Social-Behavior Barriers to Hypertension Self-Care: Extending the Theory of Planned Behavior

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While the Theory of Planned Behavior (TPB) is widely used in health behavior research, its applicability in s ocial and behavioral contextsremains underexplored. This study aimed to extend TPB by identifying social-behavioral constructs that influence hypertension self-care behavior. Methods : A qualitative descriptive study was conducted in Jatinangor District, West Java, Indonesia. Twenty-four key informants were purposively selected, including patients with uncontrolled hypertension, family members, community health workers (cadres), and nurses. Data were collected through semi-structured interviews and analysed using thematic content analysis guided TPB constructs. Ethical approval was obtained from Padjadjaran University, and informed consent was provided by all participants. Results: Five themes were identified as barriers to sustainable self-care: 1) Lack of information and misperception (attitude), 2) Low perception of susceptibility and severity (perceived behavioral control), 3) Lack of family support and insufficient workforce (subjective norms), 4) Conventional custom of gathering and culture of eating habits (subjective norms), 5) Doubt of benefits and efficacy (attitude). These themes illustrate how social and behavioral contexts, including family interactions and daily habits, shape TPB constructs. Conclusions: This study contributes to the theoretical development of TPB by embedding social-behavioral constructs that influence hypertension self-care in low-resource settings. Findings highlight the need for socially responsive and family-oriented strategies to strengthen hypertension self-care. These insights are relevant for designing sustainable intervention in LMICs, particularly in Southeast Asia. Hypertension Self-care social-behavior barriers Family support Theory of Planned Behavior Health behavior Figures Figure 1 Introduction Hypertension is a primary global health concern that poses a significant burden in terms of morbidity and mortality. [ 1 ]. The World Health Organization (WHO) in 2023 estimated that more than 1.28 billion adults were living with hypertension, especially in lower-middle-income countries with limited accessibility to health services. [ 2 ]. In Indonesia, the prevalence among adults has reached 30.8% [ 2 ], underscoring the urgent need for effective management strategies. Self-care is a cornerstone of hypertension management such as medication adherence, dietary modification, and physical activity, and routine blood pressure monitoring. These behaviors are proven to reduce complications such as stroke, heart failure, and kidney disease [ 3 , 4 ]. However, sustaining long-term engagement remains challenging. Social relationships, family dynamics, and behavioral patterns strongly influence perceptions of risk and control. Despite their significance, social-behavioral determinants are often overlooked in conventional hypertension interventions, which tend to emphasize biomedical approaches rather than context-specific strategies [ 3 – 5 ]. Evidence from various settings demonstrates barriers to sustained self-care. United States, patients reported difficulties in maintaining physical activity due to lack of motivation, fear of injury, financial obstacles to accessing medications, and neglect of regular clinical visits [ 6 ]. Other study revealed that poor understanding of hypertension, limited access to sustainable treatment, and ineffective communication with health providers were critical obstacles [ 7 ]. These challenges are rooted in behavioral routines and social norms influencing health-seeking behaviors rather than cultural customs alone [ 8 ]. Furthermore, dietary practices, especially the high consumption of sodium rich traditional foods, continue to hinder effective blood pressure control [ 9 , 10 ]. Despite government initiatives, including Posbindu PTM (Integrated Non-Communicable Disease Post) to promote early detection and management, these programs face inconsistent implementation, shortages of health workers, and limit patients engagement [ 11 ]. The Theory of Planned Behavior (TPB) has been widely employed to explain and predict health-related behaviors through three central constructs: attitudes, subjective norms, and perceived behavioral control [ 12 ]. Although TPB is a robust model, its application has primarily focused on individual-level determinants, with limited attention to how cultural and familial contexts may modify these constructs. In collectivist societies such as Indonesia, family dynamics, communal norms, and culturally embedded food preferences can significantly shape health-related decision-making [ 13 ]. This study addresses that gap by extending the TPB to include social-behavior constructs influencing hypertension self-care in a low-resource Indonesian context. The findings aim to inform the design of contextually adapted interventions and contribute to the refinement of TPB for use in similar low and middle income countries. Figure 1 present the conceptual framework of this study, extending TPB by incorporating social-behavior and family influences into its core constructs, linked to nursing practice implications. Study Objective The study aimed to explore the social-behavior barriers to sustainable self-care management practice, focusing on extending the Theory of Planned Behavior (TPB) by identifying social-behavioral constructs · Methods · Study Design and Setting A descriptive qualitative study was conducted through in-depth interviews. The study was conducted in the Jatinangor Health Center, Sumedang, West Java, Indonesia. Jatinangor is a semi-urban subdistrict with the third-highest population density in the region, representing a typical Indonesian community experiencing rapid demographic shifts and increasing non-communicable disease burdens. The site was purposively selected due to its diverse socioeconomic composition, healthcare access disparities, and growing epidemiological burden of hypertension. These characteristics mirror the conditions in many semi-urban areas across Indonesia, making Jatinangor a representative setting for exploring social-behavior and systemic barriers to sustainable hypertension self-care. Local public health reports also highlight a high prevalence of uncontrolled hypertension in this area, further supporting its relevance as a study location. · Population and Samples We involved individuals living in the Jatinangor area who were directly involved in treatment and had experiences and insights related to self-care management. The key informants included hypertension patients, families, community health workers, and nurses. The sample for this study consisted of 24 key informants who were intentionally selected based on specific inclusion criteria (See Table 1 ). The first group included hypertensive patients with uncontrolled blood pressure who had lived in Jatinangor for at least one year and were willing to participate in the study. The second group comprised five family members who were directly involved in caring for the hypertensive patients and lived with them. The third group consisted of five community health workers managing hypertensive patients. The fourth group included nurses who participated in the hypertensive patient care program in the Jatinangor area and had one year of experience caring for hypertensive patients in the community. Both cadres and nurses played direct roles in health checking, blood pressure monitoring, home visiting, health education, and follow-up care. Table 1 Inclusion Criteria of Informants Informants Sample Number Inclusion Criteria Patients with uncontrolled hypertension 8 • The minimum age is 35 years. • Individuals must have been diagnosed with hypertension for a minimum of one year. Family 8 • Caring for Patients with Hypertension • Providing care for hypertension patients for a minimum of one year. Health Community workers (Cadre) 5 • Support the management of blood pressure and salt preferences in the community. • Have at least one year of experience in hypertension care. Person in charge of PTM (Non-Communicable Diseases) and PROLANIS (Chronic Disease Management) programs 3 • Participate in the care of patients with hypertension at health centers. • Involved in a hypertension management program for at least one year. Instrumentation The semi-structured interview guide was developed based on an extensive review of literature on hypertension self-care, salt preference, and the Theory of Planned Behavior (TPB). The initial draft was structured around the three core constructs of TPB-attitude, subjective norm, and perceived behavioral control-while incorporating contextual elements relevant to Indonesian social-behavior practices To ensure the content validity, the semi-structured interview guide was reviewed by the expert panel in nursing, medical doctor, nutritionist, and anthropology. Each expert addressed the clarity, relevance, and comprehensiveness of the questions and provided the feedback to refine wording and thematic focus related to topic. Prior to formal data collection process, the pilot testing was approached to the five hypertensive patients from community to evaluate the cultural appropriateness, comprehension, and sequencing of the questions. Feedback from this process was led to adjust the phrase of socially resonsive topics (such as dietary habits and family support) and ensure the questions elicited in-depth. Ultimately, the credibility of the data was strengthened by making iterative adjustments during the initial stages of fieldwork, with minor revisions introduced when participants indicated confusion or ambiguity. This adaptive yet systematic process ensured that the interview guide remained both methodologically sound and culturally appropriate Data Collection Procedure In-depth interviews were conducted using a semi-structured format with open-ended questions guided by key themes and subthemes. The aim was to explore experiences and barriers to hypertension self-care management through the lens of planned behavior theory. Interviews with patient informants, their families, and community health workers were held in their homes, while discussions with nurses occurred at the health center. Each interview session lasted approximately 60 minutes. The researcher and a research assistant recorded and transcribed all information gathered during the interview. The interview guidelines were divided into four key informant groups, as follows: 1. Uncontrolled Hypertension Patients: This group covered themes such as demographic information, attitudes toward blood pressure management, perceived subjective norms, management behaviors for controlling self-care management, and barriers to blood pressure management and salt intake. 2. Families: This group included themes related to demographic information, family attitudes in supporting blood pressure management and patient salt preference, subjective norms that can provide support, behaviors, and barriers experienced in assisting patients. 3. Community health workers: This group focused on themes of demographic information, the attitudes of cadres in helping patients control self-care management, subjective norms that can provide support, behaviors in managing blood pressure and patient salt preference, and barriers faced in assisting patients. 4. Nurses: This group addressed themes of demographic information, as well as barriers to implementing hypertension management programs and addressing salt preference within the community and health centers. Before the study commenced, the interview guidelines were reviewed by three experts and tested on five hypertensive patients with uncontrolled blood pressure at a location different from the study site. Data Analysis The data were transcribed and translated from the audio recordings. A deductive content analysis approach was employed, guided by the theoretical constructs of the Theory of Planned Behavior (attitudes, subjective norms, and perceived behavioral control). The process of data analysis consisted of several steps. First, we read the transcript repeatedly to meet the immersion data. The meaningful information related to TPB model and aims of this study was initial coding. Following data collection, a data reduction process was conducted to identify initial themes and subthemes aligned with the theoretical framework. Content analysis was then used to systematically code and categorize the data, allowing for identification, analysis, and reporting of themes within the local social-behavior context. The final stage involved organizing these themes into categories and subcategories, reflecting the perspectives of each key informant group such as patients, families, volunteers and nurses who are responsible in NCD. To enhance trustworthiness, two researchers were independently coded the set of transcripts and compared their results. Inconsistencies of information were discussed until consensus was achieved. Triangulation was applied by comparing perspectives across the four different informant groups to validate recurring patterns and highlight contextual variations. In addition, member checking was conducted with selected participants to confirm that the interpretations accurately represented their experiences. These strategies collectively enhanced the credibility, dependability, and confirmability of the findings Theoretical Framework This study applied the Theory of Planned Behavior (TPB) to explore social-behavior barriers to hypertension self-care. TPB's core constructs: attitudes, subjective norms, and perceived behavioral control, guided the analysis of how patients and