The Knowledge and Attitudes of Coronary Heart Disease Prevention among Middle and Older Aged People in a Community in Taipei

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1 Vol.4 Original No.4 Article Wei-Chien Chen et al Taiwan Geriatrics & Gerontology The Knowledge and Attitudes of Coronary Heart Disease Prevention among Middle and Older Aged People in a Community in Taipei Wei-Chien Chen 1, Yi-Cheng Yu 2, Karen Glaser 1 Abstract Objectives: Given increases in prevalence of coronary heart disease (CHD) in Taiwan, the aim of this study was to investigate knowledge and attitudes towards CHD prevention among aged adults in Taiwan. Methods: This is a cross-sectional study, based on a telephone survey. People aged 45 and over were systematically sampled from a family physician s clinic in a residential area of Taipei City. Participants were invited to talk about risk factors, prevention strategies and preventability of CHD. Chi-Square tests and the Kruskal-Wallis test were used to examine associations between selected factors (e.g. having CHD risk factors or not, educational levels and age) that can affect people s knowledge and attitudes towards CHD prevention. Results: Of the 376 people sampled, 211 agreed to take part in the study, resulting in a response rate of 56%. Most people had only limited knowledge of CHD prevention, even though 77% reported at least 1 risk factor for CHD. Three quarters of participants were not sure CHD is a preventable disease. Around 82% knew only two or fewer risk factors for CHD and 26% were not able to name any prevention strategies for CHD. Smokers and people with diabetes were not aware themselves as being at high risk for CHD. People aged 60 and over and those with lower educational levels were less likely to be aware of strategies for CHD prevention. Conclusions: As CHD is a growing public health concern in Taiwan, lay people s knowledge of CHD prevention needs to be heightened. Information from this study will help to inform CHD policy in Taiwan. It gives insight into what information may need more emphasis and which subgroups of people may need more attention from health professionals in Taiwan s CHD prevention. (Taiwan Geriatrics & Gerontology 2009; 4(4): ) Key words: coronary heart disease, prevention, attitudes, health education, community 1 Institute of Gerontology, King s College London, U.K. 2 Chih-Shan Clinic, Taipei City, Taiwan. Correspondence to: Wei-Chien Chen 1F., No.82, Zhongyi St., Shilin Dist., Taipei City 111, Taiwan (Chih-Shan Clinic) TEL: (886) cathychen8@gmail.com 251

2 台灣老誌 Lay People s knowledge and attitudes of CHD prevention 第 4 卷第 4 期 Introduction According to the World Health Organization, Coronary Heart Disease (CHD) is the leading cause of death globally and one of the major health burdens worldwide [1]. A westernized life style has meant increases in the past three decades in CHD mortality in East Asian countries like Japan, South Korea and Taiwan [2]. In Taiwan, heart disease is the second leading cause of death [3]. Even though mortality from CHD in Taiwan has declined in recent years, mainly due to improvements in acute cardiac treatments; its incidence and prevalence is estimated to be rising [4]. Although CHD is a growing public health concern in Taiwan, it is a highly preventable disease. According to recent studies, 84%-100% of CHD can be explained by potentially modifiable risk factors, such as smoking, hypertension, diabetes, hyperlipidemia, abdominal obesity, physical inactivity and diet [5-7]. Therefore, it is important that people know how to prevent CHD by adopting health behaviors, such as being physically active, consuming a healthy diet and abstaining from tobacco. The prevention of CHD depends largely on people s health behavior, and people s health behavior is likely to be dependent on their health beliefs, including their perceptions of susceptibility, severity, benefits and barriers [8]. It is found the beliefs about the importance of physical activity for health were related to behavior in dose-dependent fashion [9]. Health beliefs also explained 76% of the variance of the CHD preventive behaviors among women without a history of CHD [10]. Study focused on the elderly showed the increasing age does not diminish the relation between health beliefs and health behaviors [11]. Therefore, it is important to explore people s beliefs. Examining people s knowledge and attitudes has been used to investigate people s beliefs on CHD prevention [12-14]. Although knowledge alone does not necessarily lead to a healthier life style in heart disease prevention [15,16], a modification in behavior will not take place without adequate awareness of the health problem. Previous studies in other countries such as Canada, Pakistan and the U.S. found that lay people have only limited knowledge of risk factors for CHD; these studies also revealed that awareness of risk factors for CHD varies considerably across societies [12-14]. Since few studies have explored people s knowledge and attitudes of CHD prevention in Taiwan, research investigating this issue will provide information for health professionals to communicate more efficiently and effectively with lay people, thus promoting the prevention of CHD in Taiwanese population. 252

