Abstract Hypertension is a global health issue, especially among in low-and-middle-income countries (LMIC) including Myanmar. Young adults (18 – 34 years) are affected due to unhealthy lifestyles, conversely, practising preventive behaviours can mitigate risks. However, there is a dearth in the number of studies regarding preventive behaviours in this age group. This study aimed to investigate the preventive behaviours of hypertension and its associated factors among Myanmar young adults by applying the protection motivation theory (PMT). A cross-sectional survey was conducted among 270 young adults, using the two-stage cluster sampling. Data was analyzed by descriptive statistics, Chi-square test and stepwise multiple logistic regression with a significance level of P-value <0.05. Good level of preventive behaviours practice was observed in more than half of the participants (54.8%). Significant determinants influencing preventive behaviours were males (AOR: 1.78, CI: 1.01-3.13); unemployed young adults or students (AOR: 2.75, CI: 1.05-7.22); young adults with high perceived vulnerability (AOR: 2.41, CI: 1.40-4.13), and those with low response cost (AOR: 2.33, CI: 1.35-4.05). All four factors predicted preventive behaviours at 65.5%. A nationwide program should be implemented emphasizing health promotion interventions to reduce barriers among young women. Multisectoral collaboration to improve access to healthy food choices, infrastructure for physical activity, and use of artificial intelligence for health promotion practices should be strengthened.

Keywords: Hypertension, Preventive behaviours, Protection motivation theory, Myanmar young adults

Citation:  Oo, W.Y., Chamroonsawasdi, K., and Chansatitporn, N. 2026. Predictors of preventive behaviours of hypertension among young adults in myanmar: A cross-sectional survey. Natural and Life Sciences Communications. 26(1): e2027009.

Graphical Abstract:

INTRODUCTION

Hypertension is a major public health challenge being the leading cause of mortality and disability globally and regionally in Southeast Asia as well (He et al., 2025). Myanmar has the second-highest prevalence of hypertension among Southeast Asian nations (World Health Organization, 2018). In addition, hypertension is a multifactorial disease with a combination of biological risk factors (National Heart, Lung, and Blood Institute, 2024; Centers for Disease Control and Prevention, 2024) such as age, genetic predisposition, sex, increased body mass index and behavioural risk factors (unhealthy behaviours) (Mendonça et al., 2017; Shi et al., 2019; Nugroho and Martini, 2020; Emelianov et al., 2024) such as physical inactivity, unhealthy diet: high salt, high fat foods and processed foods, harmful alcohol consumption, and cigarette smoking.

Adoption of value-driven preventive behaviours in early life is suggested as the primary prevention of noncommunicable diseases (NCD) including hypertension (Caswell, 2024). These behaviours are healthy diet consumption (Valenzuela et al., 2021; Zhu and Wang, 2024), regular physical activity (Valenzuela et al., 2021; Diao et al., 2024; Zhu and Wang, 2024), no or cessation of smoking (American heart Association, 2024) and no or reduction of alcohol consumption (Roerecke et al., 2017).

Young adults are defined as those between 20 and 35 years old (Society for Adolescent Health and Medicine, 2017; UNESCO, 2020). According to the National Youth Policy of Myanmar (Government of Myanmar, 2017), young adults are between 18 and 34 years old. This population is currently affected by hypertension due to their engagement in unhealthy lifestyle behaviours (Fryar et al., 2024; Indriani et al., 2025) and stress (Mills et al., 2020). Adoption of preventive behaviours is critical for young adults as they are the future of Myanmar and at the age of establishing independent lifestyle habits defining their long-term health outcomes. WHO’s study on the aging process and significance also stated that chronic NCDs begin as early as 35 to 40 years of age (Chebotarev et al., 1973). Reported prevalence of hypertension among Myanmar young adults was varied as: aged 15 - 24 years (9.4%) and 25 – 34 years (14.7%) in 2009 (World Health Organization, Regional Office for South-East, 2012), 25 – 34 years (11.8%) in 2014 (Ministry of Health and Sports Myanmar, 2014), 18 - 29 years (5.5%) and 30 – 44 years (21.3%) in 2024 (Ministry of Health [Myanmar], 2026), despite the most recent WHO hypertension profile (World Health Organization, 2023) showing a national prevalence of 38%, exceeding the global prevalence underscoring a clear and rising burden.

