Journal Pre-proof

Efficacy of Empowerment Strategies for Patients with Hypertension: A

Systematic Review and Meta-analysis

Jingying Zhao, Yanan Hu, Xi Zhang, Guangqing Zhang, Meizhen

Lin, Xiaoyin Chen, Xiaoli Lin, Xia Wang

PII: S0738-3991(19)30537-3
DOI: https://doi.org/10.1016/j.pec.2019.11.025
Reference: PEC 6463

To appear in: Patient Education and Counseling

Received Date: 2 January 2019

Revised Date: 21 November 2019
Accepted Date: 27 November 2019

Please cite this article as: Zhao J, Hu Y, Zhang X, Zhang G, Lin M, Chen X, Lin X, Wang X,
Efficacy of Empowerment Strategies for Patients with Hypertension: A Systematic Review
and Meta-analysis, Patient Education and Counseling (2019),
doi: https://doi.org/10.1016/j.pec.2019.11.025

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© 2019 Published by Elsevier.

Efficacy of Empowerment Strategies for Patients with Hypertension: A

Systematic Review and Meta-analysis

Jingying Zhaoa,b,#, Yanan Huc#, Xi Zhanga,d, Guangqing Zhange*, Meizhen Lina,b,

Xiaoyin Chena,b, Xiaoli Lina,b, Xia Wanga,b

a
The Second Clinical College of Guangzhou University of Chinese Medicine,
Guangzhou, China
b
Department of Cardiovascular Medicine, Guangdong Provincial Hospital of Chinese
Medicine, Guangzhou, China
c
School of Nursing, The Guangzhou University of Chinese Medicine, Guangzhou,

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China
d
Ethics Committee Office, Guangdong Provincial Hospital of Chinese Medicine,

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Guangzhou, China
e
Office, Nanfang Hospital, Southern Medical University, Guangzhou, China

#
*
These authors contributed equally.
Corresponding author: Guangqing Zhang
10th Floor, Outpatient Building, South Hospital
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1838 Guangzhou Avenue North, Baiyun District, Guangzhou, 510515 China
Tel: +86-020-61641009
Fax:+86-020-61641009
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E-mail: 434956755@qq.com

Highlights:
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 The empowerment strategies could decrease SBP;

 The empowerment strategies could decrease DBP;
 The impacts of the empowerment strategies on body mass index, quality of life and
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self-management behavior were unclear;

 The improvements of both SBP and DBP were significant regardless of the duration and
type of interventions.
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ABSTRACT
Background: Cardiovascular disease has caused heavy health care burdens in many
countries, and hypertension (HTN) is a well-known independent cardiovascular risk
factor.
Objective: To assess the efficacy of empowerment strategies that affect systolic blood
pressure (SBP), diastolic blood pressure (DBP), body mass index (BMI), quality of
life, and self-management behaviours for patients with hypertension.
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Methods: A literature search of the Cochrane Library, PubMed, MEDLINE, Embase,
Web of Science, and several Chinese medical databases was performed. Study
screening, quality assessment, data extraction, and meta-analysis were conducted
according to Cochrane standards.
Results: Eleven randomised controlled trials with 988 subjects were identified.
Relative to control groups, the empowerment strategies showed significant decreases
in SBP (the mean difference [MD] = 9.46, 95% confidence interval [CI] = 6.36–12.55,
p < 0.00001) and DBP (MD = 6.68, 95% CI = 3.07–10.29, p = 0.0003). However, no
significant difference was found in BMI (p = 0.05). Subgroup analysis showed
significant differences in the improvement of both SBP and DBP among the various
groups, regardless of the duration and type of interventions.
Discussion: Empowerment strategies can decrease both SBP and DBP in
hypertension patients. However, its influence on patients’ BMI, quality of life, and
self-management behaviour remains unclear.

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Practical value: Empowerment strategies are useful for controlling the blood
pressure of hypertension patients.

