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Children's understanding of cancer: Developmental trend in their conceptual

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Article  in  Indian Journal of Public Health Research and Development · January 2018

DOI: 10.5958/0976-5506.2018.01309.8

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 Children’s Understanding of Cancer: Developmental
Trend in Their Conceptual Complexity

Swarajya Kopparty1, Tiamongla1, C Vanlalhruaii2, Meena Hariharan3,

Padmaja Gadiraju4, C Raghavendra Rao5
Ph.D. Research Scholar, 2Assistant Professor, 3Professor, 4Assistant Professor, Centre for Health Psychology,
1

University of Hyderabad, Hyderabad, 5Professor, School of Computer and Information Sciences, University of
Hyderabad, Hyderabad

Abstract

This study aimed to understand children’s conceptualization of the disease cancer and track the changes in
the complexity in comprehending cancer with progression in class. The sample was drawn from three schools
that enrolled socioeconomically disadvantaged group of children enrolled from class VI to class X. Results
were analyzed using a combination of qualitative and quantitative analysis. Content analysis identified a
total of seven themes into which the responses were distributed. The complexity of conceptualization was
measured by evolving Entropy scores or Divergence Index. It clearly tracked a progressive developmental
trend in complexity of the schema among the children.

Keywords: cancer, conceptual complexity, cancer awareness, children’s concept, concept development

