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Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 177-183

Conceptualizing hypertension: A developmental trend in school children

Center for Health Psychology, University of Hyderabad, School of Medical Sciences, University of Hyderabad, Central University Campus, Prof. C. R. Rao Road, Gachibowli, Hyderabad, Telangana, India

Date of Web Publication20-Jul-2018

Correspondence Address:
Prof. Meena Hariharan
Centre for Health Psychology, School of Medical Sciences, University of Hyderabad, Central University Campus, Prof. C. R. Rao Road, Gachibowli, Hyderabad - 500 046, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijhas.IJHAS_156_17

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INTRODUCTION: The exponential rise in the prevalence of hypertension signals the urgent need to focus the attention on hypertension prevention and management strategies for the vulnerable groups.
OBJECTIVE: The objectives of the study were to explore children's conceptualization of hypertension and to track its changes in complexity or divergence along classes.
METHODS: A mixed methods approach combining qualitative and quantitative techniques was adopted. A total of 776 students of 6th to 12th standard from the schools catering to the need of lower socioeconomic status were recruited. A simple tool with a single open-ended question – “What do you know about hypertension/high blood pressure?” was administered. The responses were coded appropriately and content analyses of the responses were carried out following thematic method.
RESULTS: Four broad themes, namely, definition, causes, consequences, and management of hypertension emerged out of content analyses. About 22.57% of responses indicated misconceptions on hypertension. Children's understanding of hypertension, in general, was found to be inadequate. A new method of measuring the conceptual complexity of responses of each class by computing “entropy” values, or “divergent index” indicated progressive increase in complexity of conceptualizing hypertension across classes.
CONCLUSION: The need for enhancing children's knowledge of hypertension through curriculum and public health programs is emphasized in view of children constituting the vulnerable group with reference to future projections

Keywords: Conceptualization of hypertension in children, developmental trend, entropy to measure conceptual complexity, hypertension

How to cite this article:
Hariharan M, Andrew A, Kallevarapu V, Rao C R, Chivukula U. Conceptualizing hypertension: A developmental trend in school children. Int J Health Allied Sci 2018;7:177-83

How to cite this URL:
Hariharan M, Andrew A, Kallevarapu V, Rao C R, Chivukula U. Conceptualizing hypertension: A developmental trend in school children. Int J Health Allied Sci [serial online] 2018 [cited 2023 Sep 23];7:177-83. Available from: https://www.ijhas.in/text.asp?2018/7/3/177/237258

  Introduction Top

The last few years have witnessed a phenomenal spurt in the prevalence of hypertension which according to the World Health Organization has increased by 10% from 2010 to 2014.[1] The projections for 2025 sounded a caution with a predicted prevalence at 29% among men and 29.5% among women globally [2] and 22.9% among Indian men and 23.6% among Indian women.[1] Adding to the woes, the prevalence among the children has also escalated enormously in recent past. In an observational study conducted by Amritanshu, the prevalence was found to be 4.7% among those in the age range of 5–19 years.[3] Cardiovascular risk factors were found to be highly prevalent among school children.[4] This rings an alarm for Indian health-care system.

Although hypertension is one of the major risk factors for cardiovascular emergencies, only about 9.6% of Indian children studying in 6th to 10th classes are aware that cardiovascular diseases are preventable.[5] The level of knowledge was found to be inadequate.[6] Even among the entry-level students in a medical university knowledge gaps was evident.[7] In a similar study among 2nd-year medical students in Belgrade, older students were found to have significantly higher knowledge about cardiovascular disease risk factors as compared to their younger counterparts.[8]

Researcher's wisdom lies in formulating preventive interventions by empowering this group with adequate knowledge on health-promoting behaviors and health risk behaviors. This may be termed as “preventive readiness” to counter hypertension. One of the essential prerequisites for such interventions is to understand the existing level of knowledge about hypertension in the prospective vulnerable group, that is, children.

Children, when educated with rich information of diseases such as hypertension, were responsible for reduction in intake of high-salt food [9] and also in reduction of cardiovascular disease risk scores among their parents and other family members. However, before launching any awareness program, it is desirable to examine their level of understanding the concept of hypertension.

The present study aims to assess children's understanding and knowledge about the condition of hypertension and explore into the developmental complexity in the schema related to hypertension.

