Intergenerational transfer of blood pressure knowledge and screening: a school-based hypertension awareness program in Singapore

Background

Hypertension is a major contributor to adult mortality in developed countries. Failure to monitor one’s own blood pressure has been identified as one of the leading risk factors for premature deaths through stroke as well as cardiovascular diseases such as heart failure and myocardial infarction (1,2). Worldwide, 40% of adults aged 25 and above were found with raised blood pressure in 2008 (3). In Singapore, 23.5% of adults aged 30 to 69 years old were diagnosed with hypertension (2). The prevalence increased significantly as adults aged, especially among those over 40, with close to three-quarters (73.9%) of Singaporeans aged 60 onwards diagnosed with hypertension (4).

Considering its negative consequences and prevalence, it is worrying that as many as 26.3% of Singapore residents aged 30 to 69 years who were detected to have hypertension had not been previously aware of their condition (2). It is also possible that this lack of awareness is related to their lack of hypertension knowledge, as indicated by Wong et al.’s study among Singapore Chinese, which revealed that there is a need for health education on stroke risk factors, with hypertension being one of them, particularly among older people (aged 50–59 years) (5).

Despite the lack of hypertension awareness, health promotion efforts directed at the adult population prove to be very challenging (6) due to the lack of channels in which they regularly congregate, such as schools. However, there seems to be potential for children to be information intermediaries to this older population group (7,8). Traditionally, research on intergenerational influence has been unidirectional in nature, with parents being viewed as active agents, and children as the passive agents (9–12). Children were viewed as blank slates and ready to be affected in accordance with parents’ values (13). Discussion in health education management also primarily assumed that information flowed from parents to children. However, the unidirectional relationship is no longer accepted, with some studies pointing out the potential of children’s direct influence on adults’ values, attitudes and knowledge (9–11). Children were recognized as effective messengers to convey to their family members the knowledge intended (7,8,14,15). This is especially so when the message is intergenerational in nature (16). Likewise, in the context of blood pressure measurement, previous studies suggest that children can be effective intermediaries in reaching out to their family members, including possibly high-risk individuals with hypertension (8,17). One study found that parents’ knowledge about hypertension improved after their children attended a school-based program which required children to measure their parents’ blood pressure and share the knowledge learned during the program with their parents (8).

However, to our knowledge, there have been no studies on intergenerational influence on hypertension awareness conducted in an Asian context. Asian societies, such as Singapore, commonly place a huge importance on familial relationship and filial piety (18). The Singapore government, in particular, has made significant conscious efforts to promote ‘strong families as the cornerstone of the nation’ (18, p. 905). Many children in Singapore share the same household with their extended family members such as grandparents and unmarried aunts or uncles, as the government provided a host of incentives to encourage the cohabitation of family members across generations (18). In view of this, it could be surmised that effects of knowledge transfer might not be limited to parents, but also to extended family members such as grandparents, aunts and uncles. Such socio-cultural contexts can potentially augment the effectiveness of a program which utilizes intergenerational influence.

Hence, considering the family-oriented culture of Singapore and building on past hypertension education programs, the Singapore Heart Foundation (SHF) embarked on a hypertension awareness program called BP Initiative @ Schools among grade five children to reach out to a large scale sample. Recognizing the potential role of children in influencing their family members, who possibly are not in any regular blood pressure screening programs, the program aimed to enhance awareness of hypertension and blood pressure measurement among the Singapore population. Primary school students were advised to share their knowledge and measure their family members’ blood pressure level at home. The program planned to reach individuals from diverse age groups, gender, and race and educate them on the importance of blood pressure screening and the risks associated with hypertension. Eventually, adults potentially suffering from hypertension are advised to consult physicians for follow-up. Hence, keeping in mind the objective of the program, we propose the following research questions (RQ) in order to assess the program’s efficacy:

For students who have participated in the BP (blood pressure) program:

In the Results section, we present the results of the evaluation of the BP Initiative @ Schools program on the outcome pertaining to children’s blood pressure knowledge change and perception toward performance of blood pressure measurement, as well as family members’ report of their blood pressure status and attitudes toward blood pressure measurement. Results on gender differences are also presented.

