Knowledge, Attitude and Practice on Cardiovascular Disease
among Women in North-Eastcoast Malaysia

Rosediani Muhamad; Ranimah Yahya; Harmy Mohamed Yusoff

Knowledge, Attitude and Practice on Cardiovascular Disease among Women in North-Eastcoast Malaysia

Rosediani Muhamad, Ranimah Yahya, Harmy Mohamed Yusoff

Rosediani Muhamad, Ranimah Yahya, Harmy Mohamed Yusoff ^*, B. Sreenivas Rao, Devkinandan Rao
Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia

Corresponding Author: Dr. Rosediani Muhamad; Family Medicine Specialist and Medical Lecturer, Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia (USM), 16150 Kubang Kerian, Kelantan, Malaysia / Tel: +6013-9804835 / Fax: 09-7676611 / Email: rosesyam@kb.usm.my

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Abstract

Introduction: Coronary heart disease (CHD) is a leading killer not only in men but also in women worldwide and primary target for prevention. However, majority initial researchers believed it was mainly a men’s disease that resulted in fewer women being informed regarding the disease.

Aim and Objectives: A cross sectional study was conducted to determine the level of knowledge, attitude and practice on cardiovascular disease among women attended outpatient clinics with Family Medicine Specialists in Kelantan from June to December 2010.

Methods/ Study Design: A total of 448 women from 7 out of 14 clinics run by Specialist with age ranged between 25 and 65 years were selected via systematic random sampling in the ratio of 1:2 based on clinic attendance lists. Excluded were those who illiterate and having psychotic symptoms. All of consented participants were given a set of validated KAP questionnaire to be completed within 15 minutes.

Findings: Majority of respondents were Malays with mean age of 39.9 years. Among them, 3.1% were smokers and 41.1% claimed having medical illness, the commonest was obesity (23.6%). About 87% of women knew that smoking is a risk factor. However, less than 20% knew about menopause. More than 80% knew typical symptoms whereas less than half realised atypical symptoms. Less than 20% of them knew the cholesterol risk target. Only 13% of women practiced exercise as required. The mean (SD) for knowledge and practice score were 70.6 (13.76) and 63.7(13.59) accordingly. The median (IQR) for attitude score was 88.2 (14.71). Thus the good knowledge, attitude and practice score were 55.6%, 55.1 % and 51.1% respectively.

Conclusion: A structured educational programme and utilization of available CVD guidelines should be reinforced as a better preventive strategy to overcome this problem.

Keywords

Knowledge, Attitude, Practice, Cardiovascular disease, Women, Coronary Heart Disease

INTRODUCTION

Cardiovascular disease (CVD) is still a leading cause of mortality in women worldwide despite of recent advances in diagnostic and therapeutic technologies. Although there has been a decline in the overall mortality due to CVD, still its incidence in women has been gradually increasing[1-3]. In Malaysia, CVD has been the major cause of deaths since early 70’s [4,5]. CHD for example, accounted for 19.3% (12,412) mortality in men and the figure was even higher in women, 21.2% (9,746) [6]. The death rate due to CVD among women was 26.1% in 2006, which was 0.7% higher than in 2005. 15.5% Deaths was due to heart attack [7].

Hayes et al., in 2006, reported that deaths due to CVD in women increase every year since 1984 [8]. The Framingham Study had also reported that more sudden death in women occurs due to silent myocardial infarction, with no previous history of heart disease [9]. In developed countries, at 40 years of age, a lifetime CVD risk was 1 out of 3 in women compared to 1 out of 2 in men [10]. Yet, women seem largely unaware of the clinical presentation and their risk of developing CVD, having assumed that CVD is still predominantly a disease that affects mainly men.

In certain circumstances, presuming that women have less risk of developing CVD than men, physicians usually focus on screening reproductive cancers and issues related to menopause. This slows down them to develop the initiation therapies and explore the risk factors, refer for specialist opinion, diagnose, and provide acute care for cardiac conditions, such as myocardial infarction [11,12].

Most women are far more afraid of breast cancer than of cardiovascular disease even though the death ratio is higher in CVD (1 in 2.8 versus 1 in 28) [13] and (1 in 2.6 versus 1 in 4.6) [14]. The unawareness of this preventable disease may lead to the ignorance of the disease and lack of practising CVD risk reduction behaviour. These urge the Ministry of Health to release a Clinical Practice Guidelines on CVD for women, in order to alert all health care providers.

