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SOCIAL REPRESENTATIONS OF HYPERTENSIVESOCIAL ABOUT
ARTERIAL HYPERTENSION
Kallyne Luise Silva Vieira1
Pablo Amaral Silva2
Jucimere Fagundes Durães Rocha3
Dayane Indyara de Sá Silva4
Renata Di Pietro Carvalho5
Isabella Barbosa de Oliveira6
Loren Mendes Silva7
Larissa Natany Fernandes da Costa8
Adriana Mendes Rocha9
Marianna de Almeida Santana Mendes10
Raiane Katielle Pereira Silva11
Anne Vitória Silva Rodrigues12
Walter Luiz de Moura13
Giselly Sousa Silva14
1 Faculty of Health and Humanities Ibituruna
2 Faculty of Health and Humanities Ibituruna
3 Faculty of Health and Humanities Ibituruna
4 Faculty of Health and Humanities Ibituruna
5 Federal University of the Jequitinhonha and Mucuri Valleys.
6 University Center of Northern Minas Gerais.
7 North Paraná University
8 Montes Claros State University
9 Montes Claros State University
10 Montes Claros State University
11 Montes Claros State University
12 University Center of Northern Minas Gerais
13 Montes Claros State University.
14 State University of Santa Cruz
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Victoria Cristina Mascarenhas Vítor15
Victoria Sabrina Ferreira de Assis16
Kerolaine de Freitas Moreira17
Abstract: This study aimed to analyze the social representations of hypertensive patients about
systemic arterial hypertension. This is a eld research with a qualitative approach, based on the Theory
of Social Representations by Serge Moscovici (1961), based on the structural approach of Jean-Claude
Abric (1976). The study setting was in two cities in the north of Minas Gerais, questions and word
recall test. These evocations were analyzed through structural analysis and presented in a four-place
frame, built with the aid of the Ensemble de Programs Permettantl’ Analysedes Evocations (EVOC®)
software, version 2005. For this construction, the Middle Order of Evocations was considered( OME),
that is, the rang equal to 2.20 while the intermediate frequency was set at 21 and the minimum at 13
. To study the discourse from the open questions, the content analysis technique proposed by Bardin
(2011) was used. It is concluded that hypertensive individuals also believe that anxiety can trigger
an increase in their BP pressure levels. Non-pharmacological practices are less mentioned, however,
they portray that if patients have healthy lifestyle habits in their daily lives, their BP levels will be
controlled.
Keywords: Infarction. Leakage. Hypertension.
15 Faculty of Health and Humanities Ibituruna
16 Faculty of Health and Humanities Ibituruna
17 University Center of Northern Minas Gerais.
Introduction
Systemic Arterial Hypertension (SAH) is a chronic pathology, a clinical condition triggered
by several modiable factors. It is the leading cause of mortality in parents, characterized by sustained
high blood pressure levels ≥ 140 and/or 90 mmHg, and currently presents enormous public health
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complications (ARAÚJO).et al.., 2019).
It is constantly compared to metabolic disorders, functional and/or structural alterations of
target organs, and is aggravated by the existence of other risk factors (RF), such as dyslipidemia
and abdominal obesity. Thus, it maintains an independent association with events such as sudden
death, stroke, acute myocardial infarction (AMI), heart failure, peripheral arterial disease (PAD), and
chronic kidney disease (CKD), both fatal and non-fatal (MALACHIAS).et al.., 2017).
Equivalent to a major impact on morbidity and mortality and socioeconomic costs.
The epidemiology of hypertension and its determinants is still poorly understood in the Brazilian
population. Only in recent years has a robust, nationwide study been conducted in this area. The
National Health Survey (PNS), carried out in 2013 by the Ministry of Health with the help of IBGE
(Brazilian Institute of Geography and Statistics) on a specic and robust sample (N > 60,000) of adult
Brazilian citizens, indicated a self-reported prevalence of hypertension of 21.4%, affecting women
more (24.2%) than men (18.3%). When the diagnostic criteria were modied, dening hypertension
as affecting individuals who showed blood pressure measured at home ≥140/90 mmHg, or who were
using antihypertensive medication, the prevalence rose to 32.3%, with a higher prevalence in men
(MIL, 2019).
