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Volume 12, Issue 4 (2024)
Health Educ Health Promot 2024, 12(4): 623-635 |
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Received: 2024/11/10 | Accepted: 2024/12/6 | Published: 2024/12/10
Received: 2024/11/10 | Accepted: 2024/12/6 | Published: 2024/12/10
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Roza E, Rusdi M, Guspianto G, Hasibuan M. An Educational Intervention Model to Improve Hypertension Self-Management in the Elderly. Health Educ Health Promot 2024; 12 (4) :623-635
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URL: http://hehp.modares.ac.ir/article-4-77913-en.html
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1- Department of Public Health Sciences, Faculty of Mathematics and Natural Sciences Education, Jambi of University, Jambi, Indonesia
2- Department of Chemistry Education, Faculty of Teacher Training and Education, Jambi of University, Jambi, Indonesia
3- Department of Public Health Sciences, Faculty of Medicine and Health Sciences, Jambi of University, Jambi, Indonesia
2- Department of Chemistry Education, Faculty of Teacher Training and Education, Jambi of University, Jambi, Indonesia
3- Department of Public Health Sciences, Faculty of Medicine and Health Sciences, Jambi of University, Jambi, Indonesia
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Introduction
High blood pressure (BP), often referred to as hypertension, is a common chronic illness that primarily affects the elderly. It is a significant risk factor for kidney failure, stroke, and cardiovascular diseases, contributing substantially to global morbidity and mortality rates [1-4]. Among older adults, the prevalence of hypertension is particularly high, largely due to age-related vascular changes and the increased occurrence of comorbid conditions, making it a critical health issue for this population [5, 6]. According to the World Health Organization, hypertension control remains suboptimal worldwide, especially among older individuals, who face challenges such as medication non-adherence, poor self-management behaviors, and limited access to tailored health education [7].
Self-management is widely regarded as an essential component of effective hypertension control. This practice includes activities such as monitoring BP, maintaining a balanced diet, adhering to prescribed medications, and engaging in regular physical exercise [8, 9]. Research has shown that consistent self-management behaviors can substantially reduce the risk of hypertension-related complications [10, 11]. However, elderly patients often encounter unique barriers to effective self-management, such as cognitive decline, physical limitations, and limited technological literacy, which can hinder their ability to actively manage their health [12-16].
Educational interventions tailored specifically to the elderly population are essential for addressing these barriers and empowering patients to take control of their hypertension management. Studies indicate that structured educational programs can improve self-efficacy, enhance knowledge about hypertension, and encourage sustainable lifestyle changes, all of which are vital for effective disease management [17]. Furthermore, educational models grounded in theories, such as the health belief model (HBM) and social cognitive theory (SCT) provide a structured approach to instilling motivation and promoting behavioral changes that are critical for managing chronic conditions in elderly populations [18].
With the rise of digital technology, innovative educational models have emerged, including mobile applications and telehealth programs. By making health information more convenient and accessible, telehealth-based educational programs have been shown to increase self-efficacy and encourage healthier lifestyle choices [19]. Digital health tools, such as mobile apps, have been effectively utilized to deliver information on medication adherence, dietary modifications, and lifestyle management for hypertensive patients, demonstrating that technology-assisted interventions can significantly improve health outcomes in elderly patients [20, 21]. Additionally, community-based programs and group education models, which provide social support alongside practical education, have proven effective in helping older adults adopt and maintain self-management behaviors [22, 23].
Despite these advancements, there is still a need for comprehensive educational models that specifically address the unique needs and limitations of elderly populations. Recent research highlights that multidimensional approaches combining digital tools with in-person support yield the most promising outcomes in terms of adherence, self-efficacy, and sustainable lifestyle changes [24]. However, further studies are needed to develop and refine these models to maximize their effectiveness in managing hypertension among the elderly [25, 26].