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Funding: This research did not receive any specific grant from funding agencies in
the public, commercial, or not-for-profit sectors.

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Keywords: Empowerment strategy; Hypertension; Systematic review; Meta-analysis;
Randomised controlled trial
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1. Introduction
Cardiovascular disease is a global public health problem which has caused heavy
health care burdens in many countries [1]. Hypertension (HTN) is a well-known
independent cardiovascular risk factor, and its morbidity rate has been increasing
worldwide [2]. Concurrently, the prevalence of overweight and obesity is also rapidly
increasing. The association between HTN and obesity is well established, with obesity

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being the major cause of HTN and accounting for > 65% of the risk for essential HTN
[3]. Consequently, weight loss and the maintenance of healthy body weight (body
mass index [BMI] 2025 kg/m2) can reduce blood pressure in patients with HTN.
Therefore, a healthy BMI is an important indicator of the impact of HTN.
Furthermore, along with prolonged duration of disease and increased stress burden,
HTN patients also have a lower health-related quality of life (HRQOL) than
individuals without HTN. HRQOL, which refers to perceived physical and mental
health and function, is an important health indicator for medical interventions and
health surveys. It is an assessment of how an individual’s well-being may be affected
over time by a disease, disability, or disorder. Moreover, comorbidities of HTN, such
as stroke, may lead to fatal outcomes such as paralysis and death [4]. There are
several treatment modalities for HTN, including pharmacological therapy, etiological
treatment, and health education [5]. Research has shown that depending on the
severity of HTN at diagnosis, the first-line treatment is often lifestyle modification [6],

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with approximately 84% of HTN patients receiving lifestyle counselling [7]. Even so,
compared to those with normal blood pressure, people with HTN are less likely to

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report healthy lifestyle behaviours [8]. Thus, health education, which was
recommended by the 2018 ESC/ESH Guideline as the first choice to control HTN,
remains an urgent issue [5]
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Empowerment is one of the strategies that embody the concept of health education.
The World Health Organization (WHO) defines empowerment as a process through
which people gain greater control over decisions and actions affecting their health [9].
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The empowerment strategy comprises five processes: perceiving problems,
expressing emotions, setting goals, planning, and evaluation [10]. Given that there is
no criterion for utilising empowerment strategies, different methodologies have been
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used in clinical trials, such as one-to-one interviews, group sessions, and

family-centred models [11-13].
Empowerment strategies emphasise fostering patients’ motivation, skills, and
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confidence (self-efficacy) [9]. Once self-efficacy is established, patients can actively

change their self-management behaviours according to specific disease conditions
[14]. In self-management, patients, along with their family, community, and health
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care professionals, take greater responsibility for health decisions and actively engage
in behaviours that might benefit their disease conditions. Patients with optimal
self-management behaviours adapt better to patient roles and present with clear illness
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perception and illness acceptance. Self-management behaviours mainly reflect six

aspects: medication management, condition monitoring, diet management, sports
management, work and rest management, and emotional management. Numerous
studies have suggested that self-management behaviours could be crucial for patients
to achieve blood pressure reduction [14]. HTN management requires a life-long
programme combining lifestyle modifications such as weight loss [15], tobacco
cessation [16], following a heart-healthy diet [17], and increased physical activity [18].
Compared to conventional methods, these empowerment strategies have been proven
to enhance HTN patients’ capacity in achieving and maintaining healthy behaviours.

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They are also effective in reducing blood pressure, which can reduce
re-hospitalisation rates and medical costs [19].
Many studies have demonstrated that empowerment strategies could decrease systolic
blood pressure (SBP) and diastolic blood pressure (DBP) in patients with HTN [11,
20, 21]. Moreover, empowerment strategies have been associated with improvement
of HRQOL, BMI, and self-management behaviours [20, 22]. However, Rasjö Wrååk
et al. illustrated no significant difference in blood pressure between the intervention
and control groups; this may have been related to the method of empowerment and
the length of intervention [21]. There has been no previous research in this area.
Therefore, we conducted a systematic review and meta-analysis of randomised
controlled trials (RCTs) to assess the efficacy of empowerment strategies for patients
with HTN according to the length and type of intervention.
2. Methods

