Aim: The aim of the present study was to estimate the prevalence of coronary heart diseases (CHD) risk factors among Ghaza (Palastine) university students, to assess the CHD risk among them using a suitable scoring system and to identify how they perceive their risk of CHD. Methods: During the period from May 2008 to May 2009, 501 students were involved. Participants were subjected to the following activities; self administered questionnaire: including socio-demographic data, medical history of chronic diseases, family history about CHD, knowledge and perception of risk factors, anthropometric measurements in addition to laboratory testing. Results: The mean age was 20.8 ± 2.07 years; 54% were females. The prevalence of hypertension and DM was 3.6% and 0.4% while it was 2.6% for hypercholesterolemia. The mean levels of LDL-C (88 mg/dl vs 85.5 mg/dl) and HDL-C (52.4 mg/dl vs 42.6 mg/dl) were higher among females than among males. Smoking was more prevalent among males than among females (33.1% vs 1.7%) with a total prevalence of 19%. Overweight and obesity were more prevalent among males (30.7% vs 22.5% and 9.6% vs 5.6%). In contrast to risk perception female students tend to be more knowledgeable than males with regards to different aspects of CHD. The overall level of perceived risk was moderate. Logistic regression analysis revealed that age and sex were associated significantly by higher level of total perception (p < 0.05). Conclusion: Health education and health promotion programs should be implemented and integrated within the primary health care sectors and directed to university students before admission. Further research needed to be implemented on larger sample to test knowledge and perception of the public in regard to their risk for heart disease including school children and community so that education could be provided in a more focused manner.
Although the prevention and treatment of coronary heart diseases (CHD) have received increased attention, CHD remains the leading cause of death and major cause of morbidity in developed and developing countries [
Risk assessment is defined as “a systematic approach to estimating the burden of disease and injury due to different risk” [
Risk perception is the subjective assessment of the probability of a specified type of accident happening and how much we are concerned with the consequences. Perceiving risk includes evaluations of the probability as well as the consequences of a negative outcome [
Perception of CHD risk appears to be positively correlated with a desire to make risk-reducing behavioral changes and with actual behavioral change. Perceptions of personal risk occupy a central role in theories of individual health behavior such as the health belief model (HBM), which suggests that perceptions of risk play a critical role in a patient’s compliance with recommended health behaviors [
Knowledge of risk factors and positive perception of CHD risk in younger age group is the corner stone for building effective community preventive measures and evaluation of community needs. In Palestine, weak or no national data are available on the overall incidence and prevalence of cardiovascular and other non-commu- nicable disease. The Ministry of Health depends on mortality data to estimate the impact of these diseases. There is a gradient with increasing morbidity and mortality of coronary heart disease (CHD) in Palestine. The study arose from a genuine interest in assessing CHD risk, health beliefs, knowledge and practices of this community as a fundamental concern felt for the health of this population.
The aims of the current work were to estimate the prevalence of CHD’s risk factors among university students, to assess the CHD risk among university students, by using a suitable scoring system and to assess students’ knowledge, and perception of CHD risk by using the health belief model.
The study was carried out in the main three universities in Gaza Strip (Al-Azhar University, The Islamic University of Gaza, and Al Aqsa University) through a cross sectional approach. The target population comprised the second and third year regular university students to avoid attrition by students’ failure and dismiss in the first year, and to avoid loss of follow up after graduation in the fourth year.
Based on the prevalence of diabetes mellitus (6.4%) as a risk factor for CHD [
1) A self administered questionnaire was used to collect the data concerning the following: socio-demo- graphic, medical and family history of hypertension, diabetes mellitus (DM), dyslipidemia, and their medical and non-medical management, family history of CHD and premature death, smoking habit, and physical activity by using NCD-surveillance tool-kit questionnaire (303). For physical activity: participants were classified as physically active if they practice any leisure time physical activity (LTPA).
Assessment of students’ knowledge
Seven questions were designed to assess the students’ knowledge related to CHD, i.e. signs and symptoms of CHD, onset of disease, different risk factors, complications, measures to reduce risk, at what age screening of CHD should begin The total knowledge score ranged from 0 - 12 points, it was graded into three levels: Good: 10 - 12 points (>75%), Fair: 6 - 9 points (50% - 75%), and Poor level: <6 points (<50%).
Assessment of students’ risk perception
Three questions were designed to assess the students’ level of perceived susceptibility to CHD (three point scale). The total score ranged from 3 - 9 points and graded as high level of perceived susceptibility 8 - 9 points (>75%), moderate level 5 - 7 points (50% - 75%), and low level ≤ 4 points (<50%).