This systematic review aimed to consolidate evidence on educational interventions designed to improve the self-management of hypertension in elderly populations. By reviewing studies published from 2000 to 2024, this analysis evaluated the effectiveness of various educational models, identified key factors influencing self-management behaviors, and provided evidence-based recommendations for enhancing hypertension care in older adults. These insights are intended to guide healthcare practitioners in implementing effective, tailored educational strategies that improve hypertension outcomes in this vulnerable population.
Information and Methods
Study design
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 standards were followed in the design and execution of this systematic review conducted in 2024 [27]. The goal was to synthesize existing evidence on educational interventions that improve hypertension self-management among elderly populations.
Eligibility criteria
The inclusion and exclusion criteria were developed based on the population, intervention, comparison, outcomes, and study (PICOS) framework to ensure alignment with the research question (Table 1).
Table 1. Statements of the population, intervention, comparison, outcomes, and study (PICOS) framework
![src=./files/hehp/images/HTML_Publish/77913/1.png]()
Information sources
To identify relevant studies, we systematically searched six electronic databases, including PubMed, Scopus, Web of Science, ScienceDirect, JSTOR, and Cochrane Library. These databases were chosen for their comprehensive coverage of health, clinical, and psychological research. The search encompassed publications from 2000 to 2024 to focus on the most recent 20 years of evidence. Additionally, we conducted hand searches of reference lists in eligible studies and performed citation tracking to identify potentially relevant studies. Experts in hypertension self-management were consulted for insights into unpublished or ongoing studies.
Search strategy
To ensure sensitivity and specificity, a medical librarian assisted in developing the search strategy. The search terms were formulated using both Medical Subject Headings (MeSH) and free-text keywords. The strategy combined terms related to population (“elderly,” “older adults,” “geriatric patients”), intervention (“hypertension education,” “self-management,” “educational models,” “telehealth,” “digital health,” “community-based programs”), and Outcomes (“self-efficacy,” “medication adherence,” “dietary adherence,” “blood pressure control”) (Table 2).
Table 2. Search string in databases
![src=./files/hehp/images/HTML_Publish/77913/2.png]()
Study quality
The reviewers independently evaluated the literature to determine the quality for inclusion. Although this step is not mandatory in systematic review protocols, the reviewers considered it beneficial for identifying the strengths and limitations of the selected studies. Due to the diverse nature of the articles, the critical appraisal skills program (CASP) for randomized studies was chosen for its ability to systematically evaluate study quality. CASP offers a structured set of questions specifically designed for different study designs, particularly randomized studies. Each CASP checklist includes 11 questions with response options of “yes,” “no,” or “can’t tell,” facilitating a standardized appraisal process. Study quality is classified into three categories, including strong, moderate, and weak. A study is classified as weak if there are three non-affirmative responses, moderate if there are two non-affirmative responses (“can’t tell” or “no”), and strong if all of the responses are affirmative.
Risk of bias
The assessment of bias in each study was performed using the risk of bias in randomized studies (RoB 2) tool. This tool was chosen for its structured, validated framework tailored to detecting bias specifically within randomized controlled trials (RCTs), addressing essential areas, such as randomization, deviations from the planned interventions, missing outcome data, outcome measurement, and selective reporting. The RoB 2 tool provides a comprehensive and consistent approach to quality assessment, which strengthens the reliability of the review’s conclusions. It includes five domains that assess both internal and external validity, with results classified into four levels, including Low, some concerns, high, and very high. All authors reviewed and approved the RoB assessment results, incorporating feedback from external reviewers.
Data extraction and synthesis
To enhance understanding of the content within the eligible studies, key information was condensed into a table format. Two authors collaborated during this data-gathering process. Any discrepancies in the extracted data were resolved through mutual agreement. The extraction criteria included details, such as the primary author, year of publication, country, study design, sample size, mean age, outcome, intervention, model, duration, evaluation technique, and key findings.
Findings
The initial database query yielded 598 articles. Following the removal of 405 duplicates and irrelevant articles unrelated to the review’s focus, 193 articles were available for screening. In the eligibility evaluation, 159 articles were excluded for various reasons. Ultimately, only 15 studies fulfilled the criteria and advanced to the subsequent stage of data extraction and analysis (Figure 1; Table 3).