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2.1 Data sources and search strategy

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This meta-analysis followed the PRISMA guidelines [23]. The following databases
were extensively searched from their establishment dates up to 23 March 2017:
PubMed, Embase, the Cochrane Library, Web of Science, MEDLINE, China National
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Knowledge Infrastructure, Chinese Biomedical Database (CBM), Chinese VIP
Information (VIP), and Wanfang Database. The following search terms, adjusted for
each database, were used: (“empower*” or “empowerment theory” or “empowerment
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education”) and (“hypertension” or “high blood pressure”) and (“randomised
controlled trial” or “controlled clinical trial” or “randomised” or “randomly”). In
addition, the reference lists of the retrieved articles were manually checked to identify
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any potentially relevant studies.

2.2 Study selection
Studies that met the following criteria were selected: 1) conducted via an RCT; 2)
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included adults (aged 18 and older) with diagnosed or self-reported primary HTN; 3)
focused on any empowerment strategies used in the intervention group, including but
not limited to health education based on empowerment theory, group sessions
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managed by nurses and physicians, one-to-one conversations between patients and

physicians, and family-centred empowerment models; 4) the primary outcomes were
blood pressure (SBP or DBP) and the secondary outcomes were BMI, HRQOL, and
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self-management behaviour; and 5) written in Chinese or English.

2.3 Quality of studies
Jadad scores were computed for each study based on the Jadad scale. Then, a
three-question measure was derived to rate the methodological quality of the RCT
included [24]. The Jadad scale scores RCTs from 05: 2 points for mentioning
randomisation (1 point) and for being conducted appropriately (another point),
another 2 points for blinding, and an additional point for providing reasons for
participant withdrawals. A score of ≥3 indicates high quality.

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Additionally, two reviewers assessed the risk of bias independently for the included
studies using the Cochrane Risk of Bias Tool according to the following domains:
random sequence generation, allocation concealment, blinding of outcome assessment,
incomplete outcome data, selective outcome reporting, and other domains of bias [25].
Discrepancies were resolved by consultation with a third author.
2.4 Data extraction and analysis
Two authors (Jingying Zhao and Xi Zhang) independently extracted data from the
included studies and filled in a prespecified electronic form developed by the authors.
The extracted data include author names, year of publication, sample size, age,
diagnostic criteria, description of the treatments used in the experiment and control
group, indicators, and the assessment tool. Any disagreements were resolved by
consultation with a third author (Guangqing Zhang).

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Review Manager (version 5.3.5) was used to perform the meta-analysis. A
random-effects model was used in cases of significant heterogeneity between studies.
Both the Cochrane Q test and I2 statistic were used to assess heterogeneity across

