---
title: "Adherence to Medications, Lifestyle Advice, and Self‑Monitoring for Type 2 Diabetes and Hypertensi"
id: "plos-medicine-0-adherence-to-medications-lifestyle-advice-and-self-monitoring-for-type-2"
canonical_url: "https://medichelpline.com/clinical-feed/plos-medicine-0-adherence-to-medications-lifestyle-advice-and-self-monitoring-for-type-2"
content_type: "clinical_feed_article"
specialty: "Endocrinology"
source_name: "PLOS Medicine"
source_url: "https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189"
published_at: "2026-08-03T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Adherence to Medications, Lifestyle Advice, and Self‑Monitoring for Type 2 Diabetes and Hypertensi
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-medicine-0-adherence-to-medications-lifestyle-advice-and-self-monitoring-for-type-2
- **Specialty:** [Endocrinology](https://medichelpline.com/clinical-feed/endocrinology.md)
- **Primary Source:** PLOS Medicine
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189)
- **Published At:** 2026-08-03T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- This systematic review and meta-analysis included 312 studies with 108,014 participants from 28 sub‑Saharan African countries, published between 2004 and May 14, 2026. - The authors pooled adherence estimates for three treatment pillars: **medication**, **lifestyle advice** (diet, physical activity, alcohol, smoking), and **self‑monitoring** (glucose and blood pressure). - Pooled adherence proportions: antidiabetic medication 67% (95% CI 60–73); antihypertensive medication 51% (95% CI 44–58); dietary recommendations 44% (95% CI 38–49); physical activity 42% (95% CI 37–47); alcohol abstinence 85% (95% CI 82–88); smoking cessation 95% (95% CI 94–96); glucose monitoring 18% (95% CI 12–27); blood pressure monitoring 28% (95% CI 16–45). - Overall self‑care adherence was low: 37% (95% CI 30–46) for type 2 diabetes and 35% (95% CI 29–42) for hypertension. - Statistical heterogeneity was high across analyses (I2 > 95%, p < 0.001). - Interactive network analysis identified **education**, **self‑efficacy**, and **social support** as the cross‑cutting determinants most consistently associated with better adherence across treatment pillars. - Most included studies were observational and relied on self‑reported adherence; the authors highlight these determinants as candidates for future interventional testing rather than proven causal factors. - The review is registered on PROSPERO (CRD42024626793); data and analysis code are publicly available in manuscript supplements and repositories.
## Clinical Analysis & Structured Key Points
[ Skip to main content ](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#main-content) Advertisement * [plos.org](https://plos.org/) * [Create account](https://community.plos.org/registration/new) * [Sign in](https://journals.plos.org/user/secure/login?page=%2Fplosmedicine%2Farticle%3Fid%3D10.1371%2Fjournal.pmed.1005189) * * About * Browse * Publish * [](https://journals.plos.org/plosmedicine/ "PLOS Medicine") * Search [advanced search](https://journals.plos.org/plosmedicine/search) * 0 [Save](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#savedHeader) [Total Mendeley and Citeulike bookmarks.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#savedHeader) * 0 [Citation](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#citedHeader) [Paper's citation count computed by Dimensions.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#citedHeader) * 29 [View](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#viewedHeader) [PLOS views and downloads.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#viewedHeader) * 0 [Share](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#discussedHeader) [Sum of Facebook, Twitter, Reddit and Wikipedia activity.](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189#discussedHeader) Open Access Peer-reviewed Research Article # Adherence to medications, lifestyle advice, and self-monitoring for type 2 diabetes and hypertension in sub-Saharan Africa: A systematic review, meta-analysis, and interactive network analysis * Angeliki Apostolou , Roles Conceptualization, Data curation, Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing ¶‡ These authors share first authorship on this work. Affiliation Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands ⨯ * Reuben Simfukwe , Roles Conceptualization, Data curation, Formal analysis, Investigation, Validation, Writing – original draft, Writing – review & editing ¶‡ These authors share first authorship on this work. Affiliation Clinical Medicine Program, Kamuzu University of Health Sciences, Blantyre, Malawi ⨯ * Adrias Saint, Roles Data curation, Investigation, Writing – review & editing Affiliation Clinical Medicine Program, Kamuzu University of Health Sciences, Blantyre, Malawi [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0009-0000-4798-3831 ](https://orcid.org/0009-0000-4798-3831 "ORCID Registry") ⨯ * Bridget Mushani, Roles Data curation, Investigation, Writing – review & editing Affiliation Clinical Medicine Program, Kamuzu University of Health Sciences, Blantyre, Malawi ⨯ * Hannah Chekhchar , Roles Formal analysis, Methodology, Software, Validation, Visualization, Writing – original draft, Writing – review & editing ¶‡ These authors share first authorship on this work. Affiliation Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands ⨯ * Pearl Aovare, Roles Writing – review & editing Affiliations Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands, Department of Population, Family and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-9667-2076 ](https://orcid.org/0000-0002-9667-2076 "ORCID Registry") ⨯ * Kouamivi M. Agboyibor, Roles Writing – review & editing Affiliation Department of Noncommunicable Disease, World Health Organization (WHO) HQ, Geneva, Switzerland [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-7459-6914 ](https://orcid.org/0000-0002-7459-6914 "ORCID Registry") ⨯ * Karlijn A. C. Meeks, Roles Writing – review & editing Affiliations Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands, Division of Endocrinology, Diabetes and Nutrition, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-3032-405X ](https://orcid.org/0000-0003-3032-405X "ORCID Registry") ⨯ * George F. Mkoma, Roles Writing – review & editing Affiliations Department of Epidemiology Research, Statens Serum Institut, Copenhagen, Denmark, Department of Public Health, Section of Health Services Research, University of Copenhagen, Copenhagen, Denmark [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0001-8073-3586 ](https://orcid.org/0000-0001-8073-3586 "ORCID Registry") ⨯ * Charles Agyemang, Roles Writing – review & editing Affiliations Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands, Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0002-3882-7295 ](https://orcid.org/0000-0002-3882-7295 "ORCID Registry") ⨯ * Felix P. Chilunga Roles Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Validation, Visualization, Writing – original draft, Writing – review & editing * E-mail: f.p.chilunga@amsterdamumc.nl Affiliation Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands [ ![ORCID logo](https://journals.plos.org/resource/img/orcid_16x16.png) https://orcid.org/0000-0003-4083-001X ](https://orcid.org/0000-0003-4083-001X "ORCID Registry") ⨯ # Adherence to medications, lifestyle advice, and self-monitoring for type 2 diabetes and hypertension in sub-Saharan Africa: A systematic review, meta-analysis, and interactive network analysis * Angeliki Apostolou, * Reuben Simfukwe, * Adrias Saint, * Bridget Mushani, * Hannah Chekhchar, * Pearl Aovare, * Kouamivi M. Agboyibor, … * Karlijn A. C. Meeks, * George F. Mkoma, * Charles Agyemang ![PLOS](https://journals.plos.org/resource/img/logo-plos-full-color.svg) x * Published: August 3, 2026 * * [Article](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189) * [Authors](https://journals.plos.org/plosmedicine/article/authors?id=10.1371/journal.pmed.1005189) * [Metrics](https://journals.plos.org/plosmedicine/article/metrics?id=10.1371/journal.pmed.1005189) * [Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005189) * [Media Coverage](http://plos.altmetric.com/details/doi/10.1371/journal.pmed.1005189) * [Abstract](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#abstract0) * [Author summary](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#abstract1) * [Introduction](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#sec004) * [Methodology](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#sec005) * [Results](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#sec015) * [Discussion](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#sec023) * [Supporting information](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#sec024) * [References](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#references) * [Reader Comments](https://journals.plos.org/plosmedicine/article/comments?id=10.1371/journal.pmed.1005189) * [Figures](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189) [?](https://journals.plos.org/plosmedicine/s/accepted-manuscripts#loc-early-version) ## This is an uncorrected proof. ## Abstract ### Background Type 2 diabetes and hypertension are major public health challenges in sub-Saharan Africa, yet treatment control remains poor. Patient adherence to key treatment pillars (medication, lifestyle advice, and self-monitoring) is essential for treatment control, yet adherence across these pillars has not been comprehensively synthesized. We conducted a systematic review and meta-analysis to map adherence to medication, lifestyle advice, and self-monitoring for type 2 diabetes and hypertension in sub-Saharan Africa, and applied