Methodology

Results

Students’ survey

Student respondent profile

The participation at the end of the program via the post-program survey generated a total of 5120 responses from students. We eliminated duplicate responses received from users when the same respondent clicked the ‘Submit’ button more than once when completing the online survey. In addition, some students completed only the pre-program survey, while others completed only the post-program survey. In addition, there were a number of cases with particulars missing, hence rendering a lack of match of pre- and post-program surveys. After excluding these cases, the final student sample for analysis was trimmed to 3926 responses. This sample consisted of 1963 (50.0%) for each group of male and female students with mean age of 10.71 years old. The ratio of various racial groups reflected the general population of Singapore, with 2750 (70.0%) Chinese, 674 (17.2%) Malays, 276 (7.0%) Indians, and 220 (5.6%) were from other racial groups (23), while six respondents did not state their racial group.

To analyze the data, we used SPSS 19.0 statistical software package. We performed descriptive statistics such as frequency and mean and paired-sample t-testing to gain understanding of the data. Results from the overall student sample were reported first, followed by gender comparison of the respective topics utilizing independent t-testing.

Knowledge change

In order to answer RQ1, the responses toward each of the seven knowledge questions of each student respondent in both pre- and post-program surveys were compared using a paired-sample t-test. The analysis showed that the program was generally effective in raising the blood pressure knowledge of respondents as shown by the number of questions answered correctly increasing significantly from an average of 2.78 (SD = 1.72) questions on the pre-program survey to 4.68 (SD = 1.46) questions on the post-program survey (t(3,857) = −65.7, p < 0.001). Gender comparison of the post-program knowledge revealed that female respondents (M = 4.74, SD = 1.40) were more likely to attain a higher score of total correct responses as compared to their male counterparts (M = 4.63, SD = 1.52, t(3,860) = −2.21, p < 0.05).

We also conducted an analysis of the area of blood pressure knowledge in which students became more informed, as shown in Figure 1. The results revealed that at the point of the post-program survey, the overall knowledge of the students has increased, with the largest increase in knowledge occurring in Q4 on the normal blood pressure level as indicated by the 55.5% increase in the total number of students who had responded correctly to the question (from 27.2% of sample answering correctly at the pre-program stage to 82.7% at the post-program stage). For the remaining questions, the number of students who have answered correctly increased by around 12.9% to 46.4%. The only exception to the students’ improvement in the blood pressure knowledge was Q6 where there was a 3.2% decrease in the correct answer given.

OPEN IN VIEWER

Figure 1.

Comparison of correct responses to knowledge questions at the pre- and post-program surveys.

Attitudinal change toward acquiring and sharing knowledge

The program’s effectiveness was also demonstrated through the favorable change in students’ attitudes toward acquiring and sharing knowledge about blood pressure matters after the program (RQ2). Students felt more confident in sharing the prevention methods (M_pre-program = 2.90, SD_pre-program = 1.36, M_post-program = 3.82, SD_post-program = 1.16, t(3,901)= −36.45, p < 0.001) and consequences associated with blood pressure (M_pre-program = 2.80, SD_pre-program = 1.34, M_post-program = 3.63, SD_post-program = 1.17, t(3,903)= −32.95, p < 0.001). Their perception toward their blood pressure knowledge also improved after the program (M_pre-program = 2.31, SD_pre-program = 1.11, M_post-program = 3.37, SD_post-program = 1.04, t(3,895) = −50.09, p < 0.01). Gender comparison of the attitudinal change at the post-program stage revealed that female students (M = 3.75, SD = 0.85) reported a significantly more positive attitude toward acquiring and sharing blood pressure knowledge with their family than male students (M = 3.65, SD = 0.92, t(3893.2) = −3.45, p < 0.001).