families manage self-care daily. Family involvement, particularly among cohabiting relatives, significantly shaped patients’ intentions and behaviors, influenced by cultural norms on diet, health beliefs, and shared responsibilities. Input from nurses and community health workers (cadres) illuminated systemic barriers to program implementation. Nurses reported challenges such as workforce shortages and limited community participation, while cadres encountered cultural resistance and logistical constraints in delivering community-level support. Integrating insights from all stakeholder groups allowed for contextual refinement of the TPB framework, socially embedded factors influencing self-care. These findings inform the development of community-based interventions that are both socially responsive and feasible in resource-limited, semi-urban settings such as Jatinangor. Results · Social-Behavior Barriers to Hypertension Self-Care Practice Five themes were identified as barriers to sustainable hypertension self-care. These themes illustrate how social-behavior and psychosocial contexts interact with the constructs of Theory of Planned Behavior (TPB) · Theme 1: Lack of information and the misperception (Attitude) Most patients have received information about self-care management for hypertension from healthcare workers and nurses at the health center. However, they still lack a comprehensive understanding of the information provided, which is often delivered in a one-way manner. The patients believe that high salt intake is the primary cause of high blood pressure, but they are unaware of which foods are high in salt or how to prepare food to reduce its salt content. Their understanding of hypertension is limited to its definition, and they think that high blood pressure could potentially lead to a stroke. They are not informed about other possible consequences of uncontrolled blood pressure. Additionally, they mistakenly believe that blood-boosting medications are intended to increase blood pressure rather than understanding their true purpose. Other factors that contribute to elevated blood pressure are also poorly understood. Many patients think that healthy food is synonymous with expensive food. The family members who cared for the hypertension patients conveyed their challenges in managing the care plan. They were not fully aware of how to effectively care for individuals with hypertension or how to prepare appropriate home-cooked meals. However, there was one family that successfully managed their diet, as they had previously dealt with hypertension. In the in-depth interviews conducted with community health workers, the coordinator observed an opportunity to improve the community's understanding of the factors that lead to uncontrolled blood pressure. Many believed that medication could lower blood pressure, neglecting the importance of a healthy lifestyle. Health center nurses reported challenges in educating patients due to a shortage of healthcare workers. Consequently, the education provided was suboptimal. “ We cannot eat healthy food often because we have to drink milk and fruit. It is too expensive.” (P7, 35-year-old female) “ I struggle to manage my blood pressure because I do not understand how to prepare healthy meals or what affordable healthy foods I can consume.” (P8, 52-year-old female) “ When the health center provides me with blood-boosting medicine, I refrain from taking it because my blood pressure would increase.” (P3, 40-year-old female) “ Reducing my salt consumption should help lower my blood pressure. I now try to cook with less salt since I previously had hypertension, but it is currently under control .” (KE1, 56-year-old mother) “ People here believe that food lacks flavor without salt, masako , or sasa . Thus, these three ingredients are commonly used in their dishes.” (KA3, 39-year-old female) · Theme 2: Low perception of susceptibility and severity (Perceived Behavioral Control) Lack of awareness of the risk and severity of the illness leads to non-adherence with main programs, putting their health at risk and increasing the disease complications. Five informants reported that they did not consistently take their hypertension medication or follow care management guidelines for various reasons, including financial limitations, lack of understanding about the consequences of non-adherence, and ingrained environmental habits. In addition to structural and informational barriers, several participants expressed psychological avoidance toward routine health examinations. Rather than logistical constraints, this avoidance stemmed from a fear of being diagnosed with additional illnesses, which they believed could lead to excessive worry and emotional distress, potentially exacerbating their blood pressure levels. “ I take medication for hypertension. If my blood pressure increases, I take amlodipine.” (P1, 48-year-old female) “ I rarely visit the integrated health post or health center because I have no complaints.” (P5, 55-year-old male) “I dedicated myself to a consistent workout routine, pushing my limits at the exercise, but my blood pressure remained high. Eventually, I became lazy about working out. Whenever I had a headache, I would choose to rely on medication instead of confronting the underlying problem directly. I enjoy foods like salted fish and do not have any specific dietary restrictions. If my blood pressure increases, it is easy to visit the pharmacy to buy amlodipine.” (P2, 36-year-old female) “ I am confused about my rising blood pressure despite reducing my salt intake. My mother also cooks with less salt. It seems like the increase is due to stress rather than food .” (P6, 35-year-old male) "I am scared to go for a check-up. What if they find something bad? I will keep thinking about it, and that can make my blood pressure go up again." (P3, 40-year-old female) "Better not to know. If I find out I have another disease, it will just make me overthink and get more anxious. It is easier not to worry ." (P8, 52-year-old female) "Some people say they do not want to get checked because they are afraid. If they know they are sick, they say it will make them panic or stress too much ." (KA1, 58-year-old female) "They often say, ‘If I do not know, I feel fine. If I know, I might just get worse from overthinking.’ So they avoid going to Posbindu or the health center ." (KA3, 39-year-old female) · Theme 3: Lack of family support and insufficient workforce (Subjective Norms) Family support is a particular element in managing blood pressure because family members live with the patient and influence their daily activities. Family habits and dynamics can significantly shape an individual's mindset and lifestyle. However, certain family behaviors, such as cooking salty foods or engaging in social gatherings that involve eating, can pose challenges for young individuals suffering from hypertension in maintaining a healthy diet. Additionally, the limited number of healthcare workers can hinder the effectiveness of health programs, making it difficult to reach all individuals within a health center's service area. Seven patients reported difficulties accessing health services, particularly at health centers. Distance, cost, and lack of available facilities present significant obstacles to effective hypertension management. “ I always participate in botram , bringing food from home. Sometimes, we eat salted fish or fried tempeh. Eating together is delicious, and we can chat while enjoying the meal, so we often do this.” (P1, 48-year-old female) “ I prepare the daily meals for my family, who prefer salty foods, sometimes accompanied by fries. My husband and children eat what I cook.” (P2, 36-year-old female) “ I seldom visit the health center for check-ups because it is far away. I prefer to spend money on food instead.” (P7, 37-year-old female) “ Going to the health center requires a long trip, and online transportation is expensive, so we rarely visit.” (P3, 40-year-old female) · Theme 4: Conventional customs of gathering and the culture of eating habits (Subjective Norm) Local Sundanese culture, particularly the tradition of botram (communal eating), significantly influences blood pressure management and salt preferences. It is not the act of sharing a meal that directly leads to increased blood pressure, but rather the types of food typically served at botram gatherings. These foods are high in salt, such as salted fish, fatty dishes, and crackers. As a result, this eating habit can make it challenging for individuals to manage their blood pressure, even though they understand the importance of maintaining a low-salt diet. The foods served are popular among Sundanese people, and the communal nature of these gatherings often increases their appetite. “I often visit Botram almost every day; they serve home-cooked food like salted fish and fried tempeh. This might be the reason for my uncontrolled blood pressure.” ( P7, 35-year-old female ) “It can be challenging to reduce salt, as the menu at Botram often features salted fish and crackers.” ( P3, 40-year-old female ) “ In my family, I enjoy eating salted fish, which is why I have hypertension. My mother also has hypertension because she enjoys salted fish, shrimp paste, chili sauce, and crackers.” (P7, 35-year-old female) “ I struggle to manage my eating habits. We often come together here because if we stay home all the time, our headaches and blood pressure tend to rise. In the evenings, we chat with the neighbors while enjoying snacks, such as meatballs and other treats, to relieve our stress.” (P3, 40-year-old female) · Theme 5: Doubt about benefits and efficacy of hypertension treatment (Attitude) Understanding the risks and severity of hypertension is crucial, as it directly influences patients’ motivation to manage their condition effectively. The more patients are unaware that they are at risk of uncontrolled blood pressure and the potentially severe complications associated with hypertension, the more non-compliant they are with their treatment and adopt unhealthy lifestyles. Many patients mistakenly believe that they only need to take medication when they experience symptoms, thinking that it will lower their blood pressure without considering necessary changes to their diet and lifestyle. Even if they engage in healthy behaviors, such as exercising regularly and reducing salt intake, they may still find that their blood pressure remains high. “ I do not experience any of the symptoms that often accompany high blood pressure, which leads me to believe that there is no real problem, even though my blood pressure is elevated.” (P5, 55-year-old male) “I do not take medication regularly because it tends to give me a headache.” (P1, 48-year-old female) “I dedicated myself to a consistent workout routine, pushing my limits at the exercise, but my blood pressure remained high. Eventually, I became lazy about working out. Whenever I had a headache, I would choose to rely on medication instead of confronting the underlying problem directly. I enjoy foods like salted fish and do not have any specific dietary restrictions. If my blood pressure increases, it is easy to visit the pharmacy to buy amlodipine.” (P2, 36-year-old female) “ My family and I enjoy salty foods. Sometimes, after adding salt to our meals, I sprinkle more Sasa or Masako. When I have a headache, I suspect it is due to high blood pressure, so I usually just go to sleep and take some medicine. I am wondering what I can do about this habit.” (P3, 40-year-old female) Categories Thema Sub-Theme Attitude Lack of information and the misperception Misunderstandings about hypertension and its management Lack of knowledge about proper blood pressure control Limited access to educational media and health services Ineffective one-way communication in health education Perceived Behavioral Control Low perception of susceptibility and severity Uncertainty about the benefits and effectiveness of treatment The misconception that hypertension is not a severe disease. The widespread belief that treatment is only administered in response to visible symptoms Avoidance due to fear of diagnosis and emotional distress Emotional burden and fear of receiving bad news Belief that worry can worsen hypertension Subjective Norm Lack of family support and insufficient workforce Lack of social support in managing blood pressure Family habits related to diet High workload and job demands Lack of self-confidence in managing hypertension Subjective Norm Conventional customs on gathering and the culture of eating habits Cultural preferences for high-salt foods Social pressures on communal eating habits Family traditions that conflict with dietary restrictions Lack of awareness about the impact of traditional foods on blood pressure Attitude Doubt about the benefits and efficacy of hypertension treatment Concerns about potential long-term side effects from treatment. The belief is that medication alone is sufficient. Misinformation regarding reliance on antihypertensive medications. Discussion This study explored the social-behavior barriers to sustainable self-care, guided by the Theory of Planned Behaviour (TPB). The findings emphasize how social relationships, behavioral routines, and systemic constraints interact with attitude, subjective norms, and perceived behavioural control in shaping self-care behaviors. In this theory, intention refers to a person's commitment to engaging in specific behaviours as a bridge between psychosocial and cognitive factors and actual behaviour. Individuals are more likely to successfully implement these behaviours than those without such intentions [14]. By using the TPB theory approach in qualitative research, five main themes were found in this