![src=./files/hehp/images/HTML_Publish/77913/f1.png]()
Figure 1. PRISMA flowchart for study selection.
Tabel 3. Characteristics of the eligible studies
![src=./files/hehp/images/HTML_Publish/77913/3-1.png]()
![src=./files/hehp/images/HTML_Publish/77913/3-2.png]()
![src=./files/hehp/images/HTML_Publish/77913/3-3.png]()
General characteristics of the eligible studies
The studies reviewed in this analysis used a variety of interventions aimed at improving health outcomes through educational and self-management strategies. The studies were conducted in diverse countries, including Iran, the United States, China, Italy, Thailand, and South Korea, highlighting both cultural and regional approaches to non-pharmacological health interventions.
The majority of the studies employed RCTs, with a few utilizing quasi-experimental and pre-post study designs. RCTs were the predominant design, indicating a strong focus on controlled interventions for evaluating the effectiveness of educational and behavioral strategies.
Sample sizes varied significantly across studies, ranging from as few as 20 participants in some RCTs (e.g., Sutipan et al. [41]) to larger groups, such as the 253 participants in Li et al.’s [36] cluster RCT in China. Participants were primarily adults, with mean ages typically ranging from the 50s to 70s, reflecting a focus on older adults and individuals managing chronic conditions, particularly hypertension.
Intervention durations ranged from as short as three weeks [38] to as long as six months [30, 31]. Formats included face-to-face sessions, mobile application-based interventions, telephone-based guidance, and online group discussions, indicating a mix of in-person and technology-assisted education.
Outcomes were assessed using a variety of self-reported and validated scales. For example, dietary adherence was evaluated using the DASH diet questionnaire, while self-efficacy was commonly measured using the Self-Efficacy for Managing Chronic Disease Scale and other similar scales. BP control and physical activity were also frequently monitored, often using standard clinical instruments or validated questionnaires (e.g., ABPM for BP in the study by Figar et al. [34]). The primary outcomes varied but were generally centered on improving self-efficacy, adherence to dietary and health recommendations, and managing hypertension. Several studies targeted lifestyle modifications, including improvements in physical activity, dietary diversity, and stress management. Many of the studies reported significant improvements in key outcomes, such as increased knowledge, improved dietary adherence, and better self-management behaviors. Notable findings included reductions in BP (e.g., Kordvarkane et al. [35]), increased adherence to the DASH diet [30], and enhanced self-efficacy for managing chronic conditions [37].
Study quality assessment
Based on the assessment results, the eligible studies are generally classified in the strong category, while only three studies fall into the medium category (Table 4).
Table 4. Summary of quality assessment
![src=./files/hehp/images/HTML_Publish/77913/4.png]()
Risk of bias assessment
According to the assessment across the five dimensions of the RoB 2 tool, most of the studies were found to be in the low risk of bias category (Figure 2).
![src=./files/hehp/images/HTML_Publish/77913/f2.png]()
Figure 2. Traffic light plot for risk of bias assessment.
Intervention types and models
A wide range of intervention models was used across the studies, including educational programs, mobile application-based interventions, face-to-face group education, and self-management programs. Several theoretical models supported these interventions, including BASNEF, PRECEDE, Geragogy, and the HBM. These interventions aimed to improve knowledge, self-efficacy, and adherence to dietary and health practices, targeting sustainable health behaviors.
Outcomes
Several studies reported significant improvements in participants’ knowledge and self-efficacy following the interventions. For example, the intervention by Li et al. [36] in China, which used WeChat for health education, improved both BP control (p=0.002) and knowledge/self-efficacy.
Studies focusing on dietary interventions, such as adherence to the DASH diet [30], demonstrated positive effects on dietary adherence, BP control, and physical activity levels.
