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Abstract

Hypertension remains a leading cause of cardiovascular morbidity and mortality worldwide. Effective self-care is essential for long-term blood pressure control and prevention of complications. This study aimed to assess the adequacy of self-care behaviors and identify associated predictors among adults with hypertension. A cross-sectional study was conducted among 393 adults with primary hypertension attending public primary care centers. Data were collected through structured interviews using the Self-Care of Hypertension Inventory, Multidimensional Scale of Perceived Social Support, and a validated hypertension knowledge questionnaire. Binary logistic regression was used to identify predictors of adequate self-care (≥70%). Although 71.6% of participants had good hypertension knowledge, only 26.7% demonstrated adequate self-care. Key barriers included emotional stress (98.0%), financial hardship (87.3%), and time constraints (78.4%). Significant predictors of adequate self-care included younger age (OR 0·939), being married (OR 2·48), employment (OR 0·697), fewer comorbidities (OR 0·552), controlled blood pressure (OR 0·370), higher knowledge (OR 0·949), and stronger social support (OR 1·054). This study identified self-care deficiencies among hypertensive patients, characterized by good knowledge but poor engagement in lifestyle modification, monitoring, and communication. Effective self-care was associated with younger age, family support, and higher knowledge, whereas older age, comorbidities, and blood pressure control impeded it. Emotional stress, financial hardship, and time constraints were key barriers, underscoring the need for comprehensive, multi-level strategies to enhance hypertension self-management.

Keywords

Hypertension self-care social support health literacy

Introduction

Hypertension is a major global public health concern, affecting an estimated 1.28 billion adults aged 30-79 years, with over two-thirds living in low- and middle-income countries.¹ Defined as systolic blood pressure ≥140 mm Hg or diastolic pressure ≥90 mm Hg, it is a leading contributor to cardiovascular diseases, stroke, and chronic kidney disease.² Despite effective antihypertensive therapies, nearly half of those affected remain undiagnosed or inadequately controlled.

In the Eastern Mediterranean Region, including Iraq, hypertension prevalence continues to rise due to urbanization, demographic shifts, unhealthy diets, and sedentary lifestyles.³ In the Kurdistan Region of Iraq, prevalence estimates range from 24.3% to 41.3%.^4,5 While many patients receive pharmacological treatment, achieving optimal control remains challenging, highlighting the need to strengthen self-care as an essential component of hypertension management.³

Self-care encompasses daily practices such as medication adherence, healthy diet, physical activity, blood pressure monitoring, and avoidance of risk factors.⁶ Consistent engagement in these behaviors can reduce disease burden and improve outcomes,⁷ yet adherence is often compromised by low health literacy, inadequate social support, and socioeconomic barriers.⁸ Older adults may experience additional difficulties related to cognitive decline or limited understanding.⁹ Although social support is generally beneficial, it may conflict with cultural dietary norms like excessive salt intake.¹⁰ Other barriers include healthcare access limitations, gender roles, psychological stress, and financial hardship,¹¹ which in Kurdistan are exacerbated by sociocultural norms and health system constraints.^12,13

Despite the importance of self-care, research in Iraq remains scarce, with most studies focusing on medication adherence and neglecting broader psychosocial and environmental influences. This study aims to evaluate self-care behaviors and identify associated factors among hypertensive patients in the Kurdistan Region of Iraq, providing evidence to guide culturally tailored, multifaceted interventions for improved hypertension management.

Patient and Methods

Study Design and Setting

A descriptive cross-sectional study employing a quantitative approach was conducted in a city within the Kurdistan Region of Iraq. The target population comprised hypertensive patients attending chronic disease management clinics across six randomly selected primary health care centers (PHCCs), out of twelve designated by the regional health authority as managing approximately 13,000 registered hypertensive patients. Data were collected between November 17, 2023, and March 20, 2024.

Sample Size and Sampling Procedure

A total of 393 patients participated in the study, selected through convenience sampling. The minimum required sample size was calculated using Slovin's formula [n = N/(1 + Ne²), where N = 13,000, e = 0.05], yielding 389 participants at a 95% confidence level with a 5% margin of error.¹⁴ To accommodate potential non-responses and incomplete data, 400 patients were initially approached, of whom 393 completed the study (response rate: 98.25%).

