A Community-Based, Cross-Sectional Study Assessing the Level of Awareness and Insight Related to Cardiovascular Diseases

Objective The disease outcome had been shown to improve with improving patient knowledge. The study had two objectives, firstly to assess the level of knowledge about cardiovascular diseases (CVDs) in the general population, and secondly, to provide written educational material regarding the risk factors, major symptoms, and the prevention of CVDs. Method The target population was the residents living in the Western region of Saudi Arabia, aged 18 years and above. All were invited to participate voluntarily. A pre-structured questionnaire was designed to collect data related to age, gender, marital status, education level, occupation, lifestyle habits, and a history of heart diseases, as well as cardiac symptoms, and risk factors. The educational material was provided after the questionnaire. Results The majority of the participants were female (74.8%). The risk factors most frequently identified were lack of exercise, stress, and obesity. Chest pain was recognized as a major symptom (87.6%). Other symptoms included dyspnea, syncope, and excessive sweating. The level of knowledge regarding the risk factors for cardiovascular disease was poor. Only 18.5% were knowledgeable about the risk factors. The majority (60%) could identify the preventable factors, including smoking cessation (92.2%), a high level of cholesterol (88.6%), and hypertension (78.7%). The majority (83.7%) read the educational material and 99% reported that the lecture increased their knowledge about cardiovascular disease. Conclusion Although cardiovascular risk factors are common, there is a big gap in the knowledge in our population. Further, alarming symptoms that bring the patients to medical care are also deficient. A call for action at different levels is urgent. Simple educational material in a basic language and virtual education are useful and cheap tools that must be practiced wherever possible. Education is welcomed by the participants.


Introduction
Cardiovascular diseases (CVDs) are the leading cause of death globally, with an estimated 17.9 million deaths annually. Four of five deaths are due to myocardial infarction and stroke, and one-third of these deaths occur prematurely in people under the age of 70 years [1]. The mean age for developing coronary artery disease (CAD) in the Middle East is 10 years younger than the mean age in Western countries [2]. A substantial increase in the prevalence of CVDs' risk factors in the Middle East has been reported [3], and the prevalence of CAD-related risk factors in Saudi patients with established CAD is concerning [4][5]. Improved knowledge about the disease may result in an earlier presentation to medical care and better patient outcomes. Individuals need to know and understand the implications of CVD, its symptoms, and risk factors to enable proactive minimizing of risk [6]. However, risk factors may vary between different regions and ethnicities [7,8]. A study from Eastern Saudi Arabia reported that only 3% were aware of a history of CVDs [9]. There is no literature related to the level of CVD knowledge in the Western region of Saudi Arabia. In addition, we included educational material to raise the level of CVD knowledge in the study population.

Materials And Methods
Study setting and participants: The design was a community-based cross-sectional study. Residents, residing in the Western region of Saudi Arabia, aged 18 years and older were invited to participate voluntarily. A prestructured questionnaire was used to collect the data. The sample was calculated as 385 using the Raosoft Online Software (Raosoft, Inc., Seattle, WA, USA) [10]. The margin of error was 5%, with a 95% confidence level. The population size is approximately 10 million. Due to the possibility of incomplete responses, the sample was increased by 15% to 443.
Study variables: The questionnaire was previously validated [9,11]. The online questionnaire included `six sections. The first section gathered demographic characteristics. The second section contained items exploring medical illnesses known to result in CVD: diabetes, hypertension, hypertriglyceridemia, hypercholesterolemia, smoking, and medication history. The third section focused on the risk factors for CVD, and the fourth section assessed the participants' level of knowledge of CVD symptoms. The fifth section measured the level of knowledge regarding normal levels required to prevent CVD incidence for HbA1C, blood pressure and cholesterol, and smoking cessation). The last section contained educational material developed by the authors, followed by two questions to assess the benefit, and the perceived increase in the level of knowledge.
Statistical methods and ethical considerations: The categorical variables are presented as frequency and percentage, and the continuous variables as mean ± SD. The statistical tests used included a non-parametric Mann-Whitney U test to compare the differences between two independent groups, such as gender, should the dependent variable be ordinal or continuous, but not normally distributed. A non-parametric Kruskal-Wallis test was used for variables categorized in more than two groups, instead of the ANOVA. A nonparametric, related-samples Friedman test was used for variables categorized into more than two related groups. The knowledge levels were categorized as excellent (90 and above), very good (80-89), good (70-79), acceptable (60-69), and weak (below 60). The analysis was done with SPSS version 25. The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center, SP20/348/J. The participants signed a consent form, indicating that participation was voluntary. No names or personal data were collected. The data were saved in a workplace computer to maintain confidentiality.

Discussion
This is the first study conducted in the Western region of Saudi Arabia, assessing the level of knowledge related to CVD risk factors, signs and symptoms, and preventive factors, in addition to providing educational material to the general population. The knowledge deficit that diabetes and chronic kidney disease were not considered as serious factors in causing CVD might explain the high prevalence and lack of control of these two risks. Similar findings were reported with a negative dietary intake being the highest risk factor, and only 12%, 26%, and 39% of the sample indicated that diabetes mellitus, smoking, and lack of physical activity were risk factors for CVD, respectively [2]. Although most participants were familiar with the most known CVD risk factors, the majority could not correctly identify all the risk factors. Similarly, many studies from developing African and Middle Eastern countries reported a lack of knowledge of CVD risk factors [3,[12][13][14]. The majority (60%) of a sub-study with the Omani population had low knowledge scores related to the CVD risk factors [15]. In the United States, of 1,702 participants, half had adequate knowledge of CVD.
The questionnaire asked the sample to identify 7 risk factors for CVD, and 37% of the group who responded correctly, identified all seven risk factors, with a mean of 4.9 risk factors [15].
In the current study, the majority (87.6%) indicated chest pain or discomfort as the most prominent symptom, higher than reported in studies from Kuwait and Saudi Arabia [2,16]. Being knowledgeable about CVD signs and symptoms is important, supporting early intervention and a better outcome. In Singapore, a delay in an intervention is mostly caused by the patient's inability to recognize the signs and symptoms of myocardial infarction [17]. It is concerning that the majority in the current study were not aware of the CVD symptoms. Similarly, a study revealed that 60% of the participants could not identify one symptom of myocardial infarction [18].
The current study also assessed the level of knowledge regarding the factors that prevent CVD, not frequently reported in the literature. Though almost all the participants indicated smoking cessation as an indispensable aspect of CVD prevention, a study reported that only half of the sample were aware that smoking cessation is a protective factor for CVD. This difference might be due to differences in the population [19].
The overall level of knowledge related to CVD risk factors was weak. The current study provides a unique assessment method for the level of knowledge related to preventative CVD factors. In addition, the study provided valuable educational material to reinforce knowledge about CVD and the risk factors. The majority of the sample (99%) indicated that the lecture was beneficial, and increased their knowledge (90.7%).

Conclusions
The current study demonstrates a knowledge deficit regarding CVD risk factors, symptoms, management, and the association between each domain. Such knowledge will ensure early presentation to medical attention and improve the outcome. The educational material was beneficial and increased the level of knowledge, especially if social media was used. Additional educational campaigns are required to increase the level of knowledge about CVD. Further studies in different regions of Saudi Arabia are required to estimate the level of knowledge.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. King Abdullah International Medical Research Center issued approval SP20/348/J. The above study got an IRB approved for the research proposal, informed consent, and data collection/questionnaire. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.