Which Is More Effective For Hypertension Management: User- Or Expert-Driven E-Counseling?

Commentary

According to the American Society of Hypertension and the International Society of Hypertension, about one third of adults in most communities in both the developed and developing world have hypertension (or high blood pressure), and it is the most common chronic condition dealt with by primary care physicians and other health practitioners [1]. Hypertension, particularly in older/elderly and African-American/black populations, increases the risk for cardiovascular events, strokes, and kidney disease [1]. According to the most recent American College of Cardiology and American Heart Association guidelines from November 2017, the normal blood pressure category is measured as less than 120/80 mm Hg, and intervention/treatment is recommended with higher blood pressure measures [2]. Treatment aims to manage hypertension and address other risk factors for cardiovascular disease, including lipid disorders, glucose intolerance or diabetes, obesity, and smoking [1]. Early intervention with lifestyle changes (nonpharmacological therapy) and antihypertensive drugs is recommended [1,3]. Several lifestyle interventions have been shown to reduce blood pressure while also helping to manage these other cardiovascular risk factors. These include weight loss (especially through a healthier diet, eg, the DASH diet), reducing sodium intake, increased aerobic exercise, moderation of alcohol intake, and smoking cessation [1,4,5]. However, efficacy of this approach is highly dependent on adherence to self-care behavior, a major challenge for patients. Increasing evidence has pointed to web-based, mobile, or other technology-assisted programs to facilitate delivery of and engagement with self-management and/or counseling-/therapy-based lifestyle interventions [6–11].

In a 2014 article, the authors summarized the efficacy of lifestyle counseling interventions in face-to-face, telehealth, and e-counseling settings, especially noting e-counseling as an emerging preventive strategy for hypertension [10]. E-counseling, a form of telehealth, presents information dynamically though combined video, text, image, and audio media, and incorporates two-way communication through phone, internet, and videoconferencing (ie, between patient and provider). This approach has the potential to increase adherence to counseling and self-care approaches by providing improved and convenient access to information, incorporating engaging components, expanding accessibility and comprehension of information among individuals with varying levels of health literacy, enabling increased and more frequent interactivity with health care professionals, and increasing engagement. Importantly, effective counseling approaches, whether through conventional or e-counseling approaches, should include certain core components, including goal-setting, self-monitoring of symptoms of behaviors, personalized training (based on patient setting or resources), performance-based feedback and reinforcement of health-promoting behaviors, and procedures to enhance self-efficacy [10].

This study adds to the literature by demonstrating that the counseling communication strategies (expert- and user-driven) used to deliver e-counseling can significantly influence intervention outcomes related to hypertension management. Strengths of this study include the use of a double-blind randomized controlled study design powered to detect clinically meaningful SBP differences, the three– parallel group assignments (expert-driven, user-driven, control) that incorporated multiple evidence-based counseling approaches, the measurement of changes in multiple cardiovascular and behavioral outcomes (clinical and self-report measures), the inclusion of a theory-based measure of readiness for dietary and exercise behavior change, and the low attrition rate. However, there are key limitations, many acknowledged by the authors. The majority of the study participants were white, from higher income households, had completed higher education, and were already motivated for dietary and exercise behavior change, thus limiting the generalizability of findings. The study had a limited follow-up period (only 4 months) and the study design did not allow for the identification of the most impactful components of the intervention groups.

Applications for Clinical Practice

Expert-driven e-counseling may be an effective approach to managing hypertension, as this study showed that expert-driven e-counseling was more effective than control in reducing SBP, PP, cholesterol, and 10-year CVD risk at the 4-month follow-up, and expert-driven e-counseling was more effective that user-driven counseling in improving daily steps and fruit intake. However, providers should be mindful that this approach may be limited to patients with greater motivation to change their lifestyle behaviors to lower blood pressure.