Introduction As mentioned earlier, cancer is related to lifestyle1

Cancer is one of the predominant causes of
mortality and morbidity with an increasing incidence
in India. Besides genetic and biological predisposition,
lifestyle is identified as a precipitating factor. As per the
projection of Indian Council of Medical Research2 the
incidence of cancer would increase to over 1.73 million
by 2020. This should raise an alarm culminating in plan
of action for the generation for which the projection is
relevant. Given the fact that the projections are relevant
for the present population of children, educating them
can be a step towards cancer prevention in India. Studies
conducted in India about children’s awareness of cancer
provide varied results. A study on children of class VI
to X revealed that only 16.72% have heard of cancer.4
Contrary to this, other studies indicated knowledge of
cancer among 52.6%5 and 83.59% 6 of children.
Corresponding author:
Meena Hariharan,
Professor, Centre for Health Psychology, University of
Hyderabad, Central University P.O.
Prof. C. R. Rao Road, Gachibowli, Hyderabad- 500046,
Telangana, India, Email ID: meena.healthpsychology@
gmail.com, Contact no. : 040-23134790
that includes health promotion and health risk behavior.
Among others, smoking, chewing tobacco and alcohol
were identified as the most common risk factor for cancer
by school children6. Research on children revealed that
knowledge on the risk of passive smoking and use of
cooking oil was low, though active smoking was rightly
identified7. Misconception of cancer being contagious or
communicable existed4.
It is significant to understand children’s concept of
cancer itself because knowledge about the risk factors
will assume significance only when their understanding
of cancer as a disease is correct. Accuracy of knowledge
has been found to increase and became differentiated
with age8,9.
Some of the most common methods used for
research on children are questionnaire10, interview6,
and projective techniques such as draw and write9, Q
methodology11, closed ended questions4, open ended
questions and so on. Open ended questions despite the
disadvantages of excessive details, provide the scope
for free expression, particularly when children are the
respondents. Keeping this in view, the present study is
an attempt to investigate the knowledge level of school
 Indian Journal of Public Health Research & Development, October 2018, Vol. 9, No. 10
children regarding cancer using open ended question and
a combination of qualitative and quantitative analysis.
Research questions
The main research questions of this study were:
How do school children conceptualize cancer?
Does the concept of cancer develop in its complexity
across age?
Objectives
To understand the conceptualization of cancer
among children from 6th class to 10th.
To track the divergence index in comprehending
cancer among these children.
METHOD
Participants
The sample selection was made in two stages. In
the first stage three schools catering to the children from
lower socioeconomic groups, managed by government,
Private trust were identified. All the children from class
6th through 10th who were willing to participate and sign
the assent were included in the final sample. A total
of 639 students constituted the sample. Of this 344
(53.83%) were boys and 295 (46.16%) were girls.
Instrument
A sheet of paper with one side of it to record the
personal information of the respondents and the other
side with a single open ended question – “what do you
know about cancer?” was used as the tool in this study.
The space provided for their response was limited to six
lines.
Procedure
The children were assembled in their respective
classrooms. Those willing to participate were made to
sign the assent form. The children were given verbal
instructions about their task. They were instructed to
write their response in the blank space provided beneath
the question. One could explain the concept in more than
one way. No time limit was set to complete the task.
However the maximum time taken was 15 minutes.
24
Content analysis and Coding
The total response sheets were systematically assigned
a numerical code for the purpose of identification. Owing
to irrelevant or incomprehensible responses, 47 response
sheets were discarded. The remaining responses were
read and re-read independently by three investigators,
who coded each response with a theme. The thematic
coding of the three investigators was collated. Wherever
there was total agreement the responses were classified
under the coded themes. But in case of responses where
the investigators differed in coding, discussions were
held among the three investigators to arrive at a decision
on its category on consensus. A total of 882 responses
from 639 students were classified under 7 themes. The
responses that indicated wrong notion of cancer were
brought under the head of ‘misconceptions’.
Derivation of Divergence Index as a measure of
conceptual complexity:
Responses across the classes that were distributed
along the seven themes were given a quantitative
expression by taking class-wise frequencies under each
theme as the basic value for further calculations. The
assumption for measuring conceptual complexity for
each class was that, the more the spread of responses
across the themes, the higher is the divergence, indicating
complexity of the schema. The divergence is termed as
“entropy”. The term entropy has its genesis in Physical
Sciences where it indicates ‘disorderliness’ or absence
of a predictable pattern indicating a convergence. In the
context of expressing the responses of a class across
themes, we define entropy as divergence of responses
across the themes.
An attempt was made to calculate entropy for each
class using a formula.
To evolve the entropy value, the first step was to
calculate the probability of the number of responses
given by any individual student in a class under a theme.
‘P’ stands for probability.
This value of P is then formed into a logarithmic
value for better meaningfulness. Following is the
formula applied.
 25 Indian Journal of Public Health Research & Development, October 2018, Vol. 9, No. 10
Absolute Entropy (E)= Ʃ (I×P), where
Where, I = - log
P = Probability
The ‘probability’ value is influenced by the size of
the class. Thus, the entropy value which is the logarithmic
