Development of a survey questionnaire for knowledge about cardiovascular disease: Pilot study report

Transcription

1 Development of a survey questionnaire for knowledge about cardiovascular disease: Pilot study report David R Thomas Valery Feigin Chris Bullen Suzanne Barker-Collo Yoke Leng N. Thomas School of Population Health Faculty of Medical and Health Sciences University of Auckland 16 June 2008 This research was supported by a grant from the National Heart Foundation of New Zealand for the project titled: Awareness of cardiovascular disease risk factors among adult New Zealanders Citation for this report: Thomas, D. R., Feigin V., Bullen, C., Barker-Collo, S., Thomas, Y.L. (2008). Development of a survey questionnaire for knowledge about cardiovascular disease: Pilot study report Auckland: University of Auckland, School of Population Health.

2 Contents Summary 3 Introduction 4 Methods 9 Page Findings 13 Summary and recommendations 29 References 34 Appendix 1: Questionnaire used in pilot study 35 Summary Cardiovascular disease (CVD) is New Zealand s biggest killer. Effective communitybased educational and preventive programmes rely on accurate assessment of the current levels of knowledge about CVD risk factors and warning signs and symptoms in a population. In addition, periodic measurement of knowledge of CVD risk factors is needed to assess the impact of CVD educational campaigns over time. However, no assessment of knowledge about CVD risk factors and warning signs and symptoms among population groups has yet been reported for New Zealand. This report presents the findings of our effort to complete the first step in filling this knowledge gap. We conducted a review of the literature on surveys relating to knowledge about heart disease and stroke. We subsequently developed a questionnaire measuring knowledge and awareness about CVD. This survey questionnaire was pilot tested as a telephone survey. The results of the pilot testing indicated that only minor modifications to the survey are required prior to its being used on a national level. The survey was acceptable to those who agreed to participate, and typically took only minutes to complete. There was no evidence of ethnic differences in item acceptability or comprehension. Piloting the survey has also allowed us to obtain information on likely hit rates when using the telephone survey methodology, which have informed plans to conduct the survey on a national level. 2

3 1. Introduction Cardiovascular disease (CVD - heart disease, stroke) is New Zealand s biggest killer and leading cause of loss of healthy life years. The uptake, and hence effectiveness, of evidence-based CVD prevention strategies among the population-at-risk is related to knowledge about risk factors for CVD. However there is no data available about the levels of awareness that New Zealanders have of CVD risk factors even among population groups at greatest risk of a CVD event. Periodic measurement of the knowledge of the population about CVD risk factors is needed to assess the impact of CVD educational campaigns over time, and whether effective strategies are being used. As well as implementing programmes to increase awareness of risk factors, and investing in other preventive strategies such as those that tackle the environmental determinants of CVD, it is important to identify population groups with relatively low levels of knowledge and awareness, and to better understand the optimal information and modes of communication to use for knowledge transfer. Regular population-based surveys of CVD risk factor awareness and knowledge would address this deficit. The first step in this process is to develop a survey instrument that measures knowledge about CVD and risk factors which is suitable for use in New Zealand especially with population groups most at risk of CVD. The American Heart Association Expert Panel report on awareness and behaviour change notes the central role of awareness and knowledge as a one of the key elements of heart health promotion (Carleton, et al 1996). In their view Increased awareness and knowledge is often a necessary first step before behavioral change (Table 1) and is easy to measure. However, they noted the associated limitation that awareness and knowledge on their own are universally perceived as insufficient for promotion and maintenance of long-term behavioural change. We were unable to find any systematic survey information about the extent of knowledge and awareness of the symptoms and risk factors for heart disease and stroke among New Zealand groups. Thus, we consider it a necessary first step to establish the extent of such knowledge so that programmes intending to improve heart health will know which population groups require increased knowledge as a first step, and which groups need to focus more directly on changing risk-related behaviours. In this report we use awareness to refer to extent of being aware of the symptoms and warning signs of heart attack and stroke. We use knowledge to refer to having information about risks and prevention for heart attacks and stroke. This distinction is similar to that used by the American Heart Association Expert Panel and many other authors conducting surveys on CVD. The First Step The first step towards obtaining regular population-based data about CVD risk factor awareness and knowledge is to develop a survey instrument that measures knowledge about CVD and risk factors which is suitable for use in New Zealand especially with population groups most at risk of CVD. 3

