This systematic review, meta‑analysis, and interactive network analysis synthesised evidence on patient adherence to three core treatment pillars—medication, lifestyle advice, and self‑monitoring—for adults with type 2 diabetes and hypertension in sub‑Saharan Africa. The aim was to estimate pooled adherence levels across these domains, map differences by adherence type and region, and identify cross‑cutting determinants that could serve as priority targets for future interventional studies.
The authors searched six academic databases and Google Scholar for observational and interventional studies published between January 1, 2004, and May 14, 2026. Eligible studies included adults with type 2 diabetes or hypertension in sub‑Saharan Africa. In total, 312 studies comprising 108,014 participants from 28 countries met inclusion criteria and were analysed.
Risk of bias was assessed using the Newcastle–Ottawa Scale for observational studies and Cochrane RoB 2 for randomized trials. The authors used random‑effects models to pool adherence proportions and performed subgroup analyses and meta‑regressions to explore variability. An interactive network analysis with noteworthiness scoring was applied to identify determinants that were consistently associated with adherence across multiple studies. The review is registered with PROSPERO (CRD42024626793), and supporting data and code are publicly available.
Pooled adherence estimates (with 95% confidence intervals) for individual treatment components were reported as follows:
Antidiabetic medication adherence: 67% (95% CI 60–73).
Antihypertensive medication adherence: 51% (95% CI 44–58).
Adherence to dietary recommendations: 44% (95% CI 38–49).
Adherence to recommended physical activity: 42% (95% CI 37–47).
Alcohol abstinence: 85% (95% CI 82–88).
Smoking cessation: 95% (95% CI 94–96).
Home glucose monitoring: 18% (95% CI 12–27).
Home blood pressure monitoring: 28% (95% CI 16–45).
These pooled proportions indicate that medication adherence is higher than adherence to many lifestyle recommendations and particularly higher than self‑monitoring behaviours.
When aggregated across the core pillars to estimate overall self‑care, pooled adherence was low: 37% (95% CI 30–46) for people with type 2 diabetes and 35% (95% CI 29–42) for people with hypertension. The findings indicate that fewer than half of patients adhere across the full spectrum of recommended self‑management behaviours.
Using an interactive network approach, the review identified determinants that were most consistently associated with adherence across medication, lifestyle, and monitoring behaviours. The top cross‑cutting determinants were education, self‑efficacy (confidence in managing one’s condition), and social support. The authors present these factors as priority candidates for future interventional research aimed at improving adherence across multiple treatment pillars.
Heterogeneity across pooled estimates was high (I2 > 95%, p < 0.001 throughout), reflecting substantial variability between studies. The authors used random‑effects models and conducted subgroup analyses and meta‑regressions to explore sources of heterogeneity, but high statistical heterogeneity persisted. Most primary studies were observational and commonly used self‑reported adherence measures, which may contribute to measurement variability.
Key limitations reported by the authors include the high statistical heterogeneity of pooled estimates and the predominance of observational study designs relying on self‑reported adherence. These methodological limitations reduce the ability to infer causality for the identified determinants. The authors note that the determinants highlighted by the network analysis should be treated as priority candidates for testing in future interventional studies rather than as established causal factors.
Adherence across medication, lifestyle advice, and self‑monitoring for type 2 diabetes and hypertension in sub‑Saharan Africa is suboptimal. Medication adherence estimates are higher than adherence to diet, physical activity, and home monitoring, while avoidance of alcohol and smoking show relatively high pooled adherence. Education, patient self‑efficacy, and social support emerged as the most consistently associated determinants across treatment pillars and are proposed as promising targets for future interventional trials. The authors call for intervention studies that rigorously test whether improving these determinants can increase adherence and thereby improve clinical control of diabetes and hypertension in the region.