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study outcomes [26]. For the Cochrane Q test, significant heterogeneity was
considered with a p value < 0.1. For the I2 statistic, I2 < 25%, I2 ≥ 25% < 50%, or I2 ≥
50% were considered to indicate low, moderate, or high heterogeneity, respectively
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[27]. For continuous variables, mean difference (MD) with 95% confidence intervals
(CIs) were calculated.
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3. Results
3.1 Study selection and characteristics
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Of the 520 studies identified (514 from database searches and 6 from manual
searches), 227 papers were excluded because of duplicates. After two authors
(Jingying Zhao and Xi Zhang) independently scanned the search results according to
titles and abstracts, we excluded 275 articles: 269 were irrelevant and 6 were reviews.
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The remaining 18 potentially eligible articles were retrieved for further assessment.
Seven articles were excluded for the following reasons: language other than English
or Chinese (n = 1), irrelevant primary or secondary outcomes (n = 4), and non-RCTs
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(n = 2). Finally, 11 studies [11-13, 20, 22, 28-32] with 988 patients were included. The
study selection flow diagram is shown in Figure 1, while the study characteristics are
listed in Table 1.
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Among these studies, health education based on empowerment theory was used in 5
studies [12, 28, 30, 31, 32], a group session managed by nurses and physicians was
applied in 4 studies [13, 20, 22, 29], one-to-one interview between patients and
physicians was used in 2 studies [21, 29], and a family-centred empowerment model
was used in 1 study [11].
3.2 Quality of studies
As shown in Table 1, two studies [21, 31] reached a Jadad score of 3, while the other
nine only had a scale score of 2. As shown in Table 2, 11 studies applied randomised
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controlled methods to divide participants into intervention or control groups.
Furthermore, five studies [11, 13, 21, 31, 32] used random sequence generation to
randomly assign participants into groups. Two studies [21, 31] employed appropriate
allocation and concealment methods, while the other nine did not state any specific
methods. Due to the features of empowerment strategies, it was impossible to blind
participants or researchers. They needed to know what intervention was chosen.
Therefore, none of these 11 studies used blinding. Ensuring measurement blindness
was possible in these studies; however, in three studies [11,20,32], reporting tools and
methods for measuring blood pressure were not sufficiently detailed. Thus, it is
unclear whether measurement blinding was used. This was also true for BMI
measurement. All studies reported low withdrawal rates and incomplete outcome data.
3.3 Systolic blood pressure and diastolic blood pressure
Ten studies focused on SBP and nine focused on DBP. Among them, one study used

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median (quartiles) to indicate changes in SBP and DBP [21]. Another study only
compared blood pressure values between two groups after the study intervention; thus,

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we could not calculate the changes in SBP and DBP without a baseline blood pressure
measurement [12]. Finally, the SBP data in 8 studies [11, 20, 22, 28-32] (729 patients)
and the DBP data in 7 studies [11, 20, 22, 28-30, 32] (547 patients) were analysed.
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Owing to the statistical heterogeneity among the results (SBP: I2 = 81%, p < 0.00001,
DBP: I2 = 94%, p < 0.00001), the random-effects model was used. The results showed
that compared with that in the control groups, both SBP (MD = 9.46, 95% CI =
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6.36–12.55, p < 0.00001, Fig. 2) and DBP (MD = 6.68, 95% CI = 3.07–10.29, p =
0.0003, Fig. 3) were significantly reduced in the empowerment intervention group.
Subgroups analyses according to different intervention time points (at 1.5 and 4.5
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months, 6 months, and unknown time points) revealed that blood pressure decreased
in subgroups of 1.5 and 4.5 months (SBP: MD = 9.10, 95% CI = 1.46–16.74, p = 0.02;
DBP: MD = 4.64, 95% CI = 0.83–8.44, p = 0.02), 6 months (SBP: MD = 8.02, 95%
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CI = 5.37–10.66, p < 0.00001; DBP: MD = 3.97, 95% CI = 1.92–6.03, p = 0.0002),

and unknown time points (SBP: MD = 11.06, 95% CI = 5.92–16.21, p < 0.0001; DBP:
MD = 9.98, 95% CI = 4.88–15.08, p = 0.0001) (Fig. 2 and Fig. 3).
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Subgroups analyses according to the type of intervention revealed that blood pressure
decreased in subgroups of health education based on empowerment theory (SBP: MD
= 6.26, 95% CI = 3.84–8.68, p < 0.0001; DBP: MD = 3.68, 95% CI = 1.82–5.33, p =
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0.0001), group session (SBP: MD = 11.90, 95% CI = 5.83–17.96, p = 0.0001; DBP:

MD = 9.33, 95% CI = 0.90–17.76, p = 0.03), family-centred empowerment model
(SBP: MD = 13.00, 95% CI = 8.45–17.55, p < 0.0001; DBP: MD = 6.40, 95% CI =
3.89–8.91, p < 0.0001), and group session and one-to-one interview (SBP: MD =
11.50, 95% CI = 7.61–15.39, p < 0.00001; DBP: MD = 10.50, 95% CI = 7.14–13.86,
p < 0.00001) (Fig. 4 and Fig. 5).
3.4 Body mass index