Prevention is always better than cure. One way to reduce CVD incidence is by increasing women adherence to healthy lifestyle by educating, screening, detecting and treating modifiable risk factors since women do not practice heart healthy behaviours on a routine basis. This may be attributed to their limited CVD knowledge and lack of concern for CVD [15] that may result in poor motivation for changing behaviours known to be a risk factor for CVD. Knowing the importance of it, assessing baseline knowledge (K), attitude (A) and practice (P) of women on CVD issues are crucial and important.

Methodology

Study Design and Selection of the Clinics

This study was a cross sectional study done in Kelantan from June till December 2010. Kelantan is one of the states in Malaysia that had 1.7 million populations with 50% of them were women [16] and majority were Malays at 95%. There were 56 health clinics [17] available here with only 14 clinics were run by Family Medicine Specialist (FMS) at the time of the study conducted. Flow chart and recruitment process using multistage random sampling to choose clinics and patients are shown in figure 1.

Patients

A total of 448 women ranging from 25 to 65 years were selected via systematic random sampling in the ratio of 1:2 based on clinic attendance lists were encouraged to participate. Excluded were those who illiterate and having psychotic symptoms. Informed consent was signed prior to enrolment into the study. All of them were given a set of KAP questionnaire to be completed within 15 minutes.

KAP Questionnaire

A set of KAP questionnaire were developed. First part consists of socio-demographic data. Part II consists of 31 items for knowledge regarding cardiovascular disease. The subdomains included risk factors, symptoms and target levels for CVD risk factors. Part III and IV assess participant’s attitude and practice. The Cronbach’s alpha for these questionnaires were 0.73, 0.71 and 0.60 respectively. Categorical responses (true, false and don’t know) were used for knowledge (K), 3 likert scales (agree, neutral, not agree) for attitude (A) and (never, seldom, always) for practice items (P). The total score was categorized as good and poor based on mean/ median of total score.

Analysis

Descriptive analysis was used to analyze the socio-demographic and the level of KAP on CVD among women.

Results

Socio-demographic and CVD risk characteristics of the respondents

The response rate was 100%. The sociodemographic and clinical characteristics of the respondents summarises in table 1. Majority of respondents were Malay (98.4%) with the mean (SD) age of respondents were 39.9 (10.04) years. Most of them had secondary education, unemployed (49.8%) and had low household income. Around 60% of them were either active or passive smoker. 41.3% had self-reporting medical illness with the commonest was obesity (23.7%). Hypertension was the highest (43.1%) reported risk in the family of the respondents followed by diabetes mellitus (30%).

Knowledge on cardiovascular disease

The mean (SD) knowledge score was 36.8(7.14) [70.7% (13.76)] So the percentage for good knowledge score was 55.6% (249).

Table 2 shows the items for good knowledge of CVD. For the general knowledge question, less than 40% knew that CVD is the main cause of death among women in Malaysia and two third of them get the definition of MI correctly.

For CVD risk factors, majority of the respondents answered correctly except for menopause. The item with the highest proportion of correct answer for CVD risks were “smoking” (87.1%) followed by “high blood pressure” (79.3%). However only 18% knew that menopause is one of the risk factors.

Regarding CHD symptoms, less than half did not realise the atypical IHD symptoms. The highest proportion of correct answers were “shortness of breath”(86.6%) , “chest pain” (85.9%), followed by “palpitation” (81%) and among the lowest were atypical IHD symptoms include “jaw, left shoulder and neck pain” and “nausea and vomiting”, at around 36%.

More than half of respondents recognized the normal level of blood sugar and blood pressure but less than 20% of them knew the specific level of bad and good cholesterol which is LDL and HDL levels.

Self-reported Attitude on cardiovascular disease

Attitude score ranged from 9(26.5%) and 34(100%); however the distribution was skewed to the left with median (IQR) score of 30 (5) [88.2% (14.71)]. The percentage for good attitude score was 55.1% (247). The item with highest proportion of positive attitude was “willing to exercise” and “should know blood pressure level”. Among the lowest are “Willingness to take HRT”, at 35.5% (159). Other attitudes items were showed in table 3.

Self-reported Practice on cardiovascular disease

Practice score ranged between 5(20.8%) and 22(91.7%). The mean (SD) score for practice is 15.3 (3.26)[63.7(13.59)]. The percentage for good practice score was 51.1%. . In present study, practice on healthy lifestyle was very poor. Only 13.3% exercised as required and 15.1% never eat fatty food more than 3 times per week. Details of the practice were shown in Table 4.