4 The aims for the original project funded by the National Heart Foundation in 2007 were to: 1. To identify CVD risk factors, relevant to general public knowledge, that might be used in a questionnaire assessing awareness and knowledge. 2. To develop and pilot test a CVD awareness questionnaire suitable for use in NZ. 3. To develop a proposal for a national survey on awareness of CVD risk factors. For the second aim, to develop and pilot test a CVD awareness questionnaire, the specific objectives were to: 1. Trial the questions in the CVD questionnaire to assess their suitability for a national survey 2. Assess the suitability of each of the questions for a telephone survey. 3. Recommend a core set of questions for a future national survey Interviews to pilot test the questionnaire were conducted by the Survey Research Unit at the School of Population Health at the University of Auckland. The Survey Research Unit programmed the draft questionnaire into the CATI software (SurveySystem) and carried out 83 pilot survey interviews via telephone. Questions were read out by the interviewers and responses were typed directly into the data file of the CATI software and accumulated until the target number of interviews was exceeded. Previous surveys on knowledge about heart disease and stroke Based on the literature review carried out by the research team, the main topic areas covered in surveys of CVD were grouped into nine categories which are described below. The labels heart disease, heart attack or stroke were the most common terms used in the surveys to refer to CVD. (1) Most common causes of death. Knowledge about what are the main causes of death for people in general. (2) Personal experience. Whether respondents have ever experienced a heart attack or stroke or if someone they know such as a family member or relative has had the experience. (3) Actions to take. Questions about what someone would do if they were present when someone else has a heart attack or stroke. It can also ask what they did if they had been present at a previous event. (4) Awareness of symptoms of heart attack or stroke. These include questions about chest pain in the case of a heart attack; severe headache for stroke. (5) Knowledge about risks and prevention for heart attacks and stroke including lifestyle patterns such as regular exercise, tobacco use, diet and family history. (6) Sources of information. Where people obtained information about CVD and stroke, or where they have seen information on these. (7) Assessing own risk. Asking participants to rate their chances of having a heart attack or stroke. (8) Ways to improve cardiovascular health and prevent CVD. (9) Barriers to improving heart health. What are the barriers that respondents report in relation to improving their lifestyle to reduce risk of heart attack and stroke? Examples of questions used in previous surveys are shown for each of the nine categories in Tables 1a and 1b. 4

5 Table 1.1a: Examples of questions used in previous surveys Topic Areas Examples of questions 1. Most common causes of What is the leading cause of death? death 2. Personal experiences with Have you ever had a heart attack? heart attack and stroke Has anyone (else) in your family ever had a heart attack, angina or heart problems? Has a doctor, nurse, or other health professional ever told you that you had any of the following? (For each, tell me Yes, No, or you re Not sure. ) (Ever told) you had angina or coronary heart disease? 3. Actions to take if someone has a heart attack or stroke 4. Awareness of symptoms or warning signs of heart attack and stroke 5. Knowledge about risks and prevention for heart attacks and stroke (Ever told) you had a stroke? What did you do if you or someone with you were having a stroke? How quickly do you need to go to a hospital? Would you say... 1 immediately 2 the same day 3 the next day 4 after your doctor tells you to go Could you tell if someone is having a heart attack? (if yes) What are the signs or symptoms that the person is having a heart attack? What are the signs or symptoms of a person having a stroke? Try to tell me as many as you can I am going to read you a list of signs or symptoms. For those you think are related to strokes, please answer "Yes." If you do not think it is a symptom of a stroke, please answer "No." Can you tell me what are the major causes of heart disease or heart problems? Do you know the difference between good fats and bad fats in food? Can you give me some examples of food with good fats? Do you know what your blood cholesterol level is? Please tell me what a person can do reduce his or her chances of having a heart attack. Try to tell me as many as you can. Which of these behaviours can help reduce the risk of a heart attack or stroke? Stop smoking Eating less high fat or high cholesterol foods To control weight or lose weight To increase physical activity or exercise Blood pressure control Reduce salt in food Reduce stress Not drink alcohol heavily Eat more fresh vegetables & fruits 5

6 Table 1.1b: Examples of questions used in previous surveys Topic Areas Examples of questions 6. Sources of information about How easy is it to find factual/accurate and easy-to-understand heart attack and stroke information about heart disease and stroke? Have you heard or read anything about heart attacks or their treatment in the past year? (if yes) Where did you hear it? Newspaper, Radio, Television, Magazine, Brochure/ Poster/ Flyer, Hospital, Internet, Health professional (nurse, doctor), Family & friends, Other 7. Assessing own risk, Asking participants to rate their chances of heart attack or stroke 8. Ways to improve cardiovascular health and prevent CVD 9. Barriers to improving heart health Do you know any organisations which provide information on heart disease and stokes? What is your risk for getting heart disease (High, moderate, low) Could you tell us what you think your chances are of getting heart disease? What are some things that you feel place you at risk for heart disease or stroke? What can be done to improve your heart health? What barriers might you encounter in trying to improve your heart health? There are two general techniques for assessing public awareness of and knowledge about risk factors; open-ended and structured questions. Open-ended questions are commonly used to asks respondents what they think are CVD risk factors, or what ways they can reduce their risk of CVD. For example: What are the signs or symptoms that the person is having a heart attack? Please tell me what a person can do reduce his or her chances of having a heart attack. Try to tell me as many as you can? Structured questions provide respondents with a list and ask them to identify relevant items in relation to the main question. For example: Which of these behaviours can help reduce the risk of a heart attack or stroke? Stop smoking Eating less high fat or high cholesterol foods To control weight or lose weight To increase physical activity or exercise Blood pressure control Reduce salt in food Reduce stress Not drink alcohol heavily Eat more fresh vegetables & fruits Potvin et al. (2000) suggested that structured questions give consistently better estimates of levels of knowledge. While both structured and open-ended questions are widely used and considered valid, some researchers have noted that questions which include a list of possible responses result in higher estimates of awareness or knowledge than open-ended 6

