Barriers and facilitators of hypertension control among older adults living with hypertension: A mixed-methods study

Hypertension is a major public health challenge in Nepal, particularly among older adults, with nearly half affected and many unaware of their condition. This study explored barriers and facilitators of hypertension management among older adults in Nepal using a parallel mixed-methods design. The study was conducted in Dhulikhel Municipality between September 2024 and March 2025. The quantitative component included 197 older adults (≥60 years) with hypertension. Blood pressure and body mass index (BMI) were measured, medication adherence was assessed using the Hill-Bone Medication Adherence Scale, and multivariable logistic regression was used to identify factors associated with blood pressure control. The qualitative component explored barriers and facilitators using the Capability, Opportunity, Motivation-Behavior (COM-B) model. Seven in-depth interviews with older adults and two focus group discussions with caregivers were conducted using semi-structured guides. Audio recordings were transcribed verbatim and analyzed using a framework approach with inductive and deductive coding. Overall, 59.3% of participants had uncontrolled blood pressure. No significant associations were found between blood pressure control and age, sex, education, marital status, religion, living arrangement, comorbidities, medication adherence, or BMI. Qualitative findings identified barriers across all COM-B domains, including fatigue and forgetfulness (capability), limited social interaction, poor access to information, time constraints, and low family support (opportunity), and low motivation, stress, and anger (motivation). Facilitators included greater awareness, use of pill boxes, regular blood pressure monitoring, access to nearby health facilities, community programs, support from Female Community Health Volunteers (FCHVs) and family members, fear of complications, perceived benefits of treatment, and the desire to remain healthy for family. These findings highlight the need for behavior-centered, patient-focused hypertension management strategies that integrate pharmacological and lifestyle interventions. Applying the COM-B framework can support the development of sustainable, contextually appropriate interventions to improve hypertension management among older adults in Nepal.