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Three studies reported the BMI of patients with HTN [20, 22, 30]. There was
statistical heterogeneity among the results (I2 = 95%, p < 0.00001); thus, the
random-effects model was used. Results showed that there was no significant
difference in BMI between the empowerment intervention group and the control
groups (MD = 1.69, 95% CI = –0.02 to 3.39, p = 0.05, Fig. 6). Among the three
studies, two reported significant differences in BMI between the intervention and the
control groups [20, 22].
3.5 Self-management behaviour
Two studies concentrated on the self-management behaviour of patients using the
HTN Patients Self-Management Behavior Rating Scale (HPSMBRS), which includes
diet, medication, emotional awareness, work and rest, physical activity, and condition
monitoring. In the study by Yang et al. [32], the total HPSMBRS score was
significantly higher in the empowerment intervention group than that in the control

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group. However, the other study did not provide enough data for self-management
behaviour [20].

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3.6 Quality of life
Two studies reported the HRQOL for patients with HTN [22, 32]; however, we were
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unable to combine the results due to the different measurement scales used in these
studies. While Wu et al. used the Short Form-36 Health Survey [22] for evaluation,
Yang et al. used the Quality of Life Instruments for Chronic Diseases [32].
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4. Discussion and Conclusion
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4.1 Discussion
The results of this meta-analysis showed that empowerment strategies are effective in
reducing SBP and DBP in HTN patients. However, there were no significant
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differences between the two patient groups with different BMIs. To our knowledge,
this is the first systematic review to identify 11 completed RCTs that assessed the
efficacy of empowerment strategies in patients with HTN. Subgroup analyses
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demonstrated that the improvements in both SBP and DBP were significantly different
between the groups, regardless of the study duration and the type of intervention. As
empowerment interventions can stimulate the patients’ internal motivations, patients
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can actively participate in empowerment health management. In addition, patients

could set goals and make plans according to their own living habits and conditions,
thus taking actions to adjust their lifestyles. Effective blood pressure reduction could
be achieved as long as they maintained a healthy lifestyle [33]. Consistent with the
above-mentioned findings, the results of this study indicate that empowerment
strategies have a good effect on blood pressure control, despite the considerable
heterogeneity between studies. In this systematic review, the possible sources of
heterogeneity were as follows: (1) the definition of the empowerment strategy was
relatively vague, and various methods of empowerment strategies were used in the

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included studies and (2) the methodological quality of the included studies was
inconsistent. Apart from this, only one of the included studies had estimated the
sample size. Two studies had relatively small sample sizes, and most studies reported
positive results. The CI was relatively wide, and there might be publication bias. The
reliability and stability of results need further verification.
The BMI did not decrease significantly after an empowerment intervention. Three
studies reported BMI[20, 22, 30]; of these, two with a study duration of 6 months
reported a significant reduction in BMI in the empowerment intervention group
compared with that in the control group. However, the third study, with a duration of
3 months, showed no difference between the two groups. Moreover, as a
comprehensive indicator, BMI may take a long time to change in response to
interventions [34].
Although a meta-analysis could not be performed on the studies for self-management

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behaviour and quality of life and the synthesis results were still unclear, research has
showed that empowerment could improve self-management behaviour [20,32] and