7 questions (Greenlund et al., 2004). For example one study which required participants to recognize risk factors from a list reported high levels of awareness and knowledge (Rowe et al, 2000). They concluded that an open-ended question that assesses memorized or unprompted recall knowledge would probably be a better question type for evaluating the impact of a prevention awareness campaign (Rowe et al., 2000). Relatively low levels of awareness of stroke warning signs are evident when measured by an open-ended question (assessment of recall). In contrast a much greater proportion of respondents recognized stroke warning signs when signs were read from a list (assessment of recognition) (Rowe et al., 2000). To summarise, CVD is the most common cause of death and disability in New Zealand adults. Effective community-based educational and preventive programmes rely on accurate assessment of the current levels of knowledge about CVD risk factors and warning signs and symptoms in a population. No studies were located which had surveyed levels of knowledge and awareness of CVD risks in the general population of New Zealand. The Next Step: We have completed the first step in filling this gap in knowledge by developing and piloting a questionnaire measuring structured knowledge and awareness about CVD. The next step will be conducting a national telephone survey of the general public and in specific population groups at high risk for CVD in New Zealand. The outcomes from a national survey would provide baseline data about knowledge of CVD risk factors and warning signs and symptoms in the population, including knowledge among specific population groups. An application has been submitted seeking funding to accomplish the next step. 7

8 2. Methods Development of questions A literature review was undertaken at the start of the project in August 2007 to identify research reports that had carried out surveys related to knowledge and awareness for CVD including heart disease and stroke. A total of 35 research reports were located in published literature and technical reports, 21 covering heart disease and 14 covering stroke. Where the questions used in the surveys were reported in the research papers, these questions were collated, sorted into similar groups (see Tables 1.1a and 1.1b above) and reviewed by members of the research team to identify items that might be suitable for use in New Zealand. From the review process a set of suitable items were constructed in a questionnaire format and circulated to other heart health researchers for comment. These included a Maori health researcher (Dr Lorna Dyall) and a health researcher with an interest in CVD in women (Dr Cheryl Campbell). Following this review process several changes were made and some additional questions added. The additional questions included: Do you have any cultural or religious beliefs which may influence the way you think about heart attacks? Do you have any cultural or religious beliefs which may influence the way you think about strokes? The primary questions developed for the draft questionnaire used for pilot testing are shown in Table 2.1. The questionnaire also included questions on gender, age, ethnicity, and level of education. The completed draft questionnaire was then submitted for ethical approval for pilot testing. Ethics approval Ethics approval was sought from the University of Auckland Human Participant Ethics Committee (UAHPEC). Ethics approval was completed in early December 2007, following completion of a condition required by the Ethics Committee that the research team consult with the Tumuaki Maori (Associate Professor Papaarangi Reid) regarding the sampling of Maori participants. Following this consultation it was agreed that the pilot study would involve 50% Maori participants (25 Maori, 25 non-maori), which was required under the principle of equal explanatory power. As a result of the ethics approval delay and the subsequent delay in uplifting the approved funding from the NHF, the conversion of the questionnaire into the CATI (telephone interviewing) software did not begin until late January The interviewing for the pilot testing took place during February

9 Table 2.1: Main topics and questions used in pilot study Topic Area Questions used in pilot study 1. Most common Can you tell me, what are some of the most common causes of death for causes of death people in NZ? 2. Personal Have you ever had a heart attack? experiences with heart Have you ever had a stroke? attack and stroke Has anyone in your family ever had a heart attack? (if yes) Were you present when a family member had a heart attack? What did you do? Has anyone in your family ever had a stroke? 3. Actions to take if someone has a heart attack or stroke 4. Awareness of symptoms or warning signs of heart attack and stroke 5. Knowledge about risks and prevention for heart attack and stroke 6. Sources of information about heart attack and stroke (if yes) Were you present when a family member had a stroke? If you or someone you know has any signs or symptoms of a heart attack, what should you do? If you or someone you know were having a heart attack, how quickly would the person need to go to a hospital? If you or someone you know experiences any signs or symptoms of a stroke, what should you do? Can you tell if someone is having a heart attack? What are the signs or symptoms that a person is having a heart attack? I am going to read you a list of signs or symptoms. For each one, if you think it relates to heart attacks, please say "Yes Can you tell if someone is having a stroke? What are the signs or symptoms for stroke that you would recognise? Do you know which part of the body is most directly affected when someone has a stroke? I am going to read you a list of signs or symptoms. For each one, if you think it relates to stroke, please say "Yes." Can you tell me which health conditions or risk factors increase someone s chances of having a heart attack or stroke? Try to tell me as many as you can. Now I am going to read you a list of health conditions. Please tell me which, if any, of these conditions increase someone s chances of having a heart attack or stroke. Please tell me what a person can do to reduce his or her chances of having a heart attack. Try to tell me as many as you can. Please tell me what a person can do to reduce his or her chances of having a stroke. Try to tell me as many as you can. Which of these behaviours can help reduce the risk of a heart attack or stroke? If you decided to change your behaviour to reduce your risk of heart attack or stroke, how confident are you of changing your behaviour? Have you seen or heard anything about heart attacks, or their treatment or prevention in the past year? (if yes) Where did you see or hear about it? Newspaper, Radio, Television, Magazine, Brochure/ Poster/ Flyer, Hospital, Internet, Health professional (nurse, doctor), Family & friends, Other Have you heard or read anything about strokes, or their treatment or prevention in the past year? How easy or difficult do you think it would be to find accurate and easy-tounderstand information about heart disease and stroke? Have you tried to get any information about heart attack or strokes in the last two years? (if yes) Where did you try to get information from? Do you know of any organisations in New Zealand which provide information on heart attacks and stokes? (if yes) Which ones? 9