Improvements in health-related behaviors were observed, including healthy lifestyle practices [41] and self-care behaviors related to BP control [39]. Many studies noted significant reductions in BP, such as that by Figar et al. [34] in Italy, which demonstrated a BP reduction (p=0.02) with regular BP monitoring and empowerment education.
Discussion
This systematic review aimed to consolidate evidence on educational interventions designed to improve the self-management of hypertension in elderly populations. The studies reviewed in this analysis exhibited a wide range of characteristics and approaches, emphasizing non-pharmacological interventions aimed at improving health outcomes through educational and self-management strategies. Conducted across several countries, including Iran, the United States, China, Italy, Thailand, and South Korea, the studies highlighted cultural and regional variations in health interventions, particularly for managing chronic conditions, such as hypertension. This geographic diversity in study settings underscores the universal challenge of chronic disease management and the varying methodologies researchers have adopted in different sociocultural contexts. For instance, while studies from countries, such as Iran and Thailand tended to incorporate traditional face-to-face group educational sessions, other regions, like China, leveraged popular local digital platforms, such as WeChat to deliver health education in more accessible formats [36]. This adaptation to digital platforms is indicative of a global shift toward technology-driven healthcare solutions, especially in environments where face-to-face interaction may be limited by logistical constraints or during times of increased public health concerns.
Another notable characteristic among these studies is the variation in sample sizes, which ranged from as few as 20 participants to as many as 253. Smaller studies, such as Sutipan et al. [41] with 20 participants, often provide a more detailed examination of individual-level responses to interventions but may lack the power to reliably detect smaller effects. In contrast, larger studies, such as Li et al. [36], with a sample size of 253, enhance statistical power, offering more robust insights into intervention effectiveness at the population level. The wide age range, typically focusing on adults in their 50s to 70s, is another distinguishing factor. This age demographic reflects a focus on older adults who are generally more susceptible to chronic conditions and may particularly benefit from lifestyle interventions aimed at promoting self-management and improving overall quality of life [43]. The attention to this age group also reflects a public health priority, given the rising prevalence of hypertension and other chronic diseases in aging populations worldwide [44].
Intervention duration varied significantly, from a brief three-week program [38] to extended interventions lasting up to six months [30, 31]. Shorter interventions can provide immediate insights into the feasibility and short-term effects of an intervention but may not capture long-term adherence or sustainability. On the other hand, longer interventions are advantageous for observing sustained behavior change and determining whether health improvements persist over time. Such extended interventions might offer a better model for real-world applications, where long-term adherence is critical for effectively managing chronic conditions.
In terms of delivery format, the studies employed a mix of traditional and modern methods, ranging from face-to-face sessions to mobile app-based interventions, telephone guidance, and online group discussions. This variety reflects the growing recognition of the need for flexible and accessible healthcare delivery, especially in a post-pandemic world where remote options are increasingly valuable. Mobile health applications and other technology-assisted education methods allow participants to engage with intervention materials at their convenience, which can be particularly beneficial for individuals with limited mobility or those in rural areas with reduced access to healthcare facilities [45, 46]. At the same time, face-to-face interactions remain valuable for personalized guidance, offering opportunities for real-time feedback, social support, and engagement that digital platforms may lack [47-49].
Improvements in knowledge and self-efficacy are crucial components of chronic disease management, particularly in conditions requiring significant lifestyle changes, such as hypertension. Across the reviewed studies, multiple interventions demonstrated statistically significant increases in knowledge and self-efficacy, suggesting that structured educational programs can positively influence individuals’ ability to manage their health. For instance, Li et al. [36] utilized a WeChat-based group discussion for health education in China, which resulted in notable improvements in both BP control and self-efficacy scores among participants. The use of this popular social media platform allows for frequent interaction and support, which likely contributes to the effectiveness of the intervention. This finding aligns with Bozorgi et al. [30], who found that a mobile application-based intervention in Iran improves adherence to the DASH diet, physical activity, and self-efficacy levels. Such digital platforms may enhance accessibility and engagement, providing participants with convenient and continuous support that fosters knowledge retention and self-confidence in managing health behaviors [50, 51].
