Translate this page into:
Leveraging adolescents as health advocates: Evaluating hypertension education’s impact on knowledge retention & family health compliance
For correspondence: Dr Sandra Roshni Monteiro, Department of Psychology, Easwari School of Liberal Arts, SRM University AP, Mangalgiri 522 502, Andhra Pradesh, India e-mail: monteiro.san10@gmail.com
-
Received: ,
Accepted: ,
Abstract
Background & objectives
Hypertension, traditionally a significant health issue among adults, is now increasingly being observed in the paediatric population posing long-term cardiovascular risks. This study evaluated a school-based hypertension education intervention for adolescents and its impact on their hypertensive family members. Objectives included assessing adolescents’ knowledge retention, knowledge transfer to adults, and the effects of child-led monitoring on adult compliance.
Methods
The study was conducted in two phases. In Phase 1, the study involved adolescents from classes 6-10 (n=423). Phase 1 assessed hypertension knowledge changes post-intervention from baseline scores across 6 interval points through 91 days using hypertension knowledge test (HKT). In Phase 2, adolescents and their hypertensive family members (n=181) were recruited in pairs. Changes in HKT, hypertension compliance (hypertension compliance scale: HyCompS), and mean arterial pressure (MAP) were analysed pre- and post-intervention using paired t-tests. Adolescents tracked adult adherence via daily monitoring diaries, analysed descriptively.
Results
In Phase 1, adolescents showed significant and sustained improvements in hypertension knowledge despite minor dips on the 35th and 63rd days. In Phase 2, adults’ knowledge improved significantly in overall and general awareness domains. Compliance increased, particularly for medication and lifestyle monitoring, with significant reduction in MAP. Children recorded high monitoring adherence—medication (77.6%), exercise (72%), and diet (66%).
Interpretation & conclusions
Adolescents can effectively serve as health advocates, promoting hypertension awareness and compliance within families. Structured school interventions may improve both adolescent and adult health outcomes. Longitudinal studies with larger samples are recommended.
Keywords
Adolescents health advocacy
hypertension compliance
hypertension education
family health advocacy
Hypertension affects approximately 1.28 billion adults aged 30-79 worldwide, with nearly 46 per cent unaware of their condition1. In India, the awareness of hypertension remains significantly low with over 75 per cent of rural and 58 per cent of urban patients unaware of their condition2, and over 80 per cent struggling with effective disease management. While traditionally associated with adults, hypertension is increasingly observed in children estimating a global paediatric hypertension prevalence of 4-7 per cent3 with higher rates observed in urban and overweight populations, raising concerns about early vascular damage and long-term cardiovascular complications. Indian studies report similar trends, noting increased prevalence in adolescents aged 14 years4. Paediatric hypertension is linked to structural and functional organ changes, including elevated carotid intima-media thickness, left ventricular hypertrophy, and cognitive impairments5-7.
Despite the serious implications, awareness and adherence to preventive behaviours among children remains low. A study8 found that only 11 per cent of Indian schoolchildren had basic hypertension knowledge. Health literacy plays a critical role in promoting adherence to lifestyle modifications, which are foundational to hypertension management9-11. Educational interventions have been shown to foster positive health behaviours in children across various domains, including oral hygiene12, hand hygiene13,14, and dietary habits15,16, and often extend to benefit the broader community. Adolescents, as conduits of health knowledge, can influence family health behaviours through intergenerational knowledge transfer. This approach holds promise, particularly in countries with high disease burden and limited healthcare access16-19.
In two phases, this study evaluates the effectiveness of a hypertension education programme for schoolchildren, examining its impact on their knowledge retention, and the unintended transfer of knowledge to hypertensive adult family members. It also investigates the role of the adolescents in monitoring adults’ adherence to medication, diet, and exercise regimens.
Materials & Methods
This study was undertaken by Centre for Health Psychology, University of Hyderabad, Hyderabad, India between 2018 to 2023 after obtaining the ethical clearance from the Institution Ethics Committee. A prior permission was obtained from all the participating schools.