3 Vol.4 No.4 Wei-Chien Chen et al Taiwan Geriatrics & Gerontology Materials and Methods in a response rate of 56%. This is a cross-sectional study based on telephone interviews using a questionnaire. The aim is to investigate middle and older aged lay people s knowledge and attitudes towards CHD prevention. (1) Sample Participants were recruited from a family physician s clinic in a residential area of Taipei City. The inclusion criteria were people aged 45 and over who had visited the clinic for any reason from 1 st June, 2007 to 31 st May, A total of 1,259 people meeting these criteria were selected from the clinic s computerized database to comprise the sampling frame. They were listed and numbered in the chronological order of their registration with the clinic. At first, a systematic sampling of 20% based on this frame were performed, starting from the 5 th number of the list by random, and then every 5th and 10th number till the end of the list, giving a sample of 251 people. As time was allowed, a second systematic sampling was applied later to obtain another 10% from the list, starting randomly from the 2 nd number of the list, giving an additional sample of 125. In total, 30% were drawn from the list, a sum of 376 people were sampled. Among them, 211 agreed to take part in the study, resulting (2) Instruments A questionnaire was developed by the lead researcher to identify awareness and knowledge of CHD and its risk factors. First, participants were asked if they had ever been diagnosed with heart disease, hypertension, diabetes or dyslipidemia, and whether they had a family history of CHD or not. Subsequently, they were asked How do you perceive your risk of getting a heart disease in comparison with people of your age?, How preventable is heart disease in your opinion?, How many causes or risk factors of heart disease can you think of? and How many ways of preventing heart disease can you think of?. At the end of the interview, participants were asked about their smoking habits and educational levels. Pilot work was conducted by interviewing 7 people with a non-medical background to ensure the questions were clear and elicited the appropriate information. (3) Analysis Techniques SPSS Version 14.0 was used in the analyses. Chi-square tests and the Kruskal- Wallis test were used to explore factors associated with people s knowledge and attitudes towards CHD prevention. 253

4 台灣老誌 Lay People s knowledge and attitudes of CHD prevention 第 4 卷第 4 期 Results (1) Participants and Non-Participants There were no significant differences in mean age, age group distribution and gender between participants and nonparticipants. The mean age of participants was 57, of non-participants was 58 ( t = -0.5, p = 0.349). Around 38% of participants and 43% of non-participants were male (χ 2 = 0.99, df = 1, p = 0.3). No difference was found in age group distribution between participants and non-participants (χ 2 = 4.0, df = 3, p = 0.26). Respondents were asked to rate their risk for developing CHD in comparison to people of the same age (as similar, higher or lower). The results are shown in Table 2. People with hypertension (χ 2 = 11.5, p<0.005), dyslipidemia (χ 2 = 6.5, p<0.05) or a family history of CHD (χ 2 = 12.1, p<0.005) were more likely to state that their risk of CHD was higher in comparison to other people of the same age. However, people with diabetes (χ 2 = 3.0, p = 0.08) and current-smokers (χ 2 = 0.15, p = 0.7) did not perceive their risk of developing CHD to be higher. (4) Perceptions of the Preventability of CHD (2) Self-reported CHD and CHD risk factors Five people in the sample reported that they had doctor-diagnosed CHD (Table 1). Among the remaining 206 participants who did not report having CHD, 36% reported doctor-diagnosed hypertension, 11% doctor-diagnosed diabetes, and 54% had ever been diagnosed with dyslipidemia (Table 1). Overall, 77% reported having at least 1 risk factor for CHD. (3) Risk and Self-perceived risk of CHD When asked about the preventability of CHD, 7% of the participants believed most CHD are not preventable, 19% answered half of CHD is preventable, another 50% gave a response of not sure, and only 24% replied most CHD are preventable. Table 3 showed that people aged 60 and over were more likely to reply not sure to this question (χ 2 = 31.0, df = 6, p<0.0005). People with an educational level of junior high school or below were also more likely to respond not sure, and less likely to regard CHD as mostly preventable (χ 2 = 28.9, df = 4, p<0.0005). 254

