Supporting self-management for people with hypertension: a meta-review of quantitative and qualitative systematic reviews

Abstract

BackgroundThere is a growing call to integrate self-management support into health policies on chronic diseases. Self-management support (as proposed by the US Institute of Medicine) helps individuals “with medical management, role management and emotional management of their conditions”. Although the large burden of disease from hypertension makes any potential benefit from self-management support particularly important, it is unclear which interventions are effective for this asymptomatic disease. To inform policy and service provision, we undertook a mixed methods meta-review of quantitative and qualitative systematic reviews of self-management support interventions for hypertension. MethodsWe searched for English language publications in Medline, Embase, CINAHL, PsychINFO, AMED, BNI, DARE, and the Cochrane Database of Systematic Reviews (Jan 1, 1993, to Oct 1, 2012) and did manual, forward citation, and snowball searches. Search terms included “self-management support”, “hypertension”, and “systematic review”. We included systematic reviews of randomised controlled trials or qualitative studies of self-management support interventions that also included education and empowerment strategies (excluding mono-component interventions). We used R-AMSTAR to assess quality. Outcomes of interest (blood pressure and medication adherence) from the quantitative meta-review were synthesised narratively, and a meta-ethnographic analysis was done for the qualitative meta-review; the findings from the meta-review were then combined. Findings11 098 titles were screened, with two qualitative (57 unique studies) and ten quantitative reviews (151 unique studies) included. Interventions included technological, adherence, behavioural, and lifestyle support. Evidence was mixed, but no single intervention, combined with education, was clearly most effective. Some interventions, such as self-monitoring, were most beneficial when part of more complex interventions. The heterogeneity of interventions made evaluation of complex self-management support difficult; however, evidence suggested that it was the most promising type. Qualitative evidence demonstrated that people with hypertension might understand their condition differently from clinicians, frequently blaming stress and basing medication adherence on symptoms. Evidence suggested that partnership working is effective in enabling people's engagement with their condition and in overcoming conflicting perspectives. InterpretationThis mixed methods meta-review provides an overview of what works in self-management support interventions for hypertension and why, and will help inform hypertension policy. We suggest that services should acknowledge and incorporate patients' concerns and perspectives and work with them to use a variety of self-management support interventions that are tailored to individuals. FundingNational Institute for Health Services and Delivery Research programme (project number 11/1014/04).