Protection Motivation Theory (PMT), developed by Rogers (1975), explains how cognitive process mediate behaviour change. PMT consists of two cognitive appraisals, threat appraisal and coping appraisal. Threat appraisal includes perceived vulnerability, the individual’s belief about susceptibility to an illness or condition, and perceived severity, the individual’s belief about how serious the illness or condition is. Coping appraisal includes response efficacy, the individual’s belief that engaging in preventive behaviours will be effective for disease prevention; self-efficacy, the individual’s perception of the ability to carry out the preventive behaviour; and response cost, the barriers to adopting adaptive preventive behaviours (e.g., financial, personal, time). Lastly, protection motivation refers to an individual’s determination and dedication to adopt the suggested preventive behaviours to protect against a health risk. Personal experiences, along with intrapersonal and environmental sources, influence the consideration and analysis of information about behaviours, thereby informing threat and coping appraisals. Multiple studies (Krissana, 2000; Milne et al., 2000; Chamroonsawasdi et al., 2021; Yongpet et al., 2023; Karimi et al., 2024; Sabookaew et al., 2026) have applied this theory to assess the predictors of prevention practices and the adherence to them.

Yangon is the commercial city and the most populated state with around 7.8 million population (Department of Population, 2020; Pardoel et al., 2022). Citizens living in the cities including Yangon have been proved to engage in unhealthy behaviours (Mon et al., 2023). Additionally, young adults in Myanmar have considerable public health concern as global patterns, including incidence associated with unhealthy behaviours and socioeconomic status (Mon et al., 2023). They often encounter barriers to access health care, education, and employment (Chen et al., 2023), and have low health literacy (Mahato et al., 2025) further exacerbating their vulnerability. Although previous studies have mainly focused on prevalence and risk factors (Bjertness et al., 2016; Ye et al., 2016), there has been a scarcity of studies on preventive behaviours among Myanmar young adults’ population along with less understanding the sociodemographic and cognitive determinants on those behaviours. In addition, to the best of our knowledge, this is the first study to apply PMT to identify those determinants among young adults. Therefore, this study aimed to investigate the preventive behaviours of hypertension among Myanmar young adults and their influencing factors. The results of this study would be applicable as novel evidence for designing theory-based, specific, and culturally relevant interventions promoting healthy behaviours among this under-studied population, resulting in better health outcomes, and enhanced economic productivity of the entire nation.

Conceptual framework

The study variables were defined using the PMT as a theoretical framework (Prentice-Dunn and Rogers, 1986). The factors determining the preventive behaviours consist of 1) Sociodemographic characteristics included age, sex, level of education, type of occupation, monthly income, family history, and sources of information about hypertension, 2) Knowledge about hypertension, 3) Threat appraisal comprised perceived vulnerability and perceived severity, and 4) Coping appraisal consisted of response efficacy, self-efficacy, and response cost to perform the preventive behaviours. (Figure 1)

Figure 1. Conceptual framework.

MATERIALS AND METHODS

Methods

Study design

This was a cross-sectional survey conducted among young adults aged between 18 and 34 years in 8 townships, namely as; Tarmwe, Thaketa, Hlaing, Kyauktada, Tanyin, Kyauktan, Hlaing Thar Yar, Mingalardon in Yangon, Myanmar.

Study population

This study emphasized young adults (18 - 34 years) who lives in Yangon. In Yangon region, there are more than 2 million young adults according to 2019 intercensal report (Department of Population, 2020).

Inclusion and exclusion criteria

The inclusion criteria for participants selection were young adults between 18 and 34 years, who can communicate and give consent, who are willing to participate, and sign in the informed consent form. The exclusion criteria were unavailable individuals, and those who were seriously ill and unable to be interviewed.