study, including 1) lack of information and the misperception, 2) low perception of susceptibility and severity, 3) lack of family support and insufficient workforce, 4) conventional custom on gathering and culture of eating habits, and 5) doubt of benefits and efficacy of hypertension treatment. Misperceptions and doubts about treatment efficacy reflect negative attitude that reduce patients intentions and adherence, consistent with prior studies showing that limited health literacy is associated with poor hypertension control [15]. A study was conducted by Coughlin et al indicates that a lack of information and misunderstandings about disease management lead to delayed diagnosis and treatment. This delay can negatively affect health outcomes and increase the risk of complications [16]. Other studies also suggest that misconceptions about disease management can result in poor self-management skills, worse health outcomes, and a higher reliance on health services [17]. A study conducted by Severin, E., and Dan, D. found that misinformation and false beliefs can drive patients to pursue alternative treatments that lack scientific evidence, potentially resulting in catastrophic consequences for their health. Addressing these gaps in understanding is vital to safeguarding patient well-being and improving overall health outcomes. [18]. One of the most critical challenges in self-care for patients with hypertension is their insufficient awareness of the condition's risks and severity. This knowledge gap often leaves patients either uninformed or having a weak understanding of the potential dangers and severe consequences associated with the disease [19]. As a result, they may experience delays in diagnosis, fail to adhere to treatment protocols, and face an increased risk of serious complications. Research conducted by Tan., et al reveals that when patients are unaware of the dangers posed by hypertension, they are significantly less likely to take proactive steps toward prevention and treatment adherence [12]. Moreover, other studies demonstrate that individuals lacking awareness of hypertension's risks, according to the Health Belief Model (HBM), exhibit notably lower compliance with both medical recommendations and necessary lifestyle changes [20], findings from Jee-Seon Shim, et al indicate that those who underestimate hypertension's risks are less inclined to follow medical advice and maintain dietary adjustments, such as a low-salt diet [21]. The third theme identified in this study is the lack of family support and the insufficiency of mentors in managing blood pressure control. Family support includes emotional, informational, and practical assistance from family members, essential for helping patients with hypertension manage their self-care. Within the TPB framework, subjective norms, such as family influence, are pivotal in shaping patient intentions and behaviours. It was consistent with prior research, this study found that families often lacked the knowledge and skills to support dietary modifications and medication adherence, thus undermining patients’ ability to manage their condition effectively. [22]. Family members are responsible for educating and assisting patients in disease management and making behavioural changes. [23]. Families with a clear understanding of the patient's health condition can provide better support in enhancing the patient's overall health. In addition to family support, peer mentorship is an essential element in empowering patients to take control of their hypertension. These mentors have triumphed over their battles with high blood pressure and serve as inspiring role models, educators, and guides within the community. Patients who witness the success stories of those who have effectively managed their condition often find renewed confidence and commitment to their treatment plans. Research by Kalantzi et al reveals that many patients resist lifestyle changes due to uncertainty about their ability to succeed [24]. Exposure to the experiences of those who have successfully navigated similar challenges can spark a stronger motivation to pursue health goals and adopt recommended wellness strategies actively. Furthermore, studies consistently demonstrate that peer mentors play a critical role in alleviating the pervasive fear, anxiety, and stress that accompany hypertension. Many patients often feel isolated in their struggles. However, these mentors provide vital emotional and social support, sharing proven strategies and personal success stories that significantly empower patients to improve their health outcomes [21]. The fourth theme in this study is conventional customs on gathering and communal eating habits. This theme discusses eating habits and social interactions related to food consumption patterns, including salt and fat intake levels, as well as the cultural significance of social gatherings. Culture significantly influences health by affecting patients' adherence to hypertension management diets through social habits and culinary traditions. Embracing a culture-based approach to self-care management is more effective than imposing outright restrictions on certain foods. We can enhance patients' long-term commitment to dietary guidelines by fostering a connection to cultural practices. The finding was in line with a study confirmed that food consumption is deeply embedded within social and cultural traditions, where eating together reinforces social bonds but also normalizes high intake of salt and fatty foods [25-27] Another study shows that lifestyle modifications aligned with cultural adjustments in diet, physical activity, and stress management have significantly boosted patients' adherence to hypertension dietary recommendations. [28]. A recent study by Altawili et al. demonstrated that culturally adapted diet education was more effective than generic diet education in improving the understanding of local eating habits and cultural practices. [29]. This approach proved particularly beneficial for dietary interventions aimed at patients with hypertension. Research in the United States shows a troubling trend among Filipino immigrants: a transition to a Western diet high in fats and sugars, linked to rising blood pressure and increased hypertension rates. Alarmingly, their traditional diet typically includes an average sodium intake of 12 grams per day, eight times the American Heart Association's recommended limit. This excessive sodium consumption significantly elevates the risk of hypertension. This situation shows the critical impact that cultural shifts and dietary modifications can have on public health, leading to a troubling rise in hypertension within this population. [30, 31]. A recent study revealed that the Mediterranean diet, abundant in fruits, vegetables, and healthy fats, is closely associated with a significantly lower risk of cardiovascular disease and hypertension. This robust evidence underscores the crucial role that dietary choices play in shaping an individual’s health. [32] By understanding the social and behavioral contexts within local communities, nurses can deliver more effective care and reduce the risk of miscommunication. The fifth theme in this study addresses uncertainties regarding the advantages and effectiveness of hypertension treatment. These uncertainties often manifest as scepticism or disbelief in the benefits and efficacy of treatment, stemming from various factors such as personal experiences, misinformation, and a limited understanding of hypertension management. Patients who doubt the benefits of treatment show non-compliance with medication and a lack of motivation to engage in health programs, including health checks, exercise, and dietary changes. Similarly, a study in low-resource confirmed that scepticism in treatment often arises when cultural explanations of illness conflict with medical advice, leading to treatment delays or inconsistent adherence [33-35] Another study indicates that health interventions, particularly those involving education and support combined with a comprehensive approach, are highly effective in dispelling doubts about the value of blood pressure monitoring and fostering greater patient engagement. [36]. A previous study mentioned that delivering accurate and current information is vital for transforming health behaviours. It not only alleviates uncertainties but also builds trust in treatment. [37]. From the Theory of Plan Behaviour (TPB) interpreted the uncertain attitudes toward treatment with low behavioural intention and limited perceived control was significantly has poor adherence. Therefore, the present findings reinforce the need for comprehensive, socially responsive, and family-inclusive strategies in hypertension self-care programs These findings reinforce the relevance of integrating social-behavior determinants within the TPB framework to understand self-care behaviours in hypertensive populations better. While traditional TPB applications emphasize individual cognition, This study extends the Theory of Planned Behavior by embedding social and behavioral dimensions specifically social norms, family routines, and habitual behaviors into the interpretation of attitude, subjective norm, and perceived behavioral control. These findings underscore the need for socially responsive and behavior-oriented interventions that engage family, peers, and community systems to sustain hypertension self-care. Implication for Practice The present study highlights critical considerations for community nursing practice in culturally diverse and resource-limited contexts. Nurses should prioritize socially responsive health promotion strategies that align with local beliefs and dietary habits to enhance patient engagement and to promote reduced salt consumption and consistent blood pressure monitoring. Tailored education may foster greater patient engagement and adherence to blood pressure monitoring. Family-centered interventions should be prioritized, given the prominent role of families in shaping on dietary habits, medication adherence, and care-seeking. Nursing practice should integrate family-based sessions, home visits, and group discussions into existing community health programs to enhance continuous support for patients with hypertension. At the community level, partnerships with health workers (cadres) are vital to expand outreach and bridge gaps in service delivery. Strengthening cadres through training, supervision, and accessible education tools can improve program sustainability. Finally, at the policy and professional development level, the TPB should be incorporated into continuing education to enhance nurses competencies in addressing attitude, norm, and perceived control. Multidisciplinary collaboration for socially responsive and community driven care models will be essential to sustain hypertension self-care initiative. Limitations This study offers contextualised insights derived from multiple perspectives including patients, family members, community health workers (kaders), and nurses that enrich the understanding of factors influencing hypertension self-care and strengthen data triangulation. Nevertheless , several limitations should be acknowledged. First, the relatively small number of participants may constrain the depth and variability of the findings. Second, the study was conducted within a single district, which may limit the transferability of results to settings with different sociocultural norms or health system contexts. Therefore, caution should be exercised when generalising these findings beyond the studied population. Conclusions This study offers a nuanced and contextually grounded understanding of the social and behavioural barriers that impede the sustainability of self-care management among individuals living with hypertension. The key challenges identified encompass inadequate health literacy, low perceived susceptibility, limited instrumental and emotional support from family members and healthcare professionals, socially reinforced dietary norms that encourage excessive salt consumption, and uncertainty regarding the efficacy of treatment. Collectively, these barriers correspond to the principal constructs of the Theory of Planned Behavior: attitude, subjective norm, and perceived behavioural control demonstrating how sociocultural contexts and habitual practices may shape individuals’ intentions and adherence behaviours. Healthcare professionals are therefore encouraged to implement patient-centred strategies that recognise the dynamic interplay between social identity, familial relationships, and personal motivation. Future interventions should be theoretically grounded and socio-behaviourally tailored to community realities, particularly within rural and semi-urban Indonesian settings, to strengthen adherence and foster sustainable hypertension self-care behaviours. Declarations Ethical approval and consent to participate “The study was conducted in accordance with the ethical principles of the World Medical Association Declaration of Helsinki (2013, amended 2024) , which outlines ethical standards for medical research involving human participants. Ethical approval was obtained from the Institutional Review Board of Universitas Padjadjaran , Indonesia (No. 964/UN6.KEP/EC/2024). All participants who were willing to participate in this study are required to sign informed consent and confidentiality are taken to protect the privacy of research participants . Participants were informed that they could withdraw from the study at any time without any consequences. Consent for publication Not applicable Availability of data and materials The datasets generated and analysed during the current study are not publicly available to protect participant confidentiality, but they are available from the corresponding author upon reasonable request. Competing interest The authors declare that they have no competing interest related to this study. Funding This study was supported by the Beasiswa Pendidikan Indonesia (BPI) scholarship under the Indonesia Endowment Fund for Education (LPDP), Ministry of Finance, Republic of Indonesia. Authors’ contributions AMU and RAP conceptualized and designed the study, collected and analyzed the data, and drafted the manuscript. CEK, IP, and YS supervised the study design and data analysis, provided critical revisions, and reviewed the methodology and interpretation of the findings. All authors read and approved the final version of the manuscript. Acknowledgement The authors would like to thanks the Beasiswa Pendidikan Indonesia (BPI) scholarship from the Indonesia Endowment Fund for Education (LPDP) for supporting this study. We also extend our gratitude to the patients with hypertension, their families, community health workers, and healthcare professionals in Jatinangor District, West Java, for their valuable contributions and participation throughout the data collection process. Authors’ information Andi Mayasari Usman (AMU) is a doctoral student at the Faculty of Medicine, Padjadjaran University, and a nursing lecturer at the National University of Jakarta. Rian Adi Pamungkas (RAP) is a lecturer at the Faculty of Health Sciences, Esa Unggul University, Jakarta. Cecep Eli Kosasih (CEK) and Iqbal Pramukti (IP) are senior nursing lecturers at Padjadjaran University. Yulia Sofiatin (YS) is a lecturer at the Faculty of Medicine, Padjadjaran University References World Health Organization, W., Global Report on Hypertension: The Race Against a Silent Killer . 