“We don’t care because we are not sick”: Understanding youths perceptions of hypertension in urban South Africa

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Early-life exposure to these risks contributes to adverse biological markers that increase hypertension susceptibility in adulthood. This study aimed to explore how young people in Soweto, Johannesburg, perceive hypertension risk, using the Health Belief Model (HBM) to understand their beliefs, attitudes, and barriers to prevention. Methods This study explored youth perceptions of hypertension in Soweto, Johannesburg, using focus group discussions (FGDs) with 62 participants aged 18–25, guided by the HBM. Thematic analysis was conducted to identify key beliefs, attitudes, and barriers to prevention. Results Participants largely underestimated their hypertension risk, perceiving youth as a protective factor and associating the condition primarily with older adults or those already diagnosed. While some acknowledged genetic predisposition, stress, and lifestyle factors as contributors, many saw hypertension as low severity and distant from their immediate concerns. Barriers to preventative action included social norms, stigma, financial constraints, and limited access to health-promoting resources. External cues, such as family influence and community awareness, were stronger motivators for behaviour change than personal risk assessment, while self-efficacy in adopting preventive behaviours was low. Conclusion Findings highlight a gap in youth awareness and engagement in hypertension prevention, driven by misperceptions of risk and limited access to enabling resources. Targeted interventions must address these misconceptions, enhance perceived severity, and leverage community and familial influences to promote early prevention and sustained behaviour change. hypertension cardiovascular disease youth perceptions Soweto South Africa. Health Belief Model preventative health strategies precision prevention public health Figures Figure 1 Figure 2 Figure 3 Background The burden of non-communicable diseases (NCDs) has steadily increased in Sub-Saharan Africa (SSA), with hypertension emerging as a significant driving force with prevalence rising from 25% in 2000 to 40% in 2022 in South Africa 1–3 . The development of hypertension is influenced by genetic, environmental and lifestyle factors that often begin in early life 4, 5 . Evidence suggests that blood pressure (BP) patterns established in childhood strongly predict future hypertension risk. A longitudinal study in South Africa found that one in three children with elevated BP at age five remained in higher BP categories at age 18 6 . Specifically, boys with BP above the 95th percentile at age five were 3.85 times more likely to be in the upper BP trajectory group by adolescence and 21.8 times more likely to remain in the middle BP trajectory. Similarly, girls with elevated BP at age five had an almost six-fold increased likelihood of being in the middle BP trajectory and a nearly seven-fold increased likelihood of remaining in the upper BP trajectory 6 . As young adults transition into adulthood, the personal, social and environmental changes they experience significantly influence lifestyle choices, often contributing to poor diets and rapid weight gain 7 . Adolescence, defined as the developmental stage from 10 to 25 years of age 8 , is particularly critical for establishing lifelong health as lifestyle behaviours become entrained during this stage 9 . This is also a critical period for NCD prevention, as rapid biological changes (including hormonal fluctuations and metabolic shifts), interact with behavioural and environmental factors, such as poor diet, physical inactivity and stress 10 . Adolescence is also marked by increased autonomy in dietary and lifestyle choices, often accompanied by experimentation with risk behaviours such as smoking and excessive alcohol consumption, further compounding long-term health risks 9 . There is an urgent need to support youth in adopting and sustaining behaviours that offset hypertensive risk, setting them on healthier life trajectories 11 . Prevention efforts that prioritise early prevention can significantly reduce the long-term burden of chronic diseases by equipping young people with the knowledge and tools necessary for sustained health 12 . Precision prevention (PP), a targeted approach within the broader framework of precision medicine, strengthens these efforts by customising interventions based on a combination of factors including biological, environmental and social determinants of health 13, 14 . Unlike conventional public health strategies that apply uniform interventions across populations, PP harnesses multi-dimensional data, including genetic pre-dispositions, behavioural patterns, and socioeconomic influences to tailor preventative measures to specific individuals or groups. PP may provide a useful framework in the development of youth-based interventions to minimise elevated blood pressure. A key step in the development of youth-based interventions is understanding the social, cultural and environmental factors that shape adolescent health behaviours related to elevated blood pressure 15 . Given the multifaceted influences on health behaviours (ranging from economic and interpersonal factors to structural barriers) formative research helps tailor interventions to specific risk profiles 15 . Most qualitative studies on hypertension in South Africa have focused on adults, such as Sekome et al. 16 , who examined how social and cultural factors influence hypertension control in rural South Africa. Their findings highlight the significant role of community perceptions, affordability of healthy food, and gendered expectations in shaping physical and dietary habits. There are currently no published qualitative studies that explore youth perceptions of hypertension in South Africa, leaving a critical gap in understanding how young people perceive their risk and engage with prevention efforts. This paper explores how young people in peri-urban South Africa perceive hypertension, its risk factors, and prevention strategies. By engaging directly with youth living in Soweto, this study aims to uncover the social, cultural, and structural factors that shape their understanding of hypertension and their perceptions of prevention. The findings will contribute to the development of contextually relevant PP strategies that resonate with young people’s lived experiences, ultimately strengthening hypertension precision prevention efforts in peri-urban South African settings. Methods Setting This research is part of a larger initiative for developing PP intervention mechanisms aimed at reducing the hypertension risk in Soweto, South Africa. Data collection was conducted at a health-based research centre within a local tertiary hospital in Soweto. Soweto is a historically disadvantaged peri-urban township in Gauteng, South Africa 17 . It is South Africa’s largest urban-poor township of approximately 1.8 million people. Participants Eighty five young people were approached and 62 thereof consented to participate in the study. Purposive sampling was used to recruit participants. Households that had young people that were identified from the Soweto Household Study database were approached and invited to participate in the study. Participants were considered eligible to participate in this study if they were (a) Sowetan (either living in or from Soweto) and (b) between the ages of 18 and 25. Data Collection Data was collected at the South African Medical Research Council (SAMRC) Developmental Pathways for Human Research Unit (DPHRU) at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. While the primary language used during discussions was English, researchers were multilingual, allowing participants the option to express themselves in their home vernacular as necessary, fostering a more inclusive and comfortable environment. A total of 62 youth participants were organised into six smaller groups by gender, with three male and three female groups, each consisting of approximately eight participants, and each group took part in three successive focus group discussion (FGD) sessions. The FGDs were conducted over three weekends, with sessions held on Saturdays to accommodate participants’ work and study commitments. Sessions were held concurrently, with researchers facilitating discussions in separate rooms. For each group, each day consisted of three FGD sessions that were spaced to ensure sufficient time for in-depth discussions. To enhance participant comfort and engagement, breaks were scheduled between sessions, during which refreshments were provided, and a full lunch was offered. This approach allowed participants to reflect between discussions. The FGDs, lasting around two hours each, were designed to elicit in-depth insights into participants’ experiences, knowledge, attitudes, and beliefs concerning hypertension. A semi-structured FGD guide was used to facilitate the sessions, allowing a structured yet flexible approach to maintain focus on research objectives while providing participants the freedom to guide the conversation. Discussions took place in a private room at DPHRU, where participants were seated in a circular arrangement to promote open interaction. Separating groups by gender aimed to create a setting where participants could feel comfortable sharing their views without inhibition 18 . Data was collected through both note-taking by the facilitator and audio recordings, for which participants had granted permission beforehand. These recordings were securely stored on password-protected computers and transcribed later for analysis. Ethical approval was obtained prior to the research from the University of Witwatersrand Human Research Ethics Committee (Medical) (REF: R14/49 Protocol no: M220818). The research was performed in accordance with the 1964 Declaration of Helsinki and its later amendments. Clinical trial number: not applicable. Participants received an information sheet (Appendix A) detailing the study, and informed consent was collected prior to their participation (Appendix B), including specific consent for audio recording (Appendix C). Refreshments were provided to participants at the conclusion of each session. The Health Belief Model (HBM) provided a guiding framework for structuring the FGDs. The model’s six domains: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy were used to generate discussion across the three FGDs for each group. FGD 1 focused on perceived susceptibility and severity, exploring participants’ understanding of hypertension and their beliefs about who is at risk and how the disease affects daily life. FGD 2 examined perceived barriers and benefits, as well as cues to action, by investigating the role of various environmental and social determinants in shaping health behaviours. FGD 3 emphasised self-efficacy and the development of intervention strategies, exploring how individuals, families, communities, and institutions can work together to promote healthy behaviours. Appendices D, E and F outline the FGD schedules. The HBM provides a valuable framework for formative research, as it demonstrates the cognitive and social factors influencing health behaviours 19 . By examining how youth in peri-urban South Africa perceive their susceptibility to hypertension, the severity of its consequences, and the benefits or barriers to prevention, the HBM helps identify gaps in awareness and key drivers of behaviour change. Integrating HBM insights into PP strategies allows for interventions that not only address individual risk factors but also align with youth motivations, social contexts, and structural challenges. This approach strengthens the relevance and impact of prevention efforts, ensuring that they resonate with young people and promote long-term health engagement 19 . The likelihood of engaging in preventative health behaviours for hypertension is shaped by the interaction of key constructs within the HBM (illustrated in Fig. 1 ). Perceived threat, derived from perceived susceptibility (belief in one’s risk), and perceived severity (belief in the condition’s consequences), influences motivation to act 20 . However, behaviour change also depends on whether perceived benefits of prevention outweigh perceived barriers, such as cost or accessibility 20 . Self-efficacy, or confidence in one’s ability to adopt healthy behaviours, determines follow-through, while cues to action (including health messages, social influences, or symptoms) can trigger engagement 20 . By structuring the FGDs around these domains, this study ensures that discussions not only capture youth perceptions on hypertension, but also inform targeted interventions that address both individual and contextual barriers to prevention. Data analysis All FGDs were audio-recorded, transcribed verbatim, and where necessary, translated. Data were analysed using a thematic approach guided by the constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Findings were first analysed collectively across all focus groups to identify overarching patterns, before being organised into the thematic domains of the HBM. Data from male and female groups were examined both separately and together to identify gendered perspectives. Excel was used to manage and code the data systematically. The analysis followed an iterative process, beginning with familiarisation, where all transcripts were reviewed in-depth to gain a comprehensive understanding of participants’ perspectives. A deductive coding framework was initially developed based on the HBM constructs, while inductive coding allowed for the identification of emergent themes beyond the model. Codes were continuously refined through multiple rounds of review to ensure consistency and rigour. Thematic domains were constructed based on patterns that emerged across the full dataset, reflecting shared and divergent perspectives among participants. Representative quotations were selected to illustrate key themes, providing depth and context to the findings. Reflexivity was maintained throughout the process to account for potential researcher biases, ensuring a nuanced and accurate interpretation of data. Results Sample characteristics Sixty two youth participated in the FGDs. The mean age of participants was 20.8 years. Male participants (n = 33, 53%, \(\:\stackrel{-}{x}\) = 21 years) and female participants (n = 29, 47%, \(\:\stackrel{-}{x}\) = 20,5 years) were divided for the purposes of the FGDs. 57% (n = 35) of participants were enrolled in educational institutions at the time of participation. 34% (n = 21) of participants were enrolled in tertiary or higher education facilities, 18% (n = 11) of participants were either in Grade 12 or upgrading their Grade 12 results, and 5% (n = 3) of participants were still in high school. 