Sample size calculation and sampling technique

A minimum sample of 246 was determined following the calculation using the infinite population formulation for one-proportion test (Wayne and Chad, 2013) assuming that 80% of the participants having good practicing behaviours indicated by a previous study (Su San and Plianbangchang, 2018), and degree of accuracy of 0.05. Considering an attrition rate of 10%, a total of 270 participants were planned to be chosen.

A two-stage cluster sampling was employed to select the samples. There are a total of 42 townships (Office of the Auditor General of the Union, 2018) and population of young adults aged 18 to 34 years is 2,926,730 (Department of Population, 2020)  in Yangon. To begin with, we stratified Yangon into four districts: District 1 (12 townships), District 2 (13 townships), District 3 (8 townships), and District 4 (9 townships). First step, the two townships from each district were randomly selected.  Second step, the young adults who met the study’s eligibility criteria were meant to be chosen by simple random sampling from household list at the local authorities in each township; from district 1 and 2, 35 young adults from both townships 1 and 2 respectively (a total of 140 respondents), from district 3, 34 young adults from townships 1 and 2, and from district 4, 31 young adults from townships 1 and 2 giving rise to a total of 270 respondents.

Data collection procedure

After receiving ethical approval from the Ethical Review Committee for Human Research, Faculty of Public Health, Mahidol University, 8 village health volunteers were appointed as research assistants, one for each township. They received comprehensive training to clarify the research objectives and procedures. The young adults aged 18 – 34 years old were invited to a meeting for health education in the respective township. The research assistant conducted initial screening based on inclusion and exclusion criteria, and those who aligned with the criteria were chosen as samples. A private consultation room was arranged for data collection to ensure privacy and confidentiality. The data collection was done by the research assistant by face-to-face interview with a structured questionnaire after explaining about the study objectives, and the estimated duration for interviewing. Informed consent was obtained from every participant who agreed to take part in this study. They could withdraw or refuse without any impact or care. The duration of interview was approximately 25 – 30 minutes. The data collection was carried out between 1^st November 2025 and 26^th January 2026.

Research instrument

A suitably designed and validated questionnaire was constructed for data collection survey based on the PMT and relevant literature. It comprised of 8 parts.

Part 1: Sociodemographic characteristics. 10 items of close-ended and open-ended questions were used to assess age, sex, education level, occupation, monthly income, family history, sources of information about hypertension. Part 2: Level of knowledge about hypertension. There were 12 questions in this part which were categorized as True, False and Not Sure. This section covered definition of hypertension, risk factors, complications and lifestyle behaviours concerning prevention. The correct response got 1 point and the rest got 0 point. The categorization of the total scores was based on Bloom’s classification (Veilleux, 1999): high (≥80%), moderate (60-79%), and low (<60%). Part 3 to Part 7: These parts explored about perceptions of vulnerability, severity, response efficacy, self-efficacy, and response cost of preventive behaviours towards hypertension. These sections were constructed based on PMT, with 6 questions in each, using a 5-point Likert scale: strongly agree, agree, not sure, disagree, and strongly disagree. Young adults were asked to mark only one option for each corresponding statement. Total scores were calculated and coded as high, and low. The median was used as the cut-off point for categorization as the data distribution is skewed (DeCoster et al., 2011). Part 8: Preventive behaviours of hypertension. The final part aimed to evaluate the respondent’s engagement in preventive behaviours of hypertension with regards to eating healthy diet, physical activity, cigarette smoking and drinking alcohol. It comprised of 27 questions adapted from the concept of Dietary Approaches to Stop Hypertension (DASH) diet (Mayo Clinic Staff, 2023), Global Physical Activity Questionnaire (GPAQ) (World Health Organization, 2021), Frequency, Intensity, Time, and Type (FITT) principle (Manitoba Education), and WHO STEPS instrument (World Health Organization, 2024). The respondents had to recall their performance in the last month. The responses were classified using a five-point rating scale and the scores were assigned as always (5 points), often (4 points), sometimes (3 points), seldom (2 points), and never (1 point). The total scores were calculated and categorized as good and poor based on the median cut-off point (DeCoster et al., 2011).