2023, World Health Organization: Geneva. Kemenkes, Survei Kesehatan Indonesia , B.K.P.K. (BKPK), Editor. 2023, Kementerian Kesehatan RI. Marshall, I.J., C.D. Wolfe, and C. McKevitt, Lay perspectives on hypertension and drug adherence: systematic review of qualitative research. BMJ, 2012. 345 : p. e3953. Dahlke, S.A., K.F. Hunter, and K. Negrin, Nursing practice with hospitalised older people: Safety and harm. Int J Older People Nurs, 2019. 14 (1): p. e12220. Konlan, K.D. and J. Shin, Determinants of Self-Care and Home-Based Management of Hypertension: An Integrative Review. Glob Heart, 2023. 18 (1): p. 16. Schoenthaler, A., et al., Addressing the Social Needs of Hypertensive Patients: The Role of Patient-Provider Communication as a Predictor of Medication Adherence. Circ Cardiovasc Qual Outcomes, 2017. 10 (9). Dhungana, R.R., et al., Barriers, Enablers and Strategies for the Treatment and Control of Hypertension in Nepal: A Systematic Review. Front Cardiovasc Med, 2021. 8 : p. 716080. Rahmawati, R. and B.V. Bajorek, Access to medicines for hypertension: a survey in rural Yogyakarta province, Indonesia. Rural Remote Health, 2018. 18 (3): p. 4393. Mashuri, Y.A., N. Ng, and A. Santosa, Socioeconomic disparities in the burden of hypertension among Indonesian adults - a multilevel analysis. Glob Health Action, 2022. 15 (1): p. 2129131. He, F.J., J. Li, and G.A. Macgregor, Effect of longer term modest salt reduction on blood pressure: Cochrane systematic review and meta-analysis of randomised trials. BMJ, 2013. 346 : p. f1325. Widyaningsih, V., et al., Missed opportunities in hypertension risk factors screening in Indonesia: a mixed-methods evaluation of integrated health post (POSBINDU) implementation. BMJ Open, 2022. 12 (2): p. e051315. Tan, P.P.S., et al., Health motivations and perceived barriers are determinants of self-care behaviour for the prevention of hypertension in a Malaysian community. PLoS One, 2022. 17 (12): p. e0278761. Champion, V., The Health Belief Model , in Health Behavior, Theory and Research . 2019, Jossey-Bass. Eslamimehr, F., et al., Self-Care Behaviors in Patients with Hypertension to Prevent Hypertensive Emergencies: a Qualitative Study Based on the Theory of Planned Behavior. Journal of Cardiovascular Emergencies, 2022. 8 (4): p. 75-85. Zhang, Q., et al., The effect of high blood pressure-health literacy, self-management behavior, self-efficacy and social support on the health-related quality of life of Kazakh hypertension patients in a low-income rural area of China: a structural equation model. BMC Public Health, 2021. 21 (1): p. 1114. Coughlin, S.S., et al., Health Literacy, Social Determinants of Health, and Disease Prevention and Control. Journal of Environmental Health Science, 2020. 6 (1). Shahid, R., et al., Impact of low health literacy on patients' health outcomes: a multicenter cohort study. BMC Health Serv Res, 2022. 22 (1): p. 1148. Severin, E. and D. Dan, Lack of Information on the Effects of COVID-19 on Rare Pathologies Has Further Hampered Access to Healthcare Services. Front Public Health, 2022. 10 : p. 852880. Champion, V.L. and C.S. Skinner, he Health Belief Model. In K. Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior: Theory, research, and practice. 2019: p. 75–94. de Santana Silva, J.P., et al., Illness perception and self-care in hypertension treatment: a scoping review of current literature. BMC Health Serv Res, 2024. 24 (1): p. 1529. Shim, J.S., J.E. Heo, and H.C. Kim, Factors associated with dietary adherence to the guidelines for prevention and treatment of hypertension among Korean adults with and without hypertension. Clin Hypertens, 2020. 26 : p. 5. Rosland, A.M., M. Heisler, and J.D. Piette, The impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review. J Behav Med, 2012. 35 (2): p. 221-39. Baig, A.A., et al., Family interventions to improve diabetes outcomes for adults. Ann N Y Acad Sci, 2015. 1353 (1): p. 89-112. Kalantzi, V., et al., Cardiometabolic Patient-Related Factors Influencing the Adherence to Lifestyle Changes and Overall Treatment: A Review of the Recent Literature. Life (Basel), 2023. 13 (5). Chan, A., et al., Factors affecting reductions in dietary salt consumption in people of Chinese descent: An integrative review. J Adv Nurs, 2022. 78 (7): p. 1919-1937. Malczyk, E., et al., Salt Intake of Children and Adolescents: Influence of Socio-Environmental Factors and School Education. Nutrients, 2024. 16 (4). Marcone, M.F., P. Madan, and B. Grodzinski, An Overview of the Sociological and Environmental Factors Influencing Eating Food Behavior in Canada. Front Nutr, 2020. 7 : p. 77. Miezah, D. and L.L. Hayman, Culturally Tailored Lifestyle Modification Strategies for Hypertension Management: A Narrative Review. Am J Lifestyle Med, 2024: p. 15598276241297675. Altawili, A.A., et al., An Exploration of Dietary Strategies for Hypertension Management: A Narrative Review. Cureus, 2023. 15 (12): p. e50130. Ma, G.X., et al., Risk Assessment and Prevention of Hypertension in Filipino Americans. J Community Health, 2017. 42 (4): p. 797-805. Sijangga, M.O., et al., Culturally-tailored cookbook for promoting positive dietary change among hypertensive Filipino Americans: a pilot study. Front Nutr, 2023. 10 : p. 1114919. Widmer, R.J., et al., The Mediterranean diet, its components, and cardiovascular disease. Am J Med, 2015. 128 (3): p. 229-38. McQuaid, E.L. and W. Landier, Cultural Issues in Medication Adherence: Disparities and Directions. J Gen Intern Med, 2018. 33 (2): p. 200-206. Shahin, W., G.A. Kennedy, and I. Stupans, The impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review. Patient Prefer Adherence, 2019. 13 : p. 1019-1035. van Zyl, C., et al., Unravelling 'low-resource settings': a systematic scoping review with qualitative content analysis. BMJ Glob Health, 2021. 6 (6). Martinez-Ibanez, P., et al., Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension: A Secondary Analysis of the ADAMPA Randomized Clinical Trial. JAMA Netw Open, 2024. 7 (5): p. e2410063. Kario, K., M. Mogi, and S. Hoshide, Latest hypertension research to inform clinical practice in Asia. Hypertens Res, 2022. 45 (4): p. 555-572. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":110361,"visible":true,"origin":"","legend":"\u003cp\u003eExtended TPB with\u003cstrong\u003e social-behavior \u003c/strong\u003e\u0026amp; family layer mapped to community nursing actions\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7831705/v1/90dc4c3c23f2b009c57b745f.jpg"},{"id":96452859,"identity":"c8c0f940-8b48-4525-86e2-35ce86b2b1d1","added_by":"auto","created_at":"2025-11-21 09:49:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1478066,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7831705/v1/3f6cafa5-4004-48e3-ad16-5a0fefbe2139.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eSocial-Behavior Barriers to Hypertension Self-Care: Extending the Theory of Planned Behavior\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHypertension is a primary global health concern that poses a significant burden in terms of morbidity and mortality. [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The World Health Organization (WHO) in 2023 estimated that more than 1.28\u0026nbsp;billion adults were living with hypertension, especially in lower-middle-income countries with limited accessibility to health services. [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In Indonesia, the prevalence among adults has reached 30.8% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], underscoring the urgent need for effective management strategies.\u003c/p\u003e\u003cp\u003eSelf-care is a cornerstone of hypertension management such as medication adherence, dietary modification, and physical activity, and routine blood pressure monitoring. These behaviors are proven to reduce complications such as stroke, heart failure, and kidney disease [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, sustaining long-term engagement remains challenging. Social relationships, family dynamics, and behavioral patterns strongly influence perceptions of risk and control. Despite their significance, social-behavioral determinants are often overlooked in conventional hypertension interventions, which tend to emphasize biomedical approaches rather than context-specific strategies [\u003cspan additionalcitationids=\"CR4\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e–\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEvidence from various settings demonstrates barriers to sustained self-care. United States, patients reported difficulties in maintaining physical activity due to lack of motivation, fear of injury, financial obstacles to accessing medications, and neglect of regular clinical visits [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Other study revealed that poor understanding of hypertension, limited access to sustainable treatment, and ineffective communication with health providers were critical obstacles [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThese challenges are rooted in behavioral routines and social norms influencing health-seeking behaviors rather than cultural customs alone [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Furthermore, dietary practices, especially the high consumption of sodium rich traditional foods, continue to hinder effective blood pressure control [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Despite government initiatives, including Posbindu PTM (Integrated Non-Communicable Disease Post) to promote early detection and management, these programs face inconsistent implementation, shortages of health workers, and limit patients engagement [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe Theory of Planned Behavior (TPB) has been widely employed to explain and predict health-related behaviors through three central constructs: attitudes, subjective norms, and perceived behavioral control [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Although TPB is a robust model, its application has primarily focused on individual-level determinants, with limited attention to how cultural and familial contexts may modify these constructs. In collectivist societies such as Indonesia, family dynamics, communal norms, and culturally embedded food preferences can significantly shape health-related decision-making [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThis study addresses that gap by extending the TPB to include social-behavior constructs influencing hypertension self-care in a low-resource Indonesian context. The findings aim to inform the design of contextually adapted interventions and contribute to the refinement of TPB for use in similar low and middle income countries. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e present the conceptual framework of this study, extending TPB by incorporating social-behavior and family influences into its core constructs, linked to nursing practice implications.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eStudy Objective\u003c/h3\u003e\n\u003cp\u003eThe study aimed to explore the social-behavior barriers to sustainable self-care management practice, focusing on extending the Theory of Planned Behavior (TPB) by identifying social-behavioral constructs ·\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e· \u003cb\u003eStudy Design and Setting\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA descriptive qualitative study was conducted through in-depth interviews. The study was conducted in the Jatinangor Health Center, Sumedang, West Java, Indonesia. Jatinangor is a semi-urban subdistrict with the third-highest population density in the region, representing a typical Indonesian community experiencing rapid demographic shifts and increasing non-communicable disease burdens. The site was purposively selected due to its diverse socioeconomic composition, healthcare access disparities, and growing epidemiological burden of hypertension. These characteristics mirror the conditions in many semi-urban areas across Indonesia, making Jatinangor a representative setting for exploring social-behavior and systemic barriers to sustainable hypertension self-care. Local public health reports also highlight a high prevalence of uncontrolled hypertension in this area, further supporting its relevance as a study location.