.

2.8. Data synthesis and integration

This review followed a convergent-segregated approach to synthesis and integration using the JBI methodology for mixed-methods systematic reviews [21]. Quantitative and qualitative data were first synthesized separately, followed by the integration of the two datasets. In this review, quantitative data on primary outcomes were synthesized through meta-analysis, and secondary outcomes were described narratively. Only one included study had a qualitative component, which limited the extent of qualitative synthesis and consequently, the depth of integration. The quantitative and qualitative findings are presented in tables, figures, and narrative form.

3. Results

3.1. Study inclusion

Six databases and their platforms were searched, which yielded 17,771 articles; Covidence automatically removed 3,420 duplicates, and 10 were manually removed. Title and abstract screening excluded 14,210 irrelevant articles. Two independent reviewers performed full-text screening of 108 articles; in the process, an additional 10 articles were identified from reference mining. Twenty-two articles met the inclusion criteria for this review. Details of the selection process and reasons for excluding articles are found in Fig. 1 (PRISMA flow diagram).

3.2. Methodological quality

All the included RCTs (n = 18) employed true randomization for assigning participants to treatment groups, had comparable intervention and control groups at baseline, measured outcomes consistently across groups, used reliable outcome measures, and followed an appropriate study design. Among the 18 RCTs, 94.4 % had both intervention and control groups receiving identical treatment, except for the intervention of interest. Participants’ blinding was achieved in only 11.1 % (n = 2) of included studies, and 44.4 % (n = 8) of studies achieved blinding of outcome assessors and participants analyzed in the groups to which they were randomized. Persons delivering the treatment were not blinded to treatment assignment. In the methodological appraisal of three non-randomized control trials using the MMAT, all studies (100 %) appropriately measured outcomes, there was complete data (100 %), and administered interventions as intended (100 %). None of the studies accounted for confounders in the design and analysis. The overall rating for each study was moderate risk (See Appendix B1 and B2 for details on the methodological evaluation).

3.3. Characteristics of included studies

The 22 included articles [[28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49]] were published between 2014 and 2024; most (n = 18 articles) were published between 2020 and 2024. The majority of the included studies were conducted in Asia (China, n = 7; Iran, n = 2; Thailand, n = 2; Indonesia, n = 1; Pakistan, n = 1; India, n = 1; Jordan, n = 1). The rest were from Turkey (n = 3), and one each from Australia, Spain, and the USA. Notably, the only included study with a qualitative component was conducted in Uganda, Africa. Participants’ ages ranged from 25 to 90 years, and the majority had a high school education or less. The total sample size across all included studies was 2,706, with 342 participants withdrawn. The individual articles had total sample sizes ranging from 54 participants [28] to 297 participants [29]. Eighteen of the included studies were RCTs, three were quasi-experimental designs, and one was a sequential explanatory mixed-method study. The duration of interventions in the included studies ranged from 6 weeks [30] to 12 months [31] (Appendix C). Ten out of the 22 studies reported the theoretical underpinning of their interventions. Liu et al. [29] used social cognitive theory. In addition to the social cognitive theory, Ma et al. [32] also used Motivational coaching; Zhu et al. [33] used the Chronic Care Model and the Four-C Model. Songprasert et al. [34] used participatory action-oriented training (PAOT) in their intervention for intercity van drivers with hypertension. Sukpattanasrikul et al. [35] and Zabler [36] both applied the IFSMT in their intervention, while Stephen et al. [31] utilized the 5As approach to behaviour change. Tam et al. [37] and Wang et al. [38] used the Health Promotion Model and Health Belief Model, respectively. See Appendix D in the supplementary materials.

While some interventions were collaboratively delivered by nurses and doctors [29,33,39,40], the majority were delivered by nurses. The interventions were delivered individually, group-based, or both (Appendix D). Three studies were group-based [28,30,34], nine were individual-based, and the remaining 10 were delivered both individually and group-based. Five studies delivered interventions face-to-face [17,32,[41], [42], [43], [44]] studies utilized both face-to-face and mobile health (mHealth), with mHealth interventions utilizing telephonic calls and text messaging.