The most common causes of hypertension are associated withObesity, increased consumption
of alcoholic beverages and salt, advanced age, sedentary lifestyle, stress, and low potassium and
calcium intake are risk factors. Treatment includes pharmacological actions, based on the use of
antihypertensive drugs, or non-pharmacological approaches. Therefore, physical activity, a healthy
diet, increased potassium and calcium intake, weight control, decreased salt and alcohol intake, and
reduced smoking are key indicators (MIRANDA).et al.,. 2021).
Despite the advances made in Brazil’s public health system in recent years, specically in
conjunction with primary care coverage, the current organization of the provision of these services
remains fragmented with little communication between the various levels of health care. In the state
of Minas Gerais, the method of implementing health care networks (RAS) and preparing primary
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health care (APS) began in 2003, with the suggestion of replacing the then-current model with an
integrated health standard directed towards meeting the demand for chronic conditions with proactive
actions, supported by family care (ANDRADE).et al.., 2019).
Social representations of hypertension are associated with the relationships and exchanges
established between the person living with hypertension, their family members, and healthcare
professionals. This can contribute to understanding how these different groups portray the disease
and the practices associated with its treatment (ANTUNES; CAMARGO; BOUSFIELD, 2019).
Healthcare professionals play a signicant role in the care of patients diagnosed with Systemic
Arterial Hypertension (SAH), especially in Primary Care, where follow-up care fosters afnity with
the community and an understanding of their needs and life histories. At this level of care, health
education activities, particularly those aimed at preventing comorbidities, are particularly important
(MARTINS).et al.., 2020).
Based on the content presented, a question arises: What are the social representations of
hypertension held by people with hypertension?
Therefore, the objective of this study was to analyze the social representations of hypertensive
individuals regarding systemic arterial hypertension.
Based on the above, it is necessary to understand how hypertensive individuals experience the
disease on both a social and individual level, considering that these two dimensions are interconnected
and mutually inuence each other. Therefore, it is important to research hypertension from the
perspective of the social representations it holds. shared by hypertensive patients, thus allowing
verication of their relationship with therapeutic adherence in the control of arterial hypertension..
Materials and Methods
This is a eld research, with a qualitative approach, based on the Theory of Social
Representations by Serge Moscovici (1961), through the structural approach of Jean-Claude Abric
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(1976).
The study was conducted in two cities in northern Minas Gerais, Patis and Coração de Jesus.
The sample consisted of a total of 135 hypertensive individuals. Inclusion criteria were hypertensive
individuals diagnosed with hypertension for at least six months who agreed to participate and signed
the Informed Consent Form. Exclusion criteria were hypertensive individuals who lacked the cognitive
capacity to answer the questionnaire or who did not have internet access or a compatible device for
data collection.
Data collection took place between September 2021, with participants receiving a
questionnaire in Google Doc format via a link, made available through WhatsApp and email as
needed, thus avoiding interruption of personal or professional activities. The questionnaire, developed
by the researchers themselves, consisted of ten questions: seven on sociodemographic and clinical
prole, and three using a word association technique prompted by the term “arterial hypertension.”
The data regarding the sociodemographic and clinical prole were analyzed using descriptive
statistics with the aid of the ProgramSatisticalPackage for the Social Science (SPSS), version 20.0for
Window.
The data obtained from the free word association or word association technique under
induction with the term formed acorpus which totaled 504 words, of which 113 were different, and an
average recall rate of 3.73.
