Assessing the Effectiveness of mHealth Interventions for Diabetes and Hypertension Management in Africa: Systematic Review and Meta-Analysis

Background Mobile health (mHealth) interventions are effective in improving chronic disease management, mainly in high-income countries. However, less is known about the efficacy of mHealth interventions for the reduction of cardiovascular risk factors, including for hypertension and diabetes, which are rapidly increasing in low- and middle-income countries. Objective This study aimed to assess the efficacy of mHealth interventions for diabetes and hypertension management in Africa. Methods We searched PubMed, Cochrane Library, Google Scholar, African Journals Online, and Web of Science for relevant studies published from inception to July 2022. The main outcomes of interest were changes in hemoglobin A1c (HbA1c), systolic blood pressure, and diastolic blood pressure. The random or fixed effect model was used for the meta-analysis, and the I 2 statistic was used to gauge study heterogeneity. Z tests and P values were used to evaluate the effect of mHealth interventions on HbA1c and blood pressure levels. Results This review included 7 studies (randomized controlled trials) with a total of 2249 participants. Two studies assessed the effect of mHealth on glycemic control, and 5 studies assessed the effect of mHealth on blood pressure control. The use of mHealth interventions was not associated with significant reductions in HbA1c levels (weighted mean difference [WMD] 0.20, 95% CI −0.40 to 0.80; P=.51) among patients with diabetes and systolic blood pressure (WMD −1.39, 95% CI −4.46 to 1.68; P=.37) and diastolic blood pressure (WMD 0.36, 95% CI −1.37 to 2.05; P=.69) among patients with hypertension. After conducting sensitivity analyses using the leave-one-out method, the Kingue et al study had an impact on the intervention, resulting in a 2 mm Hg reduction in systolic blood pressure (WMD −2.22, 95% CI −3.94 to −0.60; P=.01) but was nonsignificant for diastolic blood pressure and HbA1c levels after omitting the study. Conclusions Our review provided no conclusive evidence for the effectiveness of mHealth interventions in reducing blood pressure and glycemic control in Africa among persons with diabetes and hypertension. To confirm these findings, larger randomized controlled trials are required. Trial Registration PROSPERO CRD42021230642; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=230642


Rationale
3 Although the data on the efficacy of mHealth in the management of diabetes and hypertension in Africa are limited and have not yet been systematically evaluated.Therefore, the present systematic review assessed the effectiveness of mHealth interventions on blood pressure control among hypertension patients and glycemic control among diabetes patients in Africa.The findings of this paper will provide guidance to improve the adoption of mHealth for the management of diabetes and hypertension in Africa countries Objectives 4 This study aimed to assess the efficacy of mobile health interventions regarding managing diabetes and hypertension patients in Africa.

Eligibility criteria 5 Inclusion Criteria
We included studies that met the following criteria: (1) hypertension and diabetes patients aged 18 years and above; (2) patients who received

Section and Topic
Item # Checklist item Location where item is reported treatment at a selected healthcare setting; (3) the intervention included a mHealth component; (4) results included target values of glycated haemoglobin (HBA1c), systolic blood pressure and diastolic blood pressure; (5) studies were randomized controlled trials; and (6) articles were written in English.(7) Studies conducted in hospitals and primary health centres were eligible.

Exclusion Criteria
We excluded studies in which (1) full text articles were not available after attempts to contact the author (2) the research participants were pregnant women and or specific patient populations e.g., cancer patients; (3) the results did not describe primary outcomes; (4) the primary intervention did not use mHealth devices; and (5) unpublished manuscripts and conference abstracts.
Information sources 6 PubMed, Cochrane Library, Google Scholar, African Journals Online and Web of Science were searched for relevant studies published from inception to July 2022 assisted by a clinical librarian.The full search strategies, the common Medical Subject Headings and search terms used across databases are available in Supplementary Table 1.The reference lists of the included studies were hand-searched to identify additional relevant studies.