Slovin's formula was selected as an appropriate method for determining sample size in descriptive cross-sectional studies where the primary objective is to estimate population parameters (prevalence of adequate self-care) rather than test specific hypotheses.¹⁴ This formula [n = N/(1 + Ne²)] is widely used in health surveys in resource-limited settings due to its simplicity and appropriateness for finite population sampling. Given that the total registered hypertensive population in the selected PHCCs was known (N = 13 000), this approach provided a representative sample adequate for descriptive analysis and exploratory regression modeling. A post-hoc power analysis confirmed that the achieved sample size (n = 393) provided >80% power to detect medium effect sizes (OR ≥ 2.0) in logistic regression with α=0.05.

Eligibility Criteria

Eligibility criteria included: (1) age ≥18 years, (2) a confirmed diagnosis of primary hypertension for at least six months as documented in medical records, (3) current use of antihypertensive medication, (4) ability to communicate in Kurdish, and (5) provision of written informed consent. Exclusion criteria included: (1) secondary hypertension, (2) cognitive impairment preventing interview participation, (3) acute medical emergencies, and (4) pregnancy.

Data Collection Instruments

Data collection was carried out via face-to-face structured interviews using a validated multi-section questionnaire. The first section captured socio-demographic and clinical characteristics, including age, sex, body mass index (BMI), duration of hypertension, comorbid conditions, blood pressure values, and lifestyle habits. Financial status was assessed through self-reported perception of household income adequacy using three categories: ‘sufficient’ (household income consistently meets all basic needs including food, housing, utilities, medications, and occasional discretionary spending), ‘barely sufficient’ (income meets basic needs but with frequent difficulty or need to prioritize expenses, with little to no discretionary funds), and ‘insufficient’ (household income consistently fails to meet basic needs, requiring debt, assistance from relatives, or going without necessities). This subjective assessment approach was chosen, given the sensitive nature of income disclosure and the variability in household composition and regional cost of living within the Kurdistan Region.

Hypertension Knowledge Assessment

Hypertension knowledge was assessed using a 41-item researcher-developed scale encompassing three domains: general information (11 items), disease management and self-care (15 items), and the impact of hypertension on quality of life (15 items). Response options included “yes,” “no,” or “don't know.” Scores were summed and converted to a 0-100 scale, then categorized into poor (<60%), fair (60%-79%), or good (≥80%) knowledge levels using Bloom's cutoff criteria. The instrument was developed based on current hypertension guidelines and relevant literature,^2,15 then reviewed by a panel of three experts (one cardiologist, one primary care physician, and one nursing educator) for content validity. The content validity index (CVI) was 0.89. The instrument was pilot-tested with 30 hypertensive patients (not included in the final sample) and demonstrated acceptable internal consistency (Cronbach's α = 0.78).

Perceived Social Support

Perceived social support was measured using the Multidimensional Scale of Perceived Social Support (MSPSS), a validated instrument with established psychometric properties.¹⁶ The scale includes 12 items assessing support from family, friends, and significant others on a 7-point Likert scale (1 = very strongly disagree to 7 = very strongly agree). Total scores ranged from 12 to 84 and were classified as low (12-35), moderate (36-60), or high (61-84) perceived social support.

Self-Care Behaviors

Self-care behaviors were evaluated using the Self-Care of Hypertension Inventory version 3.0 (SC-HI v3.0), a validated tool with strong psychometric properties¹⁷ consisting of 23 items distributed across three core domains: self-care maintenance (9 items), self-care monitoring (7 items), and self-care management (7 items). These domains reflect behaviors such as routine adherence to medication and healthy lifestyle (maintenance), recognition of blood pressure changes (monitoring), and appropriate responses to symptoms (management). An additional 24th item provides supplementary information, though it is not included in any subscale. The SC-HI v3.0 uses a 5-point frequency scale (1 = never or rarely to 5 = always or daily) for most items, and a 5-point probability scale (1 = not likely to 5 = very likely) for management items, with one final item using a 6-point certainty scale. Scores for each subdomain were standardized and converted to a 0-100 scale, with higher scores indicating better self-care. A score ≥70 in any domain and overall was considered indicative of adequate self-care, consistent with prior research.¹⁷