Design of the study
The study employed a quasi-experimental interrupted time series design20, with a pre-test and post-test approach. While the term ‘children’ is used broadly in referencing existing literature and public health contexts, this study specifically recruited school-going adolescents (ages 11-16) due to their cognitive maturity and potential as conduits of health knowledge. The term ‘adolescents’ is used to highlight this developmental specificity where relevant.
The study was conducted in two phases.
Phase 1
Conducted in Nagaland, this phase evaluated knowledge retention among students from Classes 6-10. Schools were selected via purposive sampling. After obtaining institutional permissions, parental consent and child assent were secured. Of the 503 students initially enrolled, 423 completed all follow-ups due to attrition related to absenteeism.
Phase 2
This phase examined knowledge transfer and adherence monitoring from adolescents to their hypertensive family members. It included adolescents from Classes 6-9 and their hypertensive adult family members in Kolkata and New Delhi. School going adolescents aged 11-15 yr with a hypertensive adult at home were recruited through purposive sampling. Following a pilot test for feasibility, and despite COVID-19-related disruptions, 181 adolescent-adult pairs from 13 schools completed the study. Written informed consent and child assent were obtained.
Procedure
Phase 1
After obtaining ethical approval, permission was secured from participating schools in Nagaland. Students from classes 6-10 (ages 11-16) were recruited following informed consent from parents and assent from students. For younger adolescents (11-12), tools were explained in simple terms in English and their local language. Under supervision of a health psychologist (research investigator), students completed the self-administered questionnaire hypertension knowledge test (HKT). Participants, then, viewed a 30-min educational video on hypertension in English, developed using evidence-based guidelines. This was repeated on day 7 from first exposure to reinforce learning. HKT was re-administered immediately post-intervention and on days 14, 35, 63, and 91. Only participants present at all time points were included in the analysis.
Phase 2
With ethical clearance, adolescents from Classes 6-9 in Kolkata and New Delhi with hypertensive adult family members were enrolled after institutional permissions were acquired. Eligible adults were identified through a screening survey. After consent and assent, baseline data were measured for adults that included BP measurements (three readings averaged and converted to mean arterial pressure or MAP using standard formula), Hypertension Knowledge Test (HKT; Supplementary Table IA), and hypertension compliance scale (Supplementary Table IB). The adolescents viewed the same video (as Phase 1) on days 1, 7, and 21, followed by structured group discussions led by a health psychologist. They were trained to respectfully monitor their family member’s adherence to medication, diet, and exercise using a structured daily log (Supplementary Table IC). Monitoring was conducted at home over six wk and logs were collected weekly via school visits. Any missed or uncertain entries were noted as ‘Forgot’ or ‘Don’t Know’. Log completeness was high, with missing data attributed to scheduling conflicts or adult unavailability. At the end of six wk, adult participants were reassessed for knowledge, compliance and MAP.
Tools
Hypertension knowledge test (HKT)
The HKT21 assessed knowledge of hypertension, featuring 22 multiple-choice items categorised into general awareness (5 items), lifestyle factors (5 items), causes/casualties (6 items), and medication management (6 items). The test-retest reliability was high (α=0.92), and internal consistency (Cronbach’s α) was 0.74.
Hypertension compliance scale (HyCompS)
HyCompS22 measured clinical compliance over the past wk using a 15-item scale covering medication (7 items), diet (3 items), exercise (3 items), and lifestyle/self-monitoring (2 items), (Supplementary Table I). The Cronbach’s α for this study was 0.67.
Hypertension knowledge intervention video
This 30-min educational video featured a medical professional and a health psychologist discussing hypertension symptoms, risks, medication, and lifestyle management through a slideshow with animations.
Blood pressure reading
The blood pressure was recorded using a calibrated digital sphygmomanometer. MAP using the standard formula for conversion: (MAP=diastolic pressure + 1 3 ⁄ (systolic pressure - diastolic pressure)).
Statistical analysis
All analyses were conducted using SPSS (IBM SPSS, version 23, Chicago, New York, USA). For Phase 1, repeated measures ANOVA assessed changes in HKT and HELIPSCA scores across six time points. Bonferroni post hoc tests were used for pairwise comparisons. In Phase 2, paired t-tests evaluated pre-post changes in adult participants’ HKT scores, HyCompS scores, and MAP. Normality and sphericity assumptions were tested and met. Statistical significance was set at P< 0.05.
