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Abstract |
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 Top Abstract BackgroundMethodsResultsDiscussionReferences |
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• Objectives To describe perceptions of cardiovascular risk factors and risk-reducing behaviors among women with newly diagnosed coronary heart disease.
• Methods A descriptive study was done in a large midwestern suburban hospital. A nonprobability sample of 33 women with coronary heart disease completed a mail questionnaire. Data were collected by using the Coronary Heart Disease Knowledge Test, the Health-Promoting Lifestyle Profile II, and questions developed for the study.
• Results Thirty-three women responded. Mean age was 65.64 years (range, 36–85 years; SD, 11.32 years); mean educational level was 12.67 years (range, 8–18 years; SD, 1.79 years). Most of the respondents could not identify personal cardiovascular risk factors; the risks identified were considerably fewer and differed from those documented in the women’s medical records. Women reported moderate levels of most risk-reducing behaviors and low levels of physical activity.
• Conclusions Women with coronary heart disease may not know what risk factors they have. Women must have their risk factors assessed and should be counseled about those risks.
Historically, women’s health issues focused on menopause and breast cancer, leading women not to think about CHD as an important problem for them. As a result, women may be inadequately informed about the disease. Most women are far more afraid of breast cancer than of cardiovascular disease even though 1 in 28 deaths among women is due to breast cancer and almost 1 in 2 to cardiovascular disease.5 If women underestimate their risk or are unaware of their risk factors for CHD, they may not take the necessary steps to reduce their risk, and morbidity and mortality due to CHD among women will only become worse.
The major risk factors for CHD in women are cigarette smoking, hypertension, dyslipidemia, diabetes mellitus, obesity, sedentary lifestyle, and eating foods high in fat and low in fiber.6,7 Without an understanding of these risk factors, women are poorly prepared to carry out preventive self-care actions to reduce the risk of CHD. More knowledge is needed about what women know about their risk factors for CHD and about their risk-reducing behaviors so that healthcare professionals can better help women prevent the development and progression of CHD. The purposes of this study were to
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Background |
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The risk for cardiovascular disease among persons with diabetes mellitus is much higher in women than in men.7 In addition, approximately 78% of adults in the United States do not engage in regular, sustained physical activity of any intensity lasting 30 minutes or more 5 times a week, and physical inactivity is more prevalent among women than among men.5 Therefore, it is not surprising that among women 20 to 74 years old, 47% of whites are overweight and 23% of whites are obese.5 Approximately 52% of women more than 45 years old have high blood pressure, a condition that clearly accelerates the progression of atherosclerosis.10
Women who have few risk factors have a lower risk of CHD. Stampfer et al11 investigated the combined effects of smoking, obesity, alcohol consumption, sedentary lifestyle, and high fat on the risk of CHD in a sample of 84 129 women participating in the Nurses’ Health Study. Women at low risk did not currently smoke tobacco; had a body mass index (calculated as weight in kilograms divided by the square of the height in meters) less than 25; consumed a mean of at least half a drink of an alcoholic beverage per day; engaged in moderate-to-vigorous physical activity for at least half an hour each day; and scored in the highest 40% of the cohort for consumption of a diet that was high in cereal fiber, marine omega-3 fatty acids, and folate, had a high ratio of polyunsaturated to saturated fat, and was low in trans fat and glycemic load. Compared with all other women, women in the low-risk category (only 3% of the population) had a relative risk of coronary events of 0.17.
A few investigators have examined awareness of risk factors and preventive strategies among women. In samples of men and women with and without documented CHD, the level of knowledge of risk factors was low.12–14 Poduri and Grisso12 examined the prevalence of cardiovascular risk factors and the level of awareness of and attitudes toward risk factors in a community sample of 200 low-income women. Each of the 8 established risk factors was identified by 4% to 34% of the subjects. Among women with a specific risk factor, 0% to 45% reported that they were at increased risk because of the presence of that factor. In a sample of 105 patients hospitalized because of a myocardial infarction or coronary angiographic findings of coronary artery disease, 79% were able to identify at least 1 of 3 modifiable risk factors, but only 7% could identify all 3 factors.14 Among prospective mothers (n = 3530) and fathers (n = 3127) evaluated for knowledge of hyperlipidemia, only 7% of women and 5% of men had previous knowledge of their high cholesterol levels.13
Most of the studies on coronary artery disease and risk factors have been done on men, with women making up a small part of the total number of subjects. Women’s knowledge of their risk factors for CHD needs to be studied further, especially in women with CHD. In order to prevent progression of CHD, modification of risk factors should be included in the plan of care. Before modifications in lifestyle can occur, women need to know what risk factors for CHD they have.