10 Pilot testing procedures The questionnaire was programmed into the computer-assisted telephone interview (CATI) software (SurveySystem) and an initial trial conducted to check that the questions, the response options and sequencing were working correctly. A number of trial calls were made for the initial checking and from these calls nine interviews were completed. These nine interviews were included in the final pilot study sample. Following the check the main pilot study commenced using 400 randomly-selected residential telephone numbers from the Auckland region. After completing 64 interviews (15 Maori and 49 non-maori) a screening procedure was introduced so that only respondents identifying as Maori (in reply to the ethnicity question) were interviewed. The final sample consisted of 83 people including 58 non- Maori and 25 Maori respondents. Those included as Maori were both sole Maori and Maori and other ethnic groups, consistent with the New Zealand Census coding of ethnicity. More non-maori respondents were included than originally planned, as the decision to omit all further non-maori respondents was not made until the end of an interviewing shift when the phone log was checked for the ethnicity of those who had completed interviews. The phone log from the main pilot study which resulted in 74 completed interviews is shown in Table 2.2 Among those called, 33% declined to participate, giving an acceptance rate of 67%. Following the implementation of screening, to interview only respondents identifying themselves as Maori, a further 152 people were screened out. The average time to complete the telephone interviews was around minutes for most people, but some interviews lasted as long as 20 minutes. The interviewers reported that most people, who agreed to be interviewed, seemed pleased to participate in the interview and thought the interview topic was important. Table 2.2: Call outcomes from phone log Outcome Details Frequency Percent Total phone numbers 400 (N=400) called Phone not answered Callbacks, answer 52 13% machine, no answer, number not connected Phone answered % Language problem 13 Established contact Eligible households % (N=335) Declined Declined to participate % Screened out Quota filled for non-maori % Completed interviews 74 22% 10

11 Sample profile Demographic information for the pilot study sample is shown in Tables 2.3 and 2.4. Among the 83 people interviewed, 67% were women, 47% were 50 years or older, and 54% had no post- secondary school education or qualifications. Table 2.3: Demographic details for sample Frequency Percent Gender Men Women Ethnicity Non-Maori, non-pacific Maori Pacific Age years years Sample total Table 2.4: Highest educational qualification reported Frequency Percent No secondary school qualifications NZ School certificate in one or more subjects (or equivalent or NCEA level 2 or University entrance, Higher School Certificate, higher leaving certificate or other secondary school qualification Some university or tertiary study Trade Certificate or Diploma University or tertiary certificate University or Tertiary degree Graduate or postgraduate degree or qualification Declined to state Total

12 3. Findings The findings for each set of questions are reported for each main topic area outlined in the table in shown earlier in the Methods section. 3.1 Knowledge about common causes of death Table 3.1 shows the questions used, and Tables 3.2 and 3.3 show the responses. There were no significant differences between the Maori and non-maori groups for these questions. Table 3.1: Questions about common causes of death Topic Area Questions used in pilot study Most common causes Can you tell me, what are some of the most common causes of death of death for people in NZ? Do men and women have different rates of death for this cause? (if yes) Do men or women have higher rates? Table 3.2: What are some of the most common causes of death for people in NZ? Type of cause Frequency Percent Non-Maori Maori N=83 Frequency Frequency N=58 N=25 Heart disease/heart attacks Cancer Stroke Road traffic injuries Diabetes Other (Obesity, stress, smoking, kidney disease) Note: Up to five causes were recorded for each respondent Table 3.3: Do men and women have different rates of death for this cause? (N=83) Type of cause Yes Different No difference Heart disease/heart attacks Cancer Stroke 20 5 Road traffic injuries 21 3 The question about the most common causes of death worked well. This question allows assessment of the extent to which respondents are aware that CVD is the major cause of death. The question about gender differences was not as effective as a measure of knowledge and requires a sub-question about whether men or women have higher rates. We recommend omitting this question in future surveys. 12