Search strategy 7 Google Scholar
"Treatment Outcome" OR efficacy OR potency AND "Telemedicine" OR "mobile device$" OR "mobile technology" OR "mobile app" OR "mobile app$" OR "mobile health care" AND "Early Medical Intervention" OR mediation OR interference AND "Diabetes Mellitus" OR "high blood glucose" OR "impaired blood glucose" AND "Hypertension" OR "high blood pressure" OR "blood pressure" AND "Disease Management" OR administration AND "Africa" OR "Africa countries"

Africa journals online
Effectiveness AND "Diabetes OR Hypertension" AND Management AND Africa Selection process 8 Two independent authors (PA and KA) manually assessed and screened studies for both the titles and abstracts and full-text articles using an Excel sheet.Disagreements were resolved by consensus by a third author (CA) as necessary.This was performed in three stages as follows.
First, PA screened the titles of all papers to determine their relevance.KA performed a cross-check of the title screening by screening 20% of titles excluded by the first reviewer, and it was confirmed that none of the titles screened by the second reviewer met the inclusion criteria.
Second, abstracts of the papers selected after the title screening stage were again screened by (PA and KA) following the same procedure as described in step one.Finally, full texts of potentially relevant papers were retrieved and evaluated by (PA and KA) independently to ascertain their relevance and usefulness to the review.Disagreements were settled through dialogue with (CA) to reach an agreement.Duplicates were also identified using Endnote reference manager (version x9).

Data collection process
9 Two authors (PA and KA) independently extracted the following study characteristics from each included article using a tested extraction form: first author, year of publication, mean age, the country where the study was conducted, the participant (diabetic or hypertensive patients), mHealth location (primary care settings, hospital, clinics, etc.), condition (diabetes/hypertension), sample size, mHealth intervention, study design and outcome of the intervention( primary outcomes HbA1c, SBP, and DBP) Data items 10a Out of interest were changes in glycated haemoglobin A1c (HbA1c) levels, systolic blood pressure, and diastolic blood pressure 10b first author, year of publication, mean age, the country where the study was conducted, the participant (diabetic or hypertensive patients), mHealth location (primary care settings, hospital, clinics, etc.), condition (diabetes/hypertension), sample size, mHealth intervention, study design and outcome of the intervention( primary outcomesglycated haemoglobin A1c (HbA1c) levels systolic blood pressure and diastolic blood pressure )

Study risk of bias assessment
11 The quality of each study was assessed using a 28-point scoring system as adopted from the Downs and Black checklist [25].The included studies focused on the following items for assessment: Items 1 through 10 evaluated whether the information provided was adequate for the reader to make an objective assessment of the study's findings; Items 11 through 13 evaluated external validity, which examined the extent to which study findings could be applied to the population from which the study subjects were drawn; Items 14 through 20 assessed possible bias, which focused on biases in the assessment of the intervention and the result; Items 21 through 26 assessed confounding, which focused on biases in the research participants' selection.To determine if neutral research results may be the result of chance or insufficient power, item 27 evaluated the study's power Effect measures 12 The data for primary outcomes (glycated haemoglobin A1c (HbA1c) levels, systolic blood pressure, and diastolic blood pressure) were analyzed

Item # Checklist item
Location where item is reported separately using random or fixed effects models with a weighted mean difference (WMD) in Review Manager (RevMan; version 5.4,The Cochrane Collaboration, 2020) [26].The I 2 statistic was calculated to measure the percentage of variation across trials due to heterogeneity, with values of <50% and ≥50% indicating low and high levels of heterogeneity, respectively.The WMD in blood pressure and HbA1c between the intervention and control Z tests were used to compare groups, and P values less than 0.05 were regarded as statistically significant.We checked publication bias subjectively by funnel plot and objectively by Begg's and Egger's tests using STATA version 16.Begg's and Egger's tests with P < .05were considered significant publication bias.