Discussion

Knowledge on cardiovascular disease

The findings showed that only about half of women had good knowledge score for CVD which was also consistent with other studies [17, 18, 19] . With the mean score of 36.8(70.8%), women still had limited amount of CVD knowledge despite many efforts by Ministry of Health and information availability via mass media. This result was compatible with the study done among women without history of heart disease [20] and as well as among those who already had IHD [21]. They found that the mean score for knowledge was only 60% and 64% respectively which indicates limited awareness among regarding CVD regardless their risk and disease status.

The poor knowledge about CVD which is the main cause of death among Malaysian women in current study was much lower compared to women in the U.S which was already 40% in 2003 [8]. Smoking was recognised as CVD risk factors with the highest score compared to other risk factors. This is because smoking is a well-known major risk factor for CVD [22] and is commonly highlighted in the media. However, chronic renal failure (CRF) showed the lowest score since it usually occurs as a consequence of other diseases such as diabetes, hypertension and obstructive nephropathy. It was also given less attention by primary care doctors and even in the media since the individual with CRF more likely to die from CVD then CRF itself [23].

Question that most women got it wrong was menopause as a CVD risk factor which was 82.1%. This finding was comparable with the study done among inpatient women that found only 3 % identified it whereas their medical record stated that 88% of them had menopause as a risk factor [24]. This reflects upon the fact that women and health care workers were more focused on the symptom of menopause rather than its long term effect on the heart.

Regarding the symptoms, most respondents recognised that chest pain, palpitation and sweating as a heart symptom but one third of them still did not recognised the atypical symptoms such as jaw, neck and left shoulder and epigastric pain, although majority of the women were presented with atypical angina [25]. In women, angina has been postulated due to vasospasm and micro vascular [26]. This may lead to delay in seeking treatment among women [27,28].

Regarding level for risk measurement, more than half of the respondents knew the normal level for blood pressure and blood sugar, however they were not aware of bad (LDL), good (HDL) cholesterols and BMI. This is because blood pressure and diabetes mellitus is a well-known CVD risk factor whereas cholesterol and obesity or overweight were less being discussed during consultation as proven by the Direct Observation of Primary Care (DOPC) study where only about 20% of physicians gave exercise and dietary advice to their chronic care patients [29]. It has also been highlighted in another study that 70% of female patients reported that their physicians had never discussed CVD with them [21]. Furthermore, education or health campaign for women in public is done once or twice per year that covers various women’s topics which are not specific to CVD per se.

Attitude on cardiovascular disease

Our results indicates that women in our population had good attitude. Majority of them agreed that they should know their level of blood pressure, blood sugar and blood cholesterol, reduce the sugar and fat intake. These high proportion of positive attitude on screening and measuring risk factors were due to their awareness toward the healthy lifestyles as promoted lately in the mass media regarding healthy eating and regular exercise .

In quitting from smoking, about 20% still did not agree to stop smoking or being a passive smoker even though passive smoking also increase their risk of CVD [30]. This finding was consistent with the study in Kerala India that nearly 70% of the respondents had positive attitude on advising others to stop smoking [31]. In contrast, a study among migrant Chinese in Beijing found that negative attitudes on stop smoking were still high (56.1%) among female restaurant workers and among female commercial sex worker, at 45.1%. Similarly, in a study done among French pregnant smokers also noted that 59.8% of them did not respond to the offer of cessation services [32].

Current result indicates that women in our community are already motivated enough for not involving in any tobacco product and with continuous support, they will be able to implement and maintain it as practice. For those who still had negative attitude on smoking issues, lack of understanding about the definition of passive smoker and its related CVD risk might be a cause. They may be not strong enough to encourage their husband to quit smoking.

Regarding the use of hormone replacement therapy (HRT), women were not fully understand or were not sure of its use especially for CVD prevention as supported by their knowledge on menopause where majority of them did not know that menopause is one of the risk factors for CVD and that HRT is not for CVD protection. Therefore, health care professionals, we should use this opportunity to inform, educate and discuss about CVD risks with them.

Practice on cardiovascular disease

The percentage of good practice in the present study was only around 50% which indicates the behaviour to reduce the CVD risk was still not optimal . It is consistent with the result found in a study done by Kim C et al from U.S that found overall practice regarding CVD risk reduction behaviour were suboptimal in both gender [33].