\u003c/p\u003e\u003cp\u003e· \u003cb\u003ePopulation and Samples\u003c/b\u003e\u003c/p\u003e\u003cp\u003eWe involved individuals living in the Jatinangor area who were directly involved in treatment and had experiences and insights related to self-care management. The key informants included hypertension patients, families, community health workers, and nurses.\u003c/p\u003e\u003cp\u003eThe sample for this study consisted of 24 key informants who were intentionally selected based on specific inclusion criteria (See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The first group included hypertensive patients with uncontrolled blood pressure who had lived in Jatinangor for at least one year and were willing to participate in the study. The second group comprised five family members who were directly involved in caring for the hypertensive patients and lived with them. The third group consisted of five community health workers managing hypertensive patients. The fourth group included nurses who participated in the hypertensive patient care program in the Jatinangor area and had one year of experience caring for hypertensive patients in the community. Both cadres and nurses played direct roles in health checking, blood pressure monitoring, home visiting, health education, and follow-up care.\u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eInclusion Criteria of Informants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInformants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSample Number\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eInclusion Criteria\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePatients with uncontrolled hypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e• The minimum age is 35 years.\u003c/p\u003e\u003cp\u003e• Individuals must have been diagnosed with hypertension for a minimum of one year.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFamily\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e• Caring for Patients with Hypertension\u003c/p\u003e\u003cp\u003e• Providing care for hypertension patients for a minimum of one year.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHealth Community workers (Cadre)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e• Support the management of blood pressure and salt preferences in the community.\u003c/p\u003e\u003cp\u003e• Have at least one year of experience in hypertension care.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerson in charge of PTM (Non-Communicable Diseases) and PROLANIS (Chronic Disease Management) programs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e• Participate in the care of patients with hypertension at health centers.\u003c/p\u003e\u003cp\u003e• Involved in a hypertension management program for at least one year.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e\u003ch3\u003eInstrumentation\u003c/h3\u003e\u003cp\u003eThe semi-structured interview guide was developed based on an extensive review of literature on hypertension self-care, salt preference, and the Theory of Planned Behavior (TPB). The initial draft was structured around the three core constructs of TPB-attitude, subjective norm, and perceived behavioral control-while incorporating contextual elements relevant to Indonesian social-behavior practices\u003c/p\u003e\u003cp\u003eTo ensure the content validity, the semi-structured interview guide was reviewed by the expert panel in nursing, medical doctor, nutritionist, and anthropology. Each expert addressed the clarity, relevance, and comprehensiveness of the questions and provided the feedback to refine wording and thematic focus related to topic.\u003c/p\u003e\u003cp\u003ePrior to formal data collection process, the pilot testing was approached to the five hypertensive patients from community to evaluate the cultural appropriateness, comprehension, and sequencing of the questions. Feedback from this process was led to adjust the phrase of socially resonsive topics (such as dietary habits and family support) and ensure the questions elicited in-depth.\u003c/p\u003e\u003cp\u003eUltimately, the credibility of the data was strengthened by making iterative adjustments during the initial stages of fieldwork, with minor revisions introduced when participants indicated confusion or ambiguity. This adaptive yet systematic process ensured that the interview guide remained both methodologically sound and culturally appropriate\u003c/p\u003e\u003ch3\u003eData Collection Procedure\u003c/h3\u003e\u003cp\u003eIn-depth interviews were conducted using a semi-structured format with open-ended questions guided by key themes and subthemes. The aim was to explore experiences and barriers to hypertension self-care management through the lens of planned behavior theory. Interviews with patient informants, their families, and community health workers were held in their homes, while discussions with nurses occurred at the health center. Each interview session lasted approximately 60 minutes. The researcher and a research assistant recorded and transcribed all information gathered during the interview. The interview guidelines were divided into four key informant groups, as follows: 1. Uncontrolled Hypertension Patients: This group covered themes such as demographic information, attitudes toward blood pressure management, perceived subjective norms, management behaviors for controlling self-care management, and barriers to blood pressure management and salt intake. 2. Families: This group included themes related to demographic information, family attitudes in supporting blood pressure management and patient salt preference, subjective norms that can provide support, behaviors, and barriers experienced in assisting patients. 3. Community health workers: This group focused on themes of demographic information, the attitudes of cadres in helping patients control self-care management, subjective norms that can provide support, behaviors in managing blood pressure and patient salt preference, and barriers faced in assisting patients. 4. Nurses: This group addressed themes of demographic information, as well as barriers to implementing hypertension management programs and addressing salt preference within the community and health centers. Before the study commenced, the interview guidelines were reviewed by three experts and tested on five hypertensive patients with uncontrolled blood pressure at a location different from the study site.\u003c/p\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe data were transcribed and translated from the audio recordings. A deductive content analysis approach was employed, guided by the theoretical constructs of the Theory of Planned Behavior (attitudes, subjective norms, and perceived behavioral control). The process of data analysis consisted of several steps. First, we read the transcript repeatedly to meet the immersion data. The meaningful information related to TPB model and aims of this study was initial coding. Following data collection, a data reduction process was conducted to identify initial themes and subthemes aligned with the theoretical framework. Content analysis was then used to systematically code and categorize the data, allowing for identification, analysis, and reporting of themes within the local social-behavior context. The final stage involved organizing these themes into categories and subcategories, reflecting the perspectives of each key informant group such as patients, families, volunteers and nurses who are responsible in NCD.\u003c/p\u003e\u003cp\u003eTo enhance trustworthiness, two researchers were independently coded the set of transcripts and compared their results. Inconsistencies of information were discussed until consensus was achieved. Triangulation was applied by comparing perspectives across the four different informant groups to validate recurring patterns and highlight contextual variations. In addition, member checking was conducted with selected participants to confirm that the interpretations accurately represented their experiences. These strategies collectively enhanced the credibility, dependability, and confirmability of the findings\u003c/p\u003e\u003ch3\u003eTheoretical Framework\u003c/h3\u003e\u003cp\u003eThis study applied the Theory of Planned Behavior (TPB) to explore social-behavior barriers to hypertension self-care. TPB's core constructs: attitudes, subjective norms, and perceived behavioral control, guided the analysis of how patients and families manage self-care daily. Family involvement, particularly among cohabiting relatives, significantly shaped patients’ intentions and behaviors, influenced by cultural norms on diet, health beliefs, and shared responsibilities.\u003c/p\u003e\u003cp\u003eInput from nurses and community health workers (cadres) illuminated systemic barriers to program implementation. Nurses reported challenges such as workforce shortages and limited community participation, while cadres encountered cultural resistance and logistical constraints in delivering community-level support.\u003c/p\u003e\u003cp\u003eIntegrating insights from all stakeholder groups allowed for contextual refinement of the TPB framework, socially embedded factors influencing self-care. These findings inform the development of community-based interventions that are both socially responsive and feasible in resource-limited, semi-urban settings such as Jatinangor.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eSocial-Behavior Barriers to Hypertension Self-Care Practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFive themes were identified as barriers to sustainable hypertension self-care. These themes illustrate how social-behavior and psychosocial contexts interact with the constructs of Theory of Planned Behavior (TPB)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eTheme 1: \u003cstrong\u003eLack of information and the misperception (Attitude)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost patients have received information about self-care management for hypertension from healthcare workers and nurses at the health center. However, they still lack a comprehensive understanding of the information provided, which is often delivered in a one-way manner. The patients believe that high salt intake is the primary cause of high blood pressure, but they are unaware of which foods are high in salt or how to prepare food to reduce its salt content. Their understanding of hypertension is limited to its definition, and they think that high blood pressure could potentially lead to a stroke. They are not informed about other possible consequences of uncontrolled blood pressure. Additionally, they mistakenly believe that blood-boosting medications are intended to increase blood pressure rather than understanding their true purpose. Other factors that contribute to elevated blood pressure are also poorly understood. Many patients think that healthy food is synonymous with expensive food.\u003c/p\u003e\n\u003cp\u003eThe family members who cared for the hypertension patients conveyed their challenges in managing the care plan. They were not fully aware of how to effectively care for individuals with hypertension or how to prepare appropriate home-cooked meals. However, there was one family that successfully managed their diet, as they had previously dealt with hypertension. In the in-depth interviews conducted with community health workers, the coordinator observed an opportunity to improve the community\u0026apos;s understanding of the factors that lead to uncontrolled blood pressure. Many believed that medication could lower blood pressure, neglecting the importance of a healthy lifestyle. Health center nurses reported challenges in educating patients due to a shortage of healthcare workers. Consequently, the education provided was suboptimal.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWe cannot eat healthy food often because we have to drink milk and fruit. It is too expensive.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7, 35-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI struggle to manage my blood pressure because I do not understand how to prepare healthy meals or what affordable healthy foods I can consume.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P8, 52-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eWhen the health\u0026nbsp;\u003c/em\u003e\u003cem\u003ecenter\u003c/em\u003e\u003cem\u003e\u0026nbsp;provides me with blood-boosting medicine, I refrain from taking it because my blood pressure would increase.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3, 40-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eReducing my salt consumption should help lower my blood pressure. I now try to cook with less salt since I previously had hypertension, but it is currently under control\u003c/em\u003e.\u0026rdquo; (KE1, 56-year-old mother)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePeople here believe that food lacks\u0026nbsp;\u003c/em\u003e\u003cem\u003eflavor\u003c/em\u003e\u003cem\u003e\u0026nbsp;without salt,\u0026nbsp;\u003c/em\u003e\u003cem\u003emasako\u003c/em\u003e\u003cem\u003e, or\u0026nbsp;\u003c/em\u003e\u003cem\u003esasa\u003c/em\u003e\u003cem\u003e. Thus, these three ingredients are commonly used in their dishes.