Knowledge and beliefs (including self-efficacy), self-regulation skills and abilities, and social facilitation were self-management domains addressed by the included studies. Two studies addressed the domain of knowledge and beliefs (including self-efficacy) [30,36]. In addition to knowledge, beliefs, and self-efficacy, six studies also addressed social facilitation [28,38,41,[45], [46], [47]]. The remaining articles (n = 14) addressed all three domains of self-management based on the IFSMT. The self-management support components based on the 5As approach for behaviour change, namely: Assess, Advise, Agree, Assist, and Arrange, were also utilized in the intervention delivery by the included studies (Appendix D). Four studies [29,31,33,48] utilized all 5As elements. Five articles utilized four of the 5As, six articles used three of the 5As, seven studies used two of the 5As, and Manzoor et al. [30] used only the Advise approach to offer education on hypertension and self-management practices.

3.4. Findings of the review: quantitative evidence

3.4.1. Primary outcomes

All included studies reported SBP and DBP.

3.4.1.1. Effect on systolic blood pressure

Pooled data from the meta-analysis (Appendix E) revealed that, at 6 months (1.1.1 A), nurse-led self-management intervention may reduce SBP compared with usual care (MD = −7.82; 95 %CI: −11.59, −4.06; P < 0.001; I² = 93 %; 12 RCTs; moderate certainty evidence, random effects). At ≥ 6 months (1.1.2 B), nurse-led self-management intervention may reduce SBP (MD = −7.25; 95 %CI: −9.03, −5.47; P = 0.04; I² = 50 %; 9 RCTs; moderate certainty evidence, random effects). The overall data revealed that nurse-led self-management interventions may reduce SBP (MD = −7.60; 95 %CI: −8.83, −5.36; P = <0.001; I² = 89 %; 18 RCTs; moderate certainty evidence, random effects) compared with usual care. Nurse-led self-management interventions may reduce SBP by < 8 mmHg compared to usual care. The overall heterogeneity statistic I² = 89 %, indicating that 89 % of the variability in the effect size estimates is due to between-study differences. The test for subgroup (< 6 months and ≥ 6months) differences was Chi² = 1.00; df = 1 (P = 0.32); I² = 0.2 %. A sensitivity analysis was performed by excluding one study [30], which was an outlier. The overall heterogeneity was reduced to 78 % after excluding one study. The overall effect size also reduced to −6.68 (95 %CI: −8.36, −4.99; P ≤ 0.001). Egger’s test was performed, and the results did not show a small study effect or publication bias; Overall SPB: Intercept of −0.664, 95 %CI (−3.554, −2.226), P = 0.636, SBP at < 6 months: intercept of −1.596, 95 %CI (−7.200, −4.008), P = 0.540 and SBP at ≥6 months intercept of 0.279, 95 %CI (−2.108, −2.667), P = 0.790 (Appendix F). The summary of findings in Appendix G shows the certainty of the evidence (GRADE).

3.4.1.2. Effect on diastolic blood pressure

Nurse-led self-management interventions have the potential to reduce DBP compared with usual care at <6 months (MD = −4.76; 95 %CI: −7.70, −1.83; P ≤ 0.001; I² = 96 %; 12 RCTs moderate certainty evidence, random effects). At ≥ 6 months, nurse-led self-management interventions can reduce DBP (MD = −3.29; 95 %CI: −4.78, 1.81; P < 0.001; I² = 72 %; 9 RCTs compared with usual care; moderate certainty evidence, random effects) (Appendix I). Overall, pooled data show that nurse-led self-management interventions may reduce DBP (MD = −4.12; 95 %CI: −5.83, −2.81; P ≤ 0.001; I² = 93 %; 18 RCTs moderate certainty evidence, random effects) compared with usual care. Sensitivity analysis was performed by excluding Manzoor et al. [30] (an outlier), and the overall heterogeneity was reduced to 84 %. The overall effect size did not change much after excluding one outlier (MD = −3.48; 95 %CI: −4.68, −2.29). There were no small study effects or publication bias for overall DBP: intercept of −2.801, 95 % CI (−5.903, −0.302), P = 0.074, DBP at < 6 months: intercept of −3.928, 95 %CI (−9.831, −1.974), P = 0.169 and SBP at ≥ 6 months: intercept of −1.503, 95 %CI (−4.077, −1.071), P = 0.210 (Appendix I). Appendix G, the summary of findings, shows the certainty of the evidence (GRADE).