Data Collection Procedure

To maintain confidentiality and comfort, all interviews were conducted in private settings within the PHCCs by the principal investigator, who is a trained nurse. Each interview lasted approximately 30-45 min. Blood pressure readings were remeasured by the researcher during data collection using a calibrated aneroid sphygmomanometer following standardized protocols.¹⁸ Three consecutive readings were taken at 2-min intervals, and the average of the last two measurements was recorded. Uncontrolled hypertension was defined as an average systolic blood pressure (SBP) ≥ 140 mm Hg and/or diastolic blood pressure (DBP) ≥ 90 mm Hg, based on the 2024 European Society of Cardiology (ESC) guidelines.¹⁵

Statistical Analysis

Data analysis was performed using IBM SPSS Statistics version 26. Descriptive statistics were used to summarize participant characteristics; means and standard deviations were reported for continuous variables, and frequencies and percentages for categorical variables. Binary logistic regression analysis was conducted to identify predictors of adequate self-care (defined as a score ≥70). Independent variables included socio-demographic characteristics (age, gender, marital status, education, financial status, occupation), clinical factors (duration of hypertension, number of medications, comorbidities, BMI, blood pressure control, smoking, alcohol use), knowledge level, perceived social support, medication adherence, and self-reported barriers to self-care. The regression model was assessed using the Hosmer-Lemeshow goodness-of-fit test, Nagelkerke R², and classification accuracy . Results were presented as odds ratios (OR) with 95% confidence intervals (CI), and statistical significance was determined at a P-value <.05.

Binary logistic regression was selected rather than linear or ordinal regression for several conceptual and practical reasons. First, the SC-HI v3.0 developers and prior validation studies¹⁷ recommend using a clinical cutoff of ≥70% to define ‘adequate’ self-care, as this threshold has been associated with better clinical outcomes in chronic disease management. This dichotomization facilitates clinical interpretation and decision-making. Second, preliminary analysis revealed that self-care scores did not follow a normal distribution (Shapiro-Wilk test P < .001), with clustering around both high and low values, making binary classification more appropriate than assuming linear relationships. Third, from a clinical and public health perspective, identifying patients who meet versus do not meet an evidence-based adequacy threshold is more actionable than interpreting gradations along a continuous scale. Sensitivity analysis using continuous self-care scores in linear regression yielded similar predictor patterns (data not shown).

Results

Sociodemographic and Clinical Characteristics

The study enrolled 393 hypertensive patients with a mean age of 63.5 ± 11.3 years. The sample was predominantly male (>50%) and married (81.7%), with a low educational profile, as 36.6% were illiterate. Occupationally, housewives (42%) and retirees (32.1%) constituted the largest groups, and more than half of the participants (54.5%) experienced financial difficulties.

Regarding clinical and lifestyle characteristics, overweight and obesity were prevalent, affecting 38.2% and 28.2% of participants, respectively. Most participants were non-smokers (92.1%) and did not consume alcohol (98%). Hypertension had been present for 5-15 years in 60% of cases, and the majority (66.2%) were receiving combination therapy with two or more antihypertensive medications. Blood pressure control was achieved in 51.1% of patients, with mean systolic and diastolic blood pressures recorded at 136.8 ± 17.5 mm Hg and 83.35 ± 10.42 mm Hg, respectively (Table S1).

Hypertension Knowledge

Hypertension-related knowledge was generally high (Table S2). In the general knowledge domain, 80.4% demonstrated good knowledge (M = 86.61 ± 14.0), and only 2.5% were classified as having poor knowledge. Knowledge regarding disease management and self-care was lower, with 69.7% scoring in the fair range and 28.5% in the good range (M = 72.67 ± 8.85). Knowledge about the impact of hypertension on quality of life was good among 79.1% of participants (M = 82.07 ± 7.14). Overall, 71.6% exhibited good knowledge across all domains, with a total mean score of 80.45 ± 6.12.

Perceived Social Support

Perceived social support varied according to source (Table S3). Support from significant others was rated as high by 59% (M = 5.37 ± 0.81 on a 7-point scale) and moderate by 41%. Family support was the strongest domain, with 97.2% reporting high levels (M = 6.47 ± 0.54). In contrast, friend support was weakest, with 55.2% rating it as low (M = 3.08 ± 1.64). Overall, 42.5% of participants had high total social support, 53.7% moderate, and the mean total support score was 59.67 ± 8.77.

Barriers to Self-Care

Participants reported multiple barriers to self-care (Table 1). Emotional stress was the most frequently cited barrier (98%), followed by financial constraints (87.3%) and lack of time (78.4%). Less common barriers included insufficient family support (8.1%), cultural attitudes (3.6%), and difficulty understanding medical advice due to limited knowledge (2%). The majority (86.8%) reported experiencing three or more concurrent barriers.