These evocations were analyzed through structural analysis and presented in the four-house
framework, constructed with the aid of...softwareEnsemble de Programmes Permett ant l’Analysedes
Evocations (EVOC®), 2005 version. For this construction, the Mean Order of Evocations (MOE)
was considered, that is, a range equal to 2,20, while the intermediate frequency was set at 21 and the
minimum at 13.
For the study of the resulting discourse, open-ended questions were asked about the
justications for choosing the main evocation, and the content analysis technique proposed by Bardin
(2011) was used.
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Since this research involved data collection from human subjects, its execution adhered to
the ethical precepts of Resolution 466/2012 of the National Health Council, which regulates research
involving human beings. Therefore, the Research Project was submitted to the Research Ethics
Committee (CEP).from the United Faculties of Northern Minas Gerais - FUNORTE, which has
its headquarters in the city of Montes Claros-MG.and was approved by means of the Substantiated
Opinion No. 4,899,864 / 2021 and Certicate of Presentation for Ethical Review 48615721.7.0000.5141.
Results
Characterization of the research participants
Table 1 shows the characterization of the 135 hypertensive individuals surveyed according to
the variables of: age, city of origin, sex, marital status, education level, and occupation. The highest
prevalence in the 51-60 age group (33.4%). The city with the largest number of respondents was Patis-
MG, with 71 (55.5%) and Coração de Jesus-MG, with 64 (47.2%). The majority were female, with 77
(57%). The most common marital status was married, living with a spouse, with 52 (38.5%) having
completed high school, followed by 45 (33.3%) having completed high school, and the most common
occupation was salaried worker, with 62 (49.6%).
Table 1-Prole of hypertensive patients surveyed, according to socio-demographic variables related to
age, city of origin, sex, marital status, education and occupation. Patis/Coração de Jesus (MG), 2021.
Variables N%
Age 29 – 39 19 13,9
40-50 43 31,8
51-60 45 33,4
≥ 60 27 18,8
Tot al 135 100
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City Patios 71 52,5
Heart 64 47,2
Tot al 135 100
Variables N%
Sex Feminine 77 57
Masculine 58 43
Tot al 135 100
Marital status Widow(er) 13 9,6
Married (or living with another partner) 09 6,7
Married but not living with spouse 07 5,2
Married, living with spouse 52 38,5
Single, with a partner 12 8,9
Single, without a partner. 14 10,4
Divorced 28 20,7
Tot al 135 100
Education No schooling/illiterate 04 03
No schooling/illiterate 0,0 0,0
Incomplete primary education 06 4,4
Completed Primary Education 15 11,1
Incomplete primary education 08 5,9
Complete elementary education 05 3,7
Incomplete secondary education 07 5,2
High school diploma 45 33.3
Incomplete higher education 10 7,4
Bachelor’s degree 35 25,9
Tot al 135 100
Unemployed 07 5,2
From home 19 14,1
Occupation Student 02 1,5
Retiree 28 20,7
salaried worker 67 49,6
Self-employed professional 12 8,9
Tot al 135 100
Source: research data.
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Regarding the clinical prole, most of them have mild hypertension 27 (20%), have no
complications 117 (86.7%), have had a diagnosis for more than six years 42 (32.5%). They only use
medication as treatment 56 (41.5%).
Table 2-Prole of hypertensive patients surveyed, according to clinical prole variables, treatment,
blood pressure classication, complications and time of diagnosis. Patis/Coração de Jesus (MG), 2021.
Variables N%
Treatment Medications only 56 41,5
Diet and medication 25 18,5
Exercise and medication 17 12,6
Diet, exercise and medication 37 27,4
Classification
yes PA
Normal 14 10,3
Borderline Normal 03 2,2
Mild hypertension (stage one) 27 20
Moderate hypertension (stage two) 13 9,6
Severe hypertension (stage three) 02 1,5
Complications In the eyes 07 5,2
In the kidneys 01 0,7
I don’t celebrate 01 0,7
In the heart 04 03
None 117 86,7
Diabetes 03 2,2
High blood pressure 01 0,7
Thyroid 01 0,7
(<) one year 14 10,4
(≥) one year ago and (<) two years ago 23 17
Time diagnosis (≥) two years ago and (<) four years ago 30 22,2
(≥) four years ago and (<) six years ago 26 19,3
(≥) six years ago 42 31,5
Source: Research data.