Intergenerational knowledge transfer and blood pressure screening

In an effort to assess the extent to which the blood pressure awareness gained by the students is shared with their family members as a proxy of the Singapore population (RQ3), we asked students to list the members of their family with whom they shared their blood pressure knowledge and on whom they performed a blood pressure measurement. We found out that when sharing the blood pressure knowledge, female family members were more likely to be selected as the target of knowledge sharing by students. Mothers (76.7%) were most likely to be chosen as the sharing target, followed by fathers (67.3%). Among extended family members, they were more likely to share with grandmothers (32.2%) than with grandfathers (22.5%), and aunts (21.7%) than with uncles (17.6%). Only 7.5% of the sample did not share the blood pressure information with any of their family members. Female students were also more likely than male students to engage in knowledge sharing with their family members. The percentage of male students who claimed that they did not share knowledge was 8.7% as compared to 6.3% of female students.

Each student performed a blood pressure measurement on an average of 3.04 people (SD = 1.94). This indicates that for each trained student, there is a multiplier effect of 3.04 people whose blood pressure was measured. The difference between male (M = 3.01, SD = 2.08), and female (M = 3.08, SD = 1.81) students was not statistically significant. Similar to students’ target of knowledge sharing, female family members were more likely to be the target of blood pressure screening as compared to their male counterparts. Students were also more likely to measure the blood pressure of their mother (82.9%) first and father next (72.3%). 7.7% of the students reported not performing blood pressure measurement on any of their family members.

Among those whose blood pressure was measured, grandfathers (43.0% of all grandfathers screened) and grandmothers (38.5%) were found to be most likely to suffer from hypertension. Other male family members were also more likely to register a high level of blood pressure than their female counterparts, with 30.0% of uncles and 20.6% of fathers as compared to 21.9% of aunts and 11.1% of mothers found with hypertension.

Students’ self-efficacy and attitudes toward performing blood pressure screening

We also examined the attitudes and self-efficacy level of the students in performing the blood pressure screening in the post-program survey as an effort to measure the effectiveness of the blood pressure measurement training (RQ4). Students felt a high level of self-efficacy in performing blood pressure screening on their family members (M = 4.13, SD = 1.03), suggesting the effectiveness of the program. Female students (M = 4.22, SD = 0.97) had higher self-efficacy than male students (M = 4.04, SD = 1.08; t(3,865) = −5.40, p < 0.001).

Students’ attitudes toward taking blood pressure screening were highly positive (M = 4.25, SD = 0.72 out of a 5-point scale). Most of them were likely to find it beneficial, useful, easy, interesting, relaxing, and enjoyable. Similar to gender comparison on self-efficacy, female students tended to have a slightly more positive attitude (M = 4.32, SD = 0.66) as compared to male students (M = 4.18, SD = 0.77) toward measurement taking (t(3,777.2) = −6.04, p < 0.001).

Discussion

The present study sought to assess the efficacy of a hypertension awareness program which deployed school students as an intermediary to reach a larger group of the public from diverse gender, age, and racial groups. We found out that the program was effective in enhancing students’ and their family members’ awareness and knowledge about hypertension. Students generally showed an improvement in their blood pressure knowledge, positive attitudes and a high confidence level on taking a blood pressure measurement from their family members, after they attended the lecture and training session. The only exception was one knowledge item in which the percentage of students who correctly answered that question (Q6) was lower at the post-program survey than at the pre-program survey, probably caused by the item being a negative statement, and hence creating some confusion amongst the students. Students shared the information they had received about blood pressure with their family members and they also performed a blood pressure screening on them. Family members of students showed favorable attitudes toward the program and saw the benefits associated with the program. In line with past studies (8,17,25), we found that the activities from this program, specifically those involving children bringing home the blood pressure monitor, facilitated discussion and knowledge transfer to their family members. The hands-on activities in performing blood pressure measurement created the teachable moments for family members, opening them to new knowledge and attitudinal changes.

Gender analyses revealed that female students performed better in improving their blood pressure knowledge and in sharing this knowledge with family members compared to male students. Similarly, they generally responded more positively than male students in their attitudes and self-efficacy towards blood pressure screening. The results were in line with Fors et al.’s (17) findings and might be due to gender-role expectations that blood pressure measurement and other medical-nursing jobs should be done by women (26). In addition, on average, the verbal abilities of females are superior to males (27). Consequently, when the female students are given instructions, their superior verbal abilities may have aided them to perform better than their male counterparts (28). Future studies could affirm this proposition by performing a more in-depth gender analysis to find out whether male students were more likely to approach family members of the same or opposite gender, and likewise for female students.