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Methods |
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Thirty-three women were included in the nonrandom sample. Criteria for inclusion in the study were age 18 years or older, coronary artery disease diagnosed on the basis of angiographic f indings or confirmation of a myocardial infarction within the preceding 7 days, ability to read and write English, no prior personal or family-related experience with cardiac rehabilitation, no documentation in the medical record of a previous myocardial infarction or percutaneous transluminal coronary angioplasty, and mental competence as indicated by living independently in the community.
Data Collection
Potential participants were identified by using lists of patients. The lists included a list generated by the department of cardiology that indicated which patients had the diagnosis-related-group admitting diagnosis of "chest pain/rule out myocardial infarction" and a list generated by the cardiac catheterization laboratory that contained the names of all patients scheduled for a procedure in the laboratory. Also, women with a diagnosis of myocardial infarction, confirmed by the results of assays to determine serum levels of cardiac enzymes, were identified from the list that was generated daily in the coronary care unit.
One of us (S.O.M.) approached potential participants to provide an explanation of the study. Eligible women were provided with oral and written explanations of the study and were given an opportunity to have their questions answered. Each participant was given a copy of her signed consent form.
Data were collected by using a mail questionnaire after the women were discharged from the hospital. Data were collected 1 week after discharge, when participants were not under the influence of sedation, not influenced by the stress surrounding a hospital admission, and less likely to be influenced to give socially desirable answers. Participants were informed that a questionnaire would be mailed to them within 1 week of their discharge from the hospital. A stamped, addressed envelope was included with each questionnaire, and each participant was asked to return her questionnaire within 1 week of its receipt. Follow-up postcards and telephone calls were used when necessary. Altogether, 50 questionnaires were mailed, and 33 were returned, a 66% response rate.
Instruments
Data on perceived risk factors, prior experience with CHD, prior participation in a cardiovascular education program, and demographic data were collected by using a form developed by one of us (S.O.M.). All women were asked if a physician had ever told them that they had heart disease. The history and physical assessment form in each participant’s medical record was used to assess actual risk factors.
Twenty items from the Coronary Heart Disease Knowledge Test that provided a direct assessment of risk factors for CHD were selected to assess knowledge of risk factors.15 This tool is a multiple-choice test that asks the subject to identify risk factors of coronary artery disease. It is used to assess knowledge of self-care and of risk factors (diet, stress, smoking, exercise, and serum level of high-density lipoprotein cholesterol). Each question about risk factors has 1 correct answer. The total score is the sum of the number of correct answers, with potential scores of 0 to 20.
Construct validation was established through the ability of the results to discriminate between participants and nonparticipants in a cardiac rehabilitation program. Discriminant validity indicated that the mean test score of subjects participating in a cardiac rehabilitation program was significantly higher than that of nonparticipants (t = 3.51, df = 91, P
.01). The internal consistency reliability was reported as .84.15
The Health-Promoting Lifestyle Profile II (HPLP II) was used to measure cardiovascular risk-reducing behaviors.16 This 52-item questionnaire is used to evaluate personal health-promoting behaviors. Respondents are asked to indicate, on a 4-point scale (from 1 = never to 4 = routinely), the frequency with which they engage in each behavior. The tool consists of 6 subscales that are intended to measure the components of a healthy lifestyle: health responsibility, physical activity, nutrition, interpersonal relations, spiritual growth, and stress management. The HPLP II is scored by summing responses to all items; subscale scores may be obtained by summing the responses to subscale items. Reliability and validity have been established in samples of healthy adults. Internal consistency reliability has been reported as .92.16
Data Analysis
Descriptive statistics were used to analyze all study variables and the first 4 research questions. A Pearson r correlation coefficient was used to answer the fourth and fifth research questions. All data analyses were done by using SPSS-PC (SPSS Inc, Chicago, Ill). The significance level was set at P.05.
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Results |
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The length of the hospital stay ranged from 1 to 21 days (mean, 3.56 days; SD, 4.1 days). Fifteen of the participants (45%) stated that they did not receive any information during their hospital stay or upon discharge about cardiovascular risk factors.
Cardiovascular Risk Factors Documented in the Medical Record
Risk factors documented in the medical records (Table 1
) differed from the risk factors indicated by the women in the sample (Table 2). According to the medical records, the participants had numerous risk factors. Menopause was the most common risk factor noted; next, in order, were hyperlipidemia and hypertension.