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(KA3, 39-year-old female)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eTheme 2: \u003cstrong\u003eLow perception of susceptibility and severity (Perceived Behavioral Control)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLack of awareness of the risk and severity of the illness leads to non-adherence with main programs, putting their health at risk and increasing the disease complications. Five informants reported that they did not consistently take their hypertension medication or follow care management guidelines for various reasons, including financial limitations, lack of understanding about the consequences of non-adherence, and ingrained environmental habits.\u003c/p\u003e\n\u003cp\u003eIn addition to structural and informational barriers, several participants expressed psychological avoidance toward routine health examinations. Rather than logistical constraints, this avoidance stemmed from a fear of being diagnosed with additional illnesses, which they believed could lead to excessive worry and emotional distress, potentially exacerbating their blood pressure levels.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI take medication for hypertension. If my blood pressure increases, I take amlodipine.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P1, 48-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI rarely visit the integrated health post or health\u0026nbsp;\u003c/em\u003e\u003cem\u003ecenter\u003c/em\u003e\u003cem\u003e\u0026nbsp;because I have no complaints.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P5, 55-year-old male)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I dedicated myself to a consistent workout routine, pushing my limits at the exercise, but my blood pressure remained high. Eventually, I became lazy about working out. Whenever I had a headache, I would choose to rely on medication instead of confronting the underlying problem directly. I enjoy foods like salted fish and do not have any specific dietary restrictions. If my blood pressure increases, it is easy to visit the pharmacy to buy amlodipine.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P2, 36-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI am confused about my rising blood pressure despite reducing my salt intake. My mother also cooks with less salt. It seems like the increase is due to stress rather than food\u003c/em\u003e.\u0026rdquo; (P6, 35-year-old male)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;I am scared to go for a check-up. What if they find something bad? I will keep thinking about it, and that can make my blood pressure go up again.\u0026quot;\u003c/em\u003e (P3, 40-year-old female)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Better not to know. If I find out I have another disease, it will just make me overthink and get more anxious. It is easier not to worry\u003c/em\u003e.\u0026quot; (P8, 52-year-old female)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;Some people say they do not want to get checked because they are afraid. If they know they are sick, they say it will make them panic or stress too much\u003c/em\u003e.\u0026quot; (KA1, 58-year-old female)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026quot;They often say, \u0026lsquo;If I do not know, I feel fine. If I know, I might just get worse from overthinking.\u0026rsquo; So they avoid going to Posbindu or the health center\u003c/em\u003e.\u0026quot; (KA3, 39-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eTheme 3: \u003cstrong\u003eLack of family support and insufficient workforce (Subjective Norms)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFamily support is a particular element in managing blood pressure because family members live with the patient and influence their daily activities. Family habits and dynamics can significantly shape an individual\u0026apos;s mindset and lifestyle. However, certain family behaviors, such as cooking salty foods or engaging in social gatherings that involve eating, can pose challenges for young individuals suffering from hypertension in maintaining a healthy diet. Additionally, the limited number of healthcare workers can hinder the effectiveness of health programs, making it difficult to reach all individuals within a health center\u0026apos;s service area. Seven patients reported difficulties accessing health services, particularly at health centers. Distance, cost, and lack of available facilities present significant obstacles to effective hypertension management.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI always participate in\u0026nbsp;\u003c/em\u003e\u003cem\u003ebotram\u003c/em\u003e\u003cem\u003e, bringing food from home. Sometimes, we eat salted fish or fried tempeh. Eating together is delicious, and we can chat while enjoying the meal, so we often do this.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P1, 48-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI prepare the daily meals for my family, who prefer salty foods, sometimes accompanied by fries. My husband and children eat what I cook.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P2, 36-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI seldom visit the health\u0026nbsp;\u003c/em\u003e\u003cem\u003ecenter\u003c/em\u003e\u003cem\u003e\u0026nbsp;for check-ups because it is far away. I prefer to spend money on food instead.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7, 37-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eGoing to the health\u0026nbsp;\u003c/em\u003e\u003cem\u003ecenter\u003c/em\u003e\u003cem\u003e\u0026nbsp;requires a long trip, and online transportation is expensive, so we rarely visit.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3, 40-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eTheme 4: \u003cstrong\u003eConventional customs of gathering and the culture of eating habits (Subjective Norm)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eLocal Sundanese culture, particularly the tradition of botram (communal eating), significantly influences blood pressure management and salt preferences. It is not the act of sharing a meal that directly leads to increased blood pressure, but rather the types of food typically served at botram gatherings. These foods are high in salt, such as salted fish, fatty dishes, and crackers. As a result, this eating habit can make it challenging for individuals to manage their blood pressure, even though they understand the importance of maintaining a low-salt diet. The foods served are popular among Sundanese people, and the communal nature of these gatherings often increases their appetite.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I often visit\u0026nbsp;\u003c/em\u003e\u003cem\u003eBotram\u003c/em\u003e\u003cem\u003e\u0026nbsp;almost every day; they serve home-cooked food like salted fish and fried tempeh. This might be the reason for my uncontrolled blood pressure.\u0026rdquo; (\u003c/em\u003eP7, 35-year-old female\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It can be challenging to reduce salt, as the menu at\u0026nbsp;\u003c/em\u003e\u003cem\u003eBotram\u003c/em\u003e\u003cem\u003e\u0026nbsp;often features salted fish and crackers.\u0026rdquo; (\u003c/em\u003eP3, 40-year-old female\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eIn my family, I enjoy eating salted fish, which is why I have hypertension. My mother also has hypertension because she enjoys salted fish, shrimp paste, chili sauce, and crackers.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P7, 35-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI struggle to manage my eating habits. We often come together here because if we stay home all the time, our headaches and blood pressure tend to rise. In the evenings, we chat with the\u0026nbsp;\u003c/em\u003e\u003cem\u003eneighbors\u003c/em\u003e\u003cem\u003e\u0026nbsp;while enjoying snacks, such as meatballs and other treats, to relieve our stress.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P3, 40-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026middot; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u003cstrong\u003eTheme 5: \u003cstrong\u003eDoubt about benefits and efficacy of hypertension treatment (Attitude)\u003c/strong\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding the risks and severity of hypertension is crucial, as it directly influences patients\u0026rsquo; motivation to manage their condition effectively. The more patients are unaware that they are at risk of uncontrolled blood pressure and the potentially severe complications associated with hypertension, the more non-compliant they are with their treatment and adopt unhealthy lifestyles. Many patients mistakenly believe that they only need to take medication when they experience symptoms, thinking that it will lower their blood pressure without considering necessary changes to their diet and lifestyle. Even if they engage in healthy behaviors, such as exercising regularly and reducing salt intake, they may still find that their blood pressure remains high.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eI do not experience any of the symptoms that often accompany high blood pressure, which leads me to believe that there is no real problem, even though my blood pressure is elevated.\u0026rdquo;\u003c/em\u003e (P5, 55-year-old male)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I do not take medication regularly because it tends to give me\u0026nbsp;\u003c/em\u003ea headache.\u0026rdquo; (P1, 48-year-old female)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;I dedicated myself to a consistent workout routine, pushing my limits at the exercise, but my blood pressure remained high. Eventually, I became lazy about working out. Whenever I had a headache, I would choose to rely on medication instead of confronting the underlying problem directly. I enjoy foods like salted fish and do not have any specific dietary restrictions. If my blood pressure increases, it is easy to visit the pharmacy to buy amlodipine.\u0026rdquo;\u0026nbsp;\u003c/em\u003e(P2, 36-year-old female)\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eMy family and I enjoy salty foods. Sometimes, after adding salt to our meals, I sprinkle more\u0026nbsp;\u003c/em\u003e\u003cem\u003eSasa\u003c/em\u003e\u003cem\u003e\u0026nbsp;or Masako. When I have a headache, I suspect it is due to high blood pressure, so I usually just go to sleep and take some medicine. I am wondering what I can do about this habit.\u0026rdquo;\u003c/em\u003e (P3, 40-year-old female)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"633\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCategories\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThema\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSub-Theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttitude\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of information and the misperception \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003col\u003e\n \u003cli\u003eMisunderstandings about hypertension and its management\u003c/li\u003e\n \u003cli\u003eLack of knowledge about proper blood pressure control\u003c/li\u003e\n \u003cli\u003eLimited access to educational media and health services\u003c/li\u003e\n \u003cli\u003eIneffective one-way communication in health education\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePerceived Behavioral Control\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow perception of susceptibility and severity\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003col\u003e\n \u003cli\u003eUncertainty about the benefits and effectiveness of treatment\u003c/li\u003e\n \u003cli\u003eThe misconception that hypertension is not a severe disease.\u003c/li\u003e\n \u003cli\u003eThe widespread belief that treatment is only administered in response to visible symptoms\u0026nbsp;\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAvoidance due to fear of diagnosis and emotional distress\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eEmotional burden and fear of receiving bad news\u003c/strong\u003e\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u003cstrong\u003eBelief that worry can worsen hypertension\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubjective Norm\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLack of family support and insufficient workforce\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003col\u003e\n \u003cli\u003eLack of social support in managing blood pressure\u003c/li\u003e\n \u003cli\u003eFamily habits related to diet\u003c/li\u003e\n \u003cli\u003eHigh workload and job demands\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003eLack of self-confidence in managing hypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSubjective Norm\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConventional customs on gathering and the culture of eating habits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003col\u003e\n \u003cli\u003eCultural preferences for high-salt foods\u003c/li\u003e\n \u003cli\u003eSocial pressures on communal eating habits\u003c/li\u003e\n \u003cli\u003eFamily traditions that conflict with dietary restrictions\u003c/li\u003e\n \u003cli\u003eLack of awareness about the impact of traditional foods on blood pressure\u003c/li\u003e\n \u003c/ol\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAttitude\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 179px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDoubt about the benefits and efficacy of hypertension treatment\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 246px;\"\u003e\n \u003col\u003e\n \u003cli\u003eConcerns about potential long-term side effects from treatment.\u003c/li\u003e\n \u003cli\u003eThe belief is that medication alone is sufficient.