Perceived seriousness of the disease, perceived benefits of risk factors modification and perceived barriers to intention to life style changes were assessed using different Likert scales. Five items (three points scale) was used for the first one with a total score ranged from 3 - 15 and ten items (three points scale) for the second with a total score ranged from 10 - 30. Both were graded as high level (>75%), moderate level (50% - 75%) and low level of perception (<50%). Concerning perception of barrier to life style changes, three questions were used for assessment a score of 3 denotes identification of two or more barriers, 2 denotes presence of only one barrier, and 1 indicates that there is no barriers for each question, total score was obtained by summing the scores for the 3 questions, it was ranged from 3 - 9 points and classified as the previous ones; high, moderate and low level of perceived barrier. The total score of risk perception ranged from 20 - 63 points and was classified as the following:
- High level of perceived risk ≥ 46 (>75%)
- Moderate level of perceived risk 31 - 45 (50% - 75%)
- Low level of perceived risk ≤ 30 (<50%)
2) Physical measurements
Blood pressure and body mass index (BMI) was calculated directly by the standard formula: weight (kg)/ height m2.
3) Laboratory investigations
Morning fasting blood specimens were collected between 8 and 10am and analyzed for serum total cholesterol (TC), high-density lipoprotein (HDL-c), and triglyceride (TG), and fasting blood glucose, while low-density lipoprotein (LDL-c) was calculated by using the formula {LDL-c = TC ? (HDL-c + TG/5)}, serum LDL-c was assessed by separation of LDL-c and determination of cholesterol bounds to these fractions. All results were reported in mg/dl using whole numbers.
An official letter of approval to conduct the study was obtained from the Helsinki Committee (Ethical Research Committee in Gaza Strip), each participant was given a letter to set forth the objectives and benefits from the study and stress upon confidentiality of information. A consent from was signed by each participant.
A pilot study was conducted for testing the reliability of the questionnaires, and different tools. Chronbacks alpha ranged from 0.66 to 0.84 for different tools.
Scoring of risk assessment computed on SPSS using the same scale of Framingham Global Risk Score [
A total of 501 students completed the survey questionnaire, the response rate was 87%, while it was 72% (361 out of 501) among those who gave blood sample for laboratory analysis. Framingham risk score formula was applied only for 361 participants, while all participants were included in the result analysis.
About 54% of the participants in the survey were males. Their age ranged from 19 - 40 years, mean age 20.8 ± 2.07 years. Six percent of the participants were married and the percentage was higher among female students.
Tobacco smoking was encountered in 19% of the study population (n = 95), which was more prevalent among male students in comparison to females (33% vs 1.7%). Family history of CHD was reported by 14.2% of the students. According to WHO classification of body mass index (BMI), overweight (≥25 - 29.9 Kg/m2), and obesity (BMI ≥ 30 Kg/m2) were more significantly prevalent among male versus female participants, where about 8% were obese and 27% were classified as overweight. Those who were practicing LTPA comprised 60.7% of the study population, yet the difference between both sexes was not statistically significant.
Based on reported history it was observed that 14.8% of the students reported the presence of two or more risk factors and the percent was more statistically significant in males (p = 0.001),
Risk assessment for determining 10-year risk for developing CHD events, was carried out by using the Framingham risk score updated for NCEP guidelines. The risk factors included in the Framingham calculation of 10-year risk were: age, total cholesterol, HDL cholesterol, smoking status, and systolic blood pressure. The risk score classified the estimated risk of CHD into three categories; low risk with total score less than 10%, moderate risk with a total risk score range from ≥10% - 20%, and the high risk category of ≥20% risk score.