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Structure of the social representation of hypertensive individuals regarding arterial hyperten-
sion.
The data from the recall test of the 135 patients interviewed were analyzed using the four-
house framework approach with the aid ofoftware EVOC®. Figure 01 demonstrates the analysis of
four cells taking into account the average order and frequency of words with the greatest statistical
importance.
Figure 1- Four-cell table showing the frequency distribution and average order of position generated
by Rang frq do software EVOC® from the database of hypertensive patients surveyed.
Core Elements Frequency >= 21/ Range <
2.20
Elements of the 1st periphery Frequency >=
21/ Range >= 2.20
Freq Rang Freq Rang
Stroke 36 2,139 Headache 38 2,211
Heart attack 48 2,854
Medication 30 2,800
Dizziness 27 2,519
Treatment 21 2,571
Contrast Elements Frequency 20 < or = >13/
Rang< 2.20
Elements of the 2nd periphery Frequency 20
< or = > 13 / Range >= 2,20
Freq Rang Freq Rang
Anxiety 13 2,154 Food 13 2,308
Fear 20 1,650 Careful 15 3,133
Health center 15 2.600
Source: Research data.
The upper left quadrant of the four-house grid in Figure 1 is dened as the central element of
the representation, which is composed of the following evocation: Stroke.
The upper right quadrant is called the 1st periphery and is formed by four evocations:Headache,
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heart attack, medication, dizziness, treatmentThe wordsfood, care, health postmakes up the 2ªperiphery
located in the lower right quadrant.
In the lower left quadrant, designated as contrasting elements, are the following
evocations:anxiety, fear.
The expressionStroke – cerebrovascular accidentIt appears in the central nucleus and was
evoked 36 times, having a range of 2,139. In this study, hypertensive patients relate stroke to increased
blood pressure and also to the fear of dying. As observed in the following statements below:
A stroke can happen because the pressure is high (B29)
Why neglecting high blood pressure can lead to a stroke (B42)
The expressionheadache the rst evocation of the 1ªThe periphery was evoked 38 times,
showing a range of 2,211. This is because hypertensive individuals relate this to the fact that when the
head hurts, the pressure tends to be high, and there is also some discomfort when feeling pain.
When you have a headache, it’s usually because your blood pressure is high,
according to reports from friends (B2).
Because when my blood pressure is high, my head hurts a lot (B18)
Because when I stop taking my medication, I know my blood pressure is high
because I have a lot of headaches (B30)
The wordheart attackIt was the most frequently evoked, 48 times, and appears in the second
most frequently evoked word.ªThe periphery shows a range of 2,854. This word refers to a negative
assessment that the individual makes about hypertension. And in this study, heart attack appears as
an aspect of fear of death.
High blood pressure can cause a heart attack (B53)
Fear of dying (B98)
Because if you don’t take care of it, it leads to death (B128).
The wordmedicine,This is the third evocation of the 1ªThe peripheral reex was evoked 30
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times, showing a range of 2,800. According to the assertions below, hypertensive patients associate
the correct use of medication with more effective treatment, thus keeping their blood pressure under
control.
Because the medicine controls my blood pressure (B8)
Because through good medication, it maintains a better quality of life and
thus keeps hypertension under control (B9)
Because when you take the medicine correctly, your blood pressure stays
good (B38).
The worddizzinessThis is the fourth evocation of the 1ªThe word “periphery” was evoked 27
times, showing a range of 2,519. The word above is positioned as a synonym for fear, referring to the
individual’s apprehension when feeling dizzy.
Whenever I feel dizzy, my blood pressure is high (B21).