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). Each of the following was identified as a personal risk factor by at least one participant: hyperlipidemia (high serum cholesterol levels), diabetes mellitus, being post-menopausal, history of smoking, being around secondhand smoke, obesity, family history, hypertension, age, stress, and symptoms of angina. Family history of heart disease and hypertension were the most commonly identified personal risk factors. Among the 6 participants (18%) who perceived hypertension as a risk factor, 2 (33%) thought that because their blood pressure was controlled with medication, hypertension was no longer a risk factor for them. Menopause, age, and lack of exercise were the least commonly identified personal risk factors. Of interest, 2 (6%) of the participants identified angina as a risk factor for coronary artery disease. With the exception of the newer risk factors, such as presence of lipoprotein(a) or elevated levels of homocysteine, each of the established risk factors was identified at least once.
Women’s Knowledge of Risk Factors
Scores on the Coronary Heart Disease Knowledge Test ranged from 15% (3 correct answers) to 95% (19 correct answers); the mean score was 64% (12.75 correct answers; SD, 15.26). Table 3 is a list of the questions most often answered correctly. The majority of the sample recognized that heredity is a nonmodifiable risk factor, that 0.9 kg/wk (2 lb/wk) is a reasonable weight-loss goal, that rhythmic breathing is an element of relaxation, that warming up before exercising reduces strain on the heart, and that saturated fats are solid at room temperature. The questions not listed in Table 3 and Table 4 were answered correctly by 51% of the participants. Table 4 gives the questions that were most often answered incorrectly. Unfortunately, the majority of the sample did not recognize that high-density lipoprotein ("good cholesterol") is a blood fat that is thought to lower risk of coronary heart disease, that exercise improves the overall function of the heart, and that fatigue after exercise is an indication of overexertion and had difficulty understanding the relationship between stress and heart disease. Even though stress management scores were high on the HPLP II (ie, women performed stress management), the mean knowledge score relative to stress on the Coronary Heart Disease Knowledge Test was low.
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gives the mean subscale scores. In rank order of frequency, women performed the following risk-reducing behaviors: stress management, nutrition (ie, eating heart-healthy foods), spirituality (ie, feeling connected to a higher power, being aware of life’s priorities), health responsibility (ie, taking action to learn more about health), and physical activity.
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Relationship Between Age, Education, Knowledge of CHD Risk Factors, and Health Behavior
We found no significant relationship between education and knowledge of risk factors for CHD (r = 0.05, P = .78) or between education and health-promoting lifestyles (r = 0.21, P = .24). We also found no significant relationship between age and educational level (r = 0.107, P = 0.55) or between age and health-promoting lifestyles (r = 0.293, P = .10).
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Discussion |
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The participants’ risk factors differed from their documented risk factors. Participants who had a family history of coronary artery disease identified other causes for their disease. Surprisingly, despite all the attention in the media given to the hazards of smoking, all of the women who either smoked or had a history of smoking did not perceive smoking as a cardiovascular risk factor. Only one woman recognized that menopause is a risk factor for coronary heart disease. Information about the participants’ knowledge of hormone replacement therapy as a preventive strategy would have been useful.
Stress and hypertension were the most frequently reported risk factors, possibly because of the high prevalence of these risk factors in the general population and information about these factors in the media. Women who were overweight did not perceive themselves as overweight. Even though 93% of the participants knew that they had risk factors for coronary artery disease, they did not necessarily see themselves as having multiple risk factors. The participants did not understand the impact that levels of high-density lipoprotein and exercise have on coronary artery disease.
We found no relationship between knowledge of cardiovascular risk factors and risk-reducing behaviors. Greater knowledge of coronary artery disease and personal risk factors was not an indication that the women were engaging in health-promoting behavior. Higher levels of education did not mean greater knowledge of coronary artery disease. Several other investigators16–18 found that knowledge does not necessarily lead to risk-reducing behavior.
Also, we found no relationship between perceived risk and risk-reducing behaviors. This relationship most likely is due to the small sample without much variation between the maximum and minimum scores. However, if women did not perceive themselves at risk, that is, they did not perceive high numbers of personal risk factors, they had no incentive to perform risk-reducing behaviors with any great frequency.
Limitations
Because the sample for the study was small and nonrandom, the generalizability of the findings is limited. Participants were white, middle-class, suburban women with a mean educational level of 12.67 years. Despite these limitations, the findings are worth considering.
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ACKNOWLEDGMENTS |
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REFERENCES |
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This article has been cited by other articles:
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  S. McMahan, M. Cathorall, and D. R. Romero Cardiovascular Disease Risk Perception and Knowledge: A Comparison of Hispanic and White College Students in a Hispanic-Serving Institution Journal of Hispanic Higher Education, January 1, 2007; 6(1): 5 - 18. [Abstract] [PDF]
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