13 3.2 Personal experiences with heart attack and stroke The questions included in the topics Personal experiences with heart attack and stroke and Actions to take if someone has a heart attack or stroke are shown in Table 3.4. Table 3.4: Questions about personal experiences and actions to take Topic Area Questions used in pilot study Personal experiences with heart attack and stroke Included questions about what respondent did if present Actions to take if someone has a heart attack or stroke Have you ever had a heart attack? Have you ever had a stroke? Has anyone in your family ever had a heart attack? (if yes) Were you present when a family member had a heart attack? What did you do? Who did you contact for help? Has anyone in your family ever had a stroke? (if yes) Were you present when a family member had a stroke? What did you do? Did you or someone else call an ambulance or emergency services? How soon did you or someone else contact them after the family member had a stroke or heart attack? If you or someone you know has any signs or symptoms of a heart attack, what should you do? If you or someone you know were having a heart attack, how quickly would the person need to go to a hospital? If you or someone you know experiences any signs or symptoms of a stroke, what should you do? If you or someone you know were having a heart attack, how quickly would the person need to go to a hospital? Would you think; 1 immediately 2 the same day 3 the next day 4 after your doctor tells you to go Responses to the personal experiences questions are shown in Table 3.5. These questions were easily answered by respondents. We would recommended keeping these questions in future surveys as they allow an assessment of the extent to which direct personal experience may be related to increased awareness and knowledge about heart attacks and stroke. Table 3.5: Personal experience of heart attack and stroke Frequency Percent of Yes responses N=83 Ever had a heart attack Ever had a stroke Someone in family had a heart attack Present when family member had a heart attack Someone in family had a stroke Present when family member had a stroke

14 Responses to the questions about actions people reported taking if they were present when someone had a heart attack or stroke are shown in Table 3.6. Respondents were sometimes vague in their responses to these questions as the event may have been some time ago. Also because some of the questions may refer to the respondent themselves or another person present there was some ambiguity in responses. In their present form, the questions do not elicit clear-cut responses from which knowledge can be measured. We would recommend omitting these questions in future surveys due to their ambiguity and because they did not allow a clear assessment of knowledge about actions to take if someone has a heart attack or stroke. What did you do? Who did you contact for help? Table 3.6: Actions taken if respondent present when someone had a heart attack or stroke Type of response Did you or someone else call an ambulance or emergency services? How soon did you or someone else contact them after the family member had a stroke or heart attack? Phoned the doctor and took mother to doctor Dialled 111/called ambulance Called doctor/hospital Too late Interviewee called ambulance Someone else called ambulance Immediately Within 15 Minutes That day Frequency (N=11) Responses to the questions about actions to take if someone has a heart attack or stroke are shown in Table 3.7. These questions were straightforward for respondents. Most people who responded knew what to do if they recognised someone was having a heart attack or stroke. We would recommend using these questions in future surveys if a more detailed assessment of knowledge was required in relation to appropriate actions to take for heart attack and stroke. These questions might be relevant to topics covered in first aid training programmes. Table 3.7: Actions to take when someone has a heart attack or stroke Type of response Frequency If you or someone you know has any signs or symptoms of a heart attack, what should you do? Call Call 111 & make comfortable Make comfortable, prop up 62 (75%) 14 (17%) 3 (4%) If you or someone you know were having a heart attack, how quickly would the person need to go to a hospital? If you or someone you know experiences any signs or symptoms of a stroke, what should you do? Other Immediately Same day Next day After your doctor tells you to go Call Call 111 & make comfortable Make comfortable, prop up Other 4 (5%) (87%) 4 (5%) 2 (2%) 5 (6%) 14

15 3.3 Awareness of symptoms and warning signs The questions included in the topic awareness of symptoms or warning signs of heart attack and stroke are shown in Table 3.8. The responses to these questions are shown in the following tables. Table 3.8: Questions about awareness of symptoms and warning signs Topic Area Questions used in pilot study 4. Awareness of Can you tell if someone is having a heart attack? symptoms or What are the signs or symptoms that a person is having a heart attack? warning signs of I am going to read you a list of signs or symptoms. heart attack and For each one, if you think it relates to heart attacks, please say "Yes stroke If you do not think it relates to a heart attack, please say "No." If you are not sure, say Don t know. Chest pain, Neck pain, Pain in stomach, Pain in one or both arms Back pain, Jaw pain, Crushing pain, Feeling like being sick or vomiting, Sweating, Faintness, Shortness of breath, Tightness in the chest Can you tell if someone is having a stroke? (if yes) What are the signs or symptoms for stroke that you would recognise? Do you know which part of the body is most directly affected when someone has a stroke? I am going to read you a list of signs or symptoms. For each one, if you think it relates to stroke, please say "Yes." If you do not think it relates to a heart attack, please say "No." If you are not sure, say Don t know. Sudden weakness or numbness in face, arm or leg Sudden double or blurred vision Sudden blindness on one eye, Shooting pain in the arm, Sudden difficulty speaking or understanding of others, Chest pain, Dizziness, Headaches, Sudden unexpected severe headache, Joint pain Table 3.9 shows that 46 out of the 83 respondents (55%) thought they could tell if someone was having a heart attack. The signs and symptoms mentioned by seven of the respondents are shown in Table Due to a programming error, the responses for the other 39 people who said they could tell were not recorded. Both these questions seemed to work well and we would recommend they be included in a national survey. Table 3.9: Can you tell if someone is having a heart attack? Frequency Percent Yes No Don t know Total