Table 1.

Self-Reported Barriers to Self-Care Among Participants (N = 393).

Types of Barriers to Self-care	F	%
Lack of Time (Time constraints)	308	78.4
Cultural Habit & Personal Attitude	14	3.6
Financial Limitation	343	87.3
Lack of Support from Family	32	8.1
Difficulty understanding medical advice (lack of knowledge)	8	2
Emotional Stress	358	98.0
Number of Barriers
1–2	53	13.2
≥ 3	340	86.8

Self-Care Behaviors

Self-care behaviors were generally suboptimal (Table 2). In the self-care maintenance domain—which includes medication adherence, healthy diet, and physical activity—only 31% achieved adequacy (≥70), with a mean score of 68.15 ± 8.57. For self-care monitoring, involving recognition of symptoms and physiological changes, 67.7% scored below adequacy (M = 63.75 ± 9.11). The lowest performance was in self-care management, reflecting appropriate responses to symptoms and blood pressure changes, where only 26.2% met the adequacy threshold (M = 64.89 ± 9.72). Overall, just 26.7% of participants achieved adequate self-care, with a total mean score of 64.37 ± 7.28.

Table 2.

Distribution of Participants’ Self-Care Level According to (SC-HI v3) (N = 393).

Self-care Domains	Class	F (393)	%
Self-care Maintenance	Poor < 70%	271	69.0
	Adequate ≥ 70%	122	31.0
	Mean ± SD (0-100)	68.15 ± 8.57
Self-care Monitoring	Poor < 70%	266	67.7
	Adequate ≥ 70%	127	32.3
	Mean ± SD (0-100)	63.75 ± 9.11
Self-care Management	Poor < 70%	290	73.8
	Adequate ≥ 70%	103	26.2
	Mean ± SD (0-100)	64.89 ± 9.72
Overall Self-care	Poor < 70%	288	73.3
	Adequate ≥ 70%	105	26.7
	Mean ± SD (0-100)	64.37 ± 7.28

Item-level analysis (Table 3) indicated stronger adherence to pharmacological treatment than to lifestyle-related behaviors. In self-care maintenance, the highest-scoring items were regular antihypertensive medication use (M = 3.81 ± 0.52), requesting low-salt food (M = 3.74 ± 0.44), and avoiding missed doses (M = 3.65 ± 0.52). The lowest-scoring items were physical activity (M = 1.24 ± 0.66), engagement in stress-relief activities (M = 1.31 ± 0.61), and fruit and vegetable consumption (M = 2.04 ± 0.85). In self-care monitoring, the most practiced behaviors were monitoring fatigue during activity (M = 2.71) and assessing general well-being (M = 2.70), whereas weight monitoring (M = 1.57 ± 0.74) and observing medication side effects (M = 2.14 ± 0.59) were least practiced. Self-care management behaviors scored slightly better than monitoring but remained inadequate, with reducing salt intake (M = 3.79 ± 0.41) and consistent medication use (M = 3.54 ± 0.63) performing highest. Patient-initiated communication with healthcare providers scored particularly low—calling a provider when needed (M = 1.18 ± 0.56) and discussing symptoms at the next visit (M = 1.14 ± 0.45) were among the weakest areas. Confidence in self-care actions was generally low to moderate (M = 2.07 ± 0.82), indicating limited self-efficacy in managing acute symptoms.

Table 3.

Distribution of Descriptive Data of Hypertension Self-Care Inventory Items.