International Journal of Collaborative Research on Internal Medicine & Public Health Rosediani M, Ranimah Y, Harmy MY Vol. 4 No. 1 (2012) 90 In the present study half of practice items were reported as positive practice including maintaining the normal weight, reducing life stress, not smoking or being a passive smoker,visiting heath care professional regularly and taking treatment as recommended by the doctor. Another study noted that the practice regarding maintaining the desired weight among CVD patients was lower between 27.6%-52% as compared to our result, at about 58.7% [34]. The comparison here may be biased since the interpretation of normal weight might differ as reported in other studies among British Bangladeshi women, 20% of them perceived that their weight were normal although the actual fact, it was abnormal [35].

On the other hand, the present study showed very poor practice in performing regular exercise (13.4 %)which was much more lower as compared to a study done by Kim et al, at about 63% [33], using less than 3 tea spoons salt daily (25.7%), taking fatty food less than 3 times per week (15.2 %) and taking omega 3 (15.8%). Limited consultation time might be a cause of less physicians’ ability to give proper dietary advice to their patients as supported by Kim C et al that only 31.3% women received dietary advice [33].

By right, the Ministry of Health had already provided the health care workers with lifestyle module and training but lack of resourses such as qualified dietitians or educator nurses in primary health centres had caused the problem to become even worse. A lot of campaign via mass media had also been done, yet it seemed ineffective even though our respondents’ attitude toward practising healthy lifestyle was good. The reason was modifying someone’s lifestyle was not an easy job especially in dietary intake, one of that, which was related to our culture or norms for example eating salty food such as anchovy sauce, and even, sweet food such as traditional cakes that can be found everywhere. Secondly, lifestyle modernisation with increasing trend of eating fast and processed foods, had made them reluctant to resist the temptation of eating delicious and unhealthy food.

With regards to consumption of omega-3 fatty acids, evidence showed that this fatty acids may be considered helpful or therapeutic for women with hypercholesterolemia and/or hypertriglyceridemia for primary and secondary prevention [35]. Current study showed that only a small proportion of respondents take omega 3 for CVD prevention. However, the risk of this respondents was not measured either high or low. The public may be quite aware about taking omega 3 as CVD prevention but they do not really know the recommendation is mainly for high risk patient or those with hyperlipidemia . Apart from that, the emphasis on healthy lifestyles by the current health system may be insufficient [37] as suggested by findings in a study using NHANES data. They measured adherence of adults aged 40- 74 years to all 5 healthy lifestyle habits including reduction of weight , regular physical activity and eating more fruits and vegetables a day and the results revealed that the good practice decreased from 15% to 8% within 18 years. It was postulated that the process to change the lifestyle habits are complex and multiplies including unwillingness to change, perceiving that they have low risk [38] and are either too young or too old to contract the disease.

The self reported practice regarding measuring of CVD risks was good in our women population which accounted between 64.3% for cholesterol level and up to more than 92% for blood pressure and even higher for body weight measurement which was almost similar to Kim et al’s findings except for cholesterol level measurement, which was slightly higher [32]. Among those who had measured their CVD risk, majority measured their blood pressure (83.1%), blood sugar(74.1%), cholesterol (58.5%) or body weight (90%) regularly within yearly or more interval . The percentage of them who reported that their blood presure, blood sugar, body weight and cholesterol levels as normal were 77.7%, 67.6%, 60.9% and 44% respectively and it was comparable with Kim et al [33]. The practice of cholesterol measurement in the present study was comparable with the study done among Asian or Pacific Islanders (62.7%) [39].

The practice regarding common CVD risk screening is good in our population and it is most probably due to our Ministry of Health’s policy that encourages all government servants to do CVD health screening regularly in the wellness clinics and further check up for women has been done if they are involved in family planning programs and during antenatal care .

Conclusions

The percentage of good score for knowledge, attitude and practice on CVD among women were 55.6%, 55.1% and 51.1% respectively. Women’s knowledge on CVD is still limited and not optimal that needs continuous efforts from health care providers. Primary care doctors should focus on the strategies to increase knowledge, attitude and practice in women. As a result, structured educational programme and utilization of available CVD guidelines should be reinforced as a better preventive strategy to overcome this problem.

Competing interests: None

Authors' contributions:

a. Conception and Design: Harmy MY, and Rosediani M

b. Acquisition of Data and Analysis: Ranimah Y

c. Interpretation of Data: Rosediani M, Ranimah Y

d. Drafting: Rosediani M

e. Critical revision and Final approval of completed of Manuscript: Rosediani M, Ranimah Y, and Harmy MY

Acknowledgements

We wish to express our gratitude to all Family Physician Specialists, staffs and all respondents for their cooperation in this study and the ethics committee of USM and Ministry of Health for allowing us to conduct the study. This study was supported by Universiti Sains Malaysia Short Term Grant No.604/PPSP/61310036.

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