a network analysis to identify cross-cutting determinants as priority candidates for future interventional studies. ### Methods and findings We searched six academic databases, and Google Scholar, for observational and interventional studies in adults with type 2 diabetes or hypertension in sub-Saharan Africa published between January 1, 2004, and May 14, 2026. Risk of bias was assessed using Newcastle–Ottawa Scale and Cochrane RoB 2. We used random-effects models to pool adherence proportions and conducted subgroup analyses and meta-regressions. Cross-cutting determinants were identified using interactive network analysis with noteworthiness scores. We included 312 studies with 108,014 participants from 28 countries. Pooled adherence was 67% (95% CI [60, 73]) for antidiabetic medications, 51% (95% CI [44, 58]) for antihypertensive medications, 44% (95% CI [38, 49]) for dietary recommendations, 42% (95% CI [37, 47]) for physical activity, 85% (95% CI [82, 88]) for alcohol abstinence, 95% (95% CI [94, 96]) for smoking cessation, 18% (95% CI [12, 27]) for glucose monitoring, and 28% (95% CI [16, 45]) for blood pressure monitoring. Overall self-care adherence was 37% (95% CI [30, 46]) for type 2 diabetes and 35% (95% CI [29, 42]) for hypertension. Heterogeneity was high (_I_ 2 > 95%, _p_ ). The analysis code is permanently archived on Zenodo ( ). **Funding:** This work was supported by a ZonMw Off Road grant (04510242410063) awarded to FPC ( ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. **Competing interests:** The authors have declared that no competing interests exist. **Abbreviations:** CIs, confidence intervals; GLMM, generalized linear mixed models; HRs, hazard ratios; MMAS-8, Morisky Medication Adherence Scale; NCD, noncommunicable disease; NOS, Newcastle–Ottawa Scale; ORs, odds ratios; PRs, prevalence ratios; PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses; RRs, relative risks; SDSCA, Summary of Diabetes Self-Care Activities ## Introduction Cardiometabolic diseases such as type 2 diabetes and hypertension are a major public health challenge in sub-Saharan Africa [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref001)–[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref003)]. While infectious diseases were the predominant health burden before the 1990s [[4](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref004)], the prevalence of cardiometabolic diseases has risen sharply over the past three decades, contributing substantially to morbidity and mortality [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref001)–[3](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref003)]. For example, the prevalence of type 2 diabetes among adults has nearly doubled, increasing from 6.4% in 1990 to 10.5% in 2021 [[1](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref001)], while hypertension now affects about 37.4% of adults [[5](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref005)]. This rapid rise has been attributed to a complex interplay of factors, including rapid urbanization, lifestyle transitions, adverse early-life exposures, population aging, and limited access to preventive and curative health services [[2](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref002),[6](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref006)]. Although interventions have been introduced at the global level (e.g., World Health Organisation HEARTS technical Packages for hypertension and diabetes, Global noncommunicable disease (NCD)s best buys) [[7](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref007),[8](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref008)], the regional level (e.g., African Union’s strategic frameworks on NCDs) [[9](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref009)], the national level (e.g., integration of diabetes and hypertension care into primary healthcare programs) [[10](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref010)], and the community level (e.g., task-shifting to nurses and community health workers) [[11](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref011)], the control of type 2 diabetes and hypertension in clinical practice remains a major challenge. For instance, a meta-analysis of 74 studies in sub-Saharan Africa showed that only 30% of patients with type 2 diabetes achieve adequate glucose control [[12](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref012)], and nearly half of those treated for hypertension remain uncontrolled [[13](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref013)]. Complications are also common, with one in three patients (~35%) affected by diabetic eye disease, chronic kidney disease, stroke, or heart failure [[14](https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1005189#pmed.1005189.ref014)]. T
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