Stroke is the second-most common cause of death and one of the leading contributors to long-term disability worldwide [1]. Although stroke is a devastating condition that can result in lifelong disability or death, these consequences can be prevented [2]. According to the 2019 Global Burden of Disease (GBD) study, more than 90% of the stroke burden is caused by potentially modifiable risk factors. Controlling metabolic and behavioral risk factors could reduce more than 75% of this burden. Hypertension has been identified as the single most important modifiable risk factor for stroke [3–8], with more than half of all strokes worldwide attributed to hypertension [9, 10].

Primary prevention of stroke requires regular awareness campaigns, governmental education on risk factors, and individual control of blood pressure [11, 12]. Despite this, there is poor adherence to anti-hypertension treatment among hypertensive patients, even though they are aware that the disease is a serious risk factor for stroke. This is a significant concern as it suggests a wide gap between knowledge and practice of stroke prevention in this patient group [13]. According to a nationwide survey to assess the prevalence of hypertension in China, 23.2% (244.5 million) of the Chinese adult population had hypertension: despite a high prevalence of hypertension, awareness, treatment, and control of hypertension remain low [14]. Barriers still exist between patients and prevention strategies. Individuals’ perceptions of the disease are crucial in influencing actions toward prevention and adherence to treatment [15]. Studies have shown that the fear of being stigmatized can act as a barrier to the disclosure of a diagnosis [16–18].

Stigma has been described, based on the work of Goffman, as a quality that “significantly discredits” an individual in the eyes of others [19]. It is an attribute that reduces a person “from a whole and usual person to a tainted, discounted one” [SIC] [19]. Health-related stigma involves the stigmatization of a disease, which can be directed at an individual or a group of people with a specific condition, and to the illness more generally [20]. It is “characterized by exclusion, rejection, blame or devaluation that results from experience, perception or reasonable anticipation of an adverse social judgment about a person or group” [SIC] [21]. This phenomenon is not limited to patients with certain stigmatized diseases, but also affects the general public [19]. Stigma can be conceptualized as both external (public stigma) and personal (felt stigma). Public stigma, as described by Corrigan and Watson [22], encompasses the stigmatizing attitudes or reactions that the general population holds toward people with stigmatizing attributes, such as HIV infection or drug use.

Stigma can lead to negative consequences. Discrimination not only fosters fear and ignorance but also hampers the expansion of AIDS prevention and treatment services. Nevertheless, the success of AIDS prevention and treatment must be based on prevention and treatment services [23]. Meanwhile, the accessibility of cancer detection and prevention procedures (e.g., screening and HPV vaccination) requires people to consider the possibility of a cancer diagnosis. The fear of stigmatization has been identified as a potential barrier to self-examination, screening, and delayed presentation of cancer symptoms [24]. Moreover, research on Alzheimer’s disease has revealed that cultural stigma and misconceptions about the disease may contribute significantly to delays in diagnosis and treatment [25].

Stroke is a stigmatized disease, and this can be explained through a multidimensional concept of stigma. Jones et al. (1984) identified six components of health-related stigma, which apply to different degrees depending on the illness of interest [24]. The first component, “course,” refers to changes in the illness over time, with conditions that become progressively disabling, chronic and incurable becoming more stigmatized. This aspect is particularly relevant for stroke, as it is a major cause of long-term disability worldwide [26, 27]. The second component, “origin,” relates to when and how the illness is believed to have occurred. A particularly relevant aspect of this is the attribution of perceived responsibility. When a person is believed to have caused their illness, the stigma associated with it is greater [24, 28, 29]. This concept gains significance for stroke as lifestyle determinants are more widely recognized. The remaining four components are “peril” “concealability,” “disruptiveness,” and “aesthetics” (described as a primitive response by the perceiver to a non-concealable mark that makes the person less “pleasing on the eye”). These aspects are relevant to stroke, approximately 45% of stroke patients experience lasting disability [30]. In the community, stroke survivors often live with different degrees of physical, psychosocial, and cognitive challenges such as hemiplegia, aphasia, depression, or low self-esteem [31]. These six components help to highlight the aspects of the disease that may contribute to its stigmatization. Meanwhile, a high standard of stigma is characterized by personal guilt associated with acquiring the disease, the perception of it as incurable, a lack of knowledge about the disease, and symptoms that cannot be hidden [32]. Stroke possesses the majority of these characteristics.

Previous public stigma studies have found that stigma can prevent people from seeking or fully participating in health services [33, 34], and it can be a significant barrier to establishing widespread stroke health education. However, perceptions of stroke within the most important target for education, the hypertensive group, remain unknown. We aim to uncover and understand the perceptions of stroke among individuals with hypertension to address the critical need for targeted approaches to stroke prevention.

The characteristics of the participants are shown in Table 1. Analysis of the interviews revealed that the perceptions and behaviors of the hypertensive group toward stroke patients were complex and varied. During the interview, participants highlighted their past events, current health behaviors, and their feelings about stroke patients. Three themes and eight sub-themes were generalized in the analysis. The three themes were: Obvious physical disabilities; The negative image of stroke; and Keeping a distance from stroke. These are described in more detail below, exemplified through interview quotations (Table 2).

