Introduction

Hypertension is a sustained elevation of systemic arterial blood pressure, most commonly defined as systolic blood pressure (SBP) ≥ 140 mmHg or diastolic blood pressure (DBP) ≥ 90 mmHg, but definitions vary by professional organization and by level of cardiovascular risk1,2,3. Onset is generally at age 20–50 years, but the prevalence increases with age4. The global prevalence of hypertension was 24% in men and 20% in women in 20155. Although the age-standardized global prevalence of hypertension appears to have remained stable from 1990 to 2019, the rates of controlled hypertension vary worldwide with economic status6. The risk factors for hypertension include but are not limited to, weight gain and obesity, alcohol use (particularly for men), and exposure to insulin2,7,8. Most patients (85–90%) with hypertension have primary or essential hypertension9. Untreated or incompletely treated hypertension is associated with an increased risk of cardiovascular events and mortality10,11,12.

Drugs can be necessary for many patients, including thiazide-type diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, and β-blockers1,2,3,4,11. Still, selected lifestyle interventions, including weight reduction, diet modifications (sodium restriction), smoking cessation, regular exercise, and restriction of alcohol intake, can lower blood pressure and prevent or reduce the likelihood of developing hypertension or hypertension progression. The American College of Cardiology/American Heart Association (ACC/AHA) recommends increased physical activity with structured exercise programs in adults with hypertension or elevated blood pressure3. Hypertension Canada recommends 30–60 min of moderate-intensity aerobic exercise 4–7 days/week in addition to routine activities of daily living1. Physical activity reduces cardiovascular mortality in persons with high blood pressure13. Walking might reduce systolic and diastolic blood pressure and heart rate in adults with or without hypertension14.

Still, exercising to manage hypertension requires lifestyle modifications and specific knowledge to implement the changes. In addition, attitude (or motivation) is a prerequisite for such modifications. Knowledge, attitude, and practice (KAP) studies allow the identification of gaps, misconceptions, and misunderstandings that can constitute barriers to properly implementing a given set of actions toward a disease15,16. Educational interventions can then be built using KAP results. Studies from Malaysia17 and Lebanon18 reported poor practice of exercise among patients with hypertension. An early study in the Republic of Seychelles revealed good knowledge of exercise in hypertension, but poor practice19, and similar results were observed in East Africa20. Although data are available on the KAP of hypertension in Chinese patients21, no studies examined the KAP of exercise in hypertension in China.

Hypertension is a common and treatable disease, and uncontrolled hypertension can lead to serious multisystem sequelae1,2,3,4,11. Given the global and local hypertension prevalence5,6, ensuring compliance with antihypertensive management should be a top priority. Additionally, considering the economic constraints imposed by the cost and side effects of antihypertensive medications, adopting a healthy lifestyle remains fundamental to hypertension management1,2,3,4,11. Therefore, this study aimed to examine the KAP regarding exercise management among patients with primary hypertension and explore the factors influencing the KAP. The results could help improve the management of hypertension.

Methods

Study design and participants

This cross-sectional study was conducted between March and May 2024 at the People’s Hospital of Lixia District of Jinan and Baotuquan Community Health Service Center and enrolled patients with primary hypertension. The exclusion criteria were (1) completion time of < 90 s and (2) did not consent to participate in the study.

Questionnaire introduction and quality control

The questionnaire design was based on the best evidence summary of exercise management interventions for patients with primary hypertension1,2,3,4,11,13,22. The questionnaire was pre-tested in 35 participants, and its Cronbach’s α was 0.838.

The final questionnaire, in Chinese, covered four aspects: demographic information (gender, age, education level, occupation type, monthly income, etc.) and the knowledge, attitude, and practice dimensions. The knowledge dimension included eight questions, with 1 point for a correct answer, 0 points for unclear or incorrect answers, and a score range of 0–8 points. The attitude dimension comprised nine questions, using a 5-point Likert scale ranging from strongly agree to strongly disagree (5–1 points), with a score range of 9–45 points. The practice dimension included seven questions, using a 5-point Likert scale ranging from strongly agree/always (5 points) to strongly disagree/never (1 point), with a score range of 7–35 points.

