Coronary heart disease is the leading cause of death in the United States. The American Heart Association has proposed improving overall cardiovascular health by promoting 7 components of ideal cardiovascular health, including health behaviors (not smoking, regular exercise, and healthy diet) and health factors (ideal body mass index, cholesterol, blood pressure, and blood glucose). The patients’ knowledge of these 7 components is unknown. We performed a cross-sectional survey of patients at 4 primary care and 1 cardiology clinic. The survey measured demographic data, personal behaviors/health factors, cardiovascular disease history, and knowledge about these 7 components. A multivariate model was developed to assess patient characteristics associated with high knowledge scores. Of the 2,200 surveys distributed, 1,702 (77%) were returned with sufficient responses for analysis. Of these, 49% correctly identified heart disease as the leading cause of death, and 37% (95% confidence interval [CI] 35% to 39%) correctly identified all 7 components. The average respondent identified 4.9 components (95% CI 4.7 to 5.0). The lowest recognition rates were for exercise (57%), fruit/vegetable consumption (58%), and diabetes (63%). In a multivariate model, knowledge of all 7 components was positively associated with high school education or greater (odds ratio 2.43, 95% CI 1.68 to 3.52) and white ethnicity (odds ratio 1.78, 95% CI 1.27 to 2.50), and negatively associated with attending an urban neighborhood clinic (odds ratio 0.60, 95% CI 0.44 to 0.82). In conclusion, just >1/3 of patients could identify all 7 components of ideal cardiovascular health. Educational efforts should target patients in low socioeconomic strata and focus on improving knowledge about healthy diet and regular exercise. Although patients with diabetes were more likely than those without diabetes to recognize their risk, 1 in 5 were not aware that diabetes is a risk factor for cardiovascular disease.
Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in the United States. In 2010, the American Heart Association (AHA) published a strategic plan to reduce CVD deaths by 20% by 2020 by targeting 7 components of ideal cardiovascular health, including health behaviors (not smoking, exercise, and fruit and vegetable consumption) and health factors (ideal body mass index, cholesterol, blood pressure, and blood glucose). Although an understanding of CVD’s overall link to mortality has been established for women, awareness of the specific, modifiable risk factors for CVD has, to date, only been studied in high-risk and non–United States samples. Patients’ knowledge and beliefs about CVD are important, because studies have shown that perceived personal susceptibility can increase prevention-seeking behaviors. The objective of the present study was to measure the present level of awareness of the components of cardiovascular health in a convenience sample of patients aged ≥40 years and to identify the factors associated with knowledge deficits. We hypothesized that knowledge would be greater among patients at greater risk of CVD and greatest for patients with known coronary disease.
Methods
We administered a self-report survey (the Health Attitudes Survey) from March 2009 to August 2009 to a convenience sample of 2,200 patients at 4 university-affiliated general medicine practices and 1 cardiology practice in Western Massachusetts. Of the 5 practices, 2 serve economically depressed neighborhoods (23% of residents at less than the poverty line) and 2 serve suburban communities (<6% of residents at less than the poverty line). The cardiology practice is a regional specialty clinic serving a heterogeneous patient mix. The clinic staff distributed the survey to consecutive patients at check-in, as permitted by clinic patient flow. The participants were required to be literate in either English or Spanish. Those <40 years old were excluded, because their risk of CVD is low. The survey was anonymous and voluntary—completion implied consent. No incentive was provided, and no attempt was made to characterize the patients who refused the survey or did not return it. The Baystate Medical Center institutional review board approved the study protocol.
The paper and pencil survey (see Appendix 1 ) was available in English and Spanish. The survey was developed with input from the clinical staff and physicians from the sites where it was to be administered, pilot tested for clarity, and revised. It consisted of the following sections: demographics, anthropometrics (weight and height), CVD-related co-morbidities, health maintenance behavior, and knowledge of the effects of the 7 components (i.e., smoking, obesity, exercise, diet, cholesterol, blood pressure, and blood glucose) on the risk of myocardial infarction. Other behaviors were also included for comparison purposes. The options for each were increases risk, decreases risk, and no effect on risk.
Each response was dichotomized as correct or incorrect, and the proportions and 95% confidence intervals (CIs) were estimated. Bivariate associations between component knowledge, demographics, and co-morbidities were evaluated using chi-square tests (categorical) or one-way analysis of variance (2+ mean). Knowledge scales were created by summing the number of correct responses. The knowledge scores were dichotomized between full knowledge (all 7 components) and less than full knowledge. The recognition of CVD as the leading cause of death and a full knowledge of all 7 components were analyzed as a function of the demographic and co-morbidity data using logistic regression analysis. The sample size was held constant to those subjects who had complete information for all these variables. All analyses were performed using STATA, version 10.1 (StataCorp, College Station, Texas).