Fear of becoming dizzy (B66).
I don’t like feeling dizzy (B109).
Fear of falling (B122).
The wordtreatment isthe fth evocation of the 1ªThe term “periphery” was mentioned 21
times, showing a range of 2,571. Below, we present two factors that are considered preponderant in
enabling the above term. The individual believes that with proper treatment, their blood pressure will
tend to normalize, maintaining better health and energy levels.
Because with proper treatment the pressure returns to normal (B11)
Because through good treatment of high blood pressure it is possible to have
better health (B24)
Because through proper treatment I maintain my normal blood pressure (B31).
The wordfood This is the rst evocation of the 2nd periphery, evoked 13 times, showing
a range of 2,308. A good portion of the propositions below indicates that diet is a way to prevent
problems arising from hypertension, explaining that it is good to keep an eye on salty food and thus
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avoid it.
Because it’s always good to keep an eye on salty food (B5)
Having a good diet helps improve my blood pressure (...) (B10)
Diet because we hypertensive people can’t eat everything and if we eat in
moderation, it has to be a variety of foods (B37)
The wordCareful This is the second evocation of the 2nd periphery evoked times, evidencing
a range of 3,133. Care and importance are two aspects indicated below that will be necessary to
achieve better health. This is an indication of waiting, in this case, waiting for recovery and a change
in lifestyle.
Because when you take good care of your blood pressure, it stays normal (B4)
Because you should always take good care of your blood pressure (B28)
Taking care of your blood pressure is important for your health (B50)
Because we have to take care of our health (...) (B120)
The expressionhealth center isThe third evocation of the 2nd periphery was evoked 15 times,
showing a range of 2,600. The aforementioned modality encourages patient follow-up. In this way,
they demonstrate condence in the health center.
Where do I get my follow-up (B13)?
Where does an agent maintain a monitoring of hypertension (B19)?
Because the PSF is very important for us to have control of the pressure (B55)
The rst element of contrast is the wordanxiety The phenomenon was evoked 13 times,
showing a range of 2,154. It is dened as an attribute that allows the individual to understand that the
more anxious they become, the higher their blood pressure rises.
Because when I’m anxious my blood pressure goes up more (B47)
Because it makes my blood pressure go up (69)
The second element of contrast is the wordfear The question was evoked 20 times, showing
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a range of 1,650. The fear mentioned below reects anxiety about what might result from elevated
blood pressure.
Why do I get anxious and afraid of feeling unwell when I go to have my blood
pressure measured (B16)
Because it is a disease that can lead to many others (B99)
Fear of the consequences of the disease (B133)
DISCUSSION
The data collected from hypertensive individuals regarding social representation showed the
formation of two large groups, namely, the rst group:Stroke; anxiety; fear, headache, heart attack and
dizzinesssecond group:medicine; treatment; food; care and health center.
The rst group brings more elements related to the physiological changes of the disease,
because they are evocations associated with signs, symptoms, complications, or psychological changes
such as fear of complications related to high blood pressure. The word CVA (stroke) appears with
great importance in the central core, being the most cited, and there is a representation associated with
high blood pressure, CVA, and stroke, perhaps because it is a serious complication that is signicant
in the lives of these hypertensive individuals, based on experiences lived by people close to them.
This study has similar results to those of Miranda (2021), who evaluated the perception of
arterial hypertension and concluded that hypertensive patients knew little about the disease and ways
to prevent it, and also associated hypertension with symptoms, chronicity, and the risk of complications
and death. Distinguishing the patient’s knowledge represents an initial step in monitoring. Poor
knowledge can lead to a lack of awareness of the severity and risk of complications, disinterest in the
problem, and consequently, low adherence.
Farias (2017) also studies that having hypertension represents having a serious disease that
consequently brings health risks, as it can cause serious complications, especially acute myocardial
infarction and stroke, in addition to leading to death.