Validity and reliability test of the instrument

Three experts reviewed and determined the content validity. Mean item content validity index (CVI) of each part were as follows: Sociodemographic characteristics = 1, Level of knowledge about hypertension = 1, Perceived vulnerability = 0.835, Perceived severity = 0.835, Response efficacy = 0.89, Self-efficacy = 1, Response cost = 1, and Preventive behaviours = 1. Pilot test was carried out among 30 young adults from Yangon, outside of selected townships. The reliability of knowledge section was assessed using Kuder- Richardson 20 (KR-20) yielding a value of 0.72. Cronbach’s alpha coefficient was calculated for the reliability of threat and coping appraisal. Findings for perceived vulnerability and perceived severity were 0.716, and 0.763. Findings for response efficacy, self-efficacy, and response cost were 0.848, 0.886, and 0.861 respectively whereas that of the preventive behaviours was 0.753.

Statistical analysis

Data were analyzed using SPSS 25 (Statistical Package of Social Sciences) software, licensed through the official student account at Mahidol University. All collected data were checked, coded, and entry. Descriptive analysis comprising frequency, percentage, mean, median, standard deviation, interquartile range, 25^th quartile (Q1), 75^th quartile (Q3), minimum and maximum were used to describe both independent and dependent variables. Chi-square test was used to identify the association between independent and dependent variables. The stepwise multiple logistic regression analysis was performed subsequently to identify influencing factors of preventive behaviours. Significance of each test was determined by at P-value of less than 0.05.

Ethical consideration

Before data collection, the researcher submitted the proposal, questionnaire, and informed consent attached with the request letter to ask for the permission from the local authority of each township. The Ethical Review Committee for Human Research, Faculty of Public Health, Mahidol University approved this research before data collection (COA No. MUPH 2025-154). Informed consent was acquired from each eligible respondent. Data were kept confidential and were not directly reflect individual information on the findings.

RESULTS

Preventive behaviours

More than half of the young adults have good preventive behaviours. They prefer drinking plain water and nearly one-third often consumed vegetables in every meal. One-third of them had the leisure time such as watching movies, playing mobile games. Slightly lower than one-third always walk to school or other places instead of using vehicles. Regarding cigarette smoking and alcohol drinking habits, more than half of them always avoid all smoked tobacco products and all types of alcohol. (Supplementary Table)

Sociodemographic characteristics

Among 270 young adults, more than half (55.2%) were females with the average age of 25 years (standard deviation = ±5.119). Regarding education and occupation, those who completed high school (46.3%), and private employees (39.6%) occupied the largest proportions. About two-thirds of them (63.7%) earned monthly income of less than 500,000 Myanmar Kyats. A quarter of them denied family history (25.9%). The primary sources of information about hypertension prevention and control were health personnel (51.9%) followed by social media (32.6%) and family members and relatives (14.4%). (Table 1)

Table 1: Sociodemographic characteristics of the respondents (N = 270).

Knowledge about hypertension

Slightly less than half of the young adults (41.9%) had good understanding about hypertension, followed by fair level (29.3%) and poor level (28.9%). (Table 2)

Threat and coping appraisal constructs of hypertension

Regarding threat appraisal, more than half of the respondents exhibited a high level of perceived vulnerability (53.7%) while over half of the respondents displayed a low level of perceived severity (54.8%).

Regarding coping appraisal, young adults were equally divided (50%) for showing low and high level of response efficacy. Slightly more than half of them (51.9%) had high level of self-efficacy. A little over half (50.7%) had a low response cost. (Table 2)

Table 2. Level of knowledge, perceptions, and preventive behaviours of hypertension (N = 270).

Bivariate analysis of factors associated with preventive behaviours

Bivariate analysis identified factors associated significantly with preventive behaviours. Out of sociodemographic characteristics, sex, occupation, and sources of information showed significant associations. In the context of PMT components, perceived vulnerability and response cost were statistically significant. (Table 3)

Table 3. Factors associated with preventive behaviours of hypertension analyzed by the bivariate analysis, the Chi-square test (N = 270).