The participants were enrolled during seminars on hypertension or outpatient visits. The seminars were a common patient education program for patients with hypertension at our hospital. The questionnaire was distributed to those who participated in the seminars for the first time to reduce potential bias from the education. The electronic questionnaire was used to collect data from hypertensive patients. The questionnaire was set up on the Sojump platform (www.sojump.com), and then a link to the electronic questionnaire was generated. In order to ensure the quality and completeness of the electronic questionnaire, each IP address could be used for submission only once. All questionnaires were checked for completeness, consistency, and validity by the research team members. Questionnaires with logical contradictions (according to the trick item) and obvious repetitive patterns were considered invalid.

Statistical analysis

Statistical analysis was performed using SPSS 26.0 (IBM Corp., Armonk, N.Y., USA) and AMOS 22.0 (IBM Corp., Armonk, N.Y., USA). Continuous variables were expressed as means ± standard deviations (SDs), and between-group comparisons were conducted using t-tests or analysis of variance (ANOVA). Categorical variables were presented as n (%). Univariable and multivariable logistic regression analyses were used to explore the factors associated with the KAP dimensions. Attaining scores exceeding 70% of the maximum in each section indicated a commendable level of knowledge, positive attitudes, and proactive practices23. A structural equation model (SEM) was used to scrutinize the interrelations among the questionnaire dimensions, assuming that knowledge directly influences attitudes and practices, while attitudes directly impact practices. Two-sided P-values < 0.05 were considered statistically significant.

Results

Characteristics of the participants

A total of 1221 questionnaires were collected; 41 were excluded because of a completion time < 90 s, 2 for non-consent to participate, 25 because the question about hypertension was not answered, 4 because all questions in the knowledge section were answered as “unclear”, 599 for using the same IP address, and 3 for missing age value. Therefore, 550 valid questionnaires were included.

The participants were 52.79 ± 12.63 years. Most participants were female (55.45%), with junior high school education or below (32.18%), non-medical occupation (65.09%), a monthly income of 2000–5000 CNY/month (66.73%), hypertension for > 5 years (37.82%), controlled with medication (71.45%), exercise for at least 1 h each day (42.55%), without diabetes (87.27%), without varicose veins (93.27%), and without heart disease (92.18%) (Table 1).

Table 1 Characteristics and KAP scores of the participants.
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Knowledge

The mean knowledge score was 4.54 ± 1.03 (/8, 56.75%), indicating insufficient knowledge. The knowledge scores were associated with occupation (P = 0.003), income (P = 0.001), hypertension duration (P < 0.001), and diabetes (P = 0.010) (Table 1). Poor knowledge was observed for K3 (8.55%; “Hypertensive patients need to exercise 2–3 days a week, engaging in at least 30 min of moderate-intensity aerobic exercise (e.g., walking, jogging, cycling, or swimming) per session.”) and K6 (17.27%; “Hypertensive individuals do not need to wear devices to monitor heart rate during exercise; they should stop if they feel uncomfortable.”) (Supplementary Table S1).

Attitude

The mean attitude score was 35.40 ± 8.12 (/45, 78.67%), indicating positive attitudes. The attitude scores were associated with occupation (P < 0.001), income (P < 0.001), hypertension duration (P < 0.001), controlled with medication (P < 0.001), and exercising (P < 0.001) (Table 1). Supplementary Table S2 presents the distribution of the responses to the attitude items.

Practice

The mean practice score was 24.38 ± 4.84 (/45, 69.66%), indicating suboptimal practice. The practice scores were associated with occupation (P < 0.001), hypertension duration (P < 0.001), controlled with medication (P < 0.001), exercising for at least 1 h 2–3 days a week (P < 0.001), and heart disease (P = 0.041) (Table 1). Supplementary Table S3 presents the distribution of the responses to the practice items.

Multivariable analysis

Having a non-medical occupation (vs. a medical occupation; OR 0.418, 95% CI 0.176–0.995, P = 0.049), earning 5000–10,000 (vs. < 2000; OR 3.263, 95% CI 1.404–7.587, P = 0.006) and > 10,000 (vs. < 2000, OR 3.927, 95% CI 1.368–11.272, P = 0.011) CNY/month, diagnosed with hypertension for 3–5 (vs. < 3; OR 0.591, 95% CI 0.361–0.967, P = 0.036) and > 5 (vs. < 3; OR 0.537, 95% CI 0.332–0.869, P = 0.011) years, and diabetes (vs. without diabetes; OR 0.573, 95% CI 0.335–0.981, P = 0.042) were independently associated with knowledge (Table 2).