5 Vol.4 No.4 Wei-Chien Chen et al Taiwan Geriatrics & Gerontology Table 1 Demographics, prevalence of CHD and CHD risk factors by gender Total number % Male number % Female number % Significance test Total Mean age 57±10 58±10 57±10 t = 0.31 Age group 45~ χ 2 = ~ df = 3 55~ Educational level Lower χ 2 = 33.5*** Medium df = 2 Higher Doctor-diagnosed CHD (Self-reported) Having risk factors of CHD (Self-reported) Hypertension χ 2 = 1.1 Diabetes χ 2 = 0.15 Dyslipidemia χ 2 = 0.03 Family history χ 2 = 0.44 Smoking χ 2 = 55.9*** Current-smoker Ex-smoker At least 1 self-reported risk factor of CHD χ 2 = 1.2 Educational level: Lower : junior high school, primary school or none. Medium : senior high school or vocational school. Higher : university and above. ***: p <0.0005, Chi-square test Table 2 Self-perceived risk of CHD by having risk factors of CHD or not Higher than other people Similar as or lower than other people Significance test % n % n With hypertension χ 2 = 11.5** Without hypertension With diabetes χ 2 = 3.0 Without diabetes With dyslipidemia χ 2 = 6.5* Without dyslipidemia With family history χ 2 = 12.1** Without family history Current smoker χ 2 = 0.15 Ex- or none-smoker With 2 or more RF χ 2 = 17.7*** With 1 RF Without RF RF: risk factors of CHD. * p < 0.05 ** p < *** p < (Chi-square test) 255

6 台灣老誌 Lay People s knowledge and attitudes of CHD prevention 第 4 卷第 4 期 Table 3 Perceptions of preventability of CHD by age group and educational level (n = 207) Preventability <50% 50% >50% Not sure Total Significance test Age group 45~ χ 2 = 31.0* 50~ df = 9 55~ and over Education group Lower χ 2 = 28.9* Medium df = 6 Higher * p < (Chi-square test). Education level: Lower : None or primary school or junior high school. Medium : Senior high school or vocational school. Higher : university and above. Knowledge of Risk Factors for CHD Participants were asked to enumerate as many risk factors for CHD as possible. Around 19% of participants replied don t know, 26% mentioned only 1 risk factor and 37% named 2 risk factors. Figure 1a shows the frequency of each risk factor mentioned by the 211 participants. Unhealthy diet (37%), obesity (28%) and family history (27%) were the most commonly mentioned risk factors. Smoking and diabetes were only named by 8% and 4% of participants. It was found people aged 60 and over listed significantly fewer risk factors in comparison to those under 60 (p<0.005, Kruskal-Wallis test). People who reported more risk factors for CHD were not significantly more knowledgeable concerning CHD risk factors in comparison to those who had fewer or no risk factors (p = 0.49, Kruskal-Wallis test). Participants were also asked to list as many prevention strategies for CHD as possible. A total of 26% gave a don t know reply and 23% only mentioned one way to prevent CHD. The most commonly named prevention strategies were a healthier diet (58%) and being physically active (56%) (Figure 1b). Other strategies were rarely mentioned. Smoking cessation, controlling blood pressure, blood lipid levels and blood sugar were only listed by 4%, 4%, 3% and 2% of participants respectively. It was also found that people aged 60 and over enumerated significantly fewer risk factors in comparison to their younger counterparts ( p < , Kruskal-Wallis test). People reporting more risk factors for CHD did not significantly enumerate more prevention strategies for CHD than those who had fewer or no risk factors of CHD ( p = 0.31, Kruskal-Wallis test) Knowledge of Ways to Prevent CHD 256