Note: *Significant at P - value <0.05, **Significant at P - value <0.05 by Fisher’s exact test

Multivariate logistic regression analysis

Five significant variables from the bivariate analysis were analyzed the stepwise multiple logistic regression analysis. As the results, male young adults had 1.78 times of good preventive behaviours compared to female young adults (AOR = 1.777, 95% CI = 1.009 – 3.129). Unemployed respondents or students were significant predictors (AOR = 2.75, 95% CI = 1.047 – 7.223). Among the PMT components, high perceived vulnerability, and low response cost were significant predictors. Young adults with a high level of perceived vulnerability have 2.4 times of good preventive behaviours compared to those with a low level (AOR = 2.405, 95% CI = 1.402 – 4.126). Those with a low level of response cost have 2.3 times of good preventive behaviours compared to those with a high level (AOR = 2.334, 95% CI = 1.345 – 4.05). The model correctly predicted good preventive behaviours in 65.5% of the young adults (Hosmer-Lemeshow Chi-square goodness of fit = 16.121, P-value = 0.041). (Table 4)

Table 4. Factors predicting good preventive behaviours by stepwise multiple logistic regression analysis.

Note: *P - value <0.05, Abbreviations: B = unstandardized coefficient, S.E (B) = standard error of coefficient, OR = odds ratio, CI = confidence interval

Remarks:   a = Female is the reference group, b = Unskilled workers is the reference group,  c = Low level is the reference group, d = High level is the reference group

DISCUSSION

The present study found that slightly more than half of young adults had good preventive behaviours. Predictive factors of preventive behaviours among Myanmar young adults are sex, occupation, perceived vulnerability, and response cost. 

Slightly more than half of young adults had good preventive behaviours focusing on having fresh fruits and vegetables in every meal, avoiding all kinds of smoked tobacco products, and alcohol. However, young adults’ engagement in regular physical activity was notably low. Several studies (Su San and Plianbangchang, 2018) also found the similar results regarding always adding extra salt or fish sauce to every meal and preferred fried foods, low physical activity, but never smoking and alcohol drinking habits.

Regarding always adding extra salt, fish sauce or soy sauce in every meal can be explained by the traditional cooking style of Southeast Asian countries which always use fermented fish products, fish sauce or salty condiments for the exceptional flavor and affordability (Oo et al., 2018; Julmohammad et al., 2025). Moreover, they preferred fried foods (e.g., fried chicken) and fast foods due to the convenience, easy preparation, and seasoned flavor (Askari Majabadi et al., 2016; Chirlici et al., 2021).  Regarding non-smoking and non-alcohol drinking, one plausible explanation could be that this study sample contained a higher proportion of females and a risk of social stigmatization by religious and cultural norms especially to women (David et al., 2024; Aresi et al., 2025). Furthermore, regulation of school or workplace and peer influence could deter smoking and alcohol drinking habits (Lowenstein et al., 2020; Steffens and Pereda, 2025). Concerning low physical activity, this can be explained by majority of them being in the workplace. Previous findings reported that daily workers mostly spend more than 8 hours per day at work and cannot perform physical exercises after work due to reasons such as time, family, work schedules (Sornlorm and Thi, 2024; Sprajcer et al., 2025). In addition, there is an increasing prevalence of sedentary lifestyle among young population as they prefer to spend time on social network applications and digital media platforms leading to negative health impacts (Chinapong and Amornsriwatanakul, 2023; Khanani et al., 2025).

Concerning significant predictors, the first factor is sex. Males were found to have good preventive behaviours. In terms of physical activity, males have higher physical activity than females due to peer influence and enjoyment in skill development, physical fitness, psychological wellbeing, and body image (Zou et al., 2023; Ugau et al., 2024). Nevertheless, some studies reported that females generally have better preventive behaviours practice than males due to higher agreeableness and conscientiousness (Mortada et al., 2021; Otterbring and Festila, 2022). The second predictor is occupation. The students/unemployed individuals were found to have good preventive behaviours compared to unskilled workers. This finding is agreed with Seung-Yeon Lee et al.’s finding that unskilled manual workers are more likely to be engaged in unhealthy behaviours (Lee et al., 2022) and it can be explained by low socioeconomic status, duration of working hours, and vigorous working conditions. Moreover, several studies stated that students with better health literacy are proven to have better health behaviours (Sikaow and Trakulsithichoke, 2024; Gao et al., 2026). On the contrary, some studies have demonstrated that unemployed individuals are more likely to engage in poor behaviours due to financial situations and mental conditions (Pharr et al., 2011; Plessz et al., 2020).