Results
Of the 2,200 surveys distributed, 1,742 (79%) were returned. An additional 40 surveys were excluded because of excessive missing data, for a total of 1,416 English surveys and 286 Spanish surveys. The demographic characteristics are summarized in Table 1 . Of the 1,702 respondents, 49% identified heart disease as the leading cause of death. Gender was not associated with a knowledge of heart disease as the leading cause of death (male vs female, odds ratio [OR] 0.95, 95% CI 0.75 to 1.19). Spanish-speaking patients were significantly less likely than English-speaking patients to identify heart disease as the leading cause of death, even after adjusting for education (adjusted OR 0.25, 95% CI 0.18 to 0.35).
| Characteristic | n (%) |
|---|---|
| Age (years) | |
| 40–49 | 504 (31%) |
| 50–59 | 500 (30%) |
| 60–69 | 353 (21%) |
| ≥70 | 294 (18%) |
| Women | 995 (62%) |
| Married | 805 (49%) |
| Education | |
| Less than high school | 382 (23%) |
| High school graduate | 573 (35%) |
| Some college | 418 (25%) |
| College plus | 282 (17%) |
| Clinics (5 total) | |
| Middle-class/suburban (n = 2) | 549 (35%) |
| Low income/urban (n = 2) | 803 (50%) |
| Cardiology practice (n = 1) | 239 (15%) |
| Race/ethnicity | |
| White | 921 (55%) |
| Hispanic | 463 (28%) |
| Black | 212 (13%) |
| Other | 62 (4%) |
| Self-reported cardiac risk factors | |
| Obese (body mass index ≥30 kg/m 2 ) | 508 (39%) |
| Smoked within 12 months | 357 (23%) |
| Coronary heart disease | 128 (8%) |
| High cholesterol | 626 (37%) |
| Hypertension | 829 (49%) |
| Diabetes mellitus | 403 (24%) |
After adjustment for education, ethnicity, age, language, and clinic site, the subjects with high cholesterol and hypertension were more likely to answer this question correctly (OR 1.70, 95% CI 1.34 to 2.14 vs OR 1.44, 95% CI 1.15 to 1.81, respectively). Smokers were less likely to answer correctly, but the difference was not significant (OR 0.74, 95% CI 0.52 to 1.04). No association was seen between answering correctly and a history of diabetes mellitus, obesity, myocardial infarction, or percutaneous coronary intervention/coronary bypass grafting.
Fewer than ½ of subjects (37%) correctly identified all 7 components of ideal cardiovascular health ( Figure 1 ). The average respondent correctly identified 4.9 components (95% CI 4.7 to 5.0) and 69% recognized ≥5 components. Recognition was greatest for obesity and hypertension and lowest for exercise, fruit/vegetable consumption, and diabetes ( Figure 2 ). The patients also mistakenly identified other behaviors such as eating fried food (1,239 [72.8%] of 1,702) and having >3 alcoholic drinks/week (796 [46.8%] of 1,702) as increasing risk.
On univariate analyses ( Table 2 ), patients with at least a high school education were more likely to know the effect of all 7 components than patients with less education (47% vs 19%, p <0.0001), as were white patients compared to other racial/ethnic groups (52% vs 26%, p <0.0001). Patients who attended an urban clinic (28% vs 53%, p <0.0001) and Spanish-speaking patients (24% vs 44%, p <0.0001) were less likely know the effect of all 7 components. Gender was not associated with knowledge. In a multivariate model, the knowledge of all 7 components was positively associated with at least a high school education (OR 2.43, 95% CI 1.68 to 3.52) and white ethnicity (OR 1.78, 95% CI 1.27 to 2.50) and negatively associated with urban clinic (OR 0.60, 95% CI 0.44 to 0.82). Language, age, and gender were not independently associated with full knowledge.
| Characteristic | Proportion | p Value ⁎ |
|---|---|---|
| Education | ||
| High school or more | 47% | |
| Less than high school | 19% | <0.0001 |
| Clinic | ||
| Affluent | 53% | |
| Not affluent | 28% | <0.0001 |
| Race/ethnicity | ||
| White | 52% | |
| Hispanic | 24% | |
| Black | 32% | |
| Other | 27% | <0.0001 |
| History of myocardial infarction | ||
| Yes | 35% | |
| No | 47% | 0.12 |
| Age (years) | ||
| 40–49 | 36% | |
| 50–59 | 44% | |
| 60–69 | 43% | |
| 70–79 | 39% | |
| ≥80 | 49% | 0.05 † |
| Language | ||
| English | 44% | |
| Spanish | 24% | <0.0001 |
| History of percutaneous coronary intervention/coronary bypass grafting | ||
| Yes | 44% | |
| No | 41% | 0.54 |
| Gender | ||
| Male | 44% | |
| Female | 40% | 0.15 |
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