The obvious physical disabilities caused by a stroke are easily recognized by hypertensive participants, and they perceive a stroke as a negative thing. Recognizing the link between hypertension and stroke, participants express a desire to maintain a distance from the stroke. However, their strategies for achieving this distance are complex, diverse, and at times contradictory—ranging from avoidance to preventive measures.

More than 85% of people survive a stroke, and of these, more than 80% are discharged to the community [42]. Their symptoms are visible to the public and are likely to lead to a situation in which the individual is excluded from full social acceptance, as defined by Goffman in 1963 [19], which is an important reason why hypertensive patients can recognize that stroke patients are “different.” Studies [43, 44] have shown that many people understand that hypertension is the main risk factor for stroke, and people with hypertension themselves are generally aware that their disease is related to stroke. The perceived origin of a disease is an important component of stigma [24]. According to Jones et al. (1984), the concept of origin encompasses perceptions about the responsibility of the individual for contracting the stigmatizing condition. “Attributions about why a negative event occurred, especially the stigmatized person’s perceived control over the cause, have great influence over how others will think of and behave toward that person” [45] (p. 513). In the current study, we found that participants believed that stroke patients should take responsibility for their disease and viewed stroke as a lack of discipline. Meanwhile, culture contributes significantly to shaping the health beliefs and attitudes of individuals. In this study, participants thought they should not treat the disease as a moral punishment, but they actually thought it was true deep in their minds. This finding is supported by other studies. People perceive Alzheimer’s disease as a punishment from God [46]. Some subjects diagnosed with stroke perceived stigma against these conditions because of their association with curses and evil deeds [47]. Some people believe that the reason a person gets cancer is perceived as a result of witchcraft and karma [48, 49]. In addition, in China’s traditional culture, family members always take care of the diseased [50], with the illness seen often as a burden to the entire family, not just an individual. All of these contribute to the feeling of fear in the hypertension group.

China has been conducting stroke health education programs for many years, such as the “Stroke 120” campaign [2], and many other educational interventions launched in recent years [51–55]. All of these studies have made great progress, but the current study, as one of its limitations, found that a group of hypertensive individuals may avoid addressing stroke altogether. They simply do not want to hear about stroke, and they are afraid of it. This explains why the existing intervention methods have blind spots.

Perhaps the answer is in other studies of health-related stigma. A meta-analysis found that both contact with the patients and education seem to significantly improve attitudes and behavioral intentions toward people with mental illness, with face-to-face contact with the person, rather than a videotaped story, having the greatest effect among adults [56]. The role of media is vital; appraisal theory argues that emotions arise from automatic cognitive evaluations of a situation, with each emotion distinguished from another by its specific pattern of cognitive appraisals [57, 58]. Appraisal theory predicts that the action tendency associated with sadness is introspection [43]. One study found that empathy could reduce stigma toward people with AIDS, homeless people, and murder convicts [59]. A study on cancer found that compassion was indirectly related to individual behavioral intentions [60]. Another study indicated that the most important sources of information were the internet and television [46].

The participants in this study are very worried about becoming a burden to their families, but perhaps families can be motivated. The impact of stigma is magnified by the fact that stigma is attached not only to the individual with mental illness but also to the individual’s family [61]. Individuals always manage their personal affairs with the help of support networks formed by family ties. Family emotional support plays an important role in promoting subjective support and requires further research [50]. Meanwhile, peer support is crucial. Studies have indicated that peer support may contribute to the prognosis of stroke by facilitating connections between stroke survivors and like-minded individuals in the community [62, 63]. Peer support also plays a positive role in hypertension control [64]. Research suggests that peer support may enhance the scope of comprehensive care, contributing to the sustainable development of healthcare systems [65].

Therefore, educational programs should be planned with the spirit that the approach needs to be changed. The hypertension group in this study wants more ways to prevent the disease, not just manage the stroke. Education can start this way; behavioral/lifestyle modifications have been shown to contribute to up an 80% reduction in the risk of stroke [66]. To bridge effective knowledge to people with high blood pressure, we need to increase our use of the media, increase sympathy, and encourage the interaction of patients with hypertension and stroke in the community. At the same time, we should encourage hypertensive patients who are actively acquiring knowledge about stroke prevention to share it with their friends so that education can be more widely disseminated and percolate into the population through the power of peers. Encourage a shift in approach for those passively avoiding the mention of the disease. Utilizeindirect communication about stroke and effectively leverage familial channels for educational purposes.

We acknowledge that in some instances in our study, despite our best efforts to clarify and explain, some respondents understanding of the stroke conditions under study may have been unclear. At the same time, he also thought that after talking to him about stroke, he would constantly think about the disease, and he might get a stroke. Hence, the participants selected for this study were individuals who demonstrated a willingness to discuss stroke, indicating a moderate level of openness and receptiveness to the topic. Despite these limitations, we believe that the study provides an important perception of stroke.