The third predictor is perceived vulnerability. Young adults with high perceived vulnerability had good preventive behaviours. This finding is compatible with that of Masoud Karimi et al. (2024) and Kanittha Chamroonsawasdi et al. (2021). When young adults have a stronger perception on their vulnerability, it may lead to a stronger motivation to practice preventive behaviours (Park and Oh, 2023). However, some studies indicated that they tend to underestimate their vulnerability (Afam and Nakalega, 2024; Toledo, 2025). The last predictor is the response cost. Young adults with low response cost had good preventive behaviours. This finding is supported by Trhas Tadesse et al. (2020). If young adults have low barriers or cost to perform, they will have regular adherence to preventive behaviours (Fitriadi et al., 2026). Reciprocally, elevated cost or barriers are associated with poor preventive practices (Wang et al., 2021; Bayrami et al., 2024).

The findings of this study have demonstrated that PMT-based cognitive components, particularly perceived vulnerability, and response cost, can predict the preventive behaviours rather than knowledge. This underscores a gap between knowledge and practice suggesting the future interventions to focus on enhancing perceptions on hypertension by helping young adults realize their own lifestyle related to their own risk of hypertension and serious complications rather than a distant concern, reduction of the burden in accessing healthy food choices and safe places for physical exercises especially for young women, sharing experiences between peers, appreciation of good practice by school and employers, and having the role models enhancing their motivation of practice. Additionally, A nationwide program should be implemented emphasizing health promotion interventions to reduce barriers among young women, and unskilled employers. Multisectoral collaboration to improve access to healthy food choices, infrastructure for physical activity, and use of artificial intelligence for health promotion practices should be strengthened.

LIMITATIONS

This study was performed only in the urban region of Yangon and the results may not represent those of young adults from rural and other regions of Myanmar. The cross-sectional nature may limit the generalizability and cannot measure the changes in knowledge, perceptions, and behaviours over time. In addition, this study design can identify the associations yet limits the causal inference between PMT components and preventive behaviours. Longitudinal studies may need to be conducted to identify it. Recall bias may exist as the data is self-reported and the respondents may underreport due to misunderstanding or forgetfulness. They may have a feeling of insecurity while sitting for interview leading to affect the outcome. This research did not collaborate with objective measurements such as blood pressure measurement, a diary on daily diet, smoking, and alcohol intake suggesting that future studies should consider objective measurements during the study.

CONCLUSION

In conclusion, our findings have revealed that there was a certain gap between knowledge and prevention practice against hypertension among Myanmar young adults. Resulting predictors demonstrated that health promotion interventions should be implemented to reduce barriers among young women, and unskilled employees, focusing on enhancing perceived vulnerability of hypertension and its complications, the role of school and employees should be strengthened to support continuous preventive practices among young adults. Collaboration with local authorities, community leaders, and health workers should be undertaken for sustainable behavioural changes and positive health outcomes.

ACKNOWLEDGEMENTS

The authors would like to thank all the respondents and health volunteers for data collection, which contributed to the successful completion of this research. Heartfelt gratitude would like to extend to the township health departments of respective townships: township medical officers, and health staffs for their cooperation in data collection.

AUTHOR CONTRIBUTION

Wai Yan Oo: Conceptualization (Lead), Methodology (Lead), Formal analysis (Equal), Investigation (Lead), Writing – Original Draft (Lead), Visualization (Lead). Kanittha Chamroonsawasdi: Conceptualization (Lead), Methodology (Lead), Validation (Lead), Formal analysis (Equal), Writing – Review & Editing (Lead), Supervision (Lead). Natkamol Chansatitporn: Supervision (Supporting).

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

DECLARATION OF GENERATIVE AI USE

The authors declare that no AI tools were used in the preparation of this manuscript.

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Supplementary

Table S1. Preventive behaviours of hypertension (N = 270)