Nearly 32% of the studied sample stated that they don’t know any of the risk factors. The most identified risk factors for CHD were smoking (47%), obesity (42.3%), high blood cholesterol (38.5%), high blood pressure (31.5%), genetics and physical inactivity 25% for each, stress (24%), and advanced age(21)%. With exception to smoking and advanced age, females tend to be more knowledgeable of obesity, high BP, high cholesterol, and stress as risk factors for CHD. More than half (52%) of the participants mentioned that they don’t know any of the signs and symptoms of CHD. The most common risk reducing methods of CHD identified by the study participants were cessation of smoking (50%), practicing LTPA (49.3%), maintain ideal weight (41.1%), avoidance of psychological stress (26.5%), control of blood sugar level in diabetic patients (21.4%), and about one fifth mentioned blood pressure control in hypertensive patients. Concerning different aspects of knowledge; risk factors, signs and symptoms, risk reduction strategies, complications, in addition to the total CHD knowledge mean
History of Hypertension | Male n = 270 % | Female n = 231 % | Total n = 501 % | p Value |
---|---|---|---|---|
Yes | 8 3.0 | 10 4.3 | 18 3.6 | 0.475 (NS) |
History of DM yes | 2 0.7 | 00 00 | 2 0.4 | 0.19 (NS) |
History of Hypercholesterolemia yes | 7 2.6 | 6 2.6 | 13 2.6 | 0.997 (NS) |
Smoking Behavior Current Ex-smoker Never | 91 33.1 21 7.8 158 58.5 | 4 1.7 3 1.3 224 97.0 | 95 19.0 24 4.8 382 76.2 | 0.001 |
Family History of CHD Yes | 39 14.4 | 32 13.9 | 71 14.2 | 0.850 (NS) |
BMI Kg/m2 Underweight < 18.5 Normal weight 18.5 - 24.9 Overweight ≥ 25 - 29.9 Obese ≥ 30 | 12 4.4 149 55.2 83 30.7 26 9.6 | 13 5.6 153 66.2 52 22.5 13 5.6 | 25 5.0 302 60.3 135 26.9 39 7.8 | 0.036 |
Practicing LTPA Yes | 170 63 | 134 58 | 304 60.7 | 0.272 (NS) |
Only positive answers (yes) were reported in the table. NS: non significant.
No. of Risk Factors | Male n = 270 (%) | Female n = 231 (%) | Total N = 501 (%) | p Value |
---|---|---|---|---|
No risk factors Only one risk factor ≥2 risk factors | 105 38.9 107 39.6 058 21.5 | 111 48.1 104 45.0 016 06.9 | 216 43.1 211 42.1 074 14.8 | <0.001 |
No. of Risk Factors | Male n = 270 (%) | Female n = 231 (%) | Total N = 501 (%) | p Value |
---|---|---|---|---|
No risk factors Only one risk factor ≥2 risk factors | 108 40.0 121 44.8 041 09.6 | 149 64.5 066 28.6 016 05.2 | 257 51.3 187 37.3 057 11.4 | <0.001* |
Score % | Male n = 192 % | Female n = 169 % | Total n = 361 % |
---|---|---|---|
<1 1 2 3 4 6 | 147 76.6 32 16.7 8 4.2 2 1.0 2 1.0 1 0.5 | 168 99.4 - - 1 0.6 - - | 315 87.2 32 8.9 8 2.2 3 0.8 2 0.6 1 0.3 |
score, females were more statistically knowledgeable than males (9.9% vs 8.3%, p = 0.001). Those who had good level of knowledge constituted 21.2% of the sample, while those with poor level comprised more than one half of the sample (51.9%),
Risk perception (perceived susceptibility, seriousness, benefit, and barriers)
The distribution of the studied sample according to the perceived seriousness (severity) to the CHD is presented in
Less than 2% of the studied sample agreed to the benefit of stop smoking, and practicing LTPA as CHD risk reduction methods. Nearly similar percentage (2.6%, and 2.4%) agreed to that “eating fat free diet and increase vegetables intake” and “avoidance of stress” reduce the risk of developing CHD. Less than four percent (3.4%) agreed that ideal body weight and avoidance of obesity reduce the risk of CHD occurrence. Also nearly similar percentage (4.2%, and 4%) agreed to that regular measurement of blood pressure and blood glucose level is essential to prevent the development CHD. It is worth mentioning that a considerable percentage of our population ranged from 65% - 80% didn’t perceive any benefits of the previous measure for CHD risk reduction.
Perceived barriers of lifestyle changes in areas of smoking, dietary habits and practicing LTPA
With regards to stop smoking; the most commonly perceived barriers were social and cultural strain (44.2%), study pressure (24.2%), all friends are smoking (23%), type of strong tolerance (22%), and it needs will power (21%). There was a statistically significant difference between males and females participants. 24% of the participants perceived no barriers. Concerning eating healthy diet; the mostly commonly perceived barriers were increased cost (21%), prefer quick meals (19.4%), don’t mind for increased weight, don’t know healthy diet (10.6% and 9.6% respectively). 44% of the study population were reported that they had no barriers to take healthy diet. 23% of the students perceived no barriers to practicing LTPA. While barriers like no desire, having no time, having no suitable place, and having no decency represented 31.5%, 30.5%, 20.6% and 11.7% respectively. No statistically significant difference between male and female participants was detected regarding diet and LTPA.
