Effectiveness of nurse-led hypertension interventions on retention, adherence, and blood pressure control among adults in low- and middle-income countries: A systematic review

Background: Hypertension affects more than 1.28 billion adults globally and remains the leading modifiable risk factor for cardiovascular disease, stroke, renal failure, and premature death. This burden is inconsistently distributed across Low- and Middle-Income Countries (LMICs), where nearly three-quarters of adults live with hypertension. This gap is largely driven by poor adherence and low retention. This systematic review aims to assess the effectiveness of nurse-led interventions on retention in care, medication adherence, and blood pressure among adult patients with hypertension in primary health care settings in LMICs. Methods: The protocol was registered (PROSPERO CRD420251136515) following the PRISMA guidelines. We searched PubMed, Scopus, and Cochrane for articles published between 2000 and 2026. Eligibility criteria included: adults (≥18 years) with hypertension receiving care from primary care clinics; nurse-led interventions; usual care as comparator; primary outcome: retention rates; secondary outcomes: medication adherence, blood pressure (BP) control. Inclusion: experimental, quasi-experimental, and prospective cohort studies. Dual independent screening and data extraction were performed. Quality assessment was performed using Cochrane Risk of Bias 2(RoB2) for randomized controlled trials and Joanna Briggs Institute (JBI) tools for quasi-experimental and observational studies. Due to heterogeneity in intervention duration, outcome measures, and follow-up periods, a narrative synthesis was employed. Results: Eleven unique studies (n = 19,005) were identified: 63.6% RCTs, 18.2% quasi-experimental, and 18.2% observational. Seven studies were conducted in Africa and four in Asia. The mean age range was 52.0–67.4 years; 51.3%−76.0% were female. Risk-of-bias assessment revealed high or unclear risk in the missing outcomes data domain for most RCTs. Ten studies used multicomponent interventions. Retention rates varied with appointment attendance (12.6–96.5%), routine clinical retention (27.0–62.8%), and study completion of follow-up (83.8% to 97.2%). Four studies reported medication adherence with varying effects in the intervention group compared to the control or baseline. Ten studies reported systolic blood pressure (SBP) outcomes; 9 reported mean SBP after intervention; the majority reported the mean reduction of SBP was greater than 10 mmHg. Nine studies reported diastolic blood pressure (DBP) outcomes; all studies reported a reduction in DBP after the intervention, with a range of −1.8 mmHg to −20.6 mmHg. Reported SBP and DBP reductions included both within-group controlled estimates; these should not be interpreted as a pooled effect. Conclusion: This systematic review included 11 studies that showed nurse-led interventions improved blood pressure control in primary health care facilities of LMICs. But retention in care showed substantial variability in nurse-led interventions in primary health care facilities of LMICs. Nurse-led interventions in LMICs are a promising strategy for improving blood pressure control. However, retention in care was substantially and variably due to heterogeneous definitions and evidence on medication adherence was limited. Future research should prioritize standardized outcome measures and robust study designs to strengthen the evidence base and inform sustainable scale-up of these models in LMICs.