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HRQOL in patients with HTN [22,32]. The reason for this may be that empowerment
strategies are patient centred. It can enhance the patient’s self-confidence and
initiatives and foster the internal driving force for patients to self-manage and improve
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their quality of life. However, further research is necessary to gather evidence
supporting this finding.
HTN is a major public health problem worldwide. However, 9 of the 11 included
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studies were conducted in China, while the other 2 were conducted in Iran and
Sweden. This might make the sample population less representative of the general
HTN population. More studies from America and Africa would help improve sample
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representation; however, no study from these regions was included. According to the
Report on Cardiovascular Diseases in China (2014), 270 million patients have HTN,
and HTN has become one of the most common chronic diseases endangering the
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health of elderly people in China [35]. Thus, increasing attention has been paid to
health management of HTN. Empowerment strategies have been widely promoted
and applied in China. Some of the Chinese studies in this meta-analysis also
illustrated this point. However, specific contents and forms of empowerment
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strategies are yet to be standardized, and the most effective empowerment method for
patients with HTN remains unclear. Further studies are needed to identify the effects
of empowerment strategies on patients with HTN.
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This systematic review integrated the results of similar research, increased the sample
size, improved statistical efficiency, and provided a reference basis for the application
of empowerment strategies in patients with HTN. However, this study still had the
following limitations: (1) the number of included RCTs was too small to draw a
funnel plot; (2) the included studies was of low quality; (3) the difference in the types
of data and evaluation methods limited the application of meta-analysis in some
indices, such as HRQOL; and (4) the samples included in this review showed poor

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representativeness. Future ethnically diverse RCTs using rigorous methodologies will
increase the quality and credibility of systematic reviews.
4.2 Conclusion
This systematic review showed that empowerment strategies could decrease the SBP
and DBP of HTN patients. However, the influence on patients’ BMI, HRQOL, and
self-management behaviour remains unclear.
4.3 Practice implications
Lifestyle changes are critical and recommended by treatment guidelines for HTN
patients. Empowerment strategies can enhance the self-management ability of HTN
patients to achieve lifestyle changes. Different empowerment methods are used
worldwide, and emphasis on the active participation of patients and the cultivation of
self-efficacy is necessary, regardless of the method. Some previous studies, along with

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this review, have shown that empowerment strategies are useful for blood pressure
reduction in HTN patients. However, there is insufficient evidence to support the

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improvement in BMI. Currently, there is no uniform standard for the type of
empowerment strategy. Empowerment strategies should be promoted and applied for
further research and in clinical practice.

Funding
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This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
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Declarations of interest: none.

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Acknowledgements
We thank Qing Huang for proofreading this paper.
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na

patients with primary hypertension, Huazhong University of Science and Technology. (2014).
[33] J. Xie, C.Y. Zhang, G. Lin, Y.P. Zhang, W.C. A meta-analysis of the effect of self-management
intervention on blood pressure in patients with hypertension, Chinese Preventive Medicine. 7 (2018) 2.
ur

[34] N. Lv, K.M.J. Azar, L.G. Rosas, S. Wulfovich, L. Xiao, J. Ma, Behavioral Lifestyle Interventions
for Moderate and Severe Obesity: A Systematic Review, Prev Med. 100 (2017) 180-93.
[35] J. Xie, Z. Dong, Effects of community hypertension on self-efficacy and blood pressure related
Jo

behavioral risk factors, Chinese Journal of Prevention and Control of Chronic Diseases. 22 (2014)
329-31.

11
Figure captions

Records identified through database searching (n=514):

PubMed(n=51), Embase(n=140), The Cochrane Library(n=76),
web of science(n=162), Medline(n=51), CNKI(n=21),
WanFang Database(n=5), CBM(n=7), VIP(n=1)
Additional studies from manual searching (n=6)

Potentially relevant studies after duplicates

removed (n=293)

of
Articles screened on basis of

ro
title and abstract (n=293)

Articles excluded for the

-p
following reasons (n=275):
Irrelevant studies: 269
Reviews: 6
re
Full-tex screening for
eligibility (n=18)
lP

Articles excluded for the following

reasons (n=7):
na

Non English or Chinese: 1

Non-RCTs: 2
No primary or secondary outcomes: 4
ur

Studies included in qualitative synthesis (n=11)

Jo

Studies included in quantitative synthesis

(meta-analysis) (n=8)

Figure 1. Flowchart of the study delection process.