Results
Phase 1
The participant demographics of Phase 1 are presented in supplementary table II.
Sustainability of hypertension knowledge
Repeated measures ANOVA revealed significant improvements in overall hypertension knowledge and across all four HKT dimensions (general awareness, lifestyle, causes/casualties, and medication management) over six time points (Table I).
| Variables | Pre-test | Post-test 1 (Immediate) | Post-test 2 (14th day) | Post-test 3 (35th day) | Post-test 4 (63rd day) | Post-test (91st day) | F (5,2110) | η2 | ||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| M | SD | M | SD | M | SD | M | SD | M | SD | M | SD | |||
| HK (overall knowledge) | 3.91 | 3.22 | 10.97 | 4.40 | 11.33 | 4.24 | 10.78 | 4.34 | 10.62 | 4.35 | 11.10 | 4.69 | 527.15*** | 0.56 |
| HK (general awareness) | 1.05 | 1.14 | 3.20 | 1.31 | 3.29 | 1.29 | 3.20 | 1.18 | 3.17 | 1.23 | 3.25 | 1.25 | 401.51*** | 0.49 |
| HK (lifestyle) | 0.88 | 1.06 | 2.60 | 1.44 | 2.75 | 1.40 | 2.43 | 1.42 | 2.44 | 1.39 | 2.53 | 1.46 | 229.57*** | 0.35 |
| HK (causes, care, casualty, & awareness) | 1.04 | 1.12 | 2.29 | 1.34 | 2.21 | 1.28 | 2.09 | 1.27 | 1.98 | 1.16 | 2.19 | 1.39 | 95.51*** | 0.19 |
| HK (Management of medication) | 0.94 | 1.09 | 2.87 | 1.61 | 3.08 | 1.61 | 3.06 | 1.64 | 3.04 | 1.66 | 3.12 | 1.69 | 262.27*** | 0.38 |
P ***< 0.001. HK, hypertension knowledge; M, mean; SD, standard deviation
Knowledge trends over time
Figure 1 illustrates a slight dip in knowledge scores across all domains on day 35, with a recovery by day 91. Bonferroni post hoc tests depicted in table II confirmed significant gains in all domains compared to baseline, indicating the intervention’s effectiveness in sustaining knowledge, despite temporary declines at days 35 and 63.
- Improvement in overall hypertension knowledge levels and its dimensions across time. Bar graph representation of improvement in overall hypertension knowledge levels and its dimensions across time.
| Multiple comparisons | HK (total score) | HK (general awareness) | HK (lifestyle) | HK (Causes, care, casualty, and awareness) | HK (Management of medication) |
|---|---|---|---|---|---|
| Pre-test∼ Immediate Post-test1 | -7.05* | -2.15* | -1.72* | -1.25* | -1.93* |
| Pre-test∼Post-test 14th day | -7.41* | -2.24* | -1.88* | -1.17* | -2.14* |
| Pre-test∼Post-test 35th day, | -6.87* | -2.15* | -1.56* | -1.05* | -2.12* |
| Pre-test∼Post-test 63rd day | -6.71* | -2.12* | -1.56* | -0.94* | -2.09* |
| Pre-test∼Post-test 91st day | -7.19* | -2.20* | -1.66* | -1.14* | -2.18* |
| Post-test Immediate ∼ Post-test 14th day | -0.36 | -0.085 | -0.15 | 0.08 | -0.020 |
| Post-test Immediate ∼ Post-test 14th day | -0.18 | 0.002 | 0.17 | 0.19* | -0.18 |
| Post-test Immediate∼ Post-test 63rd day | 0.35 | 0.0 | 0.16 | 0.31* | -0.16 |
| Post-test Immediate ∼ Post-test 91st day | -0.13 | -0.05 | 0.07 | 0.10 | -0.25* |
| Post-test 14th day ∼ Post-test 35th day | 0.54* | 0.09 | 0.32* | 0.12 | 0.02 |
| Post-test 14th day ∼ Post-test 63rd day | 0.70* | 0.12 | 0.31* | 0.23* | 0.04 |
| Post-test 14th day ∼ Post-test 91st day | 0.29 | 0.03 | 0.22* | 0.02 | -0.05 |
| Post-test 35th day ∼Post-test 63rd day | 0.16 | 0.03 | -0.01 | 0.11 | 0.02 |
| Post-test 35th day ∼ Post-test 91st day | -0.32 | -0.06 | -0.09 | -0.09 | -0.07 |
| Post-test 63rd day ∼Post-test 91st day | -0.48* | -0.09 | -0.09 | -0.29* | -0.09 |
P *<0.05
Phase 2
Participant demographics are summarised in supplementary table III.