34% (n = 21) of participants were unemployed, and 10% (n = 6) of participants were employed at the time of participation. Perceived susceptibility Participants generally perceived high susceptibility to hypertension. Both male and female participants recognised susceptibility due to personal diagnosis, universal risk (“Everyone is at risk of developing hypertension because it depends on diet” [Group 1, FGD 1]), genetic predisposition (“It’s not mostly older people, it’s genetics” [Group 4, FGD 1]), and stress (“For instance if you are a breadwinner everything is on you. You must make sure that children go to school, there’s food in the house. This might end up causing you stress and as a result hypertension” [Group 2, FGD 2]). However, female participants uniquely highlighted family history (“For me, like I said my mother has it and my grandmother also has it. I think that when I grow, I will also have it” [Group 3, FGD 1]) and personal vulnerability. While male participants emphasised modeling unhealthy family lifestyle behaviours (“Society regard our family members as should be our role models. So you would think that the right thing to do is to consume alcohol which may lead you having hypertension” [Group 2, FGD 2]), both genders acknowledged that current lifestyle choices increase their susceptibility. A minority expressed low susceptibility. Male and female participants cited their youth (“When you are younger, you are still strong, meant to be a tool in a way” [Group 2, FGD 1]) and healthy behaviours as protective factors. Females uniquely noted a lack of concern due to not considering hypertension a threat or being undiagnosed (“We don’t care because we are not sick and we don’t get sick as much as the elderly, they care a lot” [Group 1, FGD 2]). Males mentioned plans to adopt healthier behaviours (“It is not a threat per say because I am planning on stopping spicy and junk food” [Group 2, FGD 1]) and a belief in immunity due to strong constitution (“I am a soldier” [Group 6, FGD 2]). Perceived severity Hypertension was largely perceived as low in severity, with gender-based differences in reasoning. Female participants expressed skepticism about the disease’s existence (“My grandmother was diagnosed but there are no symptoms, zero, nothing at all” [Group 3, FGD 1]), lack of exposure to its effects (“For me it is not a big deal because I have never experienced it around me” [Group 3, FGD 1]), belief in self-healing, and only taking it seriously when life-threatening (“They don’t take them seriously, someone has to on the verge of dying then it will be taken seriously.” [Group 5, FGD 2]). Males cited treatability (“if you do take treatment, it’s not a threat to your, to your health” [Group 2, FGD 1]), perceived mild impact on quality of life (“The only way I think it affects them is, sometimes she gets swelling feet, and she does not get cold very easily.” [Group 2, FGD 1]), youth as a protective factor (“We don’t think that we as the youth can get it, we think it is only going to affect our grandmothers and grandfathers only” [Group 4, FGD 1]), and prioritising the benefits of unhealthy behaviours over potential risks (“we don’t care what happens, as long as we get what we want, you understand” [Group 4, FGD 1]). Some participants perceived hypertension as severe. Females cited its fatality (“It is a silent killer” [Group 5, FGD 1]), while males emphasised its impact on quality of life (“I have seen people with high blood pressure and how affected they are” [Group 4, FGD 1]). Perceived benefits Participants largely recognised the benefits of health-related behaviour change. Both genders cited medication adherence, a healthy diet, and an active lifestyle as preventive measures. Females uniquely emphasised prayer (“I am not going to take the medication, I am just going to pray and I am going to be fine” [Group 3, FGD 1]), traditional medicine, disease management (“Anyone can develop hypertension but not everyone will die from hypertension because they can manage it well” [Group 3, FGD 1]), and ignoring hypertension (“As much as it is ignorant but us ignoring it, does in a way decrease us dwelling in it so much that we end up dying from that disease.” [Group 1; FGD 2]), while males highlighted increasing knowledge (“I think educating them is very important because it will leave them to see the disadvantages of it” [Group 2, FGD 1]), reducing salt intake, emotional regulation and healthcare access (“the government is making the hypertension numbers go lower because they provided clinics for people to go and get healthy” [Group 2, FGD 2]). Despite this, some females believed behaviour change offers limited benefits, as hypertension is inevitable (“Even though I drink enough water and go to the gym and also avoiding salty and junk food, I think at some point when I grow up, I will have [hypertension]” [Group 3, FGD 1]). Perceived barriers Participants predominantly reported high barriers to behaviour change, with shared concerns across genders, including limited access to healthy food (“We have more access to fast foods. You will not be able to eat proper cooked meals.” [Group 3, FGD 1]), illness stigma (“You tend to hear about it in your community or your next-door neighbour telling you about the high blood, it’s always a secret, it’s always a secret, but luckily for me, my granny told me the time she got it, so I know what it is” [Group 6, FGD 1]), lack of family support (“Us the young people living with our parents, we eat whatever is provided for in the house. There aren't as many healthy choices as possible. If one wants to buy them, it would be hard since our parents are the providers” [Group 1; FGD 1]), healthcare access issues (“They are associated with death. You think that when you go to the clinic it means that you are dying.” [Group 6, FGD 2]), persuasive unhealthy food advertising (“But mostly what you see on TV especially the adverts, you hardly see broccoli being advertised. I’ve never seen asparagus being advertised. I’ve never seen cauliflower. I only see your McDonalds, get your Big Mac for R69. You never see asparagus” [Group 2, FGD 2]), lack of knowledge (“We hardly communicate about non-communicable diseases as families and if we do it is only after when someone has already developed these diseases. As families we need to discuss about this issue so that we can be aware of it but in black families it is very rare.” [Group 4, FGD 2]), social norms promoting unhealthy behaviours (“The diet is basically the people around you. It doesn’t even have to be your family. It can be your group of friends. Whenever you go out to eat, most of your friends like a bunny chow or a burger that’s very salty and high in this and that” [Group 2, FGD 2]), and environmental barriers (“You know most of the parks when you go there you are going to get mugged. We no longer have a place where we can all go and sit down. The only places that we can go to now as Soweto youth are pubs.” [Group 6, FGD 2]). Females uniquely cited side effects of medication (“My grandmother becomes depressed whenever she has to drink her medication. She just gets angry and all she wants to do is to sleep, she does not want to talk to anyone. She says they pills makes her to go to the bathroom a lot” [Group 3; FGD 1]), stress (“Getting stressed makes the disease worse” [Group 1; FGD 1]), low motivation (“We are lazy” [Group 1; FGD 2]), time (“Young people only seem to make time for school” [Group 1; FGD 1]), finances (“I feel like food that is healthy and has quality are very expensive, so we buy food that we buy is cheap, but we don’t have a choice because we want to sleep with a full belly and those ones make us sick” [Group 5; FGD 2]), peer support (“‘My friend, let us go out to drink today.’ And if you say no, they will say you are boring. And another thing is that you will see that here I am losing friends.” [Group 3; FGD 1]), information gaps (“There is no one out there to point us to the right direction where information is concerned. Some of us had no idea about it until we came here” [Group 1, FGD 1]), and language barriers. Female participants also expressed a perception that a healthy lifestyle was not meant for them, associating health-conscious behaviours with being white (Caucasian). They reported experiencing scepticism and social stigma when making healthy choices, with others reacting with surprise or mockery. For example, one participant noted that drinking water was perceived as adopting a “white person mentality” (Group 3, FGD 3). Some participants shared that they received no support from home, with family members reinforcing the belief that a healthy lifestyle was “only for white people” (Group 1, FGD 1). Despite this, some participants noted minimal obstacles. Males highlighted public access to exercise equipment (“I think they promote it in a good way, because most of the townships there have playing grounds where they take children there to exercise.” [Group 4, FGD 2]) and supportive environments like churches (“In my church every year there is health promotion, and they make sure that we do not skip it. We discuss about mental health and chronic diseases. Nurses will come and different faculties.” [Group 4, FGD 2]), while females mentioned sufficient access to health information (“it is us who don’t bother to make the necessary effort in educating ourselves” [Group 5, FGD 1]), and accessibility of healthcare and healthy food (“there are people who sell veggies but not all of us…it is the elders that see the need of buying and cooking vegetables not all of us, not the youth” [Group 1; FGD 2]). Cues to action Participants primarily discussed external cues to action. Both genders emphasised discussing illness to learn from others (“She keeps on preaching it and I feel that if ever I come across such a problem or have it, a friend of mine has it then I will remember her words, that she did say – stop having too much of this or whatever the case may be. So I do think they do help in a way, personally I do feel that my granny does help in a way in preventing us getting hypertension or any diseases.” [Group 1, FGD 2]), increasing knowledge on healthy living (“Show people what healthy meals are” [Group 5, FGD 1]), engaging diverse stakeholders in awareness campaigns (“What I think is helpful is if you have experts. If we make experts rather. So basically you have… Let's say they take this group right, whether it's the government, whoever, then they educate us on let's say a specific NCD” [Group 2, FGD 3]), family-led behaviour change (“At home they tell us that we should not smoke and if we do, something will go wrong with your life, you will not succeed, you will end up being crazy, not knowing what the cause is. Nobody smokes at home” [Group 4, FGD 2]), and integrating healthier practices into social culture (“I say by tackling the things that the youth love the most, you create a demand, you know that youth love to party, create a social market, raising an awareness” [Group 6, FGD 3]). Females highlighted diagnosis (“I think that we deal with it when we know that we already have it. Prior to knowing I don't think that we pay much attention to it” [Group 5, FGD 1]), awareness programs in clinics, schools, churches, and government initiatives, routine screenings, community-led behaviour change, improving accessibility to healthy food, demonstrating illness examples in the community ("the only way they can grab our attention, and like, through stories lines of generations and where ever the case might be, just make a scene, one scene, of that person having that disease or whatever the case might be, they, because that’s the only way, not the only way, but the easiest way to grab our attention.” [Group 1; FGD 3]), financial incentives for health, and leveraging influential figures ("Let them get them like motivational speakers, which is their models. People that they look up to. At least if they hear it from their role models, it would probably make sense to them" [Group 3, FGD 3]). Males emphasised advertising healthy lifestyles ("They should have commercials that show the positive side of what’s this… of an active lifestyle. A physical active lifestyle. So that's one way they can do it.” [Group 2, FGD 3]), strengthening community structures (“When you don’t have a very strong support structure, you’re more prone to getting into bad things and making them… basically doing them habitually.” [Group 2, FGD 3]), and tailoring approaches for different demographics ("I think it's not a one-size-fits-all sometimes. Different demographics tend to focus on different things, right? So for the younger people might be social media. For the kids might be cartoons. For the adults might be going to church and yeah, doing more productive stuff. So I think we should make the information more available and to gain more traction from it by putting them in spaces where those democracies are more focused on, right” [Group 2, FGD 3]). Internal cues to action were less emphasised. Females cited personal reflection, observation, and avoiding family members' health issues (“even if my granny doesn’t say, don’t eat this, eat that but based on her health condition I can tell that I don’t want to be like this, so I will change my ways and my actions because I don’t want to be…not sick like her but I don’t want to have a health condition that is similar to hers.” [Group 1, FGD 2]), while males stressed the conscious choice to lead a healthier lifestyle (“No one promotes that behaviour for you, it is your choices. It starts with you to break the generational curse. So, no one is promoting drinking and smoking, it is your choice.” [Group 4, FGD 2]). Self-efficacy Participants predominantly exhibited low self-efficacy in making healthy behaviour changes. Both genders admitted frequently choosing unhealthy foods (“I don’t want to lie. We eat healthy, maybe once a week, otherwise we eat junk food or unhealthy food.” [Group 1, FGD 2]). Females described automatic, mindless food choices, feeling controlled by their bodies rather than their minds (“Because you can't control your body. If ever it's something that has to do with that, your body, you can't tell your body what to do and what not to do, because it controls itself.” [Group 3, FGD 3]), and struggling with behaviour change (“What I tell myself in my mind is that I am still young so I told myself that as time goes by, I will reduce but then I try every day to reduce, but then I can’t” [Group 1, FGD 2]), as well as medication adherence. Males cited peer pressure and difficulty resisting temptation (“It was hard, because peer pressure, you see you friends smoking, the temptations of smoking are really high.” [Group 4, FGD 3]) as barriers to self-efficacy. However, some high self-efficacy was noted among males, who expressed confidence in maintaining healthy behaviours (“I am firm in my believes so I don’t think I can be defeated or my body can be defeated as long as I channel myself to the right direction” [Group 2, FGD 1]) and cited past success in lifestyle changes to improve health (“I just changed my mindset, because I used to be wild, I used to be wicked, then I overgrew that, I used to smoke cigarette, I once smoked drugs, I stopped smoking, so yeah, I just changed how I think and how I perceive myself and how I perceive things.” [Group 6, FGD 3]). Perceived risk factors: The risk factors perceived by participants are demonstrated in Fig. 2 . Perceived protective factors: The protective factors perceived by participants are demonstrated in Fig. 3 . Discussion The findings of this paper provide critical insights into the social, cultural, and structural factors that shape young South Africans’ understanding of hypertension and their perceptions of prevention. The HBM concept of perceived threat (i.e., perceived susceptibility and perceived severity) suggests that individuals are more likely to take preventive action if they recognise a health threat as serious and as something they could develop 19, 20 . For many youth in this study, the low perceived severity of hypertension acted as a barrier to behaviour change despite youth perceiving high susceptibility. Although participants recognised their likelihood of developing hypertension in the future, participants in this study largely viewed their youth, good health, and lack of diagnosis as protective factors against threat of hypertension. This perception aligns with Elkind’s 21 concept of adolescent invincibility, which has been linked to a greater likelihood of engaging in risk behaviours 22 . A female participant illustrated this by stating, “We don’t care because we