The results of multiple regression revealed that out of seven factors included in the model, both sex (female) and age were found to have a significant impact on the total perception score. These variables accounted for 18% of the variability in change of perception score,
The prevention of CHD traditionally relies on the control of risk factors and positive perception of such factors among individuals as a major element of any strategy. Despite the benefits from risk reduction, lack of adherence is a fundamental problem in risk modification efforts in individuals at high risk or with CHD [
CHD risk factors that are prevalent among the studied sample are concomitant to those identified by different
Score | Male N = 270 (%) | Female N = 231 (%) | Total N = 501 (%) | p Value |
---|---|---|---|---|
Perceived susceptibility High Moderate Low | 68 25.2 189 70 13 4.8 | 36 15.6 183 79.3 12 5.2 | 104 20.7 372 74.3 25 5 | 0.030* |
Mean (SD) | 5.8 (1.4) | 5.7 (1.29) | 5.77 (1.38) | |
Perceived seriousness High Moderate Low | 12 4.4 177 65.6 81 30 | 6 2.6 140 60.6 85 36.8 | 18 3.6 317 63.3 166 33.1 | 0.183 (NS) |
Mean (SD) | 8.4 (1.7) | 8.1 (1.6) | 8.27 (1.7) | |
Perceived benefit High Moderate Low | 1 0.4 71 26.3 198 73.3 | - - 19 8.2 212 91.8 | 1 0.2 90 18.0 410 81.8 | <0.001* |
Mean (SD) | 13.7 (2.69) | 12.75 (2.05) | 13.3 (2.47) | |
Perceived barriers High Moderate Low | 7 2.6 157 58.1 106 39.3 | - - 107 46.3 124 53.7 | 7 1.4 264 52.7 230 45.9 | 0.001* |
Mean (SD) | 5.03 (1.1) | 4.5 (0.72) | 4.8 (0.98) | |
Total perception score High Moderate Low | 1 0.4 199 73.7 70 25.9 | - - 126 54.5 105 45.5 | 1 0.2 325 64.9 175 34.9 | 0.001* |
Mean (SD) | 33.8 (3.96) | 31.1 (3.2) | 32.1 (3.7) | |
Total knowledge score | ||||
Good Fair Poor | 46 17 73 27 151 56 | 60 26 62 26.8 109 47.2 | 106 21.2 135 26.9 260 51.9 | |
Mean (SD) | 8.3 (6.7) | 9.9 (7.5) | 9.06 (7.16) | 0.011 |
NS = statistically not significant. *Statistically significant p < 0.05.
Perceived Susceptibility Variables | Male N (%) | Female N (%) | Total N (%) | p Value | |
---|---|---|---|---|---|
Compared to a same age colleague, what is the probability of MI occurrence after 10 years | Exposed more than him | 28 (10.4) | 13 (5.6) | 41 (8.2) | 0.022 |
Same possibility | 52 (19.3) | 31 (13.4) | 83 (16.6) | ||
Exposed less than him | 36 (13.3) | 26 (11.3) | 62 (12.4) | ||
There is no possibility | 154 (57) | 161 (69.7) | 315 (62.9) | ||
Self evaluation for CHD development | May occur | 189 (70) | 174 (75.3) | 363 (72.5) | 0.368 (NS) |
Many not occur | 46 (17) | 30 (13) | 76 (15.2) | ||
Don’t know | 35 (13) | 27 (11.7) | 62 (12.4) |
NS = statistically not significant.
Perceived Severity Variables | Male N (%) | Female N (%) | Total N (%) | p Value | |
---|---|---|---|---|---|
CHD is considered as | V. serious | 11 (4.1) | 7 (3) | 18 (3.6) | 0.801 (NS) |
Serious to some extent | 116 (43) | 98 (42.4) | 214 (42.7) | ||
Not serious | 143 (53) | 126 (54.5) | 269 (53.7) | ||
Anxiety from exposure to CHD | V. anxious | 141 (52.2) | 113 (48.9) | 254 (50.7) | 0.076 |
Sometimes become anxious | 112 (41.5) | 90 (39) | 202 (40.3) | ||
No need to become anxious | 17 (6.3) | 28 (12.1) | 45 (9) | ||
How does the disease affect daily life | Disturb work and ADL | 24 (8.9) | 10 (4.3) | 34 (6.8) | 0.048* |
Sometimes disturb ADL | 89 (48.6) | 94 (51.4) | 183 (36.5) | ||
Does not disturb ADL | 157 (55.3) | 127 (55) | 284 (56.7) | ||
Do you perceive CHD as a public health problem | Yes | 22 (8.1) | 19 (8.2) | 41 (8.2) | 0.367 (NS) |
No | 27 (10) | 15 (6.5) | 42 (8.4) | ||
Don’t know | 221 (81.9) | 197 (85.3) | 418 (83.4) | ||
Proportional mortality from CHD to the total mortality | High | 41 (15.2) | 15 (6.1) | 56 (11.2) | 0.005 |
Moderate | 143 (53) | 122 (46) | 256 (52.9) | ||
Low | 45 (16.7) | 58 (25.1) | 103 (20.6) | ||
Don’t know | 41 (15.2) | 36 (15.6) | 77 (15.4) |
NS = statistically not significant.