3.4.2. Secondary outcomes

A meta-analysis was not performed for the secondary outcomes due to heterogeneity in outcome measures and measurement methods. The secondary outcomes are presented as narrative summaries.

3.4.2.1. Hypertension knowledge

Four articles reported on hypertension knowledge [29,43,46,47], and Aungsuroch et al. [45] evaluated self-management knowledge. Study questionnaires to test knowledge were either developed by the research team [29,46,47], adopted fully [43], or adapted from an existing instrument [45]. Studies reported knowledge levels using mean ± standard deviation (Mean ± SD) and significance at P < 0.05. All studies demonstrated statistically significant improvement in total knowledge score at the end of the intervention for the intervention group. Aungsuroch et al. [45] reported baseline self-management knowledge scores of 75.39 ± 7.62 and 83.51 ± 4.95 at 8 weeks, with a P-value of 0.01. Kolcu and Ergun [46] reported hypertension knowledge scores of 12.10 ± 1.92 and 20.75 ± 1.01 at baseline and 6 months (24 weeks), respectively, with a statistically significant difference (P < 0.001). Similarly, Kurt and Gurdogan [43] reported a statistically significant increase in the knowledge score at 3 months, from 8.13 ± 4.57 to 20.08 ± 3.07, with P < 0.001.

3.4.2.2. Medication adherence

Fourteen included studies evaluated participants’ medication adherence. Studies used different scales to measure medication adherence and different methods to report their level of adherence, including percentages [41,46] and inter-quartile range (IQR) [33]. Three studies used the 8-item Morisky Medication Adherence Scale [38,41,47], and Kolcu and Ergun [46] used the 4-item Morisky Medication Adherence Scale to measure adherence. Ma et al. [32] and Tam et al. [37] measured adherence using the Treatment Adherence Questionnaire for Patients with Hypertension (TAQPH). Gonbad et al. [42], Kes and Polat [49], and Kurt and Gurdogan [43] also measured adherence using the Hypertension Self-Care Activity Level Effects (H-SCALE) (Medication adherence 3 questions), Medication adherence self-efficacy scale short form (MASES-SF) (13-item form), and Hill-Bone Compliance to High Blood Pressure Therapy Scale, respectively. Villafuerte et al. [40] measured adherence based on the registry in the patients’ prescription section of the electronic medical record. Seven studies [32,38,[41], [42], [43],46,49] reported significant positive differences between the intervention and control groups at the end of the intervention.

3.4.2.3. Lifestyle behaviors

• (1)Alcohol and smoking. Three studies investigated alcohol and smoking cessation [32,33,42]. The studies reported means and IQRs, with none reporting any significant difference between the intervention and control groups.
• (2)Dietary behaviors. Six included studies investigated the participants’ dietary behaviors. They measured intake of a low-salt diet [42,46] and the Dietary Approach to Stopping Hypertension (DASH) diet [32,35,43,46]. Two studies [42,43] reported a statistically significant difference between the intervention and control groups for low-salt intake. At two months, Gonbad et al. [42] reported a statistically significant difference between the intervention and control, from 26.73 ± 4.61 to 52.51 ± 3.8 vs 24.85 ± 5.33 to 35.36 ± 3.47, P = 0.001. Similarly, there was an increase in dietary salt restriction in the intervention group compared to the control group (from 25 [67.6 %] to 28 [75.7 %] vs from 22 [59.5 %] to 14 [37.8 %], P = 0.002, respectively).
• (3)Physical activity/exercise. Four studies investigated participants’ self-reported engagement in physical activity/exercise. Four studies [32,34,42,46] reported a statistically significant difference between the intervention and control groups at the end of the intervention. In contrast, Zhu et al. [33] reported a statistically significant difference from baseline to 12 weeks, but at 16 weeks, the difference was not statistically significant.
• (4)Anthropometric measures. Ten included studies reported anthropometric measures, including weight, BMI, and waist and hip circumference. Three studies [28,44,46] measured weight; five studies [29,36,39,44,46] measured BMI; four studies [36,39,44,46] measured waist circumference, and only Kolcu and Ergun [46] measured hip circumference. Nanyonga et al. [28] reported a statistically significant change in weight within the group from baseline to the end of intervention at three months, from 80.50 ± 13.7 to 72.80 ± 11.50, with P = 0.001. Two studies demonstrated a reduction in BMI [29,39]. Qiao et al. [39] reported a statistically significant reduction in BMI in the intervention group from 24.98 ± 3.63 to 23.44 ± 2.05, vs 24.94 ± 3.77 to 24.66 ± 2.19 in the control group (P = 0.005). Zabler et al. [36] reported a statistically significant difference in waist circumference reduction between the two groups, from 113.23 ± 3.35 to 108.09 ± 4.02 vs. 114.27 ± 3.29 to 118.58 ± 3.48, P = 0.001.