transformation of the ‘P’ is affected by the class size.
Since, the ‘n’ across classes is not uniform, the entropy
values of different classes cannot be compared. Hence, it
was necessary to adjust the entropy value for class size.
This is done by evolving the Balancing Factor (BF) by
dividing the sample size of the class with total sample by
applying the following formula.
When the absolute entropy is divided by the
Balancing Factor (BF), what is arrived at is Divergence
Index (DI) also called as Neutralized Entropy (En).
RESULTS
The results are presented in qualitative as well as
quantitative forms. The qualitative aspect of results
refers to the content analysis and presentation of the
themes that emerged from the responses of each class.
Fig 1 Distribution of responses across theme
The quantitative aspect of results refers to the outcome
in terms of divergence in conceptualizing cancer. This
has been arrived at by calculating entropy values using a
mathematical formula.
Seven themes emerged from the responses covering
almost all dimensions related to the disease. It is
surprising to note that the responses covered even the
psychosocial aspects related to cancer. This reflects the
exposure that the children had about the disease.
Misconceptions regarding cancer were also
considered. The subthemes under this were consumption
of excess sugar, caffeine (tea/coffee) and mosquito bite as
a cause or classifying cancer as communicable disease.
Figure 1 depicts the distribution of responses across
seven themes and misconceptions. It may be observed
from the figure that 38% of responses related to the
causes of cancer followed by the generic descriptions
of cancer (32%). Responses to the extent of 10% of
responses were related to the symptoms of cancer.
Responses pertaining to side effects of treatment and
treatment of cancer figured to 8% and 6% respectively.
In all, prevention of cancer and psychosocial correlates
were found to be contributing 3% and 1% to the total
responses. Misconceptions such as consumption of
sugar, drinking impure water, mosquito bite as the causes
of cancer and that cancer is a communicable disease
consisted of 2% of overall responses.
 Indian Journal of Public Health Research & Development, October 2018, Vol. 9, No. 10
In table 1, the trends obtained in entropy and response ratio are discussed.
Table 1 Summary showing class-wise trend of awareness on cancer disease
Class N(Participants) Responses
6 137 189
7 144 200
8 152 203
9 143 204
10 64 76
Note. N=Total number of participants; E = Absolute entropy; P = probability of responses; DI = Divergence Index
or En Nuetralized entropy)
An attempt was made to examine if the students
of different classes differed in having divergence in
conceptualizing cancer. This is measured by calculating
the ‘Entropy’ explained earlier. Table 2 presents the
Absolute Entropy values and Neutralized Entropy
(En) values or Divergence Index (DI). The progressive
growth in Divergence Index across classes indicate
that as the students’ progress in their class, higher is
their spread of responses across the themes, indicating
complexity in their schema of ‘cancer’. While there is
a minor increase in DI between class VII (DI=2.24) and
class VIII (DI=2.89), a spurt is noticed between class
VIII (DI=2.89) and class IX (DI=4.82) and class IX
(DI=4.82) and class X (DI=5.60). An inexplicable drop
is also observed from class VI (DI=2.68) to class VII
(DI=2.24).
DISCUSSION
Looking across the classes, we see a progressive
increase in Divergence Index or neutralized entropy
across the classes. Although there was only a marginal
increase in the neutralized entropy from class VI
through class VIII, with a slight dip in class VII, we
see a steep rise between IX and X classes. This is in
consistence with Piaget’s cognitive theory12, which
talks about expansion in different schema across age
through the process of assimilation and accommodation.
This is also supported by a study which indicated the
knowledge of breast cancer to increase with level of
education13. This increase could also be a reflection
of the school syllabus13. A scrutiny of the syllabus in
the subject of Biology of the present sample revealed
a strong thrust on health related topics in the textbook
26
Absolute Entropy(E) P En/DI
0.63 0.21 2.68
0.60 0.22 2.24
0.53 0.23 2.89
0.64 0.22 4.82
0.48 0.10 5.60
of class X. Bibace and Walsh12 suggested that during
the concrete operational stage, children’s explanations
of illness revolve around Contamination (transmission
through physical contact) and Internalization (external
agent enters body through swallowing or inhaling and
affects internal organs). During the formal operational
stage, children explain illness through physiologic and
psychophysiologic causes. Physiologic explanations
by children usually comprise of internal organs not
functioning properly. Psychophysiologic reasons include
how emotional states can affect our bodily functions.
Results of the present study reflect similar findings with
children of class X (who are in the age group of 15 to
16 years when their cognitive development is in formal
operation stage) giving multidimensional explanation
towards cancer, that correctly included physiological
and psychological aspect.
We can see that the children’s “general concept”
about cancer comprised of it being fatal, dangerous
or harmful, an uncontrolled growth of cells, a non-
communicable disease, highly prevalent, incurable,
curable with early detection, availability of good
treatment and reduced recurrence rate. These perceptions
of children are found to be in line with the facts stated in
research articles14,15,16,17,18.
The less discussed causes like obesity, sedentary
lifestyle, hepatitis B & C virus (HBV/HCV), human
papilloma virus (HPV), immune system dysfunction,
aging, hormonal imbalance19 need to be emphasized
either through curriculum or awareness programmes.
Similarly, orientation for children on treatment
procedure must include various option like radiation,
 27 Indian Journal of Public Health Research & Development, October 2018, Vol. 9, No. 10
surgery, hormonal therapies and individual differences
on side effects of treatment19, 20
It is very surprising and encouraging to find the
children referring to psychosocial correlates of cancer
that not only included certain affect states such as