Previous research has also demonstrated the effectiveness of educational interventions in enhancing knowledge and self-efficacy. For example, a study by Bandura and Wessels [52] shows that interventions aimed at increasing self-efficacy can lead to sustained behavior change, as higher self-efficacy is directly associated with greater resilience in overcoming obstacles. Similarly, Clark and Dodge [53] emphasize the role of self-efficacy in promoting adherence to dietary and exercise regimens, particularly in hypertensive populations. By empowering patients with the knowledge and confidence needed to make informed health choices, these interventions can yield substantial long-term benefits.
In addition to mobile-based interventions, face-to-face educational sessions have also demonstrated substantial efficacy in improving knowledge and self-efficacy. For example, Park et al. [39] implemented the HAHA program in South Korea, which included face-to-face counseling and physical activity sessions. The program led to significant improvements in both self-efficacy and systolic BP control. This r
High blood pressure (BP), often referred to as hypertension, is a common chronic illness that primarily affects the elderly. It is a significant risk factor for kidney failure, stroke, and cardiovascular diseases, contributing substantially to global morbidity and mortality rates [1-4]. Among older adults, the prevalence of hypertension is particularly high, largely due to age-related vascular changes and the increased occurrence of comorbid conditions, making it a critical health issue for this population [5, 6]. According to the World Health Organization, hypertension control remains suboptimal worldwide, especially among older individuals, who face challenges such as medication non-adherence, poor self-management behaviors, and limited access to tailored health education [7].
Self-management is widely regarded as an essential component of effective hypertension control. This practice includes activities such as monitoring BP, maintaining a balanced diet, adhering to prescribed medications, and engaging in regular physical exercise [8, 9]. Research has shown that consistent self-management behaviors can substantially reduce the risk of hypertension-related complications [10, 11]. However, elderly patients often encounter unique barriers to effective self-management, such as cognitive decline, physical limitations, and limited technological literacy, which can hinder their ability to actively manage their health [12-16].
Educational interventions tailored specifically to the elderly population are essential for addressing these barriers and empowering patients to take control of their hypertension management. Studies indicate that structured educational programs can improve self-efficacy, enhance knowledge about hypertension, and encourage sustainable lifestyle changes, all of which are vital for effective disease management [17]. Furthermore, educational models grounded in theories, such as the health belief model (HBM) and social cognitive theory (SCT) provide a structured approach to instilling motivation and promoting behavioral changes that are critical for managing chronic conditions in elderly populations [18].
With the rise of digital technology, innovative educational models have emerged, including mobile applications and telehealth programs. By making health information more convenient and accessible, telehealth-based educational programs have been shown to increase self-efficacy and encourage healthier lifestyle choices [19]. Digital health tools, such as mobile apps, have been effectively utilized to deliver information on medication adherence, dietary modifications, and lifestyle management for hypertensive patients, demonstrating that technology-assisted interventions can significantly improve health outcomes in elderly patients [20, 21]. Additionally, community-based programs and group education models, which provide social support alongside practical education, have proven effective in helping older adults adopt and maintain self-management behaviors [22, 23].
Despite these advancements, there is still a need for comprehensive educational models that specifically address the unique needs and limitations of elderly populations. Recent research highlights that multidimensional approaches combining digital tools with in-person support yield the most promising outcomes in terms of adherence, self-efficacy, and sustainable lifestyle changes [24]. However, further studies are needed to develop and refine these models to maximize their effectiveness in managing hypertension among the elderly [25, 26].
This systematic review aimed to consolidate evidence on educational interventions designed to improve the self-management of hypertension in elderly populations. By reviewing studies published from 2000 to 2024, this analysis evaluated the effectiveness of various educational models, identified key factors influencing self-management behaviors, and provided evidence-based recommendations for enhancing hypertension care in older adults. These insights are intended to guide healthcare practitioners in implementing effective, tailored educational strategies that improve hypertension outcomes in this vulnerable population.