Independent variables | Β | (SE) | t | p-Value | |
---|---|---|---|---|---|
Constant | −4.96 | 20.96 | 0.237 | 0.818 | |
Educational level | 0.199 | 6.66 | 0.030 | 0.976 | |
Sex | 18.16 | 6.64 | 2.73 | 0.008 | |
Age | 1.89 | 0.941 | 2.011 | 0.048 | |
History of (DM, HTN, Hypercholestrolemia) | −8.57 | 11.09 | 0.99 | 0.325 | |
Family history of CHD | 12.27 | 12.39 | 0.99 | 0.325 | |
Family history of PMD | 2.90 | 6.909 | 0.390 | 0.697 | |
Pretest total knowledge | 0.354 | 0.459 | 0.77 | 0.444 | |
F = 2.617, p = 0.017, R2 = 0.181.
studies conducted in different countries [
The prevalence of the presence of ≥2 risk factors and Just one factor in United States national estimate (2010) showed a marked difference in comparison to our reported results (17.9% vs 14.8%) and 37.3% vs 42.1% respectively [
Smoking in the present study was less prevalent (19%) in comparison with the studies conducted among Jordon University of Science and Technology students, 2008, (28.5%) [
The prevalence of overweight and obesity in the current study was higher and showed a significantly low percentage among female, in contrary to the results of Shahid Bahonar University of Kerman―Iran (2003) [
Concerning physical activity, the present study revealed that 39.3% of the participants were physically inactive or don’t practice any LTPA. It is less prevalent than many studies conducted in the EMR which revealed that physical inactivity is a highly prevalent health-related problem in the region. A study conducted at Alexandria University-Egypt (2007), revealed that 33.5% of the students were physically inactive [
In general, female participants in the current study tend to be more knowledgeable than males, in contrast to risk perception where males perceived themselves to be at higher risk than females.
In accordance with a study conducted in Karachi-Pakistan, less than 20% of the participants were aware of the risk factors of CHD. The major CHD risk factors identified by participants were hypertension, high cholesterol, and smoking 12% [
At Columbia University Medical Center (2005), a sub-study of 125 women with no known history of CVD participated in a clinical evaluation of CHD risk to assess perceived versus calculated risk of CHD using Framingham global risk assessment for calculating absolute 10-year risk; 59% had a 10-year risk of less than 10%, however only half of these women accurately perceived their risk as low. After brief educational intervention, the women’s ability to correctly categorized their personal CHD risk improved significantly [
The lower level of women’s risk perceptions for heart disease in the current study is parallel to a common misperception found in a study conducted in the US (2005), which revealed that the general public still perceives heart disease as primarily a health problem for men. Evidence shows that women perceive breast cancer as a greater risk than CHD. These misperceptions may lead women to underestimate their risk for CHD and fail to seek early interventions to prevent unnecessary morbidity and mortality [
Age and sex were found to be the most significant predictors of risk perception in the current study. In 2010, the study conducted in Jordan revealed that older Jordanians had higher perception of risk of CHD, in addition; Jordanian women perceive CHD more as unobservable, unknown, new and delayed in manifestation of harm than Jordanian men [
In conclusion a person perception of a threat posed by a health problem is associated with actions aimed at reducing the threat. In addition, knowledge and awareness of risk factors are essential components of behavior change [
This study is not without its limitations. In the present study, there was a sole dependence on self-report measures to gather data. Also, the cross-sectional design disallows any allusion to causality. Students in such area are under stress for long time which may affect their perception of risk and alter their way of thinking to health issues. At last health belief model as a psychological model does not take other factors into consideration, such as environmental or economic factors that may influence health behaviors.
This work was funded by College of Medicine Research Centre, Deanship of scientific Research, King Saud University.