Knowledge transfer from adolescents to hypertensive adult family members
Paired t-tests revealed significant improvements in adults’ overall hypertension knowledge (t=2.29, P<0.05) and general awareness (t=2.52, P<0.05), indicating indirect knowledge transfer from adolescents exposed to the intervention as observed in table III.
| Pre-intervention | Post-intervention | 95% CI for mean difference | ||||
|---|---|---|---|---|---|---|
| Outcome | M | SD | M | SD | Lower | Upper |
| Hypertension knowledge (total) | 10.61 | 3.07 | 10.90 | 3.10 | -0.54 | -0.04 |
| i. General awareness | 2.81 | 1.07 | 2.99 | 1.14 | -0.33 | -0.04 |
| ii. Lifestyle | 2.56 | 1.16 | 2.61 | 1.15 | -0.16 | 0.07 |
| iii. Causes, care, casualty awareness | 2.59 | 1.22 | 2.59 | 1.16 | -0.10 | 0.11 |
| iv. Medical management | 2.65 | 1.20 | 2.72 | 1.20 | -0.14 | 0.002 |
CI, confidence interval
Daily adherence monitoring
Over six wk, adolescents recorded high monitoring success rates in the daily logs: 77.6 per cent for medication, 72 per cent for exercise, and 66 per cent for diet (Fig. 2). Mean daily scores with 95 per cent confidence intervals (CI) were: medication=35.6 (CI: 35.57-35.71), exercise=32.1 (CI: 32.01-32.17), and diet=30.3 (CI: 30.24-30.40), with the highest adherence observed for medication.
- Children’s record of monitoring hypertensive adult family members for 6 wk. Mean scores (±95% Confidence Intervals) of children’s successful daily monitoring efforts across three compliance measures: Medicine (M=35.7, CI= ±0.50), Exercise (M=32.1, CI= ±0.56), and Diet (M=30.3, CI= ±0.58). Error bars represent the 95% confidence intervals around the mean, illustrating the precision of each estimate.
Impact on adults’ compliance and blood pressure outcomes
Post-intervention outcomes for adults are presented in table IV. It showed significant improvements in overall compliance (t=3.65, P<0.001), medication adherence (t=2.35, P< 0.05), and self-monitoring behaviours (t=2.40, P<0.05). Changes in exercise and diet adherence were not statistically significant. Mean arterial pressure (MAP) significantly decreased post-intervention (t=17.10, P< 0.001), with a mean reduction of over 6 points, suggesting that adolescents’ monitoring contributed meaningfully to improved clinical outcomes.
| Outcome | Before intervention was provided to the children | After intervention was provided to the children | 95% CI for mean difference | |||
|---|---|---|---|---|---|---|
| M | SD | M | SD | Lower | Upper | |
| Hypertension compliance | 35.48 | 7.06 | 36.73 | 6.33 | -1.94 | -0.58 |
| i. Medication compliance | 16.29 | 4.74 | 16.72 | 4.35 | -0.79 | -0.07 |
| ii. Dietary compliance | 7.51 | 2.18 | 7.77 | 1.68 | -0.52 | 0.01 |
| iii. Exercise compliance | 7.62 | 2.32 | 7.9 | 1.97 | -0.61 | 0.07 |
| iv. Lifestyle & self-monitoring | 4.04 | 1.67 | 4.35 | 1.88 | -0.55 | -0.05 |
| Mean arterial pressure | 116.89 | 5.12 | 110.38 | 6.01 | 5.76 | 7.26 |
Discussion
This study demonstrates that a structured hypertension education intervention significantly enhanced adolescents’ knowledge. Adolescents retained this knowledge over time and indirectly shared it with hypertensive adult family members, contributing to improved compliance and reductions in mean arterial pressure.