Information and Methods
Study design
The preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 standards were followed in the design and execution of this systematic review conducted in 2024 [27]. The goal was to synthesize existing evidence on educational interventions that improve hypertension self-management among elderly populations.
Eligibility criteria
The inclusion and exclusion criteria were developed based on the population, intervention, comparison, outcomes, and study (PICOS) framework to ensure alignment with the research question (Table 1).
Table 1. Statements of the population, intervention, comparison, outcomes, and study (PICOS) framework
Information sources
To identify relevant studies, we systematically searched six electronic databases, including PubMed, Scopus, Web of Science, ScienceDirect, JSTOR, and Cochrane Library. These databases were chosen for their comprehensive coverage of health, clinical, and psychological research. The search encompassed publications from 2000 to 2024 to focus on the most recent 20 years of evidence. Additionally, we conducted hand searches of reference lists in eligible studies and performed citation tracking to identify potentially relevant studies. Experts in hypertension self-management were consulted for insights into unpublished or ongoing studies.
Search strategy
To ensure sensitivity and specificity, a medical librarian assisted in developing the search strategy. The search terms were formulated using both Medical Subject Headings (MeSH) and free-text keywords. The strategy combined terms related to population (“elderly,” “older adults,” “geriatric patients”), intervention (“hypertension education,” “self-management,” “educational models,” “telehealth,” “digital health,” “community-based programs”), and Outcomes (“self-efficacy,” “medication adherence,” “dietary adherence,” “blood pressure control”) (Table 2).
Table 2. Search string in databases
Study quality
The reviewers independently evaluated the literature to determine the quality for inclusion. Although this step is not mandatory in systematic review protocols, the reviewers considered it beneficial for identifying the strengths and limitations of the selected studies. Due to the diverse nature of the articles, the critical appraisal skills program (CASP) for randomized studies was chosen for its ability to systematically evaluate study quality. CASP offers a structured set of questions specifically designed for different study designs, particularly randomized studies. Each CASP checklist includes 11 questions with response options of “yes,” “no,” or “can’t tell,” facilitating a standardized appraisal process. Study quality is classified into three categories, including strong, moderate, and weak. A study is classified as weak if there are three non-affirmative responses, moderate if there are two non-affirmative responses (“can’t tell” or “no”), and strong if all of the responses are affirmative.
Risk of bias
The assessment of bias in each study was performed using the risk of bias in randomized studies (RoB 2) tool. This tool was chosen for its structured, validated framework tailored to detecting bias specifically within randomized controlled trials (RCTs), addressing essential areas, such as randomization, deviations from the planned interventions, missing outcome data, outcome measurement, and selective reporting. The RoB 2 tool provides a comprehensive and consistent approach to quality assessment, which strengthens the reliability of the review’s conclusions. It includes five domains that assess both internal and external validity, with results classified into four levels, including Low, some concerns, high, and very high. All authors reviewed and approved the RoB assessment results, incorporating feedback from external reviewers.
Data extraction and synthesis
To enhance understanding of the content within the eligible studies, key information was condensed into a table format. Two authors collaborated during this data-gathering process. Any discrepancies in the extracted data were resolved through mutual agreement. The extraction criteria included details, such as the primary author, year of publication, country, study design, sample size, mean age, outcome, intervention, model, duration, evaluation technique, and key findings.
Findings
The initial database query yielded 598 articles. Following the removal of 405 duplicates and irrelevant articles unrelated to the review’s focus, 193 articles were available for screening. In the eligibility evaluation, 159 articles were excluded for various reasons. Ultimately, only 15 studies fulfilled the criteria and advanced to the subsequent stage of data extraction and analysis (Figure 1; Table 3).
Figure 1. PRISMA flowchart for study selection.
Tabel 3. Characteristics of the eligible studies
General characteristics of the eligible studies
The studies reviewed in this analysis used a variety of interventions aimed at improving health outcomes through educational and self-management strategies. The studies were conducted in diverse countries, including Iran, the United States, China, Italy, Thailand, and South Korea, highlighting both cultural and regional approaches to non-pharmacological health interventions.