3.5. Findings of the review: qualitative evidence

Only one mixed-methods study [28] was identified during the search and selection of eligible studies; it is the only study included and analyzed for the qualitative component of the review. Characteristics of participants and intervention contexts have been reported in the quantitative component. Data analysis yielded some themes: knowledge and understanding, attitude change and adherence, and access to support networks. The nurse educators and participants reported that participants had gained knowledge that influenced their lifestyle modification in diet, stress, and exercise, medication adherence, and reduction in BP: “When we started here last year, my pressure was very high. It was in 160/100 mmHg, but today … It is 130/80 mmHg. It is just because of taking the drugs every day, on time.”

The qualitative findings highlighted enablers of nurse-led self-management, including tailoring to patients’ needs, access to support networks, contextualizing interventions, continuous education and counselling, and nurses’ cultural responsiveness. Participants indicated that peer learning through the Bundled Education and Support with Text (BEST) intervention helped them acquire knowledge by exploring together the myths and beliefs surrounding hypertension: “Sharing of experiences by colleagues had helped them a lot.” Continuous education and support with follow-up text messages facilitated knowledge retention and enhanced adherence to lifestyle modifications. Low health literacy (“Awareness and hypertension knowledge remain low in Uganda and are associated with poor hypertension outcomes”) and beliefs (“he used to undermine exercises because they thought it was for children, … exercise is not important”) are barriers to self-management that were identified in the qualitative evidence.

3.6. Data integration

Data were synthesized and integrated across quantitative and qualitative strands to provide a comprehensive understanding of the impact of nurse-led interventions on hypertension outcomes. Quantitative evidence demonstrated clinically significant reductions in BP, with no notable differences between interventions delivered for < 6 months and those lasting >6 months. The single qualitative study offered complementary insights, suggesting that ongoing education and support from nurses enhanced medication adherence, thereby contributing to reductions in BP. In addition, quantitative findings indicated statistically significant improvements in patients’ knowledge and health-related behaviors. The qualitative study corroborated the outcomes; nurses and patients confirmed that increased patient knowledge facilitated positive lifestyle modifications. This convergence of findings supports the IFSMT, which posits that knowledge, positive beliefs, and self-regulation underpin self-management behaviors and ultimately lead to controlled BP.

4. Discussion

Most studies in this review originated in Asia, thus reflecting the region’s rising hypertension burden driven by ageing populations, urbanization, lifestyle changes, and increasing research interest in self-management [50,51]. Despite the rising prevalence of hypertension in Africa, few studies from the region were included, mainly due to limited research output and data availability [52]. The interventions took place in different settings and levels of healthcare. Most interventions were independently delivered by professional nurses or in collaboration with general practitioners.