Self-Care Subscales Items	Min	Max	Mean	SD
Self-Care Maintenance (1-5)
Keep appointments with your healthcare provider?	2	4	3.64	0.50
Take your blood pressure pills?	2	4	3.81	0.52
Do something to relieve stress (meditation, yoga, music)?	1	3	1.31	0.61
Do physical activity (a brisk walk, use the stairs)?	1	3	1.25	0.66
Take prescribed medicines without missing a dose?	2	4	3.65	0.52
Ask for low salt items when eating out / visiting others?	3	4	3.74	0.44
Try to avoid getting sick (flu shot, wash your hands).	1	3	2.18	0.63
Eat fruits and vegetables?	1	3	2.04	0.85
Avoid cigarettes and/or smokers?	1	4	3.02	1.01
Overall Self-Care Maintenance (0-100)	47.2	88.9	68.15	8.57
Self-Care Monitoring (1-5)
Monitor your condition?	1	4	2.41	0.60
Pay attention to changes in how you feel.	2	3	2.70	0.46
Check your blood pressure?	1	4	2.42	0.90
Monitor whether the tire is more than usual when doing normal activities.	2	3	2.71	0.46
Monitor for medication side effects?	1	3	2.14	0.59
Monitor for symptoms?	1	4	2.50	0.62
Monitor your weight?	1	3	1.57	0.74
Overall Self-Care Maintenance (0-100)	43.3	83.3	63.75	9.11
Self-Care Monitoring (1-5)
Reduce the salt in your diet	3	4	3.79	.405
Take your blood pressure medicine regularly	2	4	3.54	.626
Call your healthcare provider for guidance	1	3	1.18	.563
Reduce your stress level	1	3	1.31	.606
Talk to your healthcare provider about this at the next office visit	1	3	1.14	.446
Reduce your caffeine intake (coffee, cola, tea)	1	2	1.36	.482
How sure were you that the action you used helped? (0-5)	1	4	2.07	.816
Overall Self-Care Management (0-100)	50.0	90.9	65.47	7.88
How quickly did you recognize that your blood pressure was up? (0-5)	2	2	2.71	0.46

Predictors of Adequate Self-Care

Binary logistic regression identified several predictors of adequate self-care (Table 4). The model was statistically significant (χ² = 123.997, P < .001), explained 40% of the variance in self-care behaviors (Nagelkerke R² = 0.400), and correctly classified 81.7% of cases. The Hosmer-Lemeshow test indicated good model fit (χ² = 8.453, P = .390).

Table 4.

Binary Logistic Regression Analysis. Predictors of Adequate Self-Care Among Hypertensive Patients (N = 393).

Predictors	B	S.E.	Wald	Sig.	Exp(B)	95% CI
Age	−0.063	0.016	15.887	0.000	0.939	0.909-0.970
Gender	0.323	0.363	0.790	0.374	1.381	0.681-2.800
Marital Status	0.907	0.383	5.596	0.018	2.476	1.167-5.252
Education	−0.163	0.135	1.473	0.225	0.849	0.652-1.106
Financial	−0.294	0.317	0.861	0.353	0.745	0.400-1.387
Occupations	−0.362	0.168	4.631	0.031	0.697	0.502-0.969
Duration of Hypertension	−0.014	0.021	0.452	0.501	0.986	0.946-1.028
Medications Number	−0.251	0.244	1.060	0.303	0.778	0.483-1.253
Comorbidity	−0.595	0.217	7.524	0.006	0.552	0.365-0.837
BMI	−0.021	0.027	0.609	0.435	0.979	0.928-1.033
Hypertension Control	−0.995	0.319	9.724	0.002	0.370	0.196-0.697
Smoking	1.123	0.637	3.106	0.078	0.325	0.093-1.136
Alcohol	−0.008	1.019	0.000	0.994	0.992	0.134-7.351
Self-Care Barriers	−0.125	0.292	0.184	0.668	0.882	0.498-1.564
Knowledge	0.053	0.024	4.941	0.026	0.949	0.989-0.999
Social Support	0.052	0.018	8.069	0.005	1.054	1.016-1.094
Medication adherence	0.449	0.103	19.018	0.000	1.566	1.279-1.916
Constant	3.490	2.823	1.529	0.216	32.784

Note: Odds ratios <1.0 indicate decreased odds of adequate self-care with increasing values of the predictor. For age, employment (unemployed status), and comorbidities, lower values indicate protective effects. Blood pressure control was coded as 1 = uncontrolled, 2 = controlled; thus, OR < 1 indicates controlled BP is associated with lower odds of adequate self-care, likely reflecting reduced perceived urgency when BP is well-managed. Model fit: χ² = 123.997, P < .001; Nagelkerke R² = 0.400; Hosmer-Lemeshow test χ² = 8.453, P = .390; Classification accuracy = 81.7%.

Adequate self-care was significantly associated with younger age (OR = 0.939, 95% CI: 0.909-0.970, P < .001), indicating that each additional year of age decreased the odds of adequate self-care by 6.1%, likely reflecting age-related physical limitations and cognitive changes. Being married increased the odds of adequate self-care by 2.5-fold (OR = 2.476, 95% CI: 1.167-5.252, P = .018), suggesting the protective role of spousal support in chronic disease management.