16 Table 3.10: What are the signs or symptoms that a person is having a heart attack? Sign or symptom mentioned Breathlessness, pain, blue lips Hard to breathe, pain in left arm or shoulder, pain in stomach, vomiting, chest pain Limp, slouch, pain around the chest Pressure in throat, tingling down the arms/pressure in the chest, sweaty Shortness of breath, pain in chest, numb tingling left arm Still, experiencing pain in chest, back radiating down arm, stop breathing Tingling in arms, chest pain, collapsed Note: Responses for only 7 of 46 respondents were recorded due to a data recording error. These are the verbatim responses For the next question a list of symptoms were read to the respondents and they were given the following instructions: For each one, if you think it relates to heart attacks, please say "Yes." If you do not think it relates to a heart attack, please say "No." If you are not sure, say Don t know. The number of respondents agreeing that each of the symptoms could indicate a heart attack is shown in Table Most respondents recognised chest pain, tightness in chest, pain in arms, and crushing pain as symptoms of a heart attack. The items showed a reasonably wide spread of responses and would be suitable to include in a national survey. This question could perhaps be improved by including some items which are not symptoms of heart attack. Table 3.11: Signs or symptoms related to heart attacks (List read out by interviewer) Symptom Frequency ( Yes response)* Percent (N=83) Chest pain Tightness in the chest Pain in one or both arms Crushing pain Sweating Faintness Feeling like being sick or vomiting Back pain Neck pain Jaw pain Pain in stomach Note: Other responses were Don t know or No Table 3.12 shows that 25 out of the 83 respondents (30%) thought they could tell if someone was having a stroke. The signs and symptoms mentioned by the respondents are shown in Table Of the 25 respondents mentioning any signs and symptoms, the most commonly mentioned was slurred speech or difficulty speaking. Both questions worked well and could be included in a national survey. 16

17 Table 3.12: Can you tell if someone is having a stroke? Frequency Percent Yes No Don t know Total Table 3.13: What are the signs or symptoms for stroke you would recognise? Sign or symptom mentioned Frequency Percent Difficulty speaking, slurred speech Numbness, tingling Paralysis, can t move limbs Facial paralysis, face is affected Feeling faint Chest pains Other (e.g., sweating, vision affected) Not sure, don t know Total Note: These items were coded from verbatim comments given by respondents Table 3.14 shows responses to the question about which part of the body is most affected by stroke. Overall 53 (64%) correctly identified the brain as the most affected part. Table 3.14: Which part of the body is most directly affected when someone has a stroke? Frequency Percent Brain Left side of body Arm Face Head Chest Don t know Total Note: These items were coded from verbatim comments given by respondents The number of respondents agreeing that each of the symptoms could indicate a stroke is shown in Table Most respondents recognised difficulty speaking, weakness or numbness and dizziness as symptoms of a stroke. These two items (Tables 3.14 and 3.15) showed a good range of responses and would be suitable to include in a national survey. It was also useful to include some items which were not symptoms of stroke so that an estimate of favourable response bias can be made. These lists (Tables 3.13 and 3.15) could be used to develop an overall estimate of knowledge about heart attack and stroke respectively by adding the correct responses (and subtracting incorrect responses in the list provided for stroke symptoms) 17

18 Table 3.15: Signs or symptoms related to strokes (List read out by interviewer) Symptom Frequency ( Yes Percent (N=83) response)* Sudden difficulty speaking or understanding others Sudden weakness or numbness in face arm or leg Dizziness Sudden unexpected severe headache Sudden double or blurred vision Headaches Sudden blindness in one eye Shooting pain in the arm (not a symptom) Chest pain (not a symptom) Joint pain (not a symptom) *Note: Other responses were Don t know or No 3.4 Knowledge about risks and prevention for heart attacks and stroke The questions included in the topic knowledge about risks and prevention for heart attacks and stroke are shown in Table Table 3.16: Questions about knowledge of risks and prevention Topic Area Questions used in pilot study 5. Knowledge about Have you heard of the difference between good or healthy fats and bad or risks and prevention unhealthy fats in food? for heart attacks and Can you give me some examples of food with good or healthy fats? stroke Can you give me some examples of food with bad or unhealthy fats? Have you heard of blood cholesterol level? Do you think having high blood cholesterol is a risk factor for heart disease? Do you think high blood pressure or hypertension is a risk factor for heart disease? Can you tell me which health conditions or risk factors increase someone s chances of having a heart attack or stroke? Try to tell me as many as you can. Now I am going to read you a list of health conditions. Please tell me which, if any, of these conditions increase someone s chances of having a heart attack or stroke. Please tell me what a person can do to reduce his or her chances of having a heart attack. Try to tell me as many as you can. Please tell me what a person can do to reduce his or her chances of having a stroke. Try to tell me as many as you can. Which of these behaviours can help reduce the risk of a heart attack or stroke? Which of these behaviours can help reduce the risk of a heart attack or stroke? (list read to respondent) If you decided to change your behaviour to reduce your risk of heart attack or stroke, how confident are you of changing your behaviour? 18

