Table 1 Description of intervention content based on BCW theory

•Explain the basic health knowledge of hypertension, help patients to acquire a correct concept of hypertension

Education

Psy C, Ref M

Week 1 of the first month

•Teach blood pressure monitoring skills, train patients to communicate with medical staff effectively

Training

Psy C, Phys C

Week 3 of the first month

•Recognize the hypertension complications, teach and encourage to set the goal of behavior change by themselves

Persuasion

Realization

Psy C, Phys C, Ref M, Auto M, Soc O, Phys O

Week 1 of the second month

•Help patients understand the prevention measures of hypertension complications (medicine, diet)

Incentivisation

Ref M, Auto M

Week 3 of the second month

•Help patients understand the prevention of hypertension complications (exercise, weight management, sleep and psychological regulation)

Incentivisation

Ref M, Auto M

3th months

•Review the knowledge of complications of hypertension and feedback on behavior

Environment reconstructing

Soc O, Phys O, Auto M

4th months

•Review the preventive measures for complications of hypertension. Group instruction for patients with different health literacy problems

Environment reconstructing

Soc O, Phys O, Auto M

5th months

•Review blood pressure monitoring knowledge + peer knowledge sharing

Modeling

Auto M

6th months

•Review blood pressure monitoring knowledge + peer knowledge sharing

Modeling

Auto M

7th months

•Review blood pressure monitoring knowledge + peer knowledge sharing

Modeling

Auto M

8th months

•Review hypertension related knowledge

Education

Psy C, Ref M

9th months

• Follow-up with telephone and Wechat app

Education

Environment reconstructing

Psy C, Ref M, Auto M, Soc O, Phys O

10th, 11th, and 12th months