For each student who brought home the blood pressure monitor, an average of 3.04 people had their blood pressure screened, indicating a multiplier effect of three people on average for each student trained. In addition, female family members were more likely to have their blood pressure screened than the male counterparts. This might be attributed to gender differences in interpersonal relationships where women place a higher importance on maintaining such relationships, and hence are more likely to be open to feedback and others’ opinions than men (29). This result also reflects Malhotra et al.’s study, which found that men tended to be unaware of suffering from hypertension and remained untreated compared to women (4). The situation is a cause for concern as men are more likely to suffer from hypertension (2). Similarly, while grandparents were the highest proportion of family members identified with hypertension, parents were more likely to be students’ target of knowledge sharing and blood pressure screening than grandparents. These findings suggest that students tended not to target the higher risk family members in this program. On the other hand, it may also reflect the fact that, despite the family-oriented nature of Singapore society, not all students live with their grandparents, and were unable to reach them easily for blood pressure screening. However, our findings that grandparents have been targeted by quite a large number of students for knowledge sharing and blood pressure measurement indicate the potential of this program to reach out to the elderly population. Future efforts should be made to encourage students to engage grandparents, who are at a higher risk of suffering from hypertension, perhaps by letting students take home the blood pressure monitor over the weekend, so that they are able to perform blood pressure screening on their grandparents who live apart.

Although family members generally showed favorable attitudes toward the program, and found performing a blood pressure measurement easy, they only have moderate confidence levels and intentions of checking their blood pressure regularly. The gaps between attitudes and intention, and eventually the actual act of having regular blood pressure screening and seeking treatment from a physician if necessary, need additional examination. For instance, their level and types of response cost, or their reasons for not having a regular screening, whether time, cost, convenience, or fear of visiting a physician, could be further assessed.

In future studies, we recommend including a control group to examine effects of the program more robustly, particularly the degree to which students’ knowledge and attitudes toward blood pressure measurement differ among those exposed to the program and those who are not. The control group can be created by asking for the participation of a parallel batch of students to complete the pre- and post-program survey without undergoing the blood pressure measurement program. The training and lecture can still be conducted for these students in school, but at a later time, so that the students can still benefit from this education program. In addition, a longitudinal study design can be useful in assessing the retention of students’ blood pressure knowledge, and hence the effectiveness of the program in the long-run, for instance, by collecting responses from the same group of subjects around one year after the program, perhaps by conducting the program at the start of the school year, and the follow-up survey at the end of the school year, before the students move on to the next grade. We also recommend administering the students’ pre- and post-program surveys using a paper-and-pencil method at the school, instead of the online method, to improve the response rate of the program evaluation, as it would be easier to monitor the survey administration and ensure that proper respondent identification is included.

With regard to the impact on family members, in the present study we did not conduct follow-up on those found by students to have high blood pressure other than merely advising them to confirm the diagnosis by visiting a medical professional. We did not track whether they did go for a check-up, which admittedly is one of the current study’s limitations. Future initiatives can study the longer-term impact of the program by contacting family members found with hypertension to check if they performed any follow-up actions, such as visiting a doctor or health professional for further health screening. In addition, a longitudinal study can be designed which includes providing financial support to these family members as an incentive for them to visit a health professional to confirm if they indeed suffer from hypertension. Blood pressure knowledge of the family members can also be included to be directly aligned with what the students were taught and assessed prior to and after the program so as to ascertain the amount of the students’ knowledge sharing with family members. Future facets of the program can also incorporate encouragement of the children to measure the blood pressure of male family members and grandparents in order to better reach this more vulnerable group.

Conclusion

We found the results encouraging in terms of the program meeting its educational objectives in raising the children’s awareness on hypertension and sharing informational materials with family members while practicing blood pressure measurement skills in the home environment. An extension of this program to more schools or cohorts is recommended in order to reach higher levels of awareness diffusion among the Singapore population, especially in reaching out to those who might otherwise not receive personalized health education on blood pressure matters.