\u003c/li\u003e\n \u003cli\u003eMisinformation regarding reliance on antihypertensive medications.\u003c/li\u003e\n \u003c/ol\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study explored the \u003cstrong\u003esocial-behavior barriers\u003c/strong\u003e to sustainable self-care, guided by the Theory of Planned Behaviour (TPB). The findings emphasize how \u003cstrong\u003esocial relationships, behavioral routines, and systemic constraints\u003c/strong\u003e interact with attitude, subjective norms, and perceived behavioural control in shaping self-care behaviors. In this theory, intention refers to a person\u0026apos;s commitment to engaging in specific behaviours as a bridge between psychosocial and cognitive factors and actual behaviour. Individuals are more likely to successfully implement these behaviours than those without such intentions [14]. By using the TPB theory approach in qualitative research, five main themes were found in this study, including 1) lack of information and the misperception, 2) low perception of susceptibility and severity, 3) lack of family support and insufficient workforce, 4) conventional custom on gathering and culture of eating habits, and 5) doubt of benefits and efficacy of hypertension treatment.\u003c/p\u003e\n\u003cp\u003eMisperceptions and doubts about treatment efficacy reflect negative attitude that reduce patients intentions and adherence, consistent with prior studies showing that limited health literacy is associated with poor hypertension control [15]. A study was conducted by Coughlin et al indicates that a lack of information and misunderstandings about disease management lead to delayed diagnosis and treatment. This delay can negatively affect health outcomes and increase the risk of complications [16]. Other studies also suggest that misconceptions about disease management can result in poor self-management skills, worse health outcomes, and a higher reliance on health services [17]. A study conducted by Severin, E., and Dan, D. found that misinformation and false beliefs can drive patients to pursue alternative treatments that lack scientific evidence, potentially resulting in catastrophic consequences for their health. Addressing these gaps in understanding is vital to safeguarding patient well-being and improving overall health outcomes. [18].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOne of the most critical challenges in self-care for patients with hypertension is their insufficient awareness of the condition\u0026apos;s risks and severity. This knowledge gap often leaves patients either uninformed or having a weak understanding of the potential dangers and severe consequences associated with the disease [19]. As a result, they may experience delays in diagnosis, fail to adhere to treatment protocols, and face an increased risk of serious complications. Research conducted by Tan., et al reveals that when patients are unaware of the dangers posed by hypertension, they are significantly less likely to take proactive steps toward prevention and treatment adherence [12]. Moreover, other studies demonstrate that individuals lacking awareness of hypertension\u0026apos;s risks, according to the Health Belief Model (HBM), exhibit notably lower compliance with both medical recommendations and necessary lifestyle changes [20], findings from Jee-Seon Shim, et al indicate that those who underestimate hypertension\u0026apos;s risks are less inclined to follow medical advice and maintain dietary adjustments, such as a low-salt diet [21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe third theme identified in this study is the lack of family support and the insufficiency of mentors in managing blood pressure control. Family support includes emotional, informational, and practical assistance from family members, essential for helping patients with hypertension manage their self-care. Within the TPB framework, subjective norms, such as family influence, are pivotal in shaping patient intentions and behaviours. It was consistent with prior research, this study found that families often lacked the knowledge and skills to support dietary modifications and medication adherence, thus undermining patients\u0026rsquo; ability to manage their condition effectively. [22]. Family members are responsible for educating and assisting patients in disease management and making behavioural changes. [23]. Families with a clear understanding of the patient\u0026apos;s health condition can provide better support in enhancing the patient\u0026apos;s overall health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn addition to family support, peer mentorship is an essential element in empowering patients to take control of their hypertension. These mentors have triumphed over their battles with high blood pressure and serve as inspiring role models, educators, and guides within the community. Patients who witness the success stories of those who have effectively managed their condition often find renewed confidence and commitment to their treatment plans. Research by Kalantzi et al reveals that many patients resist lifestyle changes due to uncertainty about their ability to succeed [24]. Exposure to the experiences of those who have successfully navigated similar challenges can spark a stronger motivation to pursue health goals and adopt recommended wellness strategies actively. Furthermore, studies consistently demonstrate that peer mentors play a critical role in alleviating the pervasive fear, anxiety, and stress that accompany hypertension. Many patients often feel isolated in their struggles. However, these mentors provide vital emotional and social support, sharing proven strategies and personal success stories that significantly empower patients to improve their health outcomes [21].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fourth theme in this study is conventional customs on gathering and communal eating habits. This theme discusses eating habits and social interactions related to food consumption patterns, including salt and fat intake levels, as well as the cultural significance of social gatherings. Culture significantly influences health by affecting patients\u0026apos; adherence to hypertension management diets through social habits and culinary traditions. Embracing a culture-based approach to self-care management is more effective than imposing outright restrictions on certain foods. We can enhance patients\u0026apos; long-term commitment to dietary guidelines by fostering a connection to cultural practices. The finding was in line with a study confirmed that food consumption is deeply embedded within social and cultural traditions, where eating together reinforces social bonds but also normalizes high intake of salt and fatty foods [25-27]\u003c/p\u003e\n\u003cp\u003eAnother study shows that lifestyle modifications aligned with cultural adjustments in diet, physical activity, and stress management have significantly boosted patients\u0026apos; adherence to hypertension dietary recommendations. [28]. A recent study by Altawili et al. demonstrated that culturally adapted diet education was more effective than generic diet education in improving the understanding of local eating habits and cultural practices. [29]. This approach proved particularly beneficial for dietary interventions aimed at patients with hypertension.\u003c/p\u003e\n\u003cp\u003eResearch in the United States shows a troubling trend among Filipino immigrants: a transition to a Western diet high in fats and sugars, linked to rising blood pressure and increased hypertension rates. Alarmingly, their traditional diet typically includes an average sodium intake of 12 grams per day, eight times the American Heart Association\u0026apos;s recommended limit. This excessive sodium consumption significantly elevates the risk of hypertension. This situation shows the critical impact that cultural shifts and dietary modifications can have on public health, leading to a troubling rise in hypertension within this population. [30, 31]. A recent study revealed that the Mediterranean diet, abundant in fruits, vegetables, and healthy fats, is closely associated with a significantly lower risk of cardiovascular disease and hypertension. This robust evidence underscores the crucial role that dietary choices play in shaping an individual\u0026rsquo;s health. [32] By understanding the social and behavioral contexts within local communities, nurses can deliver more effective care and reduce the risk of miscommunication.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe fifth theme in this study addresses uncertainties regarding the advantages and effectiveness of hypertension treatment. These uncertainties often manifest as scepticism or disbelief in the benefits and efficacy of treatment, stemming from various factors such as personal experiences, misinformation, and a limited understanding of hypertension management. Patients who doubt the benefits of treatment show non-compliance with medication and a lack of motivation to engage in health programs, including health checks, exercise, and dietary changes. Similarly, a study in low-resource confirmed that scepticism in treatment\u0026nbsp;often arises when cultural explanations of illness conflict with medical advice, leading to treatment delays or inconsistent adherence [33-35]\u003c/p\u003e\n\u003cp\u003eAnother study indicates that health interventions, particularly those involving education and support combined with a comprehensive approach, are highly effective in dispelling doubts about the value of blood pressure monitoring and fostering greater patient engagement. [36]. A previous study mentioned that delivering accurate and current information is vital for transforming health behaviours. It not only alleviates uncertainties but also builds trust in treatment. [37]. From the Theory of Plan Behaviour (TPB) interpreted the uncertain attitudes toward treatment with low behavioural intention and limited perceived control was significantly has poor adherence. \u0026nbsp; Therefore, the present findings reinforce the need for \u003cstrong\u003ecomprehensive, socially responsive, and family-inclusive strategies\u003c/strong\u003e in hypertension self-care programs\u003c/p\u003e\n\u003cp\u003eThese findings reinforce the relevance of integrating \u003cstrong\u003esocial-behavior determinants\u003c/strong\u003e within the TPB framework to understand self-care behaviours in hypertensive populations better. While traditional TPB applications emphasize individual cognition, This study extends the Theory of Planned Behavior by embedding social and behavioral dimensions specifically social norms, family routines, and habitual behaviors into the interpretation of attitude, subjective norm, and perceived behavioral control. These findings underscore the need for \u003cstrong\u003esocially responsive and behavior-oriented interventions\u003c/strong\u003e that engage family, peers, and community systems to sustain hypertension self-care.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eImplication for Practice\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe present study highlights critical considerations for community nursing practice in culturally diverse and resource-limited contexts. Nurses should prioritize socially responsive health promotion strategies that align with local beliefs and dietary habits to enhance patient engagement and to promote reduced salt consumption and consistent blood pressure monitoring. Tailored education may foster greater patient engagement and adherence to blood pressure monitoring.\u003c/p\u003e\n\u003cp\u003eFamily-centered interventions should be prioritized, given the prominent role of families in shaping on dietary habits, medication adherence, and care-seeking. Nursing practice should integrate family-based sessions, home visits, and group discussions into existing community health programs to enhance continuous support for patients with hypertension.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the community level, partnerships with health workers (cadres) are vital to expand outreach and bridge gaps in service delivery. Strengthening cadres through training, supervision, and accessible education tools can improve program sustainability. Finally, at the policy and professional development level, the TPB should be incorporated into continuing education to enhance nurses competencies in addressing attitude, norm, and perceived control. Multidisciplinary collaboration for socially responsive and community driven care models will be \u0026nbsp;essential to sustain hypertension self-care initiative.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThis study offers\u003c/strong\u003e contextualised insights derived from multiple perspectives including patients, family members, community health workers (kaders), and nurses that enrich the understanding of factors influencing hypertension self-care and strengthen data triangulation. \u003cstrong\u003eNevertheless\u003c/strong\u003e, several limitations should be acknowledged. First, the relatively small number of participants may constrain the depth and variability of the findings. Second, the study was conducted within a single district, which may limit the transferability of results to settings with different sociocultural norms or health system contexts. Therefore, caution should be exercised when generalising these findings beyond the studied population.