Research questions

The research questions for this study are as follows:

  1. How do Indian schoolchildren conceptualize hypertension?
  2. Does their knowledge of hypertension show a progressive increase in complexity across classes?


The objectives of the study were to explore children's conceptualization of hypertension and to track its changes in complexity or divergence along classes.

  Methods Top

A combination of qualitative and quantitative approach was adopted.


The participants of the study were children from lower socioeconomic status enrolled in 6th to 12th class. To reach the sample, three schools were identified on the single criteria of enrollment of children from lower socioeconomic status. In this study, we confined to a single socioeconomic group in order to avoid the confounding variable of varying degrees of exposure to health information in different socioeconomic groups that subsequently influence the responses. One state social welfare residential school (exclusively for girls) managed by the government, one school managed by Christian mission (exclusively for boys), and one school managed by a cement factory where 67% of enrollment is from tribal community of the hamlets in 5 km vicinity of the factory (for both boys and girls) were identified as the first unit of the sample. These three schools were willing to participate in the study and sign informed consent. All the children from 6th to 12th class in these three identified schools willing to participate in the study by signing the assent form constituted the last unit of sample. The initial total sample consisted of 815 children. After screening and cleaning, the data the total sample consisted of 776 students of which 384 (49.48%) were boys and 392 (50.52%) were girls.


A simple tool consisting of a single open-ended question – “What do you understand by hypertension or high blood pressure (BP)?” with six lines left for the students to write the response was the tool used in the study. The other side of the paper had provision to record the demographic details of the respondents such as name, age, gender, grade, and school.


Informed consent was taken from the Principals of the schools. Assent was taken from the participants. All children assented to participate. The participants were assembled in their respective classes and were provided with the sheet consisting of the open-ended question – “What do you know about hypertension/high BP?” They were instructed to write their response in the blank space provided beneath the question. They were explained about the significance of their original genuine response. They were also appraised that, there is no evaluation for the answers. No time limit was specified to complete the answer. The students were instructed to give a descriptive answer to the question in the way they conceptualized hypertension. They could explain the concept in more than one-way.

  Results Top

The results are presented in two sections. Section 1 presents content analysis that explains emergence of subthemes. Section 2 examines the developmental trend in conceptualization of hypertension across classes by applying a formula to measure the complexity of the concept by quantifying the divergence of responses for each class.

Section 1: Content analysis

The demographic data were coded appropriately. Content analysis of the responses was carried out following thematic method. The descriptive responses of participants were independently handled and coded by the investigators. The verbatim of each participant was read and re-read independently by three investigators to gain a holistic picture of the responses. Memos of specific meaning units were noted down in the margin of the response sheets. These units of information were carefully examined and collated. In case of any differences among the investigators in classifying the responses, consensus was arrived at after discussion. An inductive process was followed in which subthemes emerged. The several subthemes that emerged were then categorized under four broader themes, namely, definition, causes, consequences, and management of hypertension. Responses indicating misconceptions were brought under one category of “Myths and Misconceptions.” The themes, subthemes, and sample responses are presented in [Table 1].
Table 1: Summary of themes and subthemes with one specimen response of participants

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As presented in [Table 1], the following four domains emerged – “definition,” “causes,” “consequences,” “management,” and myths and misconceptions. The themes are exhaustive and nonmutual in nature. The responses that were generic (e.g., a dangerous disease) or with theoretical loading (e.g., increased pressure in the blood vessels) or with a medical definition of (e.g., BP of ≥140/90 mmHg) are classified under the theme of “definition” of hypertension. The responses that explained the underlined causation of the disease such as lifestyle factors (diet and sedentary lifestyle), the psychological factors (stress), and the demographic factor (age) are classified under the theme of “causes” of hypertension. Those responses that mentioned the possible ramifications of uncontrolled hypertension such as medical consequences (heart attack, headache, paralysis, coma, or death) and the behavioral impact (fatigue, anger, irritability, and functional decline) are classified under the theme of “consequences” of hypertension. The other responses that mentioned the necessary care required to control the BP such as medical management (regular doctor consultation and medications), behavioral management (positive affect), and the lifestyle management (salt reduction) are classified under the theme of “management” of hypertension. [Table 1] also presents one example of response against each theme.