Abbreviation: CNKI, China National Knowledge Infrastructure; CBM, China
Biology Medicine disc; VIP, Chinese VIP Information; RCT, randomized clinical trial.

12
 of
ro
Figure 2. Forrest plot of systolic blood pressure subgroup analysis by length of
intervention
Abbreviation: CI, confidence interval.
-p
re
lP
na
ur
Jo

Figure 3. Forrest plot of diastolic blood pressure subgroup analysis by length of

intervention
Abbreviation: CI, confidence interval.

13
 of
ro
Figure 4. Forrest plot of systolic blood pressure subgroup analysis by type of
intervention
Abbreviation: CI, confidence interval. -p
re
lP
na
ur
Jo

Figure 5. Forrest plot of diastolic blood pressure subgroup analysis by type of

intervention
Abbreviation: CI, confidence interval.

14
 empowerment control Mean Difference Mean Difference
Study or Subgroup Mean SD Total Mean SD Total Weight IV, Random, 95% CI IV, Random, 95% CI
wu et al 2013 5.12 2.68 60 1.21 3.19 60 31.5% 3.91 [2.86, 4.96]
yang et al 2016 0.71 0.63 40 0.16 0.45 40 35.5% 0.55 [0.31, 0.79]
Zhang 2012 0.8 3.35 64 0.01 0.01 59 33.0% 0.79 [-0.03, 1.61]

Total (95% CI) 164 159 100.0% 1.69 [-0.02, 3.39]

Heterogeneity: Tau² = 2.11; Chi² = 37.13, df = 2 (P < 0.00001); I² = 95%
-100 -50 0 50 100
Test for overall effect: Z = 1.94 (P = 0.05)
Favours [Control] Favours [empowerment]

Figure 6. Forrest plot of body mass index.

Abbreviation: CI, confidence interval.

of
ro
-p
re
lP
na
ur
Jo

15
 f
Table 1. Characteristics of included studies

oo
Sample size Median age Diagnostic Study Experiment Control Indicator/ Jadad
Author, year Baseline
(Exp/Con) (Exp/Con) criteria duration group group the assessment tool score
2010 Guidelines -Health education based on the -Conventional health

pr
for Prevention theory of empowerment education Indicator:
Li et al. Not
44/44 62/63 and Treatment Yes -followed up for 3 months -followed up for 3 -DBP 2
2016 [28] specific

e-
of Hypertension bytelephone ordoor-to-door months by telephone or -SBP
in China interview door-to-door interview
Indicator:

Pr
-DBP
2010 Guidelines -SBP
-Group sessions managed By
for Prevention -Regular education -BMI
Yang et al. nurses and physicians
40/40 Not specific and Treatment Yes 6 months -After 6 months -Self-management behavior 2
2016 [20] - Monthly telephone follow-up
l
of Hypertension
once
follow-up The assessment tool:
na
in China - The Hypertension Patients
Self-Management Behavior
Rang Scale
Indicator:
ur

2004WHO and
-DBP
The
- Group sessions managed By -SBP
international -Community routine
Wu et al. Not nurses and physicians -BMI
Jo

60/60 66/69 alliance Yes health education 2

2013 [22] specific -According to the five steps of -Quality of life
diagnostic management
empowerment education The assessment tool:
criteria of
the Mositem short from health
hypertension
survey, SF-36

16
 f
-The usual care and one

oo
-Family‑centered empowerment
training Indicator:
model
session(Evaluation -DBP
-Training in four sessions of 45
process) -SBP
Keshvari et al. 1.5 min about empowerment

pr
31/31 Not specific Not specific Yes -1 week and 1.5 -empowerment assessment 2
2015 [11] months education
months after the questionnaire
-1 week and 1.5 months after
intervention The assessment tool:
the intervention performing

e-
performing the post‑ self-designed questionnaire
the post‑test
test
-Health education based on the -Conventional health
Indicator:

Pr
Lu et al. theory of empowerment education
43/41 69/70 1999WHO/ISH Yes 3 months -DBP 2
2013 [12] -Monthly -Monthly follow-up
-SBP
-follow-up telephone or the door telephone or the door
-One-to-one interview and -traditional education Indicator:
Guo et al. Not
45/45 58/55 l
Not specific Yes group session methodsfollow-up30 -DBP 2
na
2015 [29] specific
-1-2timesa month follow-up days after discharge -SBP
-Health education based on the
theory of empowerment
-Conventional health
ur

International -Face to face and telephone Indicator:

education
Zhang et al. Hypertension 4.5 teaching,Respectively 3 -DBP
64/59 Not specific Yes -The telephone 2
2012 [30] Diagnostic months times,Once a week, every -SBP
following once a month
Jo

Criteria 20-30min -BMI

for 3 months
-The telephone following once a
month for 3 months
Jiang et al. -Health education based on the -Conventional health Indicator:
30/30 65/65 WHO/ISH Yes 6 months 3
2014 [31] theory of empowerment management -SBP

17
 f
- Telephone follow-up at 6 -Telephone follow-up

oo
weeks, 3 months, 6 months at 6 weeks, 3 months, 6
months
Guidelines for -group session -Community routine
Indicator:

pr
Prevention and -Once a week, every 90 health management
-empowerment assessment
Fan et al. Treatment of minutes, a total of 8 weeks - Telephone follow-up
40/39 Not specific Yes 8 months questionnaire 2
2015 [13] Hypertension in -Telephone follow-up once a once a month, each 5 to
The assessment tool:

e-
China(Revised month, each 5 to 10 minutes, a 10 minutes, a total of 8
self-designed questionnaire
2005) total of 8 months months
Indicator:

Pr
-DBP
-SBP
-BMI
China "Internal
-Health education based on the -Self-management behavior
Medicine" -Compliance type
l theory of empowerment - Quality of life
na
seventh edition education concept
Yang et al. -Each about 30 minutes, once a The assessment tool:
53/54 75/74 published in the Yes 6 months -Telephone follow-up, 2
2014 [32] week for 1 month -The Hypertension Patients
diagnosis of once a month for 5
--Telephone follow-up, once a Self-Management Behavior
hypertension months
month for 5 months Rang Scale
ur

standards
- The Hypertension
Scale of The System of
Jo

Quality of Life Instruments

for Chronic Diseases
G. RasjöWrååk -One-to-one interview - standard hypertension Indicator:
Not
et al. 53/42 66/62 Not specific 1 year -Individual visits on an average care -DBP 3
specific
2015 [21] of 7 times - individual visits on an -SBP

18
 f
average of4 times - the Health Index

oo
The assessment tool:
-an instrument that was
developed by

pr
Hansagi&Rosenqvist
(unpublished).
Abbreviation: Exp, experiment group; con, control group; DBP, diastolic blood pressure; SBP, systolic blood pressure; BMI, body mass index.

e-
l Pr
na
ur
Jo

19
 Table 2. Risk of bias summary.

Detection Attrition Reporting

Selection Bias
Bias Bias Bias
Other
Study Random Blinding of Incomplete
Allocation Selective Bias
sequence outcome outcome
concealment reporting
generation assessment data
Li et al.
unclear unclear unclear low low low
2016 [28]

Yang et al.
unclear unclear unclear low low low
2016 [20]

Wu et al.

of
unclear unclear unclear low low low
2013 [22]

Keshvari et al.

ro
low unclear unclear low low low
2015 [11]

Lu et al.
unclear unclear unclear low low low
2013 [12]

Guo et al.
unclear unclear unclear
-p low low low
re
2015 [29]

Zhang et al.
unclear unclear unclear low low low
2012 [30]
lP

Jiang et al.
low low unclear low low low
2014 [31]
na

Fan et al.
low unclear unclear low low low
2015 [13]

Yang et al.
low unclear unclear low low low
ur

2014 [32]

G. RasjöWrååk
low low unclear low low low
Jo

et al. 2015 [21]

20