The majority of the studies employed RCTs, with a few utilizing quasi-experimental and pre-post study designs. RCTs were the predominant design, indicating a strong focus on controlled interventions for evaluating the effectiveness of educational and behavioral strategies.
Sample sizes varied significantly across studies, ranging from as few as 20 participants in some RCTs (e.g., Sutipan et al. [41]) to larger groups, such as the 253 participants in Li et al.’s [36] cluster RCT in China. Participants were primarily adults, with mean ages typically ranging from the 50s to 70s, reflecting a focus on older adults and individuals managing chronic conditions, particularly hypertension.
Intervention durations ranged from as short as three weeks [38] to as long as six months [30, 31]. Formats included face-to-face sessions, mobile application-based interventions, telephone-based guidance, and online group discussions, indicating a mix of in-person and technology-assisted education.
Outcomes were assessed using a variety of self-reported and validated scales. For example, dietary adherence was evaluated using the DASH diet questionnaire, while self-efficacy was commonly measured using the Self-Efficacy for Managing Chronic Disease Scale and other similar scales. BP control and physical activity were also frequently monitored, often using standard clinical instruments or validated questionnaires (e.g., ABPM for BP in the study by Figar et al. [34]). The primary outcomes varied but were generally centered on improving self-efficacy, adherence to dietary and health recommendations, and managing hypertension. Several studies targeted lifestyle modifications, including improvements in physical activity, dietary diversity, and stress management. Many of the studies reported significant improvements in key outcomes, such as increased knowledge, improved dietary adherence, and better self-management behaviors. Notable findings included reductions in BP (e.g., Kordvarkane et al. [35]), increased adherence to the DASH diet [30], and enhanced self-efficacy for managing chronic conditions [37].
Study quality assessment
Based on the assessment results, the eligible studies are generally classified in the strong category, while only three studies fall into the medium category (Table 4).
Table 4. Summary of quality assessment
Risk of bias assessment
According to the assessment across the five dimensions of the RoB 2 tool, most of the studies were found to be in the low risk of bias category (Figure 2).
Figure 2. Traffic light plot for risk of bias assessment.
Intervention types and models
A wide range of intervention models was used across the studies, including educational programs, mobile application-based interventions, face-to-face group education, and self-management programs. Several theoretical models supported these interventions, including BASNEF, PRECEDE, Geragogy, and the HBM. These interventions aimed to improve knowledge, self-efficacy, and adherence to dietary and health practices, targeting sustainable health behaviors.
Outcomes
Several studies reported significant improvements in participants’ knowledge and self-efficacy following the interventions. For example, the intervention by Li et al. [36] in China, which used WeChat for health education, improved both BP control (p=0.002) and knowledge/self-efficacy.
Studies focusing on dietary interventions, such as adherence to the DASH diet [30], demonstrated positive effects on dietary adherence, BP control, and physical activity levels.
Improvements in health-related behaviors were observed, including healthy lifestyle practices [41] and self-care behaviors related to BP control [39]. Many studies noted significant reductions in BP, such as that by Figar et al. [34] in Italy, which demonstrated a BP reduction (p=0.02) with regular BP monitoring and empowerment education.
Discussion
This systematic review aimed to consolidate evidence on educational interventions designed to improve the self-management of hypertension in elderly populations. The studies reviewed in this analysis exhibited a wide range of characteristics and approaches, emphasizing non-pharmacological interventions aimed at improving health outcomes through educational and self-management strategies. Conducted across several countries, including Iran, the United States, China, Italy, Thailand, and South Korea, the studies highlighted cultural and regional variations in health interventions, particularly for managing chronic conditions, such as hypertension. This geographic diversity in study settings underscores the universal challenge of chronic disease management and the varying methodologies researchers have adopted in different sociocultural contexts. For instance, while studies from countries, such as Iran and Thailand tended to incorporate traditional face-to-face group educational sessions, other regions, like China, leveraged popular local digital platforms, such as WeChat to deliver health education in more accessible formats [36]. This adaptation to digital platforms is indicative of a global shift toward technology-driven healthcare solutions, especially in environments where face-to-face interaction may be limited by logistical constraints or during times of increased public health concerns.