The results align with established theories of health behaviour change, such as the health belief model23, social cognitive theory24, and the theory of planned behaviour25 which posit that increased health-related knowledge and self-efficacy can drive behaviour change. By enhancing personal control and creating a cognitive dissonance26 between new knowledge and practiced behaviour, the intervention facilitated adherence to healthier practices27,28. Health education during early adolescence can result in lasting behavioural changes, especially in non-communicable disease prevention29,30.
Phase 2 findings revealed that knowledge transfer from adolescents to adults was largely unintentional, consistent with earlier studies indicating that children are effective intergenerational health messengers31-33. Monitoring logs showed that adolescents were particularly successful in supporting medication adherence, with comparatively lower rates for diet and exercise. This may reflect greater feasibility or familiarity with medication routines, suggesting a need to strengthen support mechanisms for lifestyle modifications.
In contemporary family dynamics, adolescents often exert considerable influence over adult decisions across domains. Harnessing this dynamic for health promotion particularly in low-resource settings offers a novel, scalable strategy to improve cardiovascular outcomes.
Despite encouraging findings, several limitations must be acknowledged. Self-reported data in Phase 1 may be affected by recall or social desirability bias. The intervention’s impact varied with individual learning retention and home contexts. In Phase 2, while adult outcomes improved post-intervention, the study did not statistically link these changes to adolescent knowledge gains, limiting causal inference. Furthermore, reliance on single-point BP measurement rather than ABPM (ambulatory blood pressure) may have affected precision. Pandemic-related constraints also limited sample diversity and follow up access.
Future research should include larger, more diverse cohorts, objective physiological assessments, and formal modelling of intergenerational knowledge pathways to validate and expand on these findings.
To conclude, this study highlights the potential of adolescent-led hypertension interventions to benefit both themselves and their adult family members. The phased, school-based design combined with adolescent-led home monitoring fostered improvements in knowledge, adherence, and clinical indicators like blood pressure. These findings support the integration of structured hypertension education into school curricula as a population-level strategy to address both paediatric and familial hypertension. Clinically, this model can be particularly impactful in low-resource settings where health personnel are limited and can enhance home-based disease management, reduce caregiver burden, and improve treatment continuity in chronic conditions like hypertension.
Acknowledgment
The authors thank all the participants for their timely responses.
Financial support & sponsorship
This study reports two phases of the research. Phase 1 was funded by the National Fellowship and Scholarship (Grant no: 201819-NFST-NAG-02050) for Higher Education of ST Students (NFST) granted to third author (TS). Phase 2 was funded by the Indian Council of Medical Research (Grant No. 3/1/3/JRF-2018/HRD (SS), granted to corresponding author (SRM).
Conflicts of Interest
The authors declare no conflict of interest.
Use of Artificial Intelligence (AI)-Assisted Technology for manuscript preparation
The authors confirm that there was no use of AI-assisted technology for assisting in the writing of the manuscript and no images were manipulated using AI.
References
- World Health Organization. Hypertension; 2023. Available from: https://www.who.int/news-room/fact-sheets/detail/hypertension, accessed on May 23, 2025.
- Hypertension in India: a systematic review and meta-analysis of prevalence, awareness, and control of hypertension. J Hypertens. 2014;32:1170-7.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Global prevalence of hypertension in children: a systematic review and meta-analysis. JAMA Pediatr. 2019;173:1154-63.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Prevalence of hypertension among children and adolescents in India: a systematic review and meta-analysis. Indian J Pediatr. 2021;88:1107-14.
- [CrossRef] [PubMed] [Google Scholar]
- Hypertension and target organ damage in children and adolescents. J Hypertens. 2007;25:1998-2000.