The meta-analysis in this review demonstrated a statistically significant reduction in SBP and DBP (primary outcome) in the intervention group compared to usual care. The high heterogeneity observed may be attributable to differences in intervention design and intensity (e.g., mHealth versus face-to-face delivery, frequency, and duration), variations in study population characteristics (e.g., baseline BP, age), delivery modes and settings (e.g., individual- or group-based formats), and sample sizes; all of which could influence BP control, individual responsiveness, and contextual variability in outcomes. Wang et al. [53] also reported high heterogeneity; even after performing sensitivity analysis, they did not observe a significant difference in the pooled mean scores. In an Egger’s test, Wang et al. [53] reported a publication bias; however, our study did not observe publication bias (SPB: intercept of −0.664; 95 %CI: −3.554, −2.226, P = 0.636) and (DBP: intercept of −2.801; 95 %CI: −5.903, −0.302; P = 0.074). The high heterogeneity reported by Manzoor et al. [30] could be explained by the fact that about 39 % of participants in the intervention group were aged 20–40 years. This differs from the age distribution in the other studies with older populations.

Our review findings are consistent with other reviews, confirming that nurse-led self-management interventions significantly reduce both SBP and DBP [54]. Similarly, another review, although not specifically focused on self-management, reported that nurse-led interventions yielded a significant reduction in BP [20]. A subgroup analysis of another systematic review reported no statistically significant differences in short-term BP control between the intervention and usual care groups [55]. Bulto et al. [20] found a smaller effect size for BP reduction over 6–12 months compared to interventions lasting ≤6 months. In contrast, this review demonstrated that nurse-led self-management interventions can significantly reduce SBP and sustain reduction for up to 12 months. Notably, two studies [36,38] reported increased MD at three and six months for both SBP and DBP. While Bulto et al. [20] reported minimal to no impact of nurse-led interventions on DBP reduction, this review provides contrasting evidence, demonstrating a sustained DBP reduction for up to 12 months.

The effectiveness of nurse-led self-management interventions can be attributed to key self-management components such as collaborative goal setting, problem-solving techniques, self-regulation, and social facilitation [8,12,13]. A 5 mmHg reduction in SBP can potentially lower the incidence of cardiovascular events by 10 % [56]. Findings from this review (≈7 mmHg SBP reduction) highlight the impact of nurse-led self-management interventions to prevent complications associated with uncontrolled hypertension, such as stroke, coronary heart disease, and CVD-related mortality.

Most of the secondary outcomes of this review showed a statistically significant benefit of nurse-led self-management interventions, consistent with similar reviews [20,57]. The qualitative findings also corroborated the quantitative findings. Although the study by Kappes and colleagues [57] did not find statistically significant differences in medication adherence between the intervention and control groups, this review did. The delivery mode of most interventions was a combination of face-to-face interactions with mobile health (mHealth) technologies. The COVID-19 pandemic significantly limited face-to-face interactions between patients and their providers [57], leading to a rapid increase in mHealth use, including telephone calls, text messaging, and mobile applications [58,59]. This highlights the vital role of integrating mHealth interventions for managing chronic diseases. The systematic review by Sukpattanasrikul et al. [60] has reported the effectiveness of digital health interventions in improving behavioral, clinical, and economic outcomes for individuals with uncontrolled hypertension. As technology advances, healthcare policies need to explore and facilitate the incorporation of mHealth into chronic disease management, particularly in primary healthcare settings [[60], [61], [62]]. The interventions in this review were either delivered individually, group-based, or a combination of both. The individual-based approach provided tailored care to address the patient’s needs through one-on-one counselling, home visits, and mHealth follow-up (telephone calls and text messages). Group-based interventions, on the other hand, provide an opportunity for peer support through shared experience to enforce behaviour change [28,63]. Although both approaches have unique benefits, combining them gives a dual benefit. For instance, some interventions in this review began as group-based approaches to build knowledge and motivation, then transitioned to individualized care.