Table 2 Factors influencing good knowledge.
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Age (continuous variable; OR 0.934, 95% CI 0.904–0.965, P < 0.001), diagnosed with hypertension for > 5 years (vs. < 3 years; OR 11.985, 95% CI 3.833–37.479, P < 0.001), and exercising for ≥ 1 h each day (vs. basically no exercise; OR 19.102, 95% CI 5.333–68.413, P < 0.001), every 2–3 days (vs. basically no exercise; OR 69.112, 95% CI 7.508–636.140, P < 0.001), every 4–5 days/week (vs. basically no exercise; OR 0.289, 95% CI 0.105–0.795, P = 0.016), and every 6–7 days/week (vs. basically no exercise; OR 0.020, 95% CI 0.004–0.108, P < 0.001) were independently associated with attitude (Table 3).

Table 3 Factors influencing positive attitudes.
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The attitude scores (continuous variable; OR 1.457, 95% CI 1.326–1.600, P < 0.001), age (continuous variable; OR 0.959, 95% CI 0.931–0.987, P = 0.004), high school/technical school education (vs. junior high school and below; OR 0.407, 95% CI 0.166–0.997, P = 0.049), bachelor’s degree or above (vs. junior high school and below; OR 0.381, 95% CI 0.148–0.981, P = 0.046), diagnosed with hypertension for 3–5 years (vs. < 3 years; OR 2.426, 95% CI 1.079–5.455, P = 0.032), rarely monitors blood pressure (vs. achieves normal level after daily medication; OR 0.152, 95% CI 0.058–0.403, P < 0.001), and exercising for ≥ 1 h each day (vs. basically no exercise; OR 5.827, 95% CI 2.072–16.384, P = 0.001), every 2–3 days (vs. basically no exercise; OR 10.280, 95% CI 3.370–31.353, P < 0.001), and every 4–5 days/week (vs. basically no exercise; OR 12.267, 95% CI 3.091–48.926, P < 0.001) were independently associated with practice (Table 4).

Table 4 Factors influencing proactive practices.
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Structural equation model

The SEM (Fig. 1) showed that knowledge influenced practice (β = 1.048, P < 0.001) and attitude influenced practice (β = 0.841, P < 0.001) (Table 5). The fit of the model was good (Supplementary Table S4).

Fig. 1
figure 1

Structural equation model for knowledge, attitude, and practice.

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Table 5 SEM results.
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Discussion

The results suggest that patients with hypertension in Baotuquan have insufficient knowledge, positive attitudes, and suboptimal practices concerning exercise management. The study identified knowledge areas that could be intervened on to improve exercise practice in patients with hypertension, especially the amount of exercise, the optimal exercise regimens, and the need for heart rate monitoring during exercise.

Pharmacological interventions are effective in the management of hypertension, but they are associated with medical expenses and side effects. Hence, nonpharmacological interventions could help manage hypertension. Indeed, lifestyle habit changes can be sufficient to manage early hypertension. Later in the course of the disease, lifestyle habit changes can prevent the progression of hypertension and the need for multiple drugs1,2,3,4,11. Still, although many changes are relatively simple (e.g., limiting sodium intake, eating more fresh fruits and vegetables, and limiting alcohol), such changes require knowing what to change, a will to change some habits, and self-discipline and rigor in implementing the changes.

Exercise is a simple way to manage hypertension and other conditions like obesity, cardiovascular disease, and diabetes24,25. The level of exercise required to achieve benefits on blood pressure can be as low as walking 1 h each day14, which does not require specialized equipment or facilities, but more intensive programs can be necessary for some patients1,3. No previous studies focused on the KAP of exercise among patients with hypertension, but some data can be obtained from KAP studies on hypertension in general. Although some studies report good knowledge of exercise for the management of hypertension19,20,21, the studies generally report poor practice17,18,19,20,21. Certainly, recognizing the benefits of a lifestyle habit change may not suffice for actual behavior modification, as such changes often entail giving up pleasurable activities or foods and engaging in actions that might be perceived as inconvenient.