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis study offers a nuanced and contextually grounded understanding of the social and behavioural barriers that impede the sustainability of self-care management among individuals living with hypertension. The key challenges identified encompass inadequate health literacy, low perceived susceptibility, limited instrumental and emotional support from family members and healthcare professionals, socially reinforced dietary norms that encourage excessive salt consumption, and uncertainty regarding the efficacy of treatment. Collectively, these barriers correspond to the principal constructs of the Theory of Planned Behavior: attitude, subjective norm, and perceived behavioural control demonstrating how sociocultural contexts and habitual practices may shape individuals\u0026rsquo; intentions and adherence behaviours.\u003c/p\u003e\n\u003cp\u003eHealthcare professionals are therefore encouraged to implement patient-centred strategies that recognise the dynamic interplay between social identity, familial relationships, and personal motivation. Future interventions should be theoretically grounded and socio-behaviourally tailored to community realities, particularly within rural and semi-urban Indonesian settings, to strengthen adherence and foster sustainable hypertension self-care behaviours.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;The study was conducted in accordance with the ethical principles of the \u003cstrong\u003eWorld Medical Association Declaration of Helsinki\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;(2013, amended 2024)\u003c/strong\u003e\u003cstrong\u003e,\u0026nbsp;\u003c/strong\u003ewhich outlines ethical standards for medical research involving human participants. Ethical approval was obtained from the \u003cstrong\u003eInstitutional Review Board of Universitas Padjadjaran\u003c/strong\u003e\u003cstrong\u003e, Indonesia\u003c/strong\u003e (No. 964/UN6.KEP/EC/2024). All participants who were willing to participate in this study are required to sign \u003cstrong\u003einformed consent and confidentiality are taken to protect the privacy of research participants\u003c/strong\u003e. Participants were informed that they could withdraw from the study at any time without any consequences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available to protect participant confidentiality, but they are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interest\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interest related to this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the Beasiswa Pendidikan Indonesia (BPI) scholarship under the Indonesia Endowment Fund for Education (LPDP), Ministry of Finance, Republic of Indonesia.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAMU and RAP conceptualized and designed the study, collected and analyzed the data, and drafted the manuscript. CEK, IP, and YS supervised the study design and data analysis, provided critical revisions, and reviewed the methodology and interpretation of the findings. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thanks the Beasiswa Pendidikan Indonesia (BPI) scholarship from the Indonesia Endowment Fund for Education (LPDP) for supporting this study. We also extend our gratitude to the patients with hypertension, their families, community health workers, and healthcare professionals in Jatinangor District, West Java, for their valuable contributions and participation throughout the data collection process.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAndi Mayasari Usman (AMU) is a doctoral student at the Faculty of Medicine, Padjadjaran University, and a nursing lecturer at the National University of Jakarta. Rian Adi Pamungkas (RAP) is a lecturer at the Faculty of Health Sciences, Esa Unggul University, Jakarta. Cecep Eli Kosasih (CEK) and Iqbal Pramukti (IP) are senior nursing lecturers at Padjadjaran University. Yulia Sofiatin (YS) is a lecturer at the Faculty of Medicine, Padjadjaran University\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization, W., \u003cem\u003eGlobal Report on Hypertension: The Race Against a Silent Killer\u003c/em\u003e. 2023, World Health Organization: Geneva.\u003c/li\u003e\n\u003cli\u003eKemenkes, \u003cem\u003eSurvei Kesehatan Indonesia\u003c/em\u003e, B.K.P.K. (BKPK), Editor. 2023, Kementerian Kesehatan RI.\u003c/li\u003e\n\u003cli\u003eMarshall, I.J., C.D. Wolfe, and C. McKevitt, \u003cem\u003eLay perspectives on hypertension and drug adherence: systematic review of qualitative research.\u003c/em\u003e BMJ, 2012. \u003cstrong\u003e345\u003c/strong\u003e: p. e3953.\u003c/li\u003e\n\u003cli\u003eDahlke, S.A., K.F. Hunter, and K. Negrin, \u003cem\u003eNursing practice with hospitalised older people: Safety and harm.\u003c/em\u003e Int J Older People Nurs, 2019. \u003cstrong\u003e14\u003c/strong\u003e(1): p. e12220.\u003c/li\u003e\n\u003cli\u003eKonlan, K.D. and J. 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Bajorek, \u003cem\u003eAccess to medicines for hypertension: a survey in rural Yogyakarta province, Indonesia.\u003c/em\u003e Rural Remote Health, 2018. \u003cstrong\u003e18\u003c/strong\u003e(3): p. 4393.\u003c/li\u003e\n\u003cli\u003eMashuri, Y.A., N. Ng, and A. Santosa, \u003cem\u003eSocioeconomic disparities in the burden of hypertension among Indonesian adults - a multilevel analysis.\u003c/em\u003e Glob Health Action, 2022. \u003cstrong\u003e15\u003c/strong\u003e(1): p. 2129131.\u003c/li\u003e\n\u003cli\u003eHe, F.J., J. Li, and G.A. 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Dan, \u003cem\u003eLack of Information on the Effects of COVID-19 on Rare Pathologies Has Further Hampered Access to Healthcare Services.\u003c/em\u003e Front Public Health, 2022. \u003cstrong\u003e10\u003c/strong\u003e: p. 852880.\u003c/li\u003e\n\u003cli\u003eChampion, V.L. and C.S. Skinner, \u003cem\u003ehe Health Belief Model. In K. Glanz, B. K. Rimer, \u0026amp; K. Viswanath (Eds.), Health behavior: Theory, research, and practice.\u003c/em\u003e 2019: p. 75\u0026ndash;94.\u003c/li\u003e\n\u003cli\u003ede Santana Silva, J.P., et al., \u003cem\u003eIllness perception and self-care in hypertension treatment: a scoping review of current literature.\u003c/em\u003e BMC Health Serv Res, 2024. \u003cstrong\u003e24\u003c/strong\u003e(1): p. 1529.\u003c/li\u003e\n\u003cli\u003eShim, J.S., J.E. Heo, and H.C. Kim, \u003cem\u003eFactors associated with dietary adherence to the guidelines for prevention and treatment of hypertension among Korean adults with and without hypertension.\u003c/em\u003e Clin Hypertens, 2020. \u003cstrong\u003e26\u003c/strong\u003e: p. 5.\u003c/li\u003e\n\u003cli\u003eRosland, A.M., M. Heisler, and J.D. Piette, \u003cem\u003eThe impact of family behaviors and communication patterns on chronic illness outcomes: a systematic review.\u003c/em\u003e J Behav Med, 2012. \u003cstrong\u003e35\u003c/strong\u003e(2): p. 221-39.\u003c/li\u003e\n\u003cli\u003eBaig, A.A., et al., \u003cem\u003eFamily interventions to improve diabetes outcomes for adults.\u003c/em\u003e Ann N Y Acad Sci, 2015. \u003cstrong\u003e1353\u003c/strong\u003e(1): p. 89-112.\u003c/li\u003e\n\u003cli\u003eKalantzi, V., et al., \u003cem\u003eCardiometabolic Patient-Related Factors Influencing the Adherence to Lifestyle Changes and Overall Treatment: A Review of the Recent Literature.\u003c/em\u003e Life (Basel), 2023. \u003cstrong\u003e13\u003c/strong\u003e(5).\u003c/li\u003e\n\u003cli\u003eChan, A., et al., \u003cem\u003eFactors affecting reductions in dietary salt consumption in people of Chinese descent: An integrative review.\u003c/em\u003e J Adv Nurs, 2022. \u003cstrong\u003e78\u003c/strong\u003e(7): p. 1919-1937.\u003c/li\u003e\n\u003cli\u003eMalczyk, E., et al., \u003cem\u003eSalt Intake of Children and Adolescents: Influence of Socio-Environmental Factors and School Education.\u003c/em\u003e Nutrients, 2024. \u003cstrong\u003e16\u003c/strong\u003e(4).\u003c/li\u003e\n\u003cli\u003eMarcone, M.F., P. 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Landier, \u003cem\u003eCultural Issues in Medication Adherence: Disparities and Directions.\u003c/em\u003e J Gen Intern Med, 2018. \u003cstrong\u003e33\u003c/strong\u003e(2): p. 200-206.\u003c/li\u003e\n\u003cli\u003eShahin, W., G.A. Kennedy, and I. Stupans, \u003cem\u003eThe impact of personal and cultural beliefs on medication adherence of patients with chronic illnesses: a systematic review.\u003c/em\u003e Patient Prefer Adherence, 2019. \u003cstrong\u003e13\u003c/strong\u003e: p. 1019-1035.\u003c/li\u003e\n\u003cli\u003evan Zyl, C., et al., \u003cem\u003eUnravelling \u0026apos;low-resource settings\u0026apos;: a systematic scoping review with qualitative content analysis.\u003c/em\u003e BMJ Glob Health, 2021. \u003cstrong\u003e6\u003c/strong\u003e(6).\u003c/li\u003e\n\u003cli\u003eMartinez-Ibanez, P., et al., \u003cem\u003eLong-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension: A Secondary Analysis of the ADAMPA Randomized Clinical Trial.\u003c/em\u003e JAMA Netw Open, 2024. \u003cstrong\u003e7\u003c/strong\u003e(5): p. e2410063.\u003c/li\u003e\n\u003cli\u003eKario, K., M. Mogi, and S. Hoshide, \u003cem\u003eLatest hypertension research to inform clinical practice in Asia.\u003c/em\u003e Hypertens Res, 2022. \u003cstrong\u003e45\u003c/strong\u003e(4): p. 555-572.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hypertension, Self-care, social-behavior barriers, Family support, Theory of Planned Behavior, Health behavior","lastPublishedDoi":"10.21203/rs.3.rs-7831705/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7831705/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Sustaining hypertension self-care practices presents ongoing challenges, particularly in socially complex and resource-limited settings. While the Theory of Planned Behavior (TPB) is widely used in health behavior research, its applicability in \u003cstrong\u003es\u003c/strong\u003eocial and behavioral contextsremains underexplored. This study aimed to extend TPB by identifying social-behavioral constructs that influence hypertension self-care behavior.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A qualitative descriptive study was conducted in Jatinangor District, West Java, Indonesia. Twenty-four key informants were purposively selected, including patients with uncontrolled hypertension, family members, community health workers (cadres), and nurses. Data were collected through semi-structured interviews and analysed using thematic content analysis guided TPB constructs. Ethical approval was obtained from Padjadjaran University, and informed consent was provided by all participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Five themes were identified as barriers to sustainable self-care: 1) Lack of information and misperception (attitude), 2) Low perception of susceptibility and severity (perceived behavioral control), 3) Lack of family support and insufficient workforce (subjective norms), 4) Conventional custom of gathering and culture of eating habits (subjective norms), 5) Doubt of benefits and efficacy (attitude). These themes illustrate how social and behavioral contexts, including family interactions and daily habits, shape TPB constructs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This study contributes to the theoretical development of TPB by embedding social-behavioral constructs that influence hypertension self-care in low-resource settings. Findings highlight the need for socially responsive and family-oriented strategies to strengthen hypertension self-care. These insights are relevant for designing sustainable intervention in LMICs, particularly in Southeast Asia.\u003c/p\u003e","manuscriptTitle":"Social-Behavior Barriers to Hypertension Self-Care: Extending the Theory of Planned Behavior","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 12:01:21","doi":"10.21203/rs.3.rs-7831705/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-22T16:19:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T03:58:47+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-05T03:37:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-30T19:54:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T07:42:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-19T14:04:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"26960064845983410639935247872722737089","date":"2025-11-17T01:15:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"100606436202186308577720882730299188558","date":"2025-11-13T07:40:15+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"211692702459279519567095736689195772297","date":"2025-11-12T19:57:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242307333901612661399867438897203257806","date":"2025-11-12T18:53:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"332998173725471773129743675893839641529","date":"2025-11-11T16:29:04+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-10T17:59:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214155372909659260241358858596670040354","date":"2025-11-10T14:21:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322090991828289895020445617628054623849","date":"2025-11-10T10:07:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"31300459587708049816837066320851837293","date":"2025-11-10T09:29:14+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-10T09:20:02+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-27T09:25:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-18T14:47:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-18T13:17:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-10-18T13:14:04+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"cd56391a-b864-424f-98a8-37c92b0beb22","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-15T17:39:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 12:01:21","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7831705","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7831705","identity":"rs-7831705","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}