7 Vol.4 No.4 Wei-Chien Chen et al Taiwan Geriatrics & Gerontology Unhealthy diet Obesity Family history Psychological stress Physical inactivity Dyslipidemia Hypertension Smoking Diabetes Figure 1a. Frequencies of risk factors of CHD identified by participants (n = 209) Healthy diet Exercise Adequate sleep Relaxation Health checkup Smoking cessation Blood pressure control Blood lipid control Blood sugar control Figure 1b. Frequencies of prevention strategies of CHD suggested by participants (n = 209) Discussion Findings from this study suggest that middle and older aged people in Taiwan have only limited knowledge regarding CHD prevention, although many are likely to have risk factors for CHD. Unhealthy diet, obesity and family history were the most mentioned risk factors by participants, which are quite different from the factors generally concerned by health professionals, such as hypertension, hyperlipidemia and hyperglycemia. Previous studies also showed the difference between lay understandings and those of health professionals regarding the risk factors and candidacy for CHD [17,18]. To bridge this knowledge gap, health professionals play an indispensable role, since lay people tend to regard the information obtained from medical professionals highly incredible, in comparison to those from media health campaigns[16]. 257

8 台灣老誌 Lay People s knowledge and attitudes of CHD prevention 第 4 卷第 4 期 Three quarters of participants in this study were not aware of the high preventability of CHD; this is similar to a population survey carried out in Australia, where 76.5% did not regard heart attack as all or mostly preventable [19]. These beliefs may be associated with the lay perception of CHD as an undetectable, sneaky disease which could not be discovered by sensory perception [18]. Encouragingly, people with more risk factors for CHD were more likely to perceive themselves to be at higher risk of developing CHD. However, they were not significantly more knowledgeable in either risk factors or prevention strategies for CHD. Furthermore, people having certain major risk factors such as smoking and diabetes did not appear to be aware they were at higher risk of developing CHD. In this study, three quarters of current smokers and half of diabetic patients did not recognize their risk of CHD to be higher, even though both smoking and diabetes can triple the risk of CHD [20,21]. It is believed that individuals who perceive their risk of CHD as higher are more likely to take actions to reduce their risk [22]. Therefore, it is crucial for health professionals to help people recognize their risk levels of CHD. One potential strategy is to quantify individual s CHD risk in a clinic by using a CHD score sheet developed from the Framingham study [23]. Setting computerized or manual reminders for primary care physicians to initiate a talk about CHD prevention with a smoker or a diabetic patient can also be helpful, since patients primary concern is normally for an acute problem [24]. People aged 60 and over appeared to be less knowledgeable about CHD prevention, even though the risk of CHD does increase with age. This may partly due to the lower educational levels prevalent among this age group (χ 2 = 25, df = 6, p <0.0005). Accordingly, older people in this cohort may need more information and explanation from health professionals about CHD prevention. Furthermore, people over the age of 60 are not a homogeneous group. The health education needs of people in their eighties are likely to be quite different from those in their sixties [25]. Health advice concerning CHD prevention needs to reflect the diversity among the older population. This study was carried out in Taipei City, where information and health resources are more abundant. Previous studies in Taiwan suggest that rural adults are significantly less educated, less likely to take prevention strategies than urban adults [26]. Therefore, people living outside Taipei City may need even more attention and resources regarding CHD prevention. There are limitations to this study. First, the sample was drawn from a local clinic, and even though a probability 258

9 Vol.4 No.4 Wei-Chien Chen et al Taiwan Geriatrics & Gerontology sampling was adopted, the characteristics of people who register in a clinic may differ from that of the local population. Second, although the questions regarding risk factors and preventability of CHD were based on those used in previous studies [12,19], and a pilot study was conducted, the reliability and validity of the other questions in the questionnaire has not been tested. Third, as a quantitative study, the data collected were relatively brief and concise; details were not fully explored. Accordingly, a qualitative design with face-to-face interviews could explore people s beliefs about CHD prevention in more depth based on the result of this research. Further studies may also benefit from reviewing participant s medical charts. This can help clarify the association between people s actual risk levels of CHD and their beliefs in CHD prevention. Studies exploring young people s beliefs in CHD prevention can also be beneficial, since the early lesions of atheroma which lead to CHD were also found in children s and adolescent s coronary arteries [27]. In conclusion, the knowledge gap between lay people and health professionals needs to be bridged with carefully planned health education and individualized counseling. Also, the health behavior towards CHD prevention should start as early as possible, in order to promote people s heart health in their old age. References 1. Mackay J, Mensah GA: The atlas of heart disease and stroke. Geneva: World health Organisation, http: // s/resources/atlas/en/ [Oct 2, 2009 accessed] 2. Sekikawa A, Kuller LH, Ueshima H, et al: Coronary heart disease mortality trends in men in the post World War II birth cohorts aged in Japan, South Korea and Taiwan compared with the United States. Int J Epidemiol 1999; 28: 行政院衛生署 :97 年度死因統計, DM2_2.aspx?now_fod_list_no = 10238&class_no = 440&level_no = 1 [Oct 2, 2009 accessed] 4. Cheng Y, Chen KJ, Wang CJ, Chan SH, Chang WC, Chen JH: Secular trends in coronary heart disease mortality, hospitalization rates, and major cardiovascular risk factors in Taiwan, Int J Cardiol 2005; 100: Heidemann C, Hoffmann K, Klipstein-Grobusch K, et al: Potentially modifiable classic risk factors and their impact on incident 259

