Objective:
The aim of this study was to identify factors influencing healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural municipalities of Sindhupalchok District, Nepal. In the context of patient-provider relationships and power dynamics, this qualitative study explored and described the perceptions and perspectives of hypertensive patients, formally diagnosed within the past six months, and of their healthcare providers on the encountered challenges, barriers and facilitators in seeking healthcare and adhering to their prescribed treatment regimen for hypertension.

Design and method:
Semi-structured in-depth interviews were conducted with 20 patients living with hypertension, five healthcare providers and four political leaders in Sindhupalchok District, Nepal. Additionally, two focus group discussions were carried out with ten female community health volunteers who conduct outreach work. Participants were recruited through purposive sampling via snowball and opportunistic sampling techniques from government-run health facilities. The socio-ecological model developed by Mcleroy et al. (1988) was applied. The data collected were transcribed verbatim and translated into English language, and thematically analyzed using NVivo software.

Results:
Several factors influenced the healthcare-seeking behavior and treatment adherence of hypertensive patients living in the rural municipalities of Sindhupalchok District, Nepal. They consisted of intrapersonal or individual factors (health literacy, knowledge, awareness and perception of disease risk factors, perceived sovereignty and autonomy over ones biological body, symptoms, manifestations and complications), interpersonal factors (family and peer support as well as interactions with the healthcare provider and their perceived authority over the patient), community factors (misconceptions about modern treatments, ayurvedic medicine, community health workers motivations to serve the community), and organizational and governmental factors (misinformation about service provision, accessibility and affordability of healthcare, trust in government authorities).

Conclusions:
Findings from this study indicate the importance of considering the four major layers and components of the socio-ecological model to understand the healthcare-seeking behavior and treatment adherence of people living with hypertension in the rural communities of Sindhupalchok District, and to design culturally appropriate, low-cost community-based interventions that can improve health service uptake. Taking actions to address the challenges faced by the formal healthcare system in educating patients about health literacy, raising awareness about hypertension risk factors, causes and prevention strategies, building loyalty within the community, conducting routine at-home screening, referrals to primary health facilities and door-to-door distribution of medicines by trusted members of the community are urgently needed to improve acceptance of care and treatment adherence of this chronic non-communicable disease.