Synthesis methods
13a PA and KA) independently extracted the following study characteristics from each included article using a tested extraction form: first author, year of publication, mean age, the country where the study was conducted, the participant (diabetic or hypertensive patients), mHealth location (primary care settings, hospital, clinics, etc.), condition (diabetes/hypertension), sample size, mHealth intervention, study design and outcome of the intervention.
13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions.
13c Describe any methods used to tabulate or visually display results of individual studies and syntheses.
13d (glycated haemoglobin A1c (HbA1c) levels, systolic blood pressure, and diastolic blood pressure) were analyzed separately using random or fixed effects models with a weighted mean difference (WMD) in Review Manager (RevMan; version 5.4,The Cochrane Collaboration, 2020) [26].The I 2 statistic was calculated to measure the percentage of variation across trials due to heterogeneity, with values of <50% and ≥50% indicating low and high levels of heterogeneity, respectively.The WMD in blood pressure and HbA1c between the intervention and control Z tests were used to compare groups, and P values less than 0.05 were regarded as statistically significant.We checked publication bias subjectively by funnel plot and objectively by Begg's and Egger's tests using STATA version 16.Begg's and Egger's tests with P < .05were considered significant publication bias.
13e The Random effect model was used to account for heterogeneity 13f Sensitivity analyses were conducted using the leave-one-out method in stata 17 Reporting bias 14 using a 28-point scoring system as adopted from the Downs and Black checklist, we use that to assess the quality of (2) patients who received treatment at a selected healthcare setting; (3) the intervention included a mHealth component; (4) results included target values of glycated haemoglobin (HBA1c), systolic blood pressure and diastolic blood pressure; (5) studies were randomized controlled trials; and (6) articles were written in English.( 7) Studies conducted in hospitals and primary health centres were eligible.The intervention group was given electronic reminders for their clinical appointments and their physicians were prompted with abnormal laboratory results for six months.
Patients received only the usual care.

Mobile phone calls
Mobile phone call intervention delivered by nurses in addition to care as usual over 12 weeks.The intervention group received up to 16 mobile phone calls (mean duration = 12 minutes) from a diabetes specialist nurse in addition to their care as usual.record system.Messages were sent for one year from enrolment.Blood pressure measurements were collected from participants as they attended their routine clinic visits.Delivery of SMS text messages was automatically tracked and if undelivered a research assistant, blinded to group allocation, would contact the number of a friend or relative to obtain a new mobile phone number from the clinic and some form of written information about hypertension and healthy living but no Personalized SMS text messages were sent.

Mobile phone calls
Interactive electronic communication between the patient and the provider or between multiple providers in either synchronous or asynchronous settings for the provision of health care services or consultation Only received routine treatment and care from the clinic.

SMS
Participants in the intervention arm received daily educational text messages on diabetes for six months.In addition, the intervention group received the SMS at an agreed time of the day, according to their needs, care plan and goals.
The control groups proceeded with their usual care including all medical visits, tests and diabetes support at the clinic.Sarfo et al., [27]

SMS
Patients received a Blue-toothed blood pressure device and smartphone with an App for monitoring blood pressure measurements and medication intake under nurse guidance for three months.Participants also received motivational and support messages, advice on lifestyle behaviours like diets, physical activity, smoking cessation, medication and appointment reminders.
The control arm received only the usual care.

Systolic blood pressure control
For SBP, we observed a reduction after the mHealth intervention compared to usual care by an average of 1.39 mm Hg, however, it was not statistically significant.After conducting leave-one-out analysis, a study by Kingue et al[29], had an impact on the WMD, and exclusion of this study resulted in pooled WMD of 2.22 mmHg reduction in SBP.This finding is consistent with previous RCT studies [21,[34][35][36]  respectively.In contrast, a study performed by Rubinstein et al., (2016), reported that the mHealth intervention did not reduce the SBP compared with usual care.This discrepancy could be explained by the relatively small sample number of studies included in this review.Another reason could be due to the different study populations, interventions, ages and medications used.

Web of Science Section and Topic Item # Checklist item Location where item is reported Effectiveness
CochraneDiabetes OR Hypertension OR DM OR HPT OR t2dm OR t1dm OR prediabetes OR prediabetic OR prediabetes OR prediabetes OR impaired glucose OR high blood pressure OR BP OR HTN in Title Abstract Keyword AND mHealth OR mobile health OR Health OR Mobile OR Telehealth OR ehealth OR e-health in Title Abstract Keyword AND High blood pressure OR systolic blood pressure OR diastolic blood pressure OR SBP OR DBP OR glycemic OR blood sugar OR glucose OR diabetes OR hypertension OR diabetic OR hypertensive in Title Abstract Keyword AND Africa OR Northern African OR Southern Africa OR Eastern Africa OR Western Africa OR central Africa in Title Abstract Keyword AND "Diabetes OR Hypertension" AND Management AND "Africa Countries"