Interestingly, paid or self-employment showed a protective effect (OR = 0.697, 95% CI: 0.502-0.969, P = .031), with unemployed status (housewives, retirees) associated with better self-care. This counterintuitive finding may reflect greater time availability for self-care activities among non-working individuals, despite financial constraints.

Absence or low comorbidity burden (OR = 0.552, 95% CI: 0.365-0.837, P = .006) and controlled blood pressure (OR = 0.370, 95% CI: 0.196-0.697, P = .002) were significant predictors. The negative association between blood pressure control and self-care odds (OR <1) appears paradoxical but likely reflects the bidirectional nature of this relationship; controlled BP may reduce perceived urgency for intensive self-care, while uncontrolled BP may motivate greater adherence efforts following medical advice.

Higher hypertension knowledge (OR = 0.994, 95% CI: 0.989-0.999, P = .026) showed a small but significant association, with each unit increase in knowledge score associated with slightly better self-care . Greater social support was positively associated with self-care (OR = 1.054, 95% CI: 1.016-1.094, P = .005), indicating that each unit increase in MSPSS score increased the odds of adequate self-care by 5.4%.

Gender, financial status, BMI, smoking/alcohol use, education level, hypertension duration, and polypharmacy were not significant predictors in the final model.

Discussion

This study examined self-care behaviors and influencing factors among hypertensive patients in the Kurdistan Region of Iraq, integrating key variables such as knowledge, social support, medication adherence, and barriers to chronic disease management. The findings reveal notable challenges and opportunities for improving hypertension self-management in this population.

The study sample comprised older adults, with a mean age of 63.5 ± 11.3 years, and 68.5% aged ≥60 years, consistent with global evidence linking advancing age to increased hypertension prevalence due to vascular and metabolic changes.¹⁹ Gender distribution was balanced, with a slight male predominance. Most participants were married (81.7%), suggesting a potential for spousal and familial support, which is known to influence chronic disease management positively.²⁰ Educational attainment was low, with 36.6% illiterate and 10.9% never attending school, while over half reported financial strain, underscoring socioeconomic barriers that may impede healthcare access and health literacy, key determinants of hypertension outcomes.^21,22 Clinically, the mean BMI of 27.5 indicated an overweight status, aligning with established associations between excess weight and hypertension risk.²³ The average hypertension duration was 11.3 years, and 66.2% were on two or more antihypertensive agents, reflecting both the chronicity of disease and adherence to guideline-based combination therapy for suboptimal blood pressure control.²⁴ Although blood pressure control was achieved in 51.1% of patients, mean systolic and diastolic values remained above optimal targets, mirroring trends in other low- and middle-income countries.^25,26

A key finding of this study is the generally high level of hypertension-related knowledge, particularly regarding general disease information and its impact on quality of life (QoL). Nearly 80% of participants demonstrated good understanding of hypertension's definition, causes, symptoms, and complications, with a mean general knowledge score of 86/100. Awareness of hypertension's adverse effect on QoL was also high (79.1% good knowledge), likely reflecting the influence of public health campaigns and personal experience with the disease. These results are consistent with earlier studies in Baghdad and Erbil.^27,28 However, knowledge of hypertension management and self-care was considerably lower, with only 28.5% achieving good scores (mean = 72.67), indicating limited understanding of lifestyle modifications, regular BP monitoring, and symptom management. Similar deficits reported in local studies^4,5 are often attributed to insufficient patient-centered education during clinical encounters. Overall, 71.6% of participants achieved good knowledge across all domains (mean = 80.45). The discrepancy between disease awareness and self-care knowledge underscores the need for structured, skills-based educational programs, consistent with Ajani et al (2021),²⁹ who stressed the importance of combining informational knowledge with practical self-management training.

Perceived social support among participants was generally favorable, with more than half reporting moderate to high overall support (mean MSPSS ≈ 60). Family support emerged as the strongest domain, with 97.2% rating it as high (mean = 6.47/7), consistent with the collectivist cultural norms of Kurdish society, where multigenerational households provide substantial emotional and practical caregiving.^12,30,31 In contrast, friend support was limited, with 55.2% reporting low levels (mean = 3.08), likely reflecting cultural preferences for family-based help and reduced peer interaction in older age.^32,33 Support from “significant others” (eg, healthcare providers, extended relatives) was moderate to high in about 60% of participants, highlighting their potential role in facilitating care adherence.¹² These findings suggest interventions should leverage strong family networks while fostering broader peer engagement.