Another notable characteristic among these studies is the variation in sample sizes, which ranged from as few as 20 participants to as many as 253. Smaller studies, such as Sutipan et al. [41] with 20 participants, often provide a more detailed examination of individual-level responses to interventions but may lack the power to reliably detect smaller effects. In contrast, larger studies, such as Li et al. [36], with a sample size of 253, enhance statistical power, offering more robust insights into intervention effectiveness at the population level. The wide age range, typically focusing on adults in their 50s to 70s, is another distinguishing factor. This age demographic reflects a focus on older adults who are generally more susceptible to chronic conditions and may particularly benefit from lifestyle interventions aimed at promoting self-management and improving overall quality of life [43]. The attention to this age group also reflects a public health priority, given the rising prevalence of hypertension and other chronic diseases in aging populations worldwide [44].
Intervention duration varied significantly, from a brief three-week program [38] to extended interventions lasting up to six months [30, 31]. Shorter interventions can provide immediate insights into the feasibility and short-term effects of an intervention but may not capture long-term adherence or sustainability. On the other hand, longer interventions are advantageous for observing sustained behavior change and determining whether health improvements persist over time. Such extended interventions might offer a better model for real-world applications, where long-term adherence is critical for effectively managing chronic conditions.
In terms of delivery format, the studies employed a mix of traditional and modern methods, ranging from face-to-face sessions to mobile app-based interventions, telephone guidance, and online group discussions. This variety reflects the growing recognition of the need for flexible and accessible healthcare delivery, especially in a post-pandemic world where remote options are increasingly valuable. Mobile health applications and other technology-assisted education methods allow participants to engage with intervention materials at their convenience, which can be particularly beneficial for individuals with limited mobility or those in rural areas with reduced access to healthcare facilities [45, 46]. At the same time, face-to-face interactions remain valuable for personalized guidance, offering opportunities for real-time feedback, social support, and engagement that digital platforms may lack [47-49].
Improvements in knowledge and self-efficacy are crucial components of chronic disease management, particularly in conditions requiring significant lifestyle changes, such as hypertension. Across the reviewed studies, multiple interventions demonstrated statistically significant increases in knowledge and self-efficacy, suggesting that structured educational programs can positively influence individuals’ ability to manage their health. For instance, Li et al. [36] utilized a WeChat-based group discussion for health education in China, which resulted in notable improvements in both BP control and self-efficacy scores among participants. The use of this popular social media platform allows for frequent interaction and support, which likely contributes to the effectiveness of the intervention. This finding aligns with Bozorgi et al. [30], who found that a mobile application-based intervention in Iran improves adherence to the DASH diet, physical activity, and self-efficacy levels. Such digital platforms may enhance accessibility and engagement, providing participants with convenient and continuous support that fosters knowledge retention and self-confidence in managing health behaviors [50, 51].
Previous research has also demonstrated the effectiveness of educational interventions in enhancing knowledge and self-efficacy. For example, a study by Bandura and Wessels [52] shows that interventions aimed at increasing self-efficacy can lead to sustained behavior change, as higher self-efficacy is directly associated with greater resilience in overcoming obstacles. Similarly, Clark and Dodge [53] emphasize the role of self-efficacy in promoting adherence to dietary and exercise regimens, particularly in hypertensive populations. By empowering patients with the knowledge and confidence needed to make informed health choices, these interventions can yield substantial long-term benefits.
In addition to mobile-based interventions, face-to-face educational sessions have also demonstrated substantial efficacy in improving knowledge and self-efficacy. For example, Park et al. [39] implemented the HAHA program in South Korea, which included face-to-face counseling and physical activity sessions. The program led to significant improvements in both self-efficacy and systolic BP control. This r