are not sick and we don’t get sick as much as the elderly, they care a lot”. This highlights a paradox in how South African youth perceive hypertension, as while they view it as an inevitable part of their future, they do not see it as an immediate threat to their health, leading to a reluctance to engage in preventative or management behaviours. Stress was also identified as a key psychological factor that further influenced participants' lack of engagement with hypertension prevention. Many emphasised the impact of stress as a key contributor to hypertension, believing that dwelling on the condition both before and after diagnosis could worsen its effects. As a result, some actively avoided thinking about hypertension as a coping mechanism. This aligns with the concept of avoidance coping, a strategy in which individuals manage distress by denying or distracting themselves from a health threat rather than actively addressing it 23, 24 . Evidence from South Africa shows that avoidance coping plays a critical role in health-related behaviours, as seen in people living with HIV, where internalised stigma predicted higher avoidant coping, leading to delayed antiretroviral therapy initiation and poorer health outcomes 23 . Similarly, in the context of hypertension, avoidant coping may diminish proactive health-seeking behaviours, reinforcing disengagement from prevention and treatment. Chasiotis et al. 24 further highlighted that avoidant motivation reduces engagement with health information-seeking and problem-focused coping, leading instead to emotion-focused coping strategies such as denial or distraction rather than direct disease management and prevention. In this study, participants demonstrated this pattern by prioritising stress management techniques, such as meditation and breathing exercises, over direct engagement with hypertension prevention strategies. While these approaches contribute to overall well-being, they may also serve as a form of psychological distancing, reinforcing inaction toward tangible risk reduction behaviours. In addition to stress, this study found that some youth (particularly female youth) viewed a healthy lifestyle in terms of drinking water and a healthy diet as something “only for white people”. This perspective reflects how racial and cultural identities influence health behaviours, particularly in a country like South Africa which continues to undergo significant social and cultural transformation 25 . South Africa’s shift from apartheid to a democratic society has created a paradox where modern, Western health practices are often viewed as foreign, while traditional beliefs and practices continue to influence health behaviours 25 . This dynamic can contribute to resistance to adopting behaviours that are perceived as "white", despite the clear links between poor dietary patterns and the prevalence of diseases like hypertension. Such cultural perceptions are not unique to South Africa, as research on dietary patterns among minorities in other regions, such as England, suggests that traditional food beliefs and cultural values significantly shape health behaviours 26 . Studies show that dietary messages and interventions often fail to resonate with minority groups if they are not culturally tailored, as factors like traditional foods, taste preferences, and social meaning play crucial roles in food choices 26 . This highlights the need for culturally responsive health interventions that acknowledge the broader socio-cultural context in which health behaviors are formed. Further to the social and cultural influences, peer pressure also played a significant role in shaping participant’s health-related behaviours. Literature suggests that adolescent males, in particular, exhibit increased risk-taking due to a stronger peer group orientation 27 . In this study, however, both genders justified unhealthy behaviours as integral to their social lives, emphasising the powerful influence of social norms. One female participant explained how social pressures dictated lifestyle choices: “My friend, let us go out to drink today.’ And if you say no, they will say you are boring. And another thing is that you will see that here I am losing friends. If you do things to please your friends, you will end up losing yourself.” A culture of social gatherings centered around high-calorie, processed foods, and limited physical activity reinforced these patterns. Some traditional cultural practices, such as the expectation to consume large portions of energy-dense foods during family or community events, were perceived as contributing to health risks. In line with findings from Buksh et al. 28 , participants in this study also shared that overconsumption of food during social gatherings was common and often encouraged. These social and cultural influences created an environment where making healthier choices was challenging, despite participants’ awareness of the long-term health consequences. As noted by Monterrosa et al. 29 , food choices are deeply influenced by cultural, social, and psychological factors, making dietary patterns both a personal and social expression of identity. This complex web of influences highlights the difficulty of adopting healthier eating habits in environments where traditional and social expectations outweigh concerns about nutritional health. Many participants learned about hypertension through observing family members or neighbours, with their views influenced by how those around them managed, or failed to manage, the condition. For some, hypertension was perceived as a minor, manageable issue, particularly when individuals neglected medication adherence yet appeared to function normally. This was especially true for those who remained asymptomatic, mirroring findings from Jimmy & Jose 30 , which highlight that non-compliance with chronic disease medications is most common when patients do not experience unpleasant symptoms. In fact, medication adherence rates for chronic conditions like hypertension often drop significantly when symptoms are absent, as patients perceive the disease as less urgent or severe. As a result, some individuals became complacent and skeptical about the true severity of the disease. This also aligns with Nouhravesh et al. 31 , who observed that asymptomatic participants often did not perceive their condition as a real threat, showing little effort to understand or manage it until symptoms appeared, further contributing to a false sense of security regarding the potential risks of hypertension. However, others who had witnessed serious complications, such as strokes, kidney failure, or premature death, regarded hypertension as a significant and life-altering condition. A major challenge was the secrecy surrounding hypertension, as many individuals hesitated to share their diagnosis due to stigma. Similar to the experiences of those living with dementia in South Africa, where internalised stigma and fear of social rejection led to secrecy and isolation 32 , individuals with hypertension often kept their condition hidden, further hindering open discussion. This lack of communication limited awareness, reducing perceived threat, and ultimately contributing to a gap in health knowledge. The stigma surrounding the condition, coupled with a reluctance to acknowledge its impact, led to indifference toward key risk factors such as poor diet and physical inactivity. Additionally, in certain cultural contexts, illness is not only seen as a biological issue but also through a social and spiritual lens, reinforcing stigma and complicating the process of seeking help or support 33, 34 . Facilitated by stigma and secrecy, participant’s in this study often did not describe having firsthand experience of hypertension’s long-term consequences. This, alongside the low perceived severity, led participants to perceive hypertension as irrelevant and unnecessary to address or prevent in their current, healthy state. Building on stigma and secrecy, family and social networks play a critical role in shaping youth’s health behaviours, particularly in the context of hypertension. Family structures and systems are essential in shaping food choices, as they establish the foundation for lifelong eating habits 29 . Food practices are primarily learned through the transmission of behaviours and norms from parents to children, influencing not only what is eaten but also how and when meals are consumed 29 . Families that actively support healthy eating by making nutritious food available, encouraging balanced meals, and modeling positive behaviours create an environment where healthy lifestyles are more easily adopted. Parents who lead by example, whether by preparing nutritious meals, prioritising family mealtimes, or promoting mindful eating, help instill lasting habits in their children 29 . Conversely, when family support for healthy food and lifestyle choices is lacking, it creates significant barriers to change. If unhealthy eating patterns are normalised within the household, individuals may struggle to prioritise nutrition, even when they recognise the importance of healthier choices. Without collective family engagement, making sustainable changes becomes challenging, as individuals often rely on social reinforcement to maintain new behaviours. Thus, families serve as both facilitators and obstacles in the pursuit of a healthier lifestyle, shaping food choices through both explicit instruction and implicit modeling in daily routines 29 . External cues played a crucial role in shaping youth behaviour in this study, often exerting a more immediate and compelling influence than internal factors such as personal reflection or family health history. Among these external influences, family members, particularly parents and guardians, were frequently cited as key drivers of health-related behaviours. Families served as the primary source of health knowledge, behavioural norms, and lifestyle patterns, with both positive and negative impacts. When families actively supported healthy behaviours, participants found it easier to make and sustain positive changes. This influence is especially significant for youth, many of whom still live at home and are heavily impacted by their families’ attitudes and actions. As noted by Bottorff et al. 35 , the family unit plays a crucial role in shaping healthy behaviours, especially in childhood, by providing opportunities for physical activity and healthy eating. Although their study focused on children, this dynamic remains relevant for youth, as family caregivers continue to play a key role in fostering healthy lifestyles and addressing modifiable risk factors, such as poor diet and physical inactivity, which can lead to long-term health issues like hypertension. These results highlight the complex, multilevel factors that shape food and lifestyle related choices, where interactions between youth and their environment influence health-related behaviours 29 . While environmental factors, such as food marketing and availability, play a crucial role, biological factors like innate preferences for sweet, salty, and high-fat foods (which are deeply rooted in our biology) also drive individuals toward unhealthy options 36 . The food industry exacerbates this dynamic by marketing highly palatable, energy-dense foods that stimulate pleasure receptors in the brain, reinforcing unhealthy eating habits 37 . Youth in this study described pervasive advertising for fast food and sugary drinks as a persistent external cue, normalising unhealthy consumption and making it harder to prioritise healthier options. Broader structural factors, including limited access to affordable healthy food, lack of fitness resources, and societal norms favouring convenience over health, create systemic barriers to adopting healthier lifestyles. Additionally, barriers to healthcare access, such as long wait times and a focus on treatment (medication) rather than prevention, deter youth from engaging in proactive health management, with perceptions that clinics are only for severe illness further delaying the adoption of preventative care 38 . These combined factors contribute to unhealthy dietary behaviours and limited engagement with health-services, increasing the risk of hypertension in South African youth. Lastly, the findings of this paper demonstrate that youth are looking to community structures such as schools, churches, clinics, and government institutions in supporting youth efforts to adopt healthier behaviours. Participants emphasised the need for greater dissemination of accurate health information and the creation of environments that actively facilitate positive change. While churches are highlighted in this paragraph to illustrate the role of these institutions, the findings can also be applied to schools, clinics, and government organisations, as they share a similar potential to influence health outcomes. Evidence, such as the Impilo neZenkolo (‘Health through Faith’) programme 39 , demonstrates the potential of church-based interventions to address health challenges in lower income communities. Further to this, churches have also played a key role in promoting health in South Africa, as seen in HIV prevention efforts 40 , underscoring their potential as important partners in public health initiatives. However, while structures such as churches hold promise as powerful agents of health promotion, participants also acknowledge their capacity to spread misinformation when not used correctly. Churches, for example, were identified by participants as both a source of guidance and a barrier; while some invited health experts to educate congregants on disease prevention and healthy living, others promoted the idea of praying illness away. Expanding on the former point, in this study, youth advocated for the inclusion of diverse stakeholders, and emphasised the importance of moving beyond one-size-fits-all health campaigns. They call for collaborative efforts that engage influential community figures such as doctors, religious leaders, media personalities, and government officials to co-create sustainable and meaningful preventive health initiatives. Limitations The study's limitations include the restricted generalisability of its findings due to the focus on a specific demographic in Soweto, which may not reflect the diversity of socioeconomic, cultural, and regional variations within urban South Africa or Sub-Saharan Africa more broadly. As such, the results may not be transferable to other regions or rural populations. Additionally, the reliance on self-reported data introduces the potential for biases in participants' health knowledge, lifestyle choices, and attitudes towards hypertension, as individuals may exaggerate or downplay certain behaviours or perceptions. Lastly, the cross-sectional nature of the study limits causal interpretations, making it difficult to determine whether the identified perceptions directly influence hypertension prevention behaviours over time. Future research should incorporate longitudinal or mixed-methods approaches to enhance the robustness of these findings. Conclusion While youth recognise their susceptibility to hypertension, they perceive low severity, often viewing their age and good health as protective factors. Stress and avoidance coping further contribute to disengagement from prevention, alongside cultural perceptions that frame healthy lifestyles as foreign. Social influences, including peer pressure and traditional dietary practices, reinforce unhealthy behaviours, while family experiences shape perceptions of hypertension’s seriousness. Stigma and secrecy surrounding the condition limit open discussions, reducing perceived threat and awareness. External influences, such as social networks and cultural norms, often outweigh individual health knowledge, emphasising the need for youth-centred, culturally responsive interventions. Addressing these barriers requires a shift from purely biomedical approaches to holistic strategies that acknowledge the broader social and psychological factors influencing youth engagement with hypertension prevention. Abbreviations NCDs - non-communicable diseases SSA - Sub-Saharan Africa BP - blood pressure PP - Precision prevention SAMRC - South African Medical Research Council DPHRU - Developmental Pathways for Human Research Unit FGD – focus group discussion HBM – Health Belief Model Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the University of Witwatersrand Human Research Ethics Committee (Medical) (REF: R14/49, Protocol no: M220818). All participants received an information sheet (Appendix A) outlining the purpose and procedures of the study. Informed consent was obtained prior to participation (Appendix B), including explicit consent for audio recording where applicable (Appendix C). Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the principle author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Funding for this study was provided by the South African Medical Research Council. Author Contributions MJS and SAN contributed to the study conception and design. MJS led data collection, conducted the data analysis, and wrote the initial manuscript draft. SAN and SHC reviewed and contributed to the final version. All authors provided edits and critiqued the manuscript for intellectual content. Acknowledgements The authors would like to acknowledge the staff of the SAMRC Developmental Pathways for Health Research Unit for their invaluable assistance in sourcing participants and facilitating the focus group discussions. Their support contributed significantly to the successful completion of this study. References Addo J, Smeeth L, Leon DA. Hypertension in sub-saharan Africa: a systematic review. Hypertension. 2007;50(6):1012-8. Kohli-Lynch CN, Erzse A, Rayner B, Hofman KJ. Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study. BMJ Open. 2022;12(2):e055621. Matheson GO, Klügl M, Engebretsen L, Bendiksen F, Blair SN, Börjesson M, et al. Prevention and management of non-communicable disease: the IOC consensus statement, Lausanne 2013. Sports Med. 2013;43(11):1075-88. Anderson GH. Effect of age on hypertension: analysis of over 4,800 referred hypertensive patients. Saudi J Kidney Dis Transpl. 1999;10(3):286-97. Ryan JC, Viana JN, Sellak H, Gondalia S, quot, Callaghan N. Defining precision health: a scoping review protocol. BMJ Open. 2021;11(2):e044663. Kagura J, Adair LS, Munthali RJ, Pettifor JM, Norris SA. Association Between Early Life Growth and Blood Pressure Trajectories in Black South African Children. Hypertension. 2016;68(5):1123-31. Winpenny EM, van Sluijs EMF, White M, Klepp K-I, Wold B, Lien N. Changes in diet through adolescence and early adulthood: longitudinal trajectories and association with key life transitions. International Journal of Behavioral Nutrition and Physical Activity. 2018;15(1):86. Sawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health. 2018;2(3):223-8. Tohi M, Bay JL, Tu'akoi S, Vickers MH. The Developmental Origins of Health and Disease: Adolescence as a Critical Lifecourse Period to Break the Transgenerational Cycle of NCDs-A Narrative Review. Int J Environ Res Public Health. 2022;19(10). Backes EP, Bonnie RJ. The promise of adolescence: Realizing opportunity for all youth. 2019. Mukoma G, Bosire EN, Klingberg S, Norris SA. Healthy eating and physical activity: Analysing Soweto’s young adults’ perspectives with an intersectionality lens. PLOS Global Public Health. 2023;3(7):e0001429. Ruthsatz M, Candeias V. Non-communicable disease prevention, nutrition and aging. Acta Biomed. 2020;91(2):379-88. Leopold JA, Loscalzo J. Emerging Role of Precision Medicine in Cardiovascular Disease. Circ Res. 2018;122(9):1302-15. Naithani N, Sinha S, Misra P, Vasudevan B, Sahu R. Precision medicine: Concept and tools. Med J Armed Forces India. 2021;77(3):249-57. Gittelsohn J, Steckler A, Johnson CC, Pratt C, Grieser M, Pickrel J, et al. Formative research in school and community-based health programs and studies: "state of the art" and the TAAG approach. Health Educ Behav. 2006;33(1):25-39. Sekome K, Gómez-Olivé FX, Sherar LB, Esliger DW, Myezwa H. Sociocultural perceptions of physical activity and dietary habits for hypertension control: voices from adults in a rural sub-district of South Africa. BMC Public Health. 2024;24(1):2194. Mpondo F, Kim AW, Tsai AC, Mendenhall E. Development and validation of the Soweto Coping Scale: A mixed-methods, population-based study of adults living in Soweto, South Africa. J Affect Disord. 2022;303:353-8. Wibeck V, Dahlgren MA, Öberg G. Learning in focus groups: An analytical dimension for enhancing focus group research. Qualitative research. 2007;7(2):249-67. Jones CJ, Smith H, Llewellyn C. Evaluating the effectiveness of health belief model interventions in improving adherence: a systematic review. Health Psychol Rev. 2014;8(3):253-69. Alyafei A, Easton-Carr R. The Health Belief Model of Behavior Change. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright © 2025, StatPearls Publishing LLC.; 2025. Elkind D. Children and adolescents: Interpretive essays on Jean Piaget. Oxford, England: Oxford U. Press; 1970. xi, 160-xi, p. Wickman ME, Anderson NL, Greenberg CS. The adolescent perception of invincibility and its influence on teen acceptance of health promotion strategies. J Pediatr Nurs. 2008;23(6):460-8. Earnshaw VA, Bogart LM, Laurenceau JP, Chan BT, Maughan-Brown BG, Dietrich JJ, et al. Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator. J Int AIDS Soc. 2018;21(10):e25198. Chasiotis A, Wedderhoff O, Rosman T, Mayer A-K. The Role of Approach and Avoidance Motivation and Emotion Regulation in Coping Via Health Information Seeking. Current Psychology. 2021;40(10):5235-44. Feigin R. White with a Black Soul: Illness Perception and Behavior and its Implications on Healthcare in the New South African Society. Illness, Crisis & Loss. 2013;21(2):125-40. Ojo AS, Nnyanzi LA, Giles EL, Ells L, Okeke SR, Ajayi KV, et al. "I am not really into the government telling me what I need to eat": exploring dietary beliefs, knowledge, and practices among ethnically diverse communities in England. BMC Public Health. 2023;23(1):800. McCoy SS, Dimler LM, Samuels DV, Natsuaki MN. Adolescent Susceptibility to Deviant Peer Pressure: Does Gender Matter? Adolescent Research Review. 2019;4(1):59-71. Buksh SM, de Wit JBF, Hay P. Sociocultural Influences Contribute to Overeating and Unhealthy Eating: Creating and Maintaining an Obesogenic Social Environment in Indigenous Communities in Urban Fiji. Nutrients. 2022;14(14). Monterrosa EC, Frongillo EA, Drewnowski A, de Pee S, Vandevijvere S. Sociocultural Influences on Food Choices and Implications for Sustainable Healthy Diets. Food Nutr Bull. 2020;41(2_suppl):59s-73s. Jimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. 2011;26(3):155-9. Nouhravesh N, Sindet-Pedersen C, Kümler T, Schou M, Lamberts MK, Højen AA. “No one told me anything about it and I cannot explain it”: Illness perception in symptomatic and asymptomatic patients with cancer-associated thrombosis. Thrombosis Research. 2022;220:125-30. Jacobs R, Schneider M, Farina N, du Toit P, Evans-Lacko S. Stigma and its implications for dementia in South Africa: a multi-stakeholder exploratory study. Ageing and Society. 2024;44(4):867-97. Mavundla T, Netswera F, Bottoman B, Toth F. Rationalization of Indigenous Male Circumcision as a Sacred Religious Custom: Health Beliefs of Xhosa Men in South Africa. Journal of transcultural nursing : official journal of the Transcultural Nursing Society / Transcultural Nursing Society. 2009;20:395-404. Mkhonto F, Hanssen I. When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. J Clin Nurs. 2018;27(1-2):e169-e76. Bottorff J, Hamilton C, Huisken A, Taylor D. Correlates of Food Insecurity Among Undergraduate Students. Canadian Journal of Higher Education. 2020;50:15-23. Drewnowski A, Almiron-Roig E. Frontiers in Neuroscience Human Perceptions and Preferences for Fat-Rich Foods. In: Montmayeur JP, le Coutre J, editors. Fat Detection: Taste, Texture, and Post Ingestive Effects. Boca Raton (FL): CRC Press/Taylor & Francis Copyright © 2010, Taylor & Francis Group, LLC.; 2010. Mc Carthy CM, de Vries R, Mackenbach JD. The influence of unhealthy food and beverage marketing through social media and advergaming on diet-related outcomes in children-A systematic review. Obes Rev. 2022;23(6):e13441. Dong R, Leung C, Naert MN, Naanyu V, Kiptoo P, Matelong W, et al. Chronic disease stigma, skepticism of the health system, and socio-economic fragility: Qualitative assessment of factors impacting receptiveness to group medical visits and microfinance for non-communicable disease care in rural Kenya. PLOS ONE. 2021;16(6):e0248496. Draper CE, Tomaz SA, Zihindula G, Bunn C, Gray CM, Hunt K, et al. Development, feasibility, acceptability and potential effectiveness of a healthy lifestyle programme delivered in churches in urban and rural South Africa. PLOS ONE. 2019;14(7):e0219787. Madlala ST, Khanyile S. The roles of churches in HIV prevention among youth at Nqutu in KwaZulu-Natal South Africa. Curationis. 2023;46(1):e1-e9. Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Published Journal Publication published 05 Aug, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 13 May, 2025 Reviews received at journal 01 May, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviewers agreed at journal 15 Apr, 2025 Reviews received at journal 11 Apr, 2025 Reviewers agreed at journal 07 Apr, 2025 Reviewers invited by journal 03 Apr, 2025 Editor invited by journal 03 Apr, 2025 Editor assigned by journal 03 Apr, 2025 Submission checks completed at journal 03 Apr, 2025 First submitted to journal 29 Mar, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6333489","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":447173235,"identity":"afd9a737-b417-4c49-8af3-6f7dbff0429e","order_by":0,"name":"Madeleine J 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1","display":"","copyAsset":false,"role":"figure","size":127539,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003eApplying the HBM to formative PP research\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e* Dotted lines indicate interacting influences between domains, and solid lines indicate a direct relationship with likelihood of engaging in health-related behaviours\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6333489/v1/efc28efacb0901793ec4bc50.png"},{"id":81938348,"identity":"d3778e15-e0de-4dc6-bff6-869da4ddad3e","added_by":"auto","created_at":"2025-05-05 06:36:35","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":255752,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRisk factors perceived by participants\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6333489/v1/7fb4ac1d6626ca727baa3db1.png"},{"id":81939649,"identity":"37c149f9-2c06-4e9e-806b-912c16a30a77","added_by":"auto","created_at":"2025-05-05 06:44:35","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":145162,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eProtective factors perceived by participants\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e* In Figures 2 and 3: (M\u0026amp;F) indicates the response was from both male and female participants, (F) indicates the response was from only female participants, and (M) indicates the response was from only male participants.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-6333489/v1/5571c6c773702cfb05a9abc4.png"},{"id":88814784,"identity":"8740b506-5bf5-4e59-9744-80a970122128","added_by":"auto","created_at":"2025-08-11 16:09:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1209803,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6333489/v1/b6fcf9ba-db5a-494c-9ea0-47d52c4e96dd.pdf"},{"id":81939646,"identity":"1a1c9709-e9ae-4043-903a-7f362e2aaa5c","added_by":"auto","created_at":"2025-05-05 06:44:35","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":41321,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-6333489/v1/00bccd97bfad9579469dca1d.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"“We don’t care because we are not sick”: Understanding youths perceptions of hypertension in urban South Africa","fulltext":[{"header":"Background","content":"\u003cp\u003eThe burden of non-communicable diseases (NCDs) has steadily increased in Sub-Saharan Africa (SSA), with hypertension emerging as a significant driving force with prevalence rising from 25% in 2000 to 40% in 2022 in South Africa\u003csup\u003e1\u0026ndash;3\u003c/sup\u003e. The development of hypertension is influenced by genetic, environmental and lifestyle factors that often begin in early life\u003csup\u003e4, 5\u003c/sup\u003e. Evidence suggests that blood pressure (BP) patterns established in childhood strongly predict future hypertension risk. A longitudinal study in South Africa found that one in three children with elevated BP at age five remained in higher BP categories at age 18\u003csup\u003e6\u003c/sup\u003e. Specifically, boys with BP above the 95th percentile at age five were 3.85 times more likely to be in the upper BP trajectory group by adolescence and 21.8 times more likely to remain in the middle BP trajectory. Similarly, girls with elevated BP at age five had an almost six-fold increased likelihood of being in the middle BP trajectory and a nearly seven-fold increased likelihood of remaining in the upper BP trajectory\u003csup\u003e6\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs young adults transition into adulthood, the personal, social and environmental changes they experience significantly influence lifestyle choices, often contributing to poor diets and rapid weight gain\u003csup\u003e7\u003c/sup\u003e. Adolescence, defined as the developmental stage from 10 to 25 years of age\u003csup\u003e8\u003c/sup\u003e, is particularly critical for establishing lifelong health as lifestyle behaviours become entrained during this stage\u003csup\u003e9\u003c/sup\u003e. This is also a critical period for NCD prevention, as rapid biological changes (including hormonal fluctuations and metabolic shifts), interact with behavioural and environmental factors, such as poor diet, physical inactivity and stress\u003csup\u003e10\u003c/sup\u003e. Adolescence is also marked by increased autonomy in dietary and lifestyle choices, often accompanied by experimentation with risk behaviours such as smoking and excessive alcohol consumption, further compounding long-term health risks\u003csup\u003e9\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThere is an urgent need to support youth in adopting and sustaining behaviours that offset hypertensive risk, setting them on healthier life trajectories\u003csup\u003e11\u003c/sup\u003e. Prevention efforts that prioritise early prevention can significantly reduce the long-term burden of chronic diseases by equipping young people with the knowledge and tools necessary for sustained health\u003csup\u003e12\u003c/sup\u003e. Precision prevention (PP), a targeted approach within the broader framework of precision medicine, strengthens these efforts by customising interventions based on a combination of factors including biological, environmental and social determinants of health\u003csup\u003e13, 14\u003c/sup\u003e. Unlike conventional public health strategies that apply uniform interventions across populations, PP harnesses multi-dimensional data, including genetic pre-dispositions, behavioural patterns, and socioeconomic influences to tailor preventative measures to specific individuals or groups. PP may provide a useful framework in the development of youth-based interventions to minimise elevated blood pressure.