19 A set of questions relating to knowledge about fats were asked early in the survey. They are included in this section as they related to knowledge about healthy and unhealthy foods. Have you heard of the difference between good or healthy fats and bad or unhealthy fats in food? Can you give me some examples of food with good or healthy fats? Can you give me some examples of food with bad or unhealthy fats? Responses are shown in Tables 3.17 and Due to a skip error in the CATI software, only eight people responded to the question about the difference between healthy and unhealthy fats in food. Seven of the eight respondents had heard of the difference and some could identify healthy and unhealthy fats (Table 3.18) Table 3.17: Have you heard of the difference between good or healthy fats and bad or unhealthy fats in food? Frequency Percent Yes No Missing Total Table 3.18: Examples of healthy and unhealthy fats N=7 Good or healthy fats Bad or unhealthy fats Avocados Curry, ginger garlic, cayenne Fish and Chips Natural products - cheese / milk Nuts, olive oil, clarified butter Unsaturated, canola deep fried, take aways Fish and chips, all take aways Fish and chips; takeaways in general fried food; takeaways; fish & chips; Oil, cholesterol pork fats, takeaways steak/pork/lamb/coffee The next set of questions related to blood cholesterol level. Have you heard of blood cholesterol level? Do you think having high blood cholesterol is a risk factor for heart disease? Do you think high blood pressure or hypertension is a risk factor for heart disease? Responses are shown in Tables 3.19 and Most people surveyed said they had heard of blood cholesterol and considered it a risk for heart disease. Given the responses to the preceding questions about healthy and unhealthy fats and blood cholesterol, these questions could be omitted from a national survey as the response distributions are highly skewed and there is some overlap with the next set of questions. 19

20 Table 3.19: Knowledge about blood cholesterol Have you heard of blood cholesterol level? Do you think having high blood cholesterol is a risk factor for heart disease? Frequency Percent Frequency Percent Yes No Total Table 3.20: Do you think high blood pressure or hypertension is a risk factor for heart disease? Frequency Percent Yes No, don t know Total The next set of questions related to knowledge about risk factors for heart attack and stroke. The first question was semi-structured and responses were recorded verbatim and subsequently coded into the categories shown in Table Can you tell me which health conditions or risk factors increase someone s chances of having a heart attack or stroke? Try to tell me as many as you can. The most commonly mentioned risk factors were: Overweight, obesity High blood pressure High cholesterol Not exercising, unfit Smoking It was noteworthy that smoking was only mentioned by 35% of respondents when asked for risk factors without prompting. Table 3.21: Which health conditions increase chances of heart attack or stroke? Health condition Frequency Percent (N=83) Overweight, obesity High blood pressure High cholesterol Not exercising, unfit Smoking Poor diet Stress Family history, hereditary Fatty food Alcohol, drink too much Diabetes Note: These items were coded from the verbatim comments given by respondents 20

21 In the next question provided respondents with a list of possible risk factor items which were read out. Now I am going to read you a list of health conditions. Please tell me which, if any, of these conditions increase someone s chances of having a heart attack or stroke. The responses are shown in Table When proved with a list the proportion of the sample identifying risk factors correctly was much higher than when a list was not provided. Smoking was identified as a risk factor for heart attack by 96% of respondents when read out in a list but only 35% of respondents when not read out. Both of these questions give useful and different estimates of knowledge about risk factors and should be included in a national survey Table 3.22: Which of these conditions increase chances of a heart attack or stroke? List read out by interviewer (N=83) Health condition Both heart attack & stroke Heart attack Stroke Frequency Percent Frequency Percent Frequency Percent Having a history of heart attacks or stroke High blood pressure/ hypertension Stress Being overweight or obese Sedentary lifestyle, not exercising Being over 55 years of age Overwork Smoking tobacco Drinking alcohol heavily Having high cholesterol Heart disease Diabetes Previous stroke Severe headache Having cancer After menopause for women Having poor eyesight Having arthritis The final question in this set asked about confidence in changing behaviour. Responses are shown in Table If you decided to change your behaviour to reduce your risk of heart attack or stroke, how confident are you of changing your behaviour? Most people (around 80) rated their confidence in changing their behaviour as between somewhat confident to very confident (5, 6 or7). This question performed well and would be useful to correlate with responses to the other questions. We would recommend including this question in a national survey. 21