Self-Care Behaviors: The most concerning finding is that nearly three-quarters (73.3%) of participants demonstrated inadequate overall self-care, with a mean score of 64.37 ± 7.28 below the 70% adequacy threshold. This aligns with previous findings in Iraq and similar settings, where systemic, cultural, and behavioral barriers impede chronic disease self-management.^34–36 Furthermore, only 31% achieved adequate scores in the maintenance domain (mean = 68.15). While medication adherence behaviors—such as taking prescribed doses regularly (mean = 3.81) and requesting low-salt meals (mean = 3.74)—were relatively strong, lifestyle-related behaviors were strikingly poor. Physical activity (mean = 1.24), stress management (mean = 1.31), and fruit/vegetable consumption (mean = 2.04) were particularly weak areas. Similar trends have been documented in other chronic disease populations,^19,37 reflecting over-reliance on pharmacological therapy at the expense of lifestyle modification. Similarly, monitoring behaviors were inadequate in 67.7% of participants (mean = 63.75). While some patients reported monitoring fatigue (mean = 2.71) and general well-being (mean = 2.70), critical practices such as weight monitoring (mean = 1.57), BP checks (mean = 2.42), and side-effect observation (mean = 2.14) were insufficient. This likely reflects limited patient education, inadequate access to monitoring tools, and low health literacy—factors also identified by Konlan et al (2023).³⁸ Management was the weakest domain, with only 26.2% meeting adequacy (mean = 64.89). Confidence in managing symptoms was low (mean = 2.07), and proactive healthcare communication was minimal—calling a provider (mean = 1.18) and discussing symptoms at visits (mean = 1.14) were among the lowest-scoring behaviors. These findings echo prior research linking self-efficacy to effective disease management^38,39 and suggest that passive, physician-directed care dominates over active patient engagement.

Participants reported multiple, interrelated barriers. Emotional stress was nearly universal (98%), consistent with evidence that anxiety and depression impair both medication adherence and lifestyle modification.⁴⁰ Financial constraints (87.3%) were also prominent, limiting access to medications, nutritious food, transportation, and monitoring equipment, as reported in other resource-limited contexts.²⁹ Time constraints affected 78.4% of participants, reflecting the difficulty of balancing caregiving, household duties, and employment with self-care routines—findings echoed in a study by Kebede et al (2024).⁴⁰ In contrast, lack of family support was uncommon (8.1%), reflecting the strong familial networks characteristic of Kurdish society. Less frequently reported barriers included cultural norms and difficulty understanding medical advice, which, while less common, may still hinder adherence for some patients. Addressing these barriers will require a patient-centered approach that integrates psychosocial support, financial assistance, and culturally appropriate education.

Predictors of Self-Care: Binary logistic regression revealed that self-care behaviors are shaped by a mix of demographic, clinical, and psychosocial factors. Among demographic and social predictors, younger age was significantly associated with better self-care (OR = 0.939, 95% CI: 0.909-0.970, P < .001), consistent with research linking aging to physical limitations and cognitive decline.^9,29 Being married doubled the odds of adequate self-care (OR = 2.476, 95% CI: 1.167-5.252, P = .018), underscoring the protective role of spousal support.⁶ Employment status also mattered, with unemployment reducing self-care likelihood (OR = 0.697, 95% CI: 0.502-0.969, P = .031), possibly reflecting economic hardship, though the direction suggests unemployed individuals (housewives, retirees) actually had better self-care, likely due to greater time availability for self-care activities.¹⁰

Among clinical and psychosocial predictors, absence or low levels of comorbidities (OR = 0.552, 95% CI: 0.365-0.837, P = .006) predicted better self-care, suggesting that the presence of multiple chronic conditions nearly halved the odds of adequate self-care. This finding is consistent with evidence that multimorbidity increases treatment complexity, creates competing self-care demands, elevates medication burden, and divides patients’ attention across multiple disease management priorities.^9,10 Controlled BP was linked to higher self-care (OR = 0.370, 95% CI: 0.196-0.697, P = .002). The inverse relationship between blood pressure control and self-care (OR <1) may initially seem counterintuitive, as better self-care is expected to lead to improved blood pressure control. However, this finding reflects the complex, bidirectional nature of this relationship documented in previous research. Patients who achieve controlled blood pressure may experience reduced motivation to maintain intensive self-care behaviors, where symptom relief diminishes perceived need for continued adherence. Conversely, patients with uncontrolled blood pressure often receive intensified medical counseling and experience more noticeable symptoms, which can prompt greater immediate efforts toward lifestyle modification and medication adherence. Similar patterns have been observed in other chronic disease populations, where clinical stability sometimes leads to relaxed self-management practices.^6,10