Self-management interventions are designed primarily to empower patients by improving knowledge, strengthening self-efficacy, self-regulation, and facilitating social support [8]. This review applied two complementary self-management theoretical frameworks, the IFSMT and the 5As, to evaluate whether interventions in the included studies provided comprehensive self-management support or were purely traditional nurse-led education. The findings established that most studies incorporated key elements of the IFSMT, targeting knowledge and self-efficacy (e.g., health education sessions), self-regulation (e.g., goal-setting and self-monitoring), and social facilitation (e.g., family or peer support). Similarly, when intervention components were assessed against the 5As, many studies stressed Assess (evaluating patients’ needs and baseline knowledge) and Advise (tailored information and counselling). Additionally, patients were equipped with practical skills and resources, including self-monitoring and medication reminders (Assist). Fewer interventions engaged patients in goal setting or decision-making (Agree), or ensuring follow-up, referral to other professionals, and continuity of care (Arrange). This, therefore, highlights a gap in ongoing self-management support. Evaluating the intervention components against these theoretical frameworks highlights opportunities to design comprehensive and theory-based self-management interventions.

Education to increase hypertension literacy and motivational interviewing are effective methods to empower patients with the needed knowledge, skills, and resources to self-manage their condition and ultimately yield positive cardiovascular health outcomes [20]; these were apparent in the present review. Effective self-management interventions apply a systematic approach with a strong theoretical underpinning in their development [64,65]; this helps identify targeted areas for behaviour change and determine the relevant outcomes or variables to be measured [66]. Half of the studies in this review either used a combination of two theories/models or a single theory/model to underpin their interventions. In a mixed-method systematic review, while quantitative measures confirm the effectiveness of an intervention, qualitative evidence offers a comprehensive assessment of the usefulness to policymakers [21]. It demonstrates how participants of an intervention experienced it, indicating what is acceptable or challenging. This can help to identify enablers and barriers in implementing an intervention. The qualitative study in this review [28] revealed that patients experienced improved knowledge, medication adherence, lifestyle changes, access to support, and ongoing mHealth assistance through nurse-led interventions. The evidence from this review highlights the effectiveness of nurse-led self-management interventions, underscoring the need to integrate them into routine hypertension care.

Although this review comprehensively examined the benefits of nurse-led self-management interventions for hypertension, it was not without limitations. The substantial heterogeneity (I²) impacts the study’s conclusions. The study set out to conduct a mixed-methods review to synthesize quantitative and qualitative evidence of the effectiveness of nurse-led self-management interventions; however, only one mixed-method study met the inclusion criteria. This resulted in limited evidence on contextual barriers and facilitators of self-management interventions from patients’ and nurses' perspectives. The ultimate goal of this review is to synthesize evidence to support the development of a guideline for nurses to provide self-management support in an African country; however, most of the eligible studies were from Asia. The limited evidence from the African context thus raises concerns about cultural and contextual issues, a vital aspect in guideline development.

5. Conclusions and recommendations

Nurse-led self-management interventions have demonstrated effectiveness in improving hypertension outcomes compared with usual care, with sustained reductions in SBP and DBP observed from <6 months to ≥6 months of follow-up. Combining individual and group-based care offers dual benefits: cost-effective, tailored care and patient peer support. With the technological explosion in the 21st century, mHealth is an effective tool for supporting patients with hypertension in self-management. However, traditional face-to-face interactions will create an avenue for peer support through shared experience and also a solution for low-resource settings where access to technology and the internet may be limited. Nurse-led self-management interventions improve patients’ knowledge, skills, and resources to take charge of their condition. By including the experiences of patients and nurses about hypertension self-management support, the review offers a contextual understanding to inform future guideline development. It is recommended that there should be a standardized training programme and guidelines to equip nurses with skills in behaviour change counselling and digital health, among others, to enhance practice. Future research should assess sustained BP control, cardiovascular outcomes, and QoL beyond 12 months. This will help determine the long-term impact of nurse-led self-management interventions.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author upon reasonable request.

CRediT authorship contribution statement

Sylvia P. Adzitey: Conceptualization, Methodology, Data curation, Writing – original draft, Writing - review & editing. Furaha Akimanimpaye: Supervision, Conceptualization, Writing - review & editing. Talitha Crowley: Supervision, Conceptualization, Methodology, Writing - review & editing.

Declaration of competing interest

The authors declare that they have no competing interests.

Appendices. Supplementary data

The following are the Supplementary data to this article: