Barriers and Enablers of Hypertension Control in Nepalese Older Adults: Implications for Dementia Prevention

Prabha Shrestha, MNS, MA, Biraj Man Karmacharya, MPH, PhD, Yunika Acharya, MSc PH, Indu Poudel, BNS, Jennifer Merrilees PhD, Victor Valcour, MD, PhD

Background

Hypertension poses a major public health challenge in Nepal, particularly among the aging population, with nearly half of older adults affected and many unaware of their condition. This study explores barriers and facilitators of hypertension management among hypertensive older adults in Nepal.

Method

We conducted a parallel mixed-method study.  We assessed blood pressure control status among 197 hypertensive older adults. We measured blood pressure (mmHg), BMI (kg/m²), and assessed medication adherence using the Hill-Bone Medication Adherence Scale. We explored barriers and facilitators of hypertension management among hypertensive older adults using the Capability, Opportunity and Motivation (COM-B) model. Trained researchers conducted seven In-Depth Interviews (IDIs) and 2 Focus Group Discussion (FGDs) among older hypertensive patients and caretakers, respectively. Interviews and FGDs were held in private settings using a semi-structured guideline in the Nepali language. We audio-recorded all sessions, transcribed into verbatim, and applied both inductive and deductive coding. We then analyzed the data using a framework approach with Taguette software.

Result

Over half of participants (59.3%) had uncontrolled blood pressure. No associations were found between hypertension control status and age, sex, education level, marital status, religion, living arrangement, presence of comorbidity, medication adherence or BMI. When explored through the lens of the COM-B model, a range of behavioral determinants emerged as critical to understanding hypertension management. These include limited physical and cognitive capability (fatigue, forgetfulness), lack of opportunity (limited social interaction, time constraints, poor access to information, and low family support), and reduced motivation (low interest in treatment or lifestyle changes, stress, and anger). On the other hand, several facilitators played a positive role in promoting blood pressure control such as improved capability through awareness, use of pill boxes, and regular BP monitoring. Other facilitators included enhanced opportunity via nearby health facilities, community programs, and FCHV and family support. Strong motivation driven by fear of complications, perceived benefits, and the desire to stay healthy for family were also identified as facilitators.

Conclusion

The findings highlight the need for a holistic, behavior-centered approach to hypertension management in older adults, integrating both pharmacological and non-pharmacological strategies. Incorporating behavioral frameworks like COM-B support the development of patient-centered interventions that are sustainable and contextually relevant in low-resource settings like Nepal to minimize the risk of dementia in this population.

 

Key words: Hypertension, older adults, barriers, facilitators, blood pressure control, Nepal, dementia