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Antunes (2017), in studying hypertension through sixty hypertensive individuals, highlights
that the main effects of hypertension reported by those living with hypertension were heart attack
and stroke. Therefore, when they think about the disease, they tend to reect on the degree of severity,
which may or may not correspond to the clinical severity of the disease. In this study, these participants
reported fear of the possible imagined consequences associated with hypertension, including the fear
of dying.
Thus, Silva and Sakon (2018) clarify that the self-perception of the health status of
hypertensive patients identied feelings of dissatisfaction manifested by the respondents regarding
their illness and treatment. The patient’s knowledge about the possibility of suffering a complication
from hypertension is limited, leading to exhaustion from living in the condition of being ill rather
than living a normal life while having the disease.
According to Sena,et al.. (2021) anxiety is seen by the respondents as having a behavioral
dimension, where the justicatory and identity functions, insofar as it informs them, show one of the
modiable causes of arterial hypertension, explain why a person can develop altered blood pressure
levels when they feel anxious, and allow the identication of behaviors and positions adopted that can
result in increased blood pressure.
The second group demonstrates elements relevant to treatment and expressions that highlight
the importance of careful medication use, maintaining a healthy diet, and thus ensuring follow-up for
blood pressure control, with the health center as a reference.
According to Santoset al.(2021) Arterial hypertension is a chronic condition characterized
by increased blood pressure; once diagnosed, treatment is of great importance in maintaining
blood pressure values within normal ranges. Lifestyle changes and adherence to treatment with
antihypertensive medication are fundamental for controlling this pathology. Therefore, for good
corroboration, it is necessary that the person with the disease has knowledge of the pathological
process and risk factors associated with this condition.
In a study conducted by Morais (2019) at the Federal University of Paraíba (UFPB), it was
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found that in the context of hypertension control, Primary Health Care, particularly the Family Health
Strategy, plays an important and fundamental role in hypertension control, as it represents a vision
of health centered on promoting quality of life through its main objectives of prevention, promotion,
and recovery of health.
According to Camposet al.. (2021) points out in their research that although one of the
biggest reasons for seeking care at the health unit is for the use of medication, the reports indicate
that hypertensive patients recognize that the treatment of hypertension should also be linked to non-
pharmacological treatment, which is also a motivating factor for follow-up at the Family Health
Strategy (ESF).
According to the study by Dutra and Fonseca (2017), when studying the adherence of
hypertensive patients to the treatment of systemic arterial hypertension, it is possible to understand
that conceptualizing adherence to treatment as an extension of behavior is more appropriate to dene
adherence, since this extension of behavior includes attendance at the unit, medication use, adherence
to an appropriate diet, acceptance and coping with the pathology, and suffering the consequences of
not treating the disease.
The researchers, in their reports, discussed diet as part of the concept of arterial hypertension.
They highlighted the importance of reducing salt/sodium in the diets of individuals with the disease,
as this will help maintain normal blood pressure levels (SILVA; SAKON, 2018).
According to Silvaet al. ((2018) the research indicated that prevention actions were centered
on the lifestyle practices of the participants, such as diet, physical activity, reduced salt consumption,
and seeking care at the health center. Therefore, it is important to highlight that participants with
hypertension see prevention as related to the complications arising from the pathology.
FINAL CONSIDERATIONS
This research revealed the social representations of hypertensive individuals regarding
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systemic arterial hypertension, its treatment, and living with the disease for people living with this
chronic condition. Based on the presented content, a social representation of hypertension is observed
that is linked to perceptions, symptoms, complications, and also psychological changes.
Those surveyed, when referring to high blood pressure, evoke words associated with
complications, mainly heart attack, stroke, and headache, highlighting a fear related to death.
People with hypertension also believe that anxiety can trigger an increase in their blood
pressure levels. Non-pharmacological practices are less frequently mentioned, however, they suggest
that if patients maintain healthy lifestyle habits on a daily basis, their blood pressure levels will be
controlled.
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