- [CrossRef] [PubMed] [Google Scholar]
- Childhood hypertension: An underappreciated epidemic? Pediatrics. 2016;138:e20162857.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Clinical implications of the revised AAP pediatric hypertension guidelines. Pediatrics. 2018;142:e20180245.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Conceptualizing hypertension: a developmental trend in school children. Int J Health Allied Sci. 2018;7:177-83.
- [Google Scholar]
- The relationship between health literacy and medication adherence in a hypertensive patient population. Int J Caring Sci. 2020;13:101-7.
- [Google Scholar]
- Health literacy: Implications for child health. Pediatr Rev. 2019;40:263-77.
- [CrossRef] [PubMed] [Google Scholar]
- Health psychology: Theory, practice and research. Sage Publications; 2020.
- Effectiveness of oral health education intervention among 12-15-year-old school children in Dharan, Nepal: a randomized controlled trial. BMC Oral Health. 2021;21:525.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Social influence on handwashing with soap: Results from a cluster randomized controlled trial in Bangladesh. Am J Trop Med Hyg. 2018;99:934-6.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Effect of hand hygiene intervention in community kindergartens: A quasi-experimental study. Int J Environ Res Public Health. 2022;19:14639.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- ‘Like a white piece of paper’. Embodiment and the moral upbringing of Vietnamese children. Ethnos. 2001;66:394-413.
- [Google Scholar]
- Long term effect of a school based intervention to prevent chronic diseases in Tunisia, 2009-2015. Afr Health Sci. 2017;17:1137-48.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- School based education programme to reduce salt intake in children and their families (School-EduSalt): Cluster randomised controlled trial. BMJ. 2015;350:h770.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Children’s participation in ethnographic research: Issues of power and representation. Children & Society. 2004;18:165-76.
- [Google Scholar]
- Children as adherence enhancing agents in management of primary hypertension of adult family members. Int J Health Allied Sci. 2021;10:280.
- [CrossRef] [Google Scholar]
- The value of interrupted time-series experiments for community intervention research. Prev Sci. 2000;1:31-49.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Hypertension knowledge test: Development and validation. Int J Indian Psychol. 2017;5:44-55.
- [CrossRef] [Google Scholar]
- Doctor-patient communication: Impact on adherence and prognosis among patients with primary hypertension. Psychol Stud. 2015;60:25-32.
- [CrossRef] [Google Scholar]
- Historical origins of the health belief model. Health Education Monographs. 1974;2:328-35.
- [CrossRef] [Google Scholar]
- Social foundations of thought and action. In: Marks DF, ed. The health psychology reader. SAGE Publications Ltd; 2002. p. :94-106.
- [Google Scholar]
- The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50:179-211.
- [CrossRef] [Google Scholar]
- Effectiveness of modified health belief model-based intervention to reduce body mass index for age in overweight junior high school students in Thailand. J Health Res. 2018;33:162-72.
- [Google Scholar]
- The effect of social cognitive theory-based interventions on dietary behavior within children. JNHFS. 2016;4:1-9.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Effectiveness of a school based intervention for prevention of non-communicable diseases in middle school children of rural North India: a randomized controlled trial. Indian J Pediatr. 2015;82:354-62.
- [CrossRef] [PubMed] [Google Scholar]
- Effect of nutrition education based on health belief model on nutritional knowledge and dietary practice of pregnant women in Dessie Town, Northeast Ethiopia: a cluster randomized control trial. J Nutr Metab. 2018;2018:6731815.
- [CrossRef] [PubMed] [PubMed Central] [Google Scholar]
- Evaluation of a diffusion strategy for school-based hypertension education. Health Educ Q. 1989;16:255-61.
- [CrossRef] [PubMed] [Google Scholar]
- Intergenerational transfer of blood pressure knowledge and screening: a school-based hypertension awareness program in Singapore. Glob Health Promot. 2016;23:27-36.
- [CrossRef] [PubMed] [Google Scholar]
- Preliminary study of a school-based program to improve hypertension awareness in the community. Fam Med. 2008;40:264-70.
- [PubMed] [Google Scholar]