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11 Vol.4 No.4 Wei-Chien Chen et al Taiwan Geriatrics & Gerontology Nurs 1991; 5: Angus J, Evans S, Lapum J, et al: "Sneaky disease": the body and health knowledge for people at risk for coronary heart disease in Ontario, Canada. Soc Sci Med 2005; 60: Smith B, Sullivan E, Bauman A, Powell-Davies G, Mitchell J: Lay beliefs about the preventability of major health conditions. Health Educ Res 1999; 14: Baba S, Iso H, Mannami T, et al: Cigarette smoking and risk of coronary heart disease incidence among middle-aged Japanese men and women: the JPHC Study Cohort I. Eur J Cardiovasc Prev Rehabil 2006; 13: Huxley R, Barzi F, Woodward M: Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ 2006; 332: Homko CJ, Santamore WP, Zamora L, et al: Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease. J Cardiovasc Nurs 2008; 23: Wilson PWF, D'Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB: Prediction of coronary heart disease using risk factor categories. Circulation 1998; 97: Makrides L, Veinot PL, Richard J, Allen MJ: Primary care physicians and coronary heart disease prevention: a practice model. Patient Educ Couns 1997; 32: Connell CM: Older adults in health education research: some recommendations. Health Educ Res 1999; 14: Chang L, McAlister AL, Taylor WC, Chan W: Behavioral change for blood pressure control among urban and rural adults in Taiwan. Health Promot Int 2003; 18: Strong J, McGill HJ: The natural history of coronary atherosclerosis. Am J Pathol 1962; 40:

12 原著 台北市某社區中老年民眾對心血管疾病預防的認知與態度 陳維茜 1 余儀呈 2 凱倫 葛雷瑟 1 摘要 目的 : 探討台灣中老年民眾對心血管疾病預防的認知與態度 方法 : 本研究採橫斷面電話訪問調查方式, 由台北市某診所過去一年的就診紀錄中, 選取 45 歲以上民眾作為樣本清冊, 進行系統抽樣 訪談內容包括受訪者個人的心血管疾病危險因子, 自覺風險高低, 舉出心血管疾病的危險因子和預防方法等 並進一步以卡方檢定及 Kruskal-Wallis 檢定來測試不同的年齡層, 教育程度和有無危險因子是否會影響受訪者對心血管疾病的認知與態度 結果 : 系統抽樣共得 376 人, 其中 211 人同意受訪, 反應率 56% 高達 77% 的受訪者至少帶有一項心血管疾病的危險因子, 但大部分受訪者, 尤其是 60 歲以上的族群, 對於心血管疾病預防的認知卻非常有限 四分之三的受訪者, 不知道大部分的心血管疾病是可預防的 有糖尿病或吸菸習慣的受訪者, 並不認為他們的心臟病風險高於同年齡的人 結論 : 心血管疾病的風險隨年齡上升, 民眾需要更多預防心血管疾病的衛教指導, 尤其是糖尿病患, 吸菸者和高齡族群 ( 台灣老年醫學暨老年學雜誌 2009;4(4): ) 關鍵詞 : 心血管疾病 冠狀動脈心臟病 預防 認知 台灣 1 英國倫敦大學國王學院 2 台北市芝山診所通訊作者 : 陳維茜通訊處 : 台北市士林區忠義街 82 號 1 樓 ( 芝山診所 ) 電話 :(886) cathychen8@gmail.com 262