‘sadness’ in patients but also the impact on the family.
Building upon this other psychological offshoots like
anger, stress, anxiety, depression and quality of life, may
also be brought into their awareness.21, 22
Though only 2% of responses constituted
misconceptions, they should be dissipated to prevent
uncalled for stigma.
Implications
This study that combined the qualitative and
quantitative approach may be considered as a robust
method to understand children conceptualization of
cancer. Further the statistical application of computing
Neutralized Entropy or Divergence Index enabled very
accurate calculation of conceptual complexity. The
results of the study clearly indicate a developmental
progression in conceptualization of cancer as a disease
among children.
Limitations
One limitations of the study is restricting the sample
to children coming from low socioeconomic family
backgrounds. Future studies may be planned on the
cross-sectional population.
Ethical Clearance: Permission was obtained from
the Principals of the participating schools prior to the
commencement of the study. Assent was also taken from
all the participants prior to their participation.
Source of Funding: Self
Conflict of Interest: Nil
References
1. Forouzanfar MH, Alexander L, Anderson HR,
Bachman VF, Biryukov S, Brauer M, Burnett R,
Casey D, Coates MM, Cohen A, Delwiche K.
Global, regional, and national comparative risk
assessment of 79 behavioural, environmental and
occupational, and metabolic risks or clusters of risks
in 188 countries, 1990–2013: a systematic analysis
for the Global Burden of Disease Study 2013. The
Lancet. 2015 Dec 11;386(10010):2287-323.
2. Indian Council of Medical Research. 2016.
Over 17 lakh new cancer cases in India by 2020:
ICMR. Available from: http://icmr.nic.in/icmrsql/
archive/2016/7.pdf [Accessed 15 September 2017].
3. Cancer Research UK. 2015. Key signs and
symptoms of cancer. Available from: http://
www.cancerresearchuk.org/about-cancer/cancer-
symptoms [Accessed 15 September 2017].
4. Divakaran B, Muttapillymyalil J, Sreedharan J,
Shalini K. Lifestyle riskfactors of noncommunicable
diseases: awareness among school children. Indian
journal of cancer. 2010 Jul 1;47(5):9..
5. Ade A, Chethana KV, Mane A, Hiremath SG. Non-
communicable diseases: awareness of risk factors
and lifestyle among rural adolescents. Int J Biol
Med Res. 2014;5(1):3769-71.
6. https://www.biomedscidirect.com/journalfiles/
IJBMRF20131309/non_communicable_diseases_
awareness_of_risk_factors_and_lifestyle_among_
rural_adolescents.pdf. Accessed 15 September
2017.
7. Mane KS, Maganalli A, siddiqua Nawaz A. A
comparative study on awareness about non-
communicable diseases and their risk factors among
government and private high school students of
Davangere city. International Journal of Medical
Science and Public Health. 2016 Oct 1;5(10):2026-
30.
8. Chin DG, Schonfeld DJ, O’hare LL, Mayne ST,
Salovey P, Showalter DR, Cicchetti DV. Elementary
school-age children’s developmental understanding
of the causes of cancer. Journal of Developmental &
Behavioral Pediatrics. 1998 Dec 1;19(6):397-403.
9. Available from https://www.ncbi.nlm.nih.gov/
pubmed/9866086 [ Accessed 15 September 2017].
10. Sigelman C, Maddock A, Epstein J, Carpenter W. Age
differences in understandings of disease causality:
AIDS, colds, and cancer. Child development. 1993
Feb 1;64(1):272-84.
11. Knighting K, Rowa‐Dewar N, Malcolm C, Kearney
N, Gibson F. Children’s understanding of cancer
and views on health‐related behaviour: a ‘draw and
write’study. Child: Care, health and development.
2011 Mar 1;37(2):289-99.
12. Bell A. Designing and testing questionnaires for
 Indian Journal of Public Health Research & Development, October 2018, Vol. 9, No. 10
children. Journal of Research in Nursing. 2007
Sep;12(5):461-9.
13. Ellingsen IT, Thorsen AA, Størksen I. Revealing
children’s experiences and emotions through Q
methodology. Child Development Research. 2014
Jun 12;2014.
14. Myant, Katherine A, and Joanne M. Williams.
2005. Children’s Concepts of Health and Illness:
Understanding of Contagious Illnesses, Non-
Contagious Illnesses and Injuries. Journal
of Health Psychology, 10(6), 805-819. doi:
10.1177/1359105305057315.
15. Ranasinghe HM, Ranasinghe N, Rodrigo C,
Seneviratne RD, Rajapakse S. Awareness of breast
cancer among adolescent girls in Colombo, Sri
Lanka: a school based study. BMC Public Health.
2013 Dec 20;13(1):1209.
16. Atre, Vasundhra. 2017. Rise and prevalence
of Cancer in India. The Times of India. http://
timesofindia.indiatimes.com/life-style/health-
fitness/health-news/rise-and-prevalence-of-cancer-
in-india/articleshow/56969996.cms. [Accessed 19
September 2017].
17. Dastan NB, Buzlu S. Psychoeducation intervention
to improve adjustment to cancer among Turkish
stage I-II breast cancer patients: a randomized
controlled trial. Asian Pacific Journal of Cancer
Prevention. 2012;13(10):5313-8.
18. Arruebo M, Vilaboa N, Sáez-Gutierrez B, Lambea
J, Tres A, Valladares M, González-Fernández Á.
Assessment of the evolution of cancer treatment
View publication stats
28
therapies. Cancers. 2011 Aug 12;3(3):3279-330.
19. American Society of Clinical Oncology.
2017. Advances in cancer treatment beyond
immunotherapy. Available from: https://www.
asco.org/research-progress/reports-studies/clinical-
cancer-advances/advances-cancer-treatment-
beyond [Accessed 19 September 2017].
20. Live Better With Cancer. 2016. Macmillan’s Cancer
Comparison: 1970s to Now. Available from: https://
livebetterwith.com/blog/2016/08/02/macmillans-
cancer-comparison-1970s-now/ [Accessed 19
September 2017].
21. National Cancer Institute. 2015. Risk Factors for
Cancer. Available from: https://www.cancer.gov/
about-cancer/causes-prevention/risk [Accessed 19
September 2017].
22. National Cancer Institute. 2017. Side Effects of
Cancer Treatment. Available from: https://www.
cancer.gov/about-cancer/treatment/side-effects
[Accessed 19 September 2017].
23. Padmaja G, Vanlalhruaii C, Rana S, Kopparty S.
Quality of life of patients with cancer: a determinant
of the quality of life of their family caregivers.
Journal of Cancer Education. 2017 Sep 1;32(3):655-
61.
24. Archer S, Buxton S, Sheffield D. The effect
of creative psychological interventions on
psychological outcomes for adult cancer patients: a
systematic review of randomised controlled trials.
Psycho‐Oncology. 2015 Jan 1;24(1):1-0.