22 Table 3.23: If you decided to change your behaviour to reduce your risk of heart attack or stroke, how confident are you of changing your behaviour? (1=not confident, 7= very confident) Frequency Percent 1 Not confident Very confident Total Sources of information about heart attack and stroke The questions related to the topic Sources of information about heart attack and stroke are shown in Table Table 3.24: Questions about sources of information Topic Area Questions used in pilot study Sources of information Have you seen or heard anything about heart attacks, or their treatment or about heart attack and prevention in the past year? stroke (if yes) Where did you see or hear about it? Have you heard or read anything about strokes, or their treatment or prevention in the past year? How easy or difficult do you think it would be to find accurate and easy-tounderstand information about heart disease and stroke? On a 7-point scale ranging from 1= Very easy to 7=Very difficult. Have you tried to get any information about heart attack or strokes in the last two years? (if yes) Where did you try to get information from? Do you know of any organisations in New Zealand which provide information on heart attacks and stokes? (if yes) Which ones? In reply to the question relating to information about heart attacks, most people (77) reported they had seen or heard something (Table 3.25). Have you seen or heard anything about heart attacks, or their treatment or prevention in the past year? (if yes) Where did you see or hear about it? Table 3.25: Have you seen or heard anything about heart attacks in the past year? Frequency Percent Yes No Don t remember Total

23 The most common sources of information were television, health professional and newspapers (Table 3.26). Table 3.26: Where did you see or hear about heart attacks? Frequency Percent (N=64) Television Health professional (nurse, doctor) Newspaper Magazines Brochure/Poster/Flyer Family & friends Hospital Internet Radio Other (first aid course, at work) Note: Interviewees could give more than one response A similar set of questions were asked about stroke. Have you heard or read anything about strokes, or their treatment or prevention in the past year? (if yes) Where did you see or hear about it? A somewhat lower proportion of people reported seeing or hearing information about stroke (61) compared to heart attacks (77). Table 3.27: Have you seen or heard anything about strokes in the past year? Frequency Percent Yes No Don t remember Total As for heart attacks, the most common sources of information for stroke were television, health professional and newspapers (Table 3.28). Table 3.28: Where did you see or hear about strokes? Frequency Percent (N=51) Television Health professional (nurse, doctor) Newspaper Brochure/Poster/Flyer Internet Magazine Family & friends Hospital Radio Other Note: Interviewees could give more than one response Both these questions provide useful information and we would recommend including them in a national survey. 23

24 The next question asked about seeking information. How easy or difficult do you think it would be to find accurate and easy-tounderstand information about heart disease and stroke? On a 7-point scale ranging from 1= Very easy to 7=Very difficult. Responses are shown in Table Most people (81) thought it would be quite easy (responses 1-3) to get information about heart disease and stroke. Table 3.29: How easy or difficult to find information about heart disease and stroke (1=Very easy, 7= very difficult) Frequency Percent 1 Very easy Very difficult Total The next two questions were about trying to get information about heart attacks and stroke in the last two years. Relatively few people reported trying to get information (Table 3.30). Most tried to get information from either the internet or their doctor (Table 3.31). These two questions did not seem to add anything useful and we would recommend omitting them from a national survey. Have you tried to get any information about heart attack or strokes in the last two years? (if yes) Where did you try to get information from? Table 3.30 Tried to get information Heart attacks Stroke Frequency Percent Frequency Percent Yes No Total Table 3.31: Where did you try to get information from? Frequency Internet 8 Doctor 7 Hospital 2 Nurse who came to visit 1 Total 18 24

25 The last question in this group asked about knowledge of organisations which provide information about heart attacks and stroke. Overall 74% of respondents said they did know at least one (Table 3.32). Do you know of any organisations in New Zealand which provide information on heart attacks and stokes? (if yes) Which ones? Table 3.32: Know any organisations providing information on heart attacks and strokes Frequency Percent Yes No Total As shown in Table 3.33, the organisations most commonly known as providing information were the National Heart Foundation (61%) and the stroke foundation (31%). These questions were useful and we would recommend including them in a national survey. Table 3.33: Organisations identified as providing information on heart attacks or stroke Frequency Percent (N=83) National Heart Foundation Stroke Foundation St Johns Ambulance Hospital Heart failure clinic Personal health assessment and cultural beliefs The final set of questions covered personal health assessment and whether respondents had any cultural or religious beliefs which may influence the way they think about heart attacks or stroke. The questions are shown in Table Table 3.34: Questions about personal health assessment and beliefs Topic Area Questions used in pilot study Personal health The final group of questions are about medical checkups and beliefs about assessment heart disease and stroke. You may decline to answer any question if you wish to. Are you willing to answer these questions? Cultural and religious beliefs How long ago did you last see a doctor for a medical check? Have you had your blood pressure checked in the last 12 months? If yes, do you recall what it was? Have you had your blood cholesterol level checked in the last 12 months? If yes, do you recall what it was? Do you have any cultural or religious beliefs which may influence the way you think about heart attacks? Do you have any cultural or religious beliefs which may influence the way you think about strokes? 25