In addition, higher hypertension knowledge (OR = 0.994, 95% CI: 0.989-0.999, P = .026) emerged as a positive predictor. Higher hypertension knowledge enhances self-care by enabling patients to understand the rationale behind recommended behaviors, recognize warning signs, and appreciate the consequences of poor adherence. Knowledge empowers patients to transition from passive recipients of medical advice to active participants in disease management, fostering self-efficacy and independent decision-making. Previous studies have consistently demonstrated that patients with better disease understanding exhibit higher medication compliance, more consistent blood pressure monitoring, and greater engagement in lifestyle modifications.^9,10,27

Furthermore, greater social support (OR = 1.054, 95% CI: 1.016-1.094, P = .005) also emerged as a positive predictor. Social support enhances self-care through multiple mechanisms, including practical assistance with medication reminders, appointment accompaniment, and financial aid for medications and monitoring equipment. Emotional support reduces psychological stress, enhances motivation, and provides accountability through encouraging family networks. Strong social connections buffer against emotional distress and isolation, which impair adherence. Research has shown that hypertensive patients with robust social support demonstrate significantly better medication adherence, blood pressure monitoring, and dietary modifications compared to socially isolated individuals.^9,10,32

Finally, gender, financial status, BMI, smoking/alcohol use, education level, hypertension duration, and polypharmacy were not significant predictors. This contrasts with some prior research⁹ but aligns with studies suggesting that in collectivist cultures, family decision-making and public healthcare access can buffer the effects of individual socioeconomic variables.¹²

Conclusion

This study revealed substantial self-care gaps among hypertensive patients in the Kurdistan Region of Iraq, as only a small proportion demonstrated adequate self-care despite generally good disease-related knowledge and social support. The marked imbalance between strong medication adherence and poor engagement in lifestyle modification, symptom monitoring, and patient-provider communication suggests that existing strategies are insufficient to support comprehensive chronic disease self-management. Older age, comorbidities, and blood pressure control hindered effective self-care, while younger age, marital status, higher knowledge, and strong support promoted it. Emotional stress, widespread financial hardship, and prevalent time constraints emerged as major barriers.

Limitations

This study's cross-sectional design limits causal inference, and reliance on self-reported data may introduce recall and social desirability biases, potentially affecting accuracy. Convenience sampling and recruitment from PHCCs further limit the generalizability of findings to the wider hypertensive population.

Supplemental Material

sj-docx-1-jpx-10.1177_23743735251406683 - Supplemental material for Self-Care Behaviors and Associated Factors among Patients with Hypertension in the Kurdistan Region of Iraq: A Cross-Sectional Study

Supplemental material, sj-docx-1-jpx-10.1177_23743735251406683 for Self-Care Behaviors and Associated Factors among Patients with Hypertension in the Kurdistan Region of Iraq: A Cross-Sectional Study by Hero Noori Ali and Muhammad Rashid Amen in Journal of Patient Experience

Footnotes

Acknowledgements

We would like to express our sincere gratitude to all the patients who participated in this study and to the staff of the primary health care centers for their valuable assistance in facilitating data collection.

Authors Contributions

Both authors contributed equally to the conception and design of the study, data collection, analysis, interpretation of results, drafting of the manuscript, and approval of the final version for publication.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Ethical Approval

Ethical approval for this study was obtained from the University of Sulaimani Ethics Committee (Approval ID: 005/5, May 2024). All procedures involving human participants were conducted following the ethical standards of the national research committee and with the 1964 Declaration of Helsinki and its later amendments and comparable ethical standards. Written informed consent was obtained from all participants prior to their inclusion in the study.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Hero Noori Ali

Muhammad Rashid Amen

Statement of Human and Animal Rights

There is no animal subject in this article.

Statement of Informed Consent

Written informed consent was obtained from the patients for their anonymized information to be published in this article.

Supplemental Material

Supplemental material for this article is available online.

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