[Table 2] presents the sample size of each class and also class-wise frequency and percentage of responses under each theme.
Table 2: Class-wise summary of themes

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It may be observed from [Table 2] that the conceptualization of hypertension of the school children in terms of causes is relatively higher followed by definition, management, and consequences of hypertension, respectively. Overall, the levels of knowledge in any of the four domains are found to be inadequate with the highest percentage of responses in the domain of causes being just over 40%. Further, the class-wise conceptualization in terms of themes does not follow a particular pattern. It is pertinent to notice the misconceptions of hypertension in the schoolchildren. [Table 2] also shows the class-wise percentage of myths and misconceptions about hypertension. While there appears to be a declining trend with the progression of classes in general, a sudden shoot up from 6th to 7th class and again from 11th to 12th class is perplexing.

While the qualitative analyses provide us insight on children's conceptualization of hypertension under the themes such as causes, definition, consequences, and management, measuring the complexity of the concept across classes has been taken up by an innovative quantitative approach.

Section 2: Assessing the complexity of the concept

Step 1

To meet the objective of examining if the responses across classes showed a progressive developmental trend in conceptualization of hypertension, the frequency of responses under themes were plotted. The convergence or diversity in responses based on the relative frequency under different themes was observed by calculating the entropy for each class. The term “Entropy” borrowed from Physics is a measure of disorderliness or divergence in responses. For better conceptualization, the derivation of entropy is explained in the following steps:

Step 2

For a particular class, the proportion of responses of each theme (P) was evolved by computing the logarithm, indicated by I so as to stabilize the value for normality. This logarithmic value facilitates better comprehension by transforming the numerical data into a human-friendly scale that enables the appreciation of the changes in responses across themes.

I = −log (P)

Step 3

Finally, the entropy was computed using the formula

Absolute entropy (E) = Σ (P × I)

This value so derived indicated the divergence of ideas (indicated by the spread of responses across themes) of each class. Higher entropy value denotes larger spread of responses across themes which indicated higher complexity in comprehension of the concept of hypertension or high BP.

Step 4

The composite value of entropy for each class evolved by the method described above would not stand the test of fitness for interclass comparison as the values inherit an error caused by class size. Each class has varying number of students. Hence, there is a need to balance the class size. This balancing factor (BF) can be obtained by dividing the class size with the total sample. The formula is

Step 5

The absolute entropy value has to be divided by the BF to arrive at an entropy value that is neutralized for class size. This is called neutralized entropy or En. It is also called “Divergence Index (DI).” The formula is

Enor DI = E/BF

The above values are presented for each class in [Table 3].
Table 3: Presents the En values of different classes

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[Table 3] reveals the figures explaining the number of responses for each class, scores of absolute entropy, response ratio, BF, and neutralized entropy otherwise called DI. It is of relevance to explain the column representing the response ratio (R) from the table. The response ratio is different from entropy in the sense that while entropy relates to spread of responses across themes the response ratio refers to the probability of the number of statements any child from a class may make to explain the concept of hypertension. These explanations may be variations of a single theme and subtheme.

The last column of [Table 3] reveals that Neutralized Entropy or the DI increases with each class, whereas there is a slight drop in the entropy at 9th class. However, there is a sudden spurt in entropy from 9th to 10th Class. Again, a noticeable increasing trend is seen from 10th to 11th class and from 11th to 12th class successively. This developmental trend graphically represented [Figure 1] clearly indicates a steady progression in complexity of conceptualization but for an inexplicable marginable drop in 9th class.
Figure 1: Line graph plotted with neutralized entropy values showing developmental trend in the conceptualization of hypertension among schoolchildren

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  Discussion Top

The current study was conducted to understand the conceptualization about hypertension among children from 6th to 12th class and to track the developmental complexity in children's schema about hypertension. We found that, in general, children's knowledge about hypertension was inadequate. This reflects in the fact that only 40% of responses identified the causes, <10% of responses reflected understanding of consequences and about 11% could spell out the management of hypertension. This finding is in line with the findings of earlier studies that found knowledge related to hypertension was inadequate in schoolchildren.[6],[10]