\u003c/p\u003e \u003cp\u003eA key step in the development of youth-based interventions is understanding the social, cultural and environmental factors that shape adolescent health behaviours related to elevated blood pressure\u003csup\u003e15\u003c/sup\u003e. Given the multifaceted influences on health behaviours (ranging from economic and interpersonal factors to structural barriers) formative research helps tailor interventions to specific risk profiles\u003csup\u003e15\u003c/sup\u003e. Most qualitative studies on hypertension in South Africa have focused on adults, such as Sekome et al.\u003csup\u003e16\u003c/sup\u003e, who examined how social and cultural factors influence hypertension control in rural South Africa. Their findings highlight the significant role of community perceptions, affordability of healthy food, and gendered expectations in shaping physical and dietary habits. There are currently no published qualitative studies that explore youth perceptions of hypertension in South Africa, leaving a critical gap in understanding how young people perceive their risk and engage with prevention efforts.\u003c/p\u003e \u003cp\u003eThis paper explores how young people in peri-urban South Africa perceive hypertension, its risk factors, and prevention strategies. By engaging directly with youth living in Soweto, this study aims to uncover the social, cultural, and structural factors that shape their understanding of hypertension and their perceptions of prevention. The findings will contribute to the development of contextually relevant PP strategies that resonate with young people\u0026rsquo;s lived experiences, ultimately strengthening hypertension precision prevention efforts in peri-urban South African settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThis research is part of a larger initiative for developing PP intervention mechanisms aimed at reducing the hypertension risk in Soweto, South Africa. Data collection was conducted at a health-based research centre within a local tertiary hospital in Soweto. Soweto is a historically disadvantaged peri-urban township in Gauteng, South Africa\u003csup\u003e17\u003c/sup\u003e. It is South Africa\u0026rsquo;s largest urban-poor township of approximately 1.8\u0026nbsp;million people.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eEighty five young people were approached and 62 thereof consented to participate in the study. Purposive sampling was used to recruit participants. Households that had young people that were identified from the Soweto Household Study database were approached and invited to participate in the study. Participants were considered eligible to participate in this study if they were (a) Sowetan (either living in or from Soweto) and (b) between the ages of 18 and 25.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eData was collected at the South African Medical Research Council (SAMRC) Developmental Pathways for Human Research Unit (DPHRU) at Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. While the primary language used during discussions was English, researchers were multilingual, allowing participants the option to express themselves in their home vernacular as necessary, fostering a more inclusive and comfortable environment. A total of 62 youth participants were organised into six smaller groups by gender, with three male and three female groups, each consisting of approximately eight participants, and each group took part in three successive focus group discussion (FGD) sessions. The FGDs were conducted over three weekends, with sessions held on Saturdays to accommodate participants\u0026rsquo; work and study commitments. Sessions were held concurrently, with researchers facilitating discussions in separate rooms. For each group, each day consisted of three FGD sessions that were spaced to ensure sufficient time for in-depth discussions. To enhance participant comfort and engagement, breaks were scheduled between sessions, during which refreshments were provided, and a full lunch was offered. This approach allowed participants to reflect between discussions.\u003c/p\u003e \u003cp\u003e The FGDs, lasting around two hours each, were designed to elicit in-depth insights into participants\u0026rsquo; experiences, knowledge, attitudes, and beliefs concerning hypertension. A semi-structured FGD guide was used to facilitate the sessions, allowing a structured yet flexible approach to maintain focus on research objectives while providing participants the freedom to guide the conversation. Discussions took place in a private room at DPHRU, where participants were seated in a circular arrangement to promote open interaction. Separating groups by gender aimed to create a setting where participants could feel comfortable sharing their views without inhibition\u003csup\u003e18\u003c/sup\u003e. Data was collected through both note-taking by the facilitator and audio recordings, for which participants had granted permission beforehand. These recordings were securely stored on password-protected computers and transcribed later for analysis. Ethical approval was obtained prior to the research from the University of Witwatersrand Human Research Ethics Committee (Medical) (REF: R14/49 Protocol no: M220818). The research was performed in accordance with the 1964 Declaration of Helsinki and its later amendments. Clinical trial number: not applicable. Participants received an information sheet (Appendix A) detailing the study, and informed consent was collected prior to their participation (Appendix B), including specific consent for audio recording (Appendix C). Refreshments were provided to participants at the conclusion of each session.\u003c/p\u003e \u003cp\u003e The Health Belief Model (HBM) provided a guiding framework for structuring the FGDs. The model\u0026rsquo;s six domains: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy were used to generate discussion across the three FGDs for each group. FGD 1 focused on perceived susceptibility and severity, exploring participants\u0026rsquo; understanding of hypertension and their beliefs about who is at risk and how the disease affects daily life. FGD 2 examined perceived barriers and benefits, as well as cues to action, by investigating the role of various environmental and social determinants in shaping health behaviours. FGD 3 emphasised self-efficacy and the development of intervention strategies, exploring how individuals, families, communities, and institutions can work together to promote healthy behaviours. Appendices D, E and F outline the FGD schedules.\u003c/p\u003e \u003cp\u003eThe HBM provides a valuable framework for formative research, as it demonstrates the cognitive and social factors influencing health behaviours\u003csup\u003e19\u003c/sup\u003e. By examining how youth in peri-urban South Africa perceive their susceptibility to hypertension, the severity of its consequences, and the benefits or barriers to prevention, the HBM helps identify gaps in awareness and key drivers of behaviour change. Integrating HBM insights into PP strategies allows for interventions that not only address individual risk factors but also align with youth motivations, social contexts, and structural challenges. This approach strengthens the relevance and impact of prevention efforts, ensuring that they resonate with young people and promote long-term health engagement\u003csup\u003e19\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe likelihood of engaging in preventative health behaviours for hypertension is shaped by the interaction of key constructs within the HBM (illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Perceived threat, derived from perceived susceptibility (belief in one\u0026rsquo;s risk), and perceived severity (belief in the condition\u0026rsquo;s consequences), influences motivation to act\u003csup\u003e20\u003c/sup\u003e. However, behaviour change also depends on whether perceived benefits of prevention outweigh perceived barriers, such as cost or accessibility\u003csup\u003e20\u003c/sup\u003e. Self-efficacy, or confidence in one\u0026rsquo;s ability to adopt healthy behaviours, determines follow-through, while cues to action (including health messages, social influences, or symptoms) can trigger engagement\u003csup\u003e20\u003c/sup\u003e. By structuring the FGDs around these domains, this study ensures that discussions not only capture youth perceptions on hypertension, but also inform targeted interventions that address both individual and contextual barriers to prevention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll FGDs were audio-recorded, transcribed verbatim, and where necessary, translated. Data were analysed using a thematic approach guided by the constructs of the HBM: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and self-efficacy. Findings were first analysed collectively across all focus groups to identify overarching patterns, before being organised into the thematic domains of the HBM. Data from male and female groups were examined both separately and together to identify gendered perspectives. Excel was used to manage and code the data systematically.\u003c/p\u003e \u003cp\u003e The analysis followed an iterative process, beginning with familiarisation, where all transcripts were reviewed in-depth to gain a comprehensive understanding of participants\u0026rsquo; perspectives. A deductive coding framework was initially developed based on the HBM constructs, while inductive coding allowed for the identification of emergent themes beyond the model. Codes were continuously refined through multiple rounds of review to ensure consistency and rigour.\u003c/p\u003e \u003cp\u003eThematic domains were constructed based on patterns that emerged across the full dataset, reflecting shared and divergent perspectives among participants. Representative quotations were selected to illustrate key themes, providing depth and context to the findings. Reflexivity was maintained throughout the process to account for potential researcher biases, ensuring a nuanced and accurate interpretation of data.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eSample characteristics\u003c/h2\u003e \u003cp\u003eSixty two youth participated in the FGDs. The mean age of participants was 20.8 years. Male participants (n\u0026thinsp;=\u0026thinsp;33, 53%, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e = 21 years) and female participants (n = 29, 47%, \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\stackrel{-}{x}\\)\u003c/span\u003e\u003c/span\u003e = 20,5 years) were divided for the purposes of the FGDs. 57% (n = 35) of participants were enrolled in educational institutions at the time of participation. 34% (n = 21) of participants were enrolled in tertiary or higher education facilities, 18% (n = 11) of participants were either in Grade 12 or upgrading their Grade 12 results, and 5% (n = 3) of participants were still in high school. 34% (n = 21) of participants were unemployed, and 10% (n = 6) of participants were employed at the time of participation.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceived susceptibility\u003c/h3\u003e\n\u003cp\u003eParticipants generally perceived high susceptibility to hypertension. Both male and female participants recognised susceptibility due to personal diagnosis, universal risk (\u0026ldquo;Everyone is at risk of developing hypertension because it depends on diet\u0026rdquo; [Group 1, FGD 1]), genetic predisposition (\u0026ldquo;It\u0026rsquo;s not mostly older people, it\u0026rsquo;s genetics\u0026rdquo; [Group 4, FGD 1]), and stress (\u0026ldquo;For instance if you are a breadwinner everything is on you. You must make sure that children go to school, there\u0026rsquo;s food in the house. This might end up causing you stress and as a result hypertension\u0026rdquo; [Group 2, FGD 2]). However, female participants uniquely highlighted family history (\u0026ldquo;For me, like I said my mother has it and my grandmother also has it. I think that when I grow, I will also have it\u0026rdquo; [Group 3, FGD 1]) and personal vulnerability. While male participants emphasised modeling unhealthy family lifestyle behaviours (\u0026ldquo;Society regard our family members as should be our role models. So you would think that the right thing to do is to consume alcohol which may lead you having hypertension\u0026rdquo; [Group 2, FGD 2]), both genders acknowledged that current lifestyle choices increase their susceptibility.\u003c/p\u003e \u003cp\u003eA minority expressed low susceptibility. Male and female participants cited their youth (\u0026ldquo;When you are younger, you are still strong, meant to be a tool in a way\u0026rdquo; [Group 2, FGD 1]) and healthy behaviours as protective factors. Females uniquely noted a lack of concern due to not considering hypertension a threat or being undiagnosed (\u0026ldquo;We don\u0026rsquo;t care because we are not sick and we don\u0026rsquo;t get sick as much as the elderly, they care a lot\u0026rdquo; [Group 1, FGD 2]). Males mentioned plans to adopt healthier behaviours (\u0026ldquo;It is not a threat per say because I am planning on stopping spicy and junk food\u0026rdquo; [Group 2, FGD 1]) and a belief in immunity due to strong constitution (\u0026ldquo;I am a soldier\u0026rdquo; [Group 6, FGD 2]).\u003c/p\u003e\n\u003ch3\u003ePerceived severity\u003c/h3\u003e\n\u003cp\u003eHypertension was largely perceived as low in severity, with gender-based differences in reasoning. Female participants expressed skepticism about the disease\u0026rsquo;s existence (\u0026ldquo;My grandmother was diagnosed but there are no symptoms, zero, nothing at all\u0026rdquo; [Group 3, FGD 1]), lack of exposure to its effects (\u0026ldquo;For me it is not a big deal because I have never experienced it around me\u0026rdquo; [Group 3, FGD 1]), belief in self-healing, and only taking it seriously when life-threatening (\u0026ldquo;They don\u0026rsquo;t take them seriously, someone has to on the verge of dying then it will be taken seriously.\u0026rdquo; [Group 5, FGD 2]). Males cited treatability (\u0026ldquo;if you do take treatment, it\u0026rsquo;s not a threat to your, to your health\u0026rdquo; [Group 2, FGD 1]), perceived mild impact on quality of life (\u0026ldquo;The only way I think it affects them is, sometimes she gets swelling feet, and she does not get cold very easily.\u0026rdquo; [Group 2, FGD 1]), youth as a protective factor (\u0026ldquo;We don\u0026rsquo;t think that we as the youth can get it, we think it is only going to affect our grandmothers and grandfathers only\u0026rdquo; [Group 4, FGD 1]), and prioritising the benefits of unhealthy behaviours over potential risks (\u0026ldquo;we don\u0026rsquo;t care what happens, as long as we get what we want, you understand\u0026rdquo; [Group 4, FGD 1]). Some participants perceived hypertension as severe. Females cited its fatality (\u0026ldquo;It is a silent killer\u0026rdquo; [Group 5, FGD 1]), while males emphasised its impact on quality of life (\u0026ldquo;I have seen people with high blood pressure and how affected they are\u0026rdquo; [Group 4, FGD 1]).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003ePerceived benefits\u003c/h2\u003e \u003cp\u003eParticipants largely recognised the benefits of health-related behaviour change. Both genders cited medication adherence, a healthy diet, and an active lifestyle as preventive measures. Females uniquely emphasised prayer (\u0026ldquo;I am not going to take the medication, I am just going to pray and I am going to be fine\u0026rdquo; [Group 3, FGD 1]), traditional medicine, disease management (\u0026ldquo;Anyone can develop hypertension but not everyone will die from hypertension because they can manage it well\u0026rdquo; [Group 3, FGD 1]), and ignoring hypertension (\u0026ldquo;As much as it is ignorant but us ignoring it, does in a way decrease us dwelling in it so much that we end up dying from that disease.\u0026rdquo; [Group 1; FGD 2]), while males highlighted increasing knowledge (\u0026ldquo;I think educating them is very important because it will leave them to see the disadvantages of it\u0026rdquo; [Group 2, FGD 1]), reducing salt intake, emotional regulation and healthcare access (\u0026ldquo;the government is making the hypertension numbers go lower because they provided clinics for people to go and get healthy\u0026rdquo; [Group 2, FGD 2]). Despite this, some females believed behaviour change offers limited benefits, as hypertension is inevitable (\u0026ldquo;Even though I drink enough water and go to the gym and also avoiding salty and junk food, I think at some point when I grow up, I will have [hypertension]\u0026rdquo; [Group 3, FGD 1]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePerceived barriers\u003c/h2\u003e \u003cp\u003eParticipants predominantly reported high barriers to behaviour change, with shared concerns across genders, including limited access to healthy food (\u0026ldquo;We have more access to fast foods. You will not be able to eat proper cooked meals.\u0026rdquo; [Group 3, FGD 1]), illness stigma (\u0026ldquo;You tend to hear about it in your community or your next-door neighbour telling you about the high blood, it\u0026rsquo;s always a secret, it\u0026rsquo;s always a secret, but luckily for me, my granny told me the time she got it, so I know what it is\u0026rdquo; [Group 6, FGD 1]), lack of family support (\u0026ldquo;Us the young people living with our parents, we eat whatever is provided for in the house. There aren't as many healthy choices as possible. If one wants to buy them, it would be hard since our parents are the providers\u0026rdquo; [Group 1; FGD 1]), healthcare access issues (\u0026ldquo;They are associated with death. You think that when you go to the clinic it means that you are dying.\u0026rdquo; [Group 6, FGD 2]), persuasive unhealthy food advertising (\u0026ldquo;But mostly what you see on TV especially the adverts, you hardly see broccoli being advertised. I\u0026rsquo;ve never seen asparagus being advertised. I\u0026rsquo;ve never seen cauliflower. I only see your McDonalds, get your Big Mac for R69. You never see asparagus\u0026rdquo; [Group 2, FGD 2]), lack of knowledge (\u0026ldquo;We hardly communicate about non-communicable diseases as families and if we do it is only after when someone has already developed these diseases. As families we need to discuss about this issue so that we can be aware of it but in black families it is very rare.\u0026rdquo; [Group 4, FGD 2]), social norms promoting unhealthy behaviours (\u0026ldquo;The diet is basically the people around you. It doesn\u0026rsquo;t even have to be your family. It can be your group of friends. Whenever you go out to eat, most of your friends like a bunny chow or a burger that\u0026rsquo;s very salty and high in this and that\u0026rdquo; [Group 2, FGD 2]), and environmental barriers (\u0026ldquo;You know most of the parks when you go there you are going to get mugged. We no longer have a place where we can all go and sit down. The only places that we can go to now as Soweto youth are pubs.\u0026rdquo; [Group 6, FGD 2]).\u003c/p\u003e \u003cp\u003eFemales uniquely cited side effects of medication (\u0026ldquo;My grandmother becomes depressed whenever she has to drink her medication. She just gets angry and all she wants to do is to sleep, she does not want to talk to anyone. She says they pills makes her to go to the bathroom a lot\u0026rdquo; [Group 3; FGD 1]), stress (\u0026ldquo;Getting stressed makes the disease worse\u0026rdquo; [Group 1; FGD 1]), low motivation (\u0026ldquo;We are lazy\u0026rdquo; [Group 1; FGD 2]), time (\u0026ldquo;Young people only seem to make time for school\u0026rdquo; [Group 1; FGD 1]), finances (\u0026ldquo;I feel like food that is healthy and has quality are very expensive, so we buy food that we buy is cheap, but we don\u0026rsquo;t have a choice because we want to sleep with a full belly and those ones make us sick\u0026rdquo; [Group 5; FGD 2]), peer support (\u0026ldquo;\u0026lsquo;My friend, let us go out to drink today.\u0026rsquo; And if you say no, they will say you are boring. And another thing is that you will see that here I am losing friends.\u0026rdquo; [Group 3; FGD 1]), information gaps (\u0026ldquo;There is no one out there to point us to the right direction where information is concerned. Some of us had no idea about it until we came here\u0026rdquo; [Group 1, FGD 1]), and language barriers. Female participants also expressed a perception that a healthy lifestyle was not meant for them, associating health-conscious behaviours with being white (Caucasian). They reported experiencing scepticism and social stigma when making healthy choices, with others reacting with surprise or mockery. For example, one participant noted that drinking water was perceived as adopting a \u0026ldquo;white person mentality\u0026rdquo; (Group 3, FGD 3). Some participants shared that they received no support from home, with family members reinforcing the belief that a healthy lifestyle was \u0026ldquo;only for white people\u0026rdquo; (Group 1, FGD 1).\u003c/p\u003e \u003cp\u003eDespite this, some participants noted minimal obstacles. Males highlighted public access to exercise equipment (\u0026ldquo;I think they promote it in a good way, because most of the townships there have playing grounds where they take children there to exercise.\u0026rdquo; [Group 4, FGD 2]) and supportive environments like churches (\u0026ldquo;In my church every year there is health promotion, and they make sure that we do not skip it. We discuss about mental health and chronic diseases. Nurses will come and different faculties.\u0026rdquo; [Group 4, FGD 2]), while females mentioned sufficient access to health information (\u0026ldquo;it is us who don\u0026rsquo;t bother to make the necessary effort in educating ourselves\u0026rdquo; [Group 5, FGD 1]), and accessibility of healthcare and healthy food (\u0026ldquo;there are people who sell veggies but not all of us\u0026hellip;it is the elders that see the need of buying and cooking vegetables not all of us, not the youth\u0026rdquo; [Group 1; FGD 2]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eCues to action\u003c/h2\u003e \u003cp\u003e Participants primarily discussed external cues to action. Both genders emphasised discussing illness to learn from others (\u0026ldquo;She keeps on preaching it and I feel that if ever I come across such a problem or have it, a friend of mine has it then I will remember her words, that she did say \u0026ndash; stop having too much of this or whatever the case may be. So I do think they do help in a way, personally I do feel that my granny does help in a way in preventing us getting hypertension or any diseases.\u0026rdquo; [Group 1, FGD 2]), increasing knowledge on healthy living (\u0026ldquo;Show people what healthy meals are\u0026rdquo; [Group 5, FGD 1]), engaging diverse stakeholders in awareness campaigns (\u0026ldquo;What I think is helpful is if you have experts. If we make experts rather. So basically you have\u0026hellip; Let's say they take this group right, whether it's the government, whoever, then they educate us on let's say a specific NCD\u0026rdquo; [Group 2, FGD 3]), family-led behaviour change (\u0026ldquo;At home they tell us that we should not smoke and if we do, something will go wrong with your life, you will not succeed, you will end up being crazy, not knowing what the cause is. Nobody smokes at home\u0026rdquo; [Group 4, FGD 2]), and integrating healthier practices into social culture (\u0026ldquo;I say by tackling the things that the youth love the most, you create a demand, you know that youth love to party, create a social market, raising an awareness\u0026rdquo; [Group 6, FGD 3]).\u003c/p\u003e \u003cp\u003eFemales highlighted diagnosis (\u0026ldquo;I think that we deal with it when we know that we already have it. Prior to knowing I don't think that we pay much attention to it\u0026rdquo; [Group 5, FGD 1]), awareness programs in clinics, schools, churches, and government initiatives, routine screenings, community-led behaviour change, improving accessibility to healthy food, demonstrating illness examples in the community (\"the only way they can grab our attention, and like, through stories lines of generations and where ever the case might be, just make a scene, one scene, of that person having that disease or whatever the case might be, they, because that\u0026rsquo;s the only way, not the only way, but the easiest way to grab our attention.\u0026rdquo; [Group 1; FGD 3]), financial incentives for health, and leveraging influential figures (\"Let them get them like motivational speakers, which is their models. People that they look up to. At least if they hear it from their role models, it would probably make sense to them\" [Group 3, FGD 3]). Males emphasised advertising healthy lifestyles (\"They should have commercials that show the positive side of what\u0026rsquo;s this\u0026hellip; of an active lifestyle. A physical active lifestyle. So that's one way they can do it.\u0026rdquo; [Group 2, FGD 3]), strengthening community structures (\u0026ldquo;When you don\u0026rsquo;t have a very strong support structure, you\u0026rsquo;re more prone to getting into bad things and making them\u0026hellip; basically doing them habitually.\u0026rdquo; [Group 2, FGD 3]), and tailoring approaches for different demographics (\"I think it's not a one-size-fits-all sometimes. Different demographics tend to focus on different things, right? So for the younger people might be social media. For the kids might be cartoons. For the adults might be going to church and yeah, doing more productive stuff. So I think we should make the information more available and to gain more traction from it by putting them in spaces where those democracies are more focused on, right\u0026rdquo; [Group 2, FGD 3]).\u003c/p\u003e \u003cp\u003eInternal cues to action were less emphasised. Females cited personal reflection, observation, and avoiding family members' health issues (\u0026ldquo;even if my granny doesn\u0026rsquo;t say, don\u0026rsquo;t eat this, eat that but based on her health condition I can tell that I don\u0026rsquo;t want to be like this, so I will change my ways and my actions because I don\u0026rsquo;t want to be\u0026hellip;not sick like her but I don\u0026rsquo;t want to have a health condition that is similar to hers.\u0026rdquo; [Group 1, FGD 2]), while males stressed the conscious choice to lead a healthier lifestyle (\u0026ldquo;No one promotes that behaviour for you, it is your choices. It starts with you to break the generational curse. So, no one is promoting drinking and smoking, it is your choice.\u0026rdquo; [Group 4, FGD 2]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eSelf-efficacy\u003c/h2\u003e \u003cp\u003eParticipants predominantly exhibited low self-efficacy in making healthy behaviour changes. Both genders admitted frequently choosing unhealthy foods (\u0026ldquo;I don\u0026rsquo;t want to lie. We eat healthy, maybe once a week, otherwise we eat junk food or unhealthy food.\u0026rdquo; [Group 1, FGD 2]). Females described automatic, mindless food choices, feeling controlled by their bodies rather than their minds (\u0026ldquo;Because you can't control your body. If ever it's something that has to do with that, your body, you can't tell your body what to do and what not to do, because it controls itself.\u0026rdquo; [Group 3, FGD 3]), and struggling with behaviour change (\u0026ldquo;What I tell myself in my mind is that I am still young so I told myself that as time goes by, I will reduce but then I try every day to reduce, but then I can\u0026rsquo;t\u0026rdquo; [Group 1, FGD 2]), as well as medication adherence. Males cited peer pressure and difficulty resisting temptation (\u0026ldquo;It was hard, because peer pressure, you see you friends smoking, the temptations of smoking are really high.\u0026rdquo; [Group 4, FGD 3]) as barriers to self-efficacy.\u003c/p\u003e \u003cp\u003eHowever, some high self-efficacy was noted among males, who expressed confidence in maintaining healthy behaviours (\u0026ldquo;I am firm in my believes so I don\u0026rsquo;t think I can be defeated or my body can be defeated as long as I channel myself to the right direction\u0026rdquo; [Group 2, FGD 1]) and cited past success in lifestyle changes to improve health (\u0026ldquo;I just changed my mindset, because I used to be wild, I used to be wicked, then I overgrew that, I used to smoke cigarette, I once smoked drugs, I stopped smoking, so yeah, I just changed how I think and how I perceive myself and how I perceive things.\u0026rdquo; [Group 6, FGD 3]).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePerceived risk factors:\u003c/h2\u003e \u003cp\u003eThe risk factors perceived by participants are demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003ePerceived protective factors:\u003c/h2\u003e \u003cp\u003eThe protective factors perceived by participants are demonstrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this paper provide critical insights into the social, cultural, and structural factors that shape young South Africans\u0026rsquo; understanding of hypertension and their perceptions of prevention. The HBM concept of perceived threat (i.e., perceived susceptibility and perceived severity) suggests that individuals are more likely to take preventive action if they recognise a health threat as serious and as something they could develop\u003csup\u003e19, 20\u003c/sup\u003e. For many youth in this study, the low perceived severity of hypertension acted as a barrier to behaviour change despite youth perceiving high susceptibility. Although participants recognised their likelihood of developing hypertension in the future, participants in this study largely viewed their youth, good health, and lack of diagnosis as protective factors against threat of hypertension. This perception aligns with Elkind\u0026rsquo;s\u003csup\u003e21\u003c/sup\u003e concept of adolescent invincibility, which has been linked to a greater likelihood of engaging in risk behaviours\u003csup\u003e22\u003c/sup\u003e. A female participant illustrated this by stating, \u0026ldquo;We don\u0026rsquo;t care because we are not sick and we don\u0026rsquo;t get sick as much as the elderly, they care a lot\u0026rdquo;. This highlights a paradox in how South African youth perceive hypertension, as while they view it as an inevitable part of their future, they do not see it as an immediate threat to their health, leading to a reluctance to engage in preventative or management behaviours.\u003c/p\u003e \u003cp\u003eStress was also identified as a key psychological factor that further influenced participants' lack of engagement with hypertension prevention. Many emphasised the impact of stress as a key contributor to hypertension, believing that dwelling on the condition both before and after diagnosis could worsen its effects. As a result, some actively avoided thinking about hypertension as a coping mechanism. This aligns with the concept of avoidance coping, a strategy in which individuals manage distress by denying or distracting themselves from a health threat rather than actively addressing it\u003csup\u003e23, 24\u003c/sup\u003e. Evidence from South Africa shows that avoidance coping plays a critical role in health-related behaviours, as seen in people living with HIV, where internalised stigma predicted higher avoidant coping, leading to delayed antiretroviral therapy initiation and poorer health outcomes\u003csup\u003e23\u003c/sup\u003e. Similarly, in the context of hypertension, avoidant coping may diminish proactive health-seeking behaviours, reinforcing disengagement from prevention and treatment. Chasiotis et al.\u003csup\u003e24\u003c/sup\u003e further highlighted that avoidant motivation reduces engagement with health information-seeking and problem-focused coping, leading instead to emotion-focused coping strategies such as denial or distraction rather than direct disease management and prevention. In this study, participants demonstrated this pattern by prioritising stress management techniques, such as meditation and breathing exercises, over direct engagement with hypertension prevention strategies. While these approaches contribute to overall well-being, they may also serve as a form of psychological distancing, reinforcing inaction toward tangible risk reduction behaviours.\u003c/p\u003e \u003cp\u003eIn addition to stress, this study found that some youth (particularly female youth) viewed a healthy lifestyle in terms of drinking water and a healthy diet as something \u0026ldquo;only for white people\u0026rdquo;. This perspective reflects how racial and cultural identities influence health behaviours, particularly in a country like South Africa which continues to undergo significant social and cultural transformation\u003csup\u003e25\u003c/sup\u003e. South Africa\u0026rsquo;s shift from apartheid to a democratic society has created a paradox where modern, Western health practices are often viewed as foreign, while traditional beliefs and practices continue to influence health behaviours\u003csup\u003e25\u003c/sup\u003e. This dynamic can contribute to resistance to adopting behaviours that are perceived as \"white\", despite the clear links between poor dietary patterns and the prevalence of diseases like hypertension. Such cultural perceptions are not unique to South Africa, as research on dietary patterns among minorities in other regions, such as England, suggests that traditional food beliefs and cultural values significantly shape health behaviours\u003csup\u003e26\u003c/sup\u003e. Studies show that dietary messages and interventions often fail to resonate with minority groups if they are not culturally tailored, as factors like traditional foods, taste preferences, and social meaning play crucial roles in food choices\u003csup\u003e26\u003c/sup\u003e. This highlights the need for culturally responsive health interventions that acknowledge the broader socio-cultural context in which health behaviors are formed.\u003c/p\u003e \u003cp\u003eFurther to the social and cultural influences, peer pressure also played a significant role in shaping participant\u0026rsquo;s health-related behaviours. Literature suggests that adolescent males, in particular, exhibit increased risk-taking due to a stronger peer group orientation\u003csup\u003e27\u003c/sup\u003e. In this study, however, both genders justified unhealthy behaviours as integral to their social lives, emphasising the powerful influence of social norms. One female participant explained how social pressures dictated lifestyle choices: \u0026ldquo;My friend, let us go out to drink today.\u0026rsquo; And if you say no, they will say you are boring. And another thing is that you will see that here I am losing friends. If you do things to please your friends, you will end up losing yourself.\u0026rdquo;\u003c/p\u003e \u003cp\u003eA culture of social gatherings centered around high-calorie, processed foods, and limited physical activity reinforced these patterns. Some traditional cultural practices, such as the expectation to consume large portions of energy-dense foods during family or community events, were perceived as contributing to health risks. In line with findings from Buksh et al.\u003csup\u003e28\u003c/sup\u003e, participants in this study also shared that overconsumption of food during social gatherings was common and often encouraged. These social and cultural influences created an environment where making healthier choices was challenging, despite participants\u0026rsquo; awareness of the long-term health consequences. As noted by Monterrosa et al.\u003csup\u003e29\u003c/sup\u003e, food choices are deeply influenced by cultural, social, and psychological factors, making dietary patterns both a personal and social expression of identity. This complex web of influences highlights the difficulty of adopting healthier eating habits in environments where traditional and social expectations outweigh concerns about nutritional health.\u003c/p\u003e \u003cp\u003eMany participants learned about hypertension through observing family members or neighbours, with their views influenced by how those around them managed, or failed to manage, the condition. For some, hypertension was perceived as a minor, manageable issue, particularly when individuals neglected medication adherence yet appeared to function normally. This was especially true for those who remained asymptomatic, mirroring findings from Jimmy \u0026amp; Jose\u003csup\u003e30\u003c/sup\u003e, which highlight that non-compliance with chronic disease medications is most common when patients do not experience unpleasant symptoms. In fact, medication adherence rates for chronic conditions like hypertension often drop significantly when symptoms are absent, as patients perceive the disease as less urgent or severe. As a result, some individuals became complacent and skeptical about the true severity of the disease. This also aligns with Nouhravesh et al.\u003csup\u003e31\u003c/sup\u003e, who observed that asymptomatic participants often did not perceive their condition as a real threat, showing little effort to understand or manage it until symptoms appeared, further contributing to a false sense of security regarding the potential risks of hypertension. However, others who had witnessed serious complications, such as strokes, kidney failure, or premature death, regarded hypertension as a significant and life-altering condition.\u003c/p\u003e \u003cp\u003eA major challenge was the secrecy surrounding hypertension, as many individuals hesitated to share their diagnosis due to stigma. Similar to the experiences of those living with dementia in South Africa, where internalised stigma and fear of social rejection led to secrecy and isolation\u003csup\u003e32\u003c/sup\u003e, individuals with hypertension often kept their condition hidden, further hindering open discussion. This lack of communication limited awareness, reducing perceived threat, and ultimately contributing to a gap in health knowledge. The stigma surrounding the condition, coupled with a reluctance to acknowledge its impact, led to indifference toward key risk factors such as poor diet and physical inactivity. Additionally, in certain cultural contexts, illness is not only seen as a biological issue but also through a social and spiritual lens, reinforcing stigma and complicating the process of seeking help or support\u003csup\u003e33, 34\u003c/sup\u003e. Facilitated by stigma and secrecy, participant\u0026rsquo;s in this study often did not describe having firsthand experience of hypertension\u0026rsquo;s long-term consequences. This, alongside the low perceived severity, led participants to perceive hypertension as irrelevant and unnecessary to address or prevent in their current, healthy state.\u003c/p\u003e \u003cp\u003eBuilding on stigma and secrecy, family and social networks play a critical role in shaping youth\u0026rsquo;s health behaviours, particularly in the context of hypertension. Family structures and systems are essential in shaping food choices, as they establish the foundation for lifelong eating habits\u003csup\u003e29\u003c/sup\u003e. Food practices are primarily learned through the transmission of behaviours and norms from parents to children, influencing not only what is eaten but also how and when meals are consumed\u003csup\u003e29\u003c/sup\u003e. Families that actively support healthy eating by making nutritious food available, encouraging balanced meals, and modeling positive behaviours create an environment where healthy lifestyles are more easily adopted. Parents who lead by example, whether by preparing nutritious meals, prioritising family mealtimes, or promoting mindful eating, help instill lasting habits in their children\u003csup\u003e29\u003c/sup\u003e. Conversely, when family support for healthy food and lifestyle choices is lacking, it creates significant barriers to change. If unhealthy eating patterns are normalised within the household, individuals may struggle to prioritise nutrition, even when they recognise the importance of healthier choices. Without collective family engagement, making sustainable changes becomes challenging, as individuals often rely on social reinforcement to maintain new behaviours. Thus, families serve as both facilitators and obstacles in the pursuit of a healthier lifestyle, shaping food choices through both explicit instruction and implicit modeling in daily routines\u003csup\u003e29\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eExternal cues played a crucial role in shaping youth behaviour in this study, often exerting a more immediate and compelling influence than internal factors such as personal reflection or family health history. Among these external influences, family members, particularly parents and guardians, were frequently cited as key drivers of health-related behaviours. Families served as the primary source of health knowledge, behavioural norms, and lifestyle patterns, with both positive and negative impacts. When families actively supported healthy behaviours, participants found it easier to make and sustain positive changes. This influence is especially significant for youth, many of whom still live at home and are heavily impacted by their families\u0026rsquo; attitudes and actions. As noted by Bottorff et al.\u003csup\u003e35\u003c/sup\u003e, the family unit plays a crucial role in shaping healthy behaviours, especially in childhood, by providing opportunities for physical activity and healthy eating. Although their study focused on children, this dynamic remains relevant for youth, as family caregivers continue to play a key role in fostering healthy lifestyles and addressing modifiable risk factors, such as poor diet and physical inactivity, which can lead to long-term health issues like hypertension.\u003c/p\u003e \u003cp\u003eThese results highlight the complex, multilevel factors that shape food and lifestyle related choices, where interactions between youth and their environment influence health-related behaviours\u003csup\u003e29\u003c/sup\u003e. While environmental factors, such as food marketing and availability, play a crucial role, biological factors like innate preferences for sweet, salty, and high-fat foods (which are deeply rooted in our biology) also drive individuals toward unhealthy options\u003csup\u003e36\u003c/sup\u003e. The food industry exacerbates this dynamic by marketing highly palatable, energy-dense foods that stimulate pleasure receptors in the brain, reinforcing unhealthy eating habits\u003csup\u003e37\u003c/sup\u003e. Youth in this study described pervasive advertising for fast food and sugary drinks as a persistent external cue, normalising unhealthy consumption and making it harder to prioritise healthier options. Broader structural factors, including limited access to affordable healthy food, lack of fitness resources, and societal norms favouring convenience over health, create systemic barriers to adopting healthier lifestyles. Additionally, barriers to healthcare access, such as long wait times and a focus on treatment (medication) rather than prevention, deter youth from engaging in proactive health management, with perceptions that clinics are only for severe illness further delaying the adoption of preventative care\u003csup\u003e38\u003c/sup\u003e. These combined factors contribute to unhealthy dietary behaviours and limited engagement with health-services, increasing the risk of hypertension in South African youth.\u003c/p\u003e \u003cp\u003eLastly, the findings of this paper demonstrate that youth are looking to community structures such as schools, churches, clinics, and government institutions in supporting youth efforts to adopt healthier behaviours. Participants emphasised the need for greater dissemination of accurate health information and the creation of environments that actively facilitate positive change. While churches are highlighted in this paragraph to illustrate the role of these institutions, the findings can also be applied to schools, clinics, and government organisations, as they share a similar potential to influence health outcomes. Evidence, such as the Impilo neZenkolo (\u0026lsquo;Health through Faith\u0026rsquo;) programme\u003csup\u003e39\u003c/sup\u003e, demonstrates the potential of church-based interventions to address health challenges in lower income communities. Further to this, churches have also played a key role in promoting health in South Africa, as seen in HIV prevention efforts\u003csup\u003e40\u003c/sup\u003e, underscoring their potential as important partners in public health initiatives. However, while structures such as churches hold promise as powerful agents of health promotion, participants also acknowledge their capacity to spread misinformation when not used correctly. Churches, for example, were identified by participants as both a source of guidance and a barrier; while some invited health experts to educate congregants on disease prevention and healthy living, others promoted the idea of praying illness away. Expanding on the former point, in this study, youth advocated for the inclusion of diverse stakeholders, and emphasised the importance of moving beyond one-size-fits-all health campaigns. They call for collaborative efforts that engage influential community figures such as doctors, religious leaders, media personalities, and government officials to co-create sustainable and meaningful preventive health initiatives.\u003c/p\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study's limitations include the restricted generalisability of its findings due to the focus on a specific demographic in Soweto, which may not reflect the diversity of socioeconomic, cultural, and regional variations within urban South Africa or Sub-Saharan Africa more broadly. As such, the results may not be transferable to other regions or rural populations. Additionally, the reliance on self-reported data introduces the potential for biases in participants' health knowledge, lifestyle choices, and attitudes towards hypertension, as individuals may exaggerate or downplay certain behaviours or perceptions. Lastly, the cross-sectional nature of the study limits causal interpretations, making it difficult to determine whether the identified perceptions directly influence hypertension prevention behaviours over time. Future research should incorporate longitudinal or mixed-methods approaches to enhance the robustness of these findings.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWhile youth recognise their susceptibility to hypertension, they perceive low severity, often viewing their age and good health as protective factors. Stress and avoidance coping further contribute to disengagement from prevention, alongside cultural perceptions that frame healthy lifestyles as foreign. Social influences, including peer pressure and traditional dietary practices, reinforce unhealthy behaviours, while family experiences shape perceptions of hypertension\u0026rsquo;s seriousness. Stigma and secrecy surrounding the condition limit open discussions, reducing perceived threat and awareness. External influences, such as social networks and cultural norms, often outweigh individual health knowledge, emphasising the need for youth-centred, culturally responsive interventions. Addressing these barriers requires a shift from purely biomedical approaches to holistic strategies that acknowledge the broader social and psychological factors influencing youth engagement with hypertension prevention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eNCDs - non-communicable diseases\u003c/p\u003e\n\u003cp\u003eSSA - Sub-Saharan Africa\u003c/p\u003e\n\u003cp\u003eBP - blood pressure\u003c/p\u003e\n\u003cp\u003ePP - Precision prevention\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSAMRC - South African Medical Research Council\u003c/p\u003e\n\u003cp\u003eDPHRU - Developmental Pathways for Human Research Unit\u003c/p\u003e\n\u003cp\u003eFGD \u0026ndash; focus group discussion\u003c/p\u003e\n\u003cp\u003eHBM \u0026ndash; Health Belief Model\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the University of Witwatersrand Human Research Ethics Committee (Medical) (REF: R14/49, Protocol no: M220818). All participants received an information sheet (Appendix A) outlining the purpose and procedures of the study. Informed consent was obtained prior to participation (Appendix B), including explicit consent for audio recording where applicable (Appendix C).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the principle author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFunding for this study was provided by the South African Medical Research Council.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMJS and SAN contributed to the study conception and design. MJS led data collection, conducted the data analysis, and wrote the initial manuscript draft. SAN and SHC reviewed and contributed to the final version. All authors provided edits and critiqued the manuscript for intellectual content.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the staff of the SAMRC Developmental Pathways for Health Research Unit for their invaluable assistance in sourcing participants and facilitating the focus group discussions. Their support contributed significantly to the successful completion of this study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAddo J, Smeeth L, Leon DA. Hypertension in sub-saharan Africa: a systematic review. Hypertension. 2007;50(6):1012-8.\u003c/li\u003e\n\u003cli\u003eKohli-Lynch CN, Erzse A, Rayner B, Hofman KJ. Hypertension in the South African public healthcare system: a cost-of-illness and burden of disease study. BMJ Open. 2022;12(2):e055621.\u003c/li\u003e\n\u003cli\u003eMatheson GO, Kl\u0026uuml;gl M, Engebretsen L, Bendiksen F, Blair SN, B\u0026ouml;rjesson M, et al. Prevention and management of non-communicable disease: the IOC consensus statement, Lausanne 2013. Sports Med. 2013;43(11):1075-88.\u003c/li\u003e\n\u003cli\u003eAnderson GH. Effect of age on hypertension: analysis of over 4,800 referred hypertensive patients. Saudi J Kidney Dis Transpl. 1999;10(3):286-97.\u003c/li\u003e\n\u003cli\u003eRyan JC, Viana JN, Sellak H, Gondalia S, quot, Callaghan N. Defining precision health: a scoping review protocol. BMJ Open. 2021;11(2):e044663.\u003c/li\u003e\n\u003cli\u003eKagura J, Adair LS, Munthali RJ, Pettifor JM, Norris SA. Association Between Early Life Growth and Blood Pressure Trajectories in Black South African Children. Hypertension. 2016;68(5):1123-31.\u003c/li\u003e\n\u003cli\u003eWinpenny EM, van Sluijs EMF, White M, Klepp K-I, Wold B, Lien N. Changes in diet through adolescence and early adulthood: longitudinal trajectories and association with key life transitions. International Journal of Behavioral Nutrition and Physical Activity. 2018;15(1):86.\u003c/li\u003e\n\u003cli\u003eSawyer SM, Azzopardi PS, Wickremarathne D, Patton GC. The age of adolescence. Lancet Child Adolesc Health. 2018;2(3):223-8.\u003c/li\u003e\n\u003cli\u003eTohi M, Bay JL, Tu\u0026apos;akoi S, Vickers MH. The Developmental Origins of Health and Disease: Adolescence as a Critical Lifecourse Period to Break the Transgenerational Cycle of NCDs-A Narrative Review. Int J Environ Res Public Health. 2022;19(10).\u003c/li\u003e\n\u003cli\u003eBackes EP, Bonnie RJ. The promise of adolescence: Realizing opportunity for all youth. 2019.\u003c/li\u003e\n\u003cli\u003eMukoma G, Bosire EN, Klingberg S, Norris SA. Healthy eating and physical activity: Analysing Soweto\u0026rsquo;s young adults\u0026rsquo; perspectives with an intersectionality lens. PLOS Global Public Health. 2023;3(7):e0001429.\u003c/li\u003e\n\u003cli\u003eRuthsatz M, Candeias V. Non-communicable disease prevention, nutrition and aging. Acta Biomed. 2020;91(2):379-88.\u003c/li\u003e\n\u003cli\u003eLeopold JA, Loscalzo J. Emerging Role of Precision Medicine in Cardiovascular Disease. Circ Res. 2018;122(9):1302-15.\u003c/li\u003e\n\u003cli\u003eNaithani N, Sinha S, Misra P, Vasudevan B, Sahu R. Precision medicine: Concept and tools. Med J Armed Forces India. 2021;77(3):249-57.\u003c/li\u003e\n\u003cli\u003eGittelsohn J, Steckler A, Johnson CC, Pratt C, Grieser M, Pickrel J, et al. Formative research in school and community-based health programs and studies: \u0026quot;state of the art\u0026quot; and the TAAG approach. Health Educ Behav. 2006;33(1):25-39.\u003c/li\u003e\n\u003cli\u003eSekome K, G\u0026oacute;mez-Oliv\u0026eacute; FX, Sherar LB, Esliger DW, Myezwa H. Sociocultural perceptions of physical activity and dietary habits for hypertension control: voices from adults in a rural sub-district of South Africa. BMC Public Health. 2024;24(1):2194.\u003c/li\u003e\n\u003cli\u003eMpondo F, Kim AW, Tsai AC, Mendenhall E. Development and validation of the Soweto Coping Scale: A mixed-methods, population-based study of adults living in Soweto, South Africa. J Affect Disord. 2022;303:353-8.\u003c/li\u003e\n\u003cli\u003eWibeck V, Dahlgren MA, \u0026Ouml;berg G. Learning in focus groups: An analytical dimension for enhancing focus group research. Qualitative research. 2007;7(2):249-67.\u003c/li\u003e\n\u003cli\u003eJones CJ, Smith H, Llewellyn C. Evaluating the effectiveness of health belief model interventions in improving adherence: a systematic review. Health Psychol Rev. 2014;8(3):253-69.\u003c/li\u003e\n\u003cli\u003eAlyafei A, Easton-Carr R. The Health Belief Model of Behavior Change. StatPearls. Treasure Island (FL): StatPearls Publishing Copyright \u0026copy; 2025, StatPearls Publishing LLC.; 2025.\u003c/li\u003e\n\u003cli\u003eElkind D. Children and adolescents: Interpretive essays on Jean Piaget. Oxford, England: Oxford U. Press; 1970. xi, 160-xi, p.\u003c/li\u003e\n\u003cli\u003eWickman ME, Anderson NL, Greenberg CS. The adolescent perception of invincibility and its influence on teen acceptance of health promotion strategies. J Pediatr Nurs. 2008;23(6):460-8.\u003c/li\u003e\n\u003cli\u003eEarnshaw VA, Bogart LM, Laurenceau JP, Chan BT, Maughan-Brown BG, Dietrich JJ, et al. Internalized HIV stigma, ART initiation and HIV-1 RNA suppression in South Africa: exploring avoidant coping as a longitudinal mediator. J Int AIDS Soc. 2018;21(10):e25198.\u003c/li\u003e\n\u003cli\u003eChasiotis A, Wedderhoff O, Rosman T, Mayer A-K. The Role of Approach and Avoidance Motivation and Emotion Regulation in Coping Via Health Information Seeking. Current Psychology. 2021;40(10):5235-44.\u003c/li\u003e\n\u003cli\u003eFeigin R. White with a Black Soul: Illness Perception and Behavior and its Implications on Healthcare in the New South African Society. Illness, Crisis \u0026amp; Loss. 2013;21(2):125-40.\u003c/li\u003e\n\u003cli\u003eOjo AS, Nnyanzi LA, Giles EL, Ells L, Okeke SR, Ajayi KV, et al. \u0026quot;I am not really into the government telling me what I need to eat\u0026quot;: exploring dietary beliefs, knowledge, and practices among ethnically diverse communities in England. BMC Public Health. 2023;23(1):800.\u003c/li\u003e\n\u003cli\u003eMcCoy SS, Dimler LM, Samuels DV, Natsuaki MN. Adolescent Susceptibility to Deviant Peer Pressure: Does Gender Matter? Adolescent Research Review. 2019;4(1):59-71.\u003c/li\u003e\n\u003cli\u003eBuksh SM, de Wit JBF, Hay P. Sociocultural Influences Contribute to Overeating and Unhealthy Eating: Creating and Maintaining an Obesogenic Social Environment in Indigenous Communities in Urban Fiji. Nutrients. 2022;14(14).\u003c/li\u003e\n\u003cli\u003eMonterrosa EC, Frongillo EA, Drewnowski A, de Pee S, Vandevijvere S. Sociocultural Influences on Food Choices and Implications for Sustainable Healthy Diets. Food Nutr Bull. 2020;41(2_suppl):59s-73s.\u003c/li\u003e\n\u003cli\u003eJimmy B, Jose J. Patient medication adherence: measures in daily practice. Oman Med J. 2011;26(3):155-9.\u003c/li\u003e\n\u003cli\u003eNouhravesh N, Sindet-Pedersen C, K\u0026uuml;mler T, Schou M, Lamberts MK, H\u0026oslash;jen AA. \u0026ldquo;No one told me anything about it and I cannot explain it\u0026rdquo;: Illness perception in symptomatic and asymptomatic patients with cancer-associated thrombosis. Thrombosis Research. 2022;220:125-30.\u003c/li\u003e\n\u003cli\u003eJacobs R, Schneider M, Farina N, du Toit P, Evans-Lacko S. Stigma and its implications for dementia in South Africa: a multi-stakeholder exploratory study. Ageing and Society. 2024;44(4):867-97.\u003c/li\u003e\n\u003cli\u003eMavundla T, Netswera F, Bottoman B, Toth F. Rationalization of Indigenous Male Circumcision as a Sacred Religious Custom: Health Beliefs of Xhosa Men in South Africa. Journal of transcultural nursing : official journal of the Transcultural Nursing Society / Transcultural Nursing Society. 2009;20:395-404.\u003c/li\u003e\n\u003cli\u003eMkhonto F, Hanssen I. When people with dementia are perceived as witches. Consequences for patients and nurse education in South Africa. J Clin Nurs. 2018;27(1-2):e169-e76.\u003c/li\u003e\n\u003cli\u003eBottorff J, Hamilton C, Huisken A, Taylor D. Correlates of Food Insecurity Among Undergraduate Students. Canadian Journal of Higher Education. 2020;50:15-23.\u003c/li\u003e\n\u003cli\u003eDrewnowski A, Almiron-Roig E. Frontiers in Neuroscience Human Perceptions and Preferences for Fat-Rich Foods. In: Montmayeur JP, le Coutre J, editors. Fat Detection: Taste, Texture, and Post Ingestive Effects. Boca Raton (FL): CRC Press/Taylor \u0026amp; Francis Copyright \u0026copy; 2010, Taylor \u0026amp; Francis Group, LLC.; 2010.\u003c/li\u003e\n\u003cli\u003eMc Carthy CM, de Vries R, Mackenbach JD. The influence of unhealthy food and beverage marketing through social media and advergaming on diet-related outcomes in children-A systematic review. Obes Rev. 2022;23(6):e13441.\u003c/li\u003e\n\u003cli\u003eDong R, Leung C, Naert MN, Naanyu V, Kiptoo P, Matelong W, et al. Chronic disease stigma, skepticism of the health system, and socio-economic fragility: Qualitative assessment of factors impacting receptiveness to group medical visits and microfinance for non-communicable disease care in rural Kenya. PLOS ONE. 2021;16(6):e0248496.\u003c/li\u003e\n\u003cli\u003eDraper CE, Tomaz SA, Zihindula G, Bunn C, Gray CM, Hunt K, et al. Development, feasibility, acceptability and potential effectiveness of a healthy lifestyle programme delivered in churches in urban and rural South Africa. PLOS ONE. 2019;14(7):e0219787.\u003c/li\u003e\n\u003cli\u003eMadlala ST, Khanyile S. The roles of churches in HIV prevention among youth at Nqutu in KwaZulu-Natal South Africa. Curationis. 2023;46(1):e1-e9.\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, cardiovascular disease, youth perceptions, Soweto, South Africa. Health Belief Model, preventative health strategies, precision prevention, public health","lastPublishedDoi":"10.21203/rs.3.rs-6333489/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6333489/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThe growing burden of cardiovascular disease (CVD) in Sub-Saharan Africa (SSA) is largely driven by hypertension, with risk factors including poor diet, physical inactivity, tobacco use, psychological stress, and limited healthcare access. Early-life exposure to these risks contributes to adverse biological markers that increase hypertension susceptibility in adulthood. This study aimed to explore how young people in Soweto, Johannesburg, perceive hypertension risk, using the Health Belief Model (HBM) to understand their beliefs, attitudes, and barriers to prevention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e This study explored youth perceptions of hypertension in Soweto, Johannesburg, using focus group discussions (FGDs) with 62 participants aged 18\u0026ndash;25, guided by the HBM. Thematic analysis was conducted to identify key beliefs, attitudes, and barriers to prevention.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eParticipants largely underestimated their hypertension risk, perceiving youth as a protective factor and associating the condition primarily with older adults or those already diagnosed. While some acknowledged genetic predisposition, stress, and lifestyle factors as contributors, many saw hypertension as low severity and distant from their immediate concerns. Barriers to preventative action included social norms, stigma, financial constraints, and limited access to health-promoting resources. External cues, such as family influence and community awareness, were stronger motivators for behaviour change than personal risk assessment, while self-efficacy in adopting preventive behaviours was low.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e \u003cp\u003eFindings highlight a gap in youth awareness and engagement in hypertension prevention, driven by misperceptions of risk and limited access to enabling resources. Targeted interventions must address these misconceptions, enhance perceived severity, and leverage community and familial influences to promote early prevention and sustained behaviour change.\u003c/p\u003e","manuscriptTitle":"“We don’t care because we are not sick”: Understanding youths perceptions of hypertension in urban South Africa","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-05-05 06:36:30","doi":"10.21203/rs.3.rs-6333489/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-13T18:04:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-01T11:03:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94996263228096371266017416798881547930","date":"2025-04-21T05:42:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"292982438269781678442557192117367708336","date":"2025-04-16T02:49:19+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-11T17:03:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"107357717876588949770152667397668116060","date":"2025-04-07T09:35:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-04-03T16:06:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-04-03T13:25:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-04-03T06:33:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-04-03T06:29:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-03-29T10:14:55+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":"bb20e3c7-fc3c-4c91-9ab2-d9058c64c03c","owner":[],"postedDate":"May 5th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-11T16:08:41+00:00","versionOfRecord":{"articleIdentity":"rs-6333489","link":"https://doi.org/10.1186/s12889-025-23729-6","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-08-05 15:58:08","publishedOnDateReadable":"August 5th, 2025"},"versionCreatedAt":"2025-05-05 06:36:30","video":"","vorDoi":"10.1186/s12889-025-23729-6","vorDoiUrl":"https://doi.org/10.1186/s12889-025-23729-6","workflowStages":[]},"version":"v1","identity":"rs-6333489","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6333489","identity":"rs-6333489","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}