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Behavioural interventions for hypertension

 

Behavioural interventions for hypertension include educational approaches to help patients adopt healthy lifestyle changes (e.g. diet and exercise) and self-monitoring of blood pressure to increase patients’ awareness about their condition (which may lead to positive behaviour changes such as improved adherence to medications). This meta-analysis aims to evaluate the effectiveness of behavioural interventions for hypertension, specifically counselling, curriculum-based training courses and patient self-monitoring of blood pressure.

Bottom line

This paper suggests that in patients taking antihypertensive medication, counselling (encouraging lifestyle changes) further improves blood pressure. There is not enough evidence to evaluate the effectiveness of training courses or self-monitoring.

Reference

LE Boulware et al. An evidence-based review of patient-centered behavioral interventions for hypertension. American Journal of Preventive Medicine 2001 21: 221-232.

Search

The literature was searched using several databases (e.g. MEDLINE, PsychInfo) from 1970 to 1999. Additional references were identified from bibliographies and experts in the field. Among the exclusion criteria were studies with less than 50 participants.

Fifteen articles were identified with a total of 4,072 participants. Ten focused on counselling, one investigated patient self-monitoring, one investigated training and four examined various combinations of interventions (e.g. counselling and self-monitoring). The counselling and training interventions advocated lifestyle changes such as healthy eating, weight loss, exercise and smoking cessation.

In the counselling studies, total participant numbers ranged from 53 to 1,880 with intervention group sizes ranging from 23 to 115. The average age was 57 years (range 50 to 65) and the average percentage of men was 51%. In eight out of nine studies participants were on antihypertensive medication. Counselling varied in length (5 to 60 minutes), frequency (every 2 weeks to every 3 months) and duration (4 months to 72 months). The sessions were run by various health professionals, e.g. pharmacists or nurses. Blood pressure was measured directly by the investigators in only half of the studies, using different methods and protocols.

Results

Studies with no comparison groups

Patients receiving counselling had a -6.2 mm Hg reduction in systolic blood pressure (95% confidence interval -2.4 to -10.0; 5 studies, 441 participants) and a -5.0 mm Hg reduction in diastolic blood pressure (95% confidence interval -2.7 to -7.2; 6 studies, 532 participants).

Studies with comparison groups

Compared with patients on medication only, those who also received counselling experienced changes in systolic blood pressure of -11.1 mm Hg (95% confidence interval -4.1 to -18.1; 2 studies, total 109 participants) and diastolic blood pressure of -3.5 mm Hg (95% confidence interval -1.0 to -6.2; 3 studies, 307 participants).

Comment

This meta-analysis demonstrates the difficulties involved with evaluating behavioural interventions and for hypertension particularly. For example the counselling varied in length, frequency and duration; different methods and protocols were used to measure blood pressure and only half of the studies obtained direct measurements. These limitations, together with the small number of studies reporting the same outcome and the small sample sizes make it impossible to draw any firm conclusions about the effectiveness of counselling for hypertension. The papers examining patient self-monitoring and training were not included in this discussion (although they were included in the meta-analysis) because there was only one paper examining each intervention, they were conducted in 1978 and 1980 and total participant numbers were 123 and 136 with less than 40 in each intervention group. Similar reasons apply for not including the results on the combinations of interventions.

This paper suggests that counselling improves blood pressure and it does make sense that additional support and advice on healthy eating, exercise and other positive lifestyle changes would make a difference to blood pressure management. However, further evidence is needed to confirm the efficacy of counselling and the extent to which it is beneficial over medication alone.