Further, it is of great concern to see the abysmally poor percentage of responses across the themes of consequences and management. Although 40% of the total responses pertained to the causes of hypertension, it is appalling that a sheer 8.4% of the total responses captured the knowledge relating to consequences of hypertension which signals that very few children understood the seriousness of the disease. This finding corroborates to the earlier findings which identified that the majority of the adolescents possessed knowledge related to causes alone and knowledge related to other areas of hypertension such as consequences and management was inadequate.[5] This indicates that there is an urgent need to orient children on the grave consequences of uncontrolled hypertension. The mere 11% of responses related to management of hypertension portrays a grim picture of future which needs to be viewed with its implications and the urgency of pragmatic steps in educating the children on hypertension as public health priority.

The second objective of the study was to find out if there was any developmental trend seen in the children in their knowledge about hypertension. The findings envisage that there was a clear developmental trend seen in the children's conceptual divergence of knowledge about hypertension. This trend corroborates with the findings of Piaget's stages of cognitive development.[11],[12] The finding of the study that, increase in multidimensional knowledge about the disease with age also resonates with the findings of previous studies where a developmental trend was observed, wherein children during earlier years of their development conceptualized illness as unidimensional concept but with the progression of age, they started conceptualizing it multidimensionally across diverse themes of health and illness.[13],[14],[15],[16],[17] This is because with the progression in age increased sophistication in the grasp of health information culminates in cognitive amalgamation of different dimensions (etiologic factors, complications, and biopsychosocial management). This is possibly due to the integration of new information learned across the classes by the child through the processes of assimilation and accommodation and also by creating new schemas if it did not fit into the existing ones. Thus, the child can perceive that there could be multiple causes of an illness.

It was argued that children's perceptions of illness are derived primarily from ideas they obtain from school and the media.[18] The sudden growth in the diversified knowledge from the 9th class to 10th class could be attributed to the curriculum related to Biological Sciences which covered the circulatory system and the chronic diseases. Most of the responses of 10th class students are found to be technical in the sense that they referred to the diagnostic cutoff values of the BP readings, use of the term “sphygmomanometer” and the consequences such as heart attack and stroke. Thus, inculcation of knowledge of hypertension in schools has enhanced the complexity of their schema from 10th class onward.

Children were also found to hold several misconceptions about various aspects related to hypertension. Around 22% of the responses were misconceptions. A commonly held misconception was that hypertension means feeling high levels of tension. The second most common misconception that children held was high BP makes a person vulnerable to “get angry,” “shout at others,” and leads to aggressive behavior what they term as “hyperbehavior.” There is a dire need to dissipate such misconceptions with appropriate cognitive restructuring because misconceptions could be counterproductive.[19],[20] It can be seen that children regard hypertension as a common disease that develops mostly in old age. This misconception could be harmful for the children as several studies based on the theory of the health belief model found that if children do not perceive their vulnerability or susceptibility to the condition, they would not engage in taking precautionary steps. This rings an alarm as the prevalence of hypertension and prehypertension have been increasing in children at a rapid rate. While the misconceptions among the whole sample were high, a decreasing trend was observed with the progress in class. However, a higher level of misconceptions at 12th class is difficult to explain. It may be related to the school curriculum. Many of the students from 12th class were from nonscience background. This suggests that the health-related topics taught at 10th class are not sustained as an important knowledge base. Hence, there may be a need to reinforce the knowledge by making health science education mandatory for all streams in intermediate education of 11th and 12th class.

Considering the paucity of studies that have addressed the knowledge of children about hypertension, our study is an attempt to fill in this gap.

  Conclusion Top

The implications of this study may be discussed under two aspects, namely, research and policy implications. So far as future research in this area is concerned, it may be desirable to compare the children from different types of schools catering to different socioeconomic groups. Second, two intriguing observations related to drop in the entropy in 9th class and larger misconceptions held by students of 12th class may be used as triggering points for further research using Focus Group Interviews with the concerned groups.

At policy level, comprehensive, age-appropriate and tailor-made interventions need to be implemented in schools and colleges to facilitate enhanced knowledge and behavioral change among school children. Government as part of its health policy should direct the education department to prepare the Science curriculum in such a way that it instills the basic information on health and illness in a way that suits the child's cognitive level. Health education programs should include dissipation of common misconceptions.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]


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