Comment on “Effect of Modular Training on Self‐Management, Disease, and Treatment Adaptation in Individuals With Hypertension: A Randomized Controlled Trial”

To the editor, We read with great interest the randomized controlled study by Keşer et al. that analyzed the effects of nurse-led modular education on medicine adherence, self-management, and the adaptation in patients with hypertension. This is a clinically significant issue and provides important information related to how structured educational interventions may motivate patients to engage in self-management and support for their chronic illness. The authors should be praised for their study design and the clinical relevance and growing need for the ongoing care of patients with hypertension. However, a few concerns should be addressed 1. First, there is lack of assessment key confounders, including health literacy, a huge factor in how well people can understand educational materials, self-manage their health, and continue with their treatments. When confounding variables are not accounted for, it will be impossible to determine whether the improvements observed were really a result of the intervention or merely due to existing differences among groups at baseline. Residual confounding may still exist after conducting an intervention and measuring response to the intervention without having controlled for baseline differences 2. Second, formal evaluation of intervention fidelity should be considered to assess the quality, consistency, and standardization of modular education delivery, including adherence to protocol and uniformity among sessions, it is imperative to consider how much variability exists in terms of the implementation since this may significantly impact outcome and bias effect sizes 3. Third, the absence of long-term follow-up limits understanding of the durability of observed improvements. Hypertension management requires sustained behavioral change, and without extended monitoring, the clinical applicability and generalizability of the findings remain uncertain 4. Lastly, it is essential to consider the possibility of the Hawthorne effect. Subjects enrolled in the experimental group underwent numerous (structured) sessions over 12 weeks, which may have led to increased engagement and self-reported results that are not attributable to the educational content. We also did not provide as much attention to the control group; therefore, the magnitude of the differences in group scores will be inflated as we are unable to attribute these differences in scores to the experimental intervention 5. Overall, as this study adds initial evidence for the impact of nurse-run modular education, methodological constraints such as the lack of controlling remnant factors, non-standardized fidelity evaluation methods, short duration of follow-up time, and indication bias due to how much you are able to focus must be acknowledged within the limitations discussed in order to properly interpret this data. Future studies must address the above through rigorous identification of remnant factors, adhering to fidelity evaluation guidelines, and assessing the longitudinal effectiveness of modular educational modalities to identify their true efficacy, sustainability, and long-term outcomes. Nevertheless, this project demonstrates the growing need for structured educational programs aimed at assisting patients with managing their own health; furthermore, it emphasizes one avenue toward enhancing the ability of patients to manage hypertension through structured education. All authors contributed equally. The authors have nothing to report. The authors declare no conflicts of interest. The data that support the findings of this study are not publicly available as this is letter and does not involve primary data.