In the present study performed in Baotuquan (China), the patients with hypertension had poor knowledge, favorable attitudes, and poor practice of exercise. The SEM and multivariable analyses suggested that knowledge influenced practice but not attitude, while attitude influenced practice. Therefore, these results suggest that the patients are willing to exercise but might lack the knowledge to perform it properly. Indeed, according to the KAP theory, knowledge is the basis for practice, while attitude is the force driving practice15,16. Therefore, interventions to improve knowledge could translate into improvements in practice. Among others, knowledge about the duration, frequency, and intensity of exercise and the need to monitor heart rate and when stopping exercise should be improved. Since the present study identified categories of patients with poorer KAP, targeted interventions could be designed to improve their KAP. Public health campaigns could also reach a large audience. Numerous digital tools to support exercise management are available. They should be evaluated for possible integration into patient management.

In the present study, patients from non-medical occupations had a lower KAP, as can be expected since people involved in medical occupations are more susceptible to being exposed to proper knowledge. A higher socioeconomic status was also generally associated with a better KAP, as supported by the fact that a higher socioeconomic status is associated with better health literacy22. A longer interval since diagnosis was associated with poorer knowledge but better practice. Age was independently associated with poorer practice, probably related to decreasing physical fitness with age. Hence, the results suggest that educational interventions should first target older and lower socioeconomic patients. They also indicate that education should be sustained after diagnosis.

This study has several limitations. The study population was derived from a solitary hospital within a specific geographic area, thereby constraining the generalizability of the findings. Some questionnaires had to be excluded based on the quality control criteria. It can impact the representativeness of the sample but increase data quality. No special action was taken to mitigate that effect except collecting many questionnaires that could dilute the impact of the 41 (3.4%) excluded questionnaires. They completed the questionnaire after the seminar at their convenience. Presences are not formally taken during such seminars, but the QR code is distributed during the seminar, ensuring that those who completed the questionnaire attended the seminar. However, the interval between the seminar attendance and completing the questionnaire could not be determined. The questionnaire was formulated by the investigators based on local policies, practices, and cultural characteristics, limiting the transferability of the questionnaire and the generalizability of the results. The study’s findings may, therefore, be more reflective of local practices than universally applicable. Still, exercise management among patients with primary hypertension is relatively similar across guidelines in different countries. Therefore, the results could have value for other regions in the world, but it should be confirmed. Nevertheless, different countries have slightly different definitions of hypertension. In addition, the drugs, especially the most recent ones, may not be available in all countries, leading to different treatment patterns. Exercising requires self-discipline and proper encouragement from peers and society, which can differ among countries. China is a society that recognizes the importance of maintaining healthy lifestyle habits for the common good26,27. A similar study should also be conducted in countries where lifestyle habits are generally not as good. On the other hand, China has one of the highest proportions of smokers, and environmental pollution is high28,29. The study was cross-sectional. The data were captured at a single time point, preventing the analysis of causal relationships or the analysis of changes in time. In addition, the associations can be difficult to interpret. It can also be susceptible to nonresponsive and recall biases. Still, the data could serve as a historical baseline for future assessments of the impact of educational interventions on exercise in hypertension. Longitudinal or interventional studies could provide more robust insights into causal relationships. Longitudinal studies could provide insights into the changes in KAP over time and after implementing an educational intervention to improve knowledge. The impact of influencing knowledge would then be observed on attitudes and practice. Randomized controlled studies of educational interventions could also provide additional insights into causality. Furthermore, like all KAP studies, this research is susceptible to social desirability bias, where participants may be inclined to respond in a manner they perceive as socially acceptable rather than accurately reflecting their beliefs or behaviors30,31. Future studies could use indirect behavioral measures or implement anonymous surveys to minimize the impact of the social desirability bias. Finally, questionnaires completed with all the same options or with logic errors were excluded. Based on the time participants spent completing the questionnaire during the pilot study, questionnaires with a completion time of less than 90 s were also excluded. Although it could mitigate bias by excluding participants who completed the questionnaire without reading it, it could have excluded questionnaires completed honestly but for which the participants could have misunderstood some questions.

In conclusion, the findings indicate that individuals with hypertension in Baotuquan possess inadequate knowledge, positive attitudes, and suboptimal practices related to exercise management. The study has pinpointed specific knowledge areas (amount of exercise, the optimal exercise regimens, and the need for heart rate monitoring during exercise) that could be targeted for enhancement, aiming to improve exercise practices among patients with hypertension.