Integrating Behavioral and Structural Theories in Blood Pressure Control: A Systematic Review of Theory-Guided Interventions

Abstract

The persistently low rate of blood pressure (BP) control particularly in low- and middle-income countries highlights the need for more effective intervention approaches. Theory-based interventions are increasingly applied to improve health outcomes through behavioral, cognitive, and structural strategies. However, the implementation and effectiveness of these theoretical frameworks in blood pressure control have not been comprehensively evaluated.  This systematic review aims to identify and evaluate studies that applied theory-based interventions for blood pressure control, focusing on four primary theoretical frameworks: the Health Belief Model (HBM), Social Cognitive Theory (SCT), Social Determinants of Health (SDH), and Participatory Action Research (PAR). A systematic literature search was conducted across six databases (PubMed, ScienceDirect, Wiley Online Library, JSTOR, CINAHL, and the Cochrane Library) up to March 2025. Eligible studies included those that explicitly applied a theoretical framework in their intervention and reported outcomes related to hypertension. Accepted study designs included randomized controlled trials, quasi-experiments, qualitative research, and mixed-methods studies. Data were extracted on the theories applied, population and setting characteristics, intervention content, and reported outcomes. Methodological quality was assessed using the JBI, CASP, and MMAT tools. Data synthesis was performed narratively according to the theoretical framework applied. A total of 30 studies met the inclusion criteria, representing diverse populations and contexts. The HBM and SCT were the most frequently applied theories, both associated with improved hypertension knowledge, self-efficacy, behavioral adherence, and blood pressure control. SDH- and PAR-based interventions emphasized community engagement and structural barriers, demonstrating strong potential for sustainability and contextual adaptation. Most studies reported positive health outcomes, though variations were observed in follow-up duration and the depth of theoretical integration. Theory-based interventions provide a solid foundation for hypertension control by addressing both individual behavioral change and structural determinants. Integrating multiple theories simultaneously may enhance intervention effectiveness and sustainability.