Accepted on 12 Jul 2022            Submitted on 15 Mar 2022

Introduction

Cardiovascular diseases (CVDs) comprise various congenital or acquired diseases that affect the heart or blood vessels [1]. According to the World Health Organization (WHO), CVDs are the major cause of mortality worldwide, resulting in 17.9 million global deaths annually [2, 3]. They are also considered to be among the most costly medical conditions [4], and prevention strategies are needed to limit the high prevalence of CVDs and mitigate their costs [5].

The American Heart Association measures cardiovascular health by seven factors: physical activity, smoking status, blood sugar level, body weight, cholesterol level, blood pressure, and diet [6]. Non-modifiable risk factors include age, sex, family history, and race, whereas modifiable risk factors are high blood pressure, dyslipidemia, smoking, diabetes, obesity, sedentary lifestyle, unhealthy diet, and stress [7, 8, 9]. Such risk factors may predispose to a wide range of complications such as coronary artery disease, cardiac dysrhythmias, cerebrovascular disease, cardiomyopathies, and peripheral vascular disease [10], hence the importance to control modifiable risk factors. In Lebanon, for instance, there is a great need to raise awareness about CVD risk factors as demonstrated by Fahs et al. in 2017 on 1,000 Lebanese participants who showed a higher prevalence of cardiovascular risk factors [11].

Management of CVDs involves on one hand non-pharmacological interventions such as: nutritional education [12], physical activity [13], lowering the Body Mass Index (BMI) and maintaining a healthy weight [14], reduction of salt intake [15], and smoking cessation [16, 17, 18]. On the other hand, pharmacological treatments include angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), aldosterone antagonists, loop diuretics, beta-blockers, anti-hypertensive drugs, anti-diabetic medications, lipid lowering agents, oral anticoagulants, and anti-platelet agents [19, 20, 21, 22]. Despite the progress in CVD management, prevalence of CVD in the world [23], and Lebanon (36%) [11] remain high, and 47% of deaths in Lebanon in 2016 were due to CVD.

One way for controlling risk factors and decreasing prevalence rate of CVD is through primary prevention, early diagnosis, and good CVD practices. Therefore, to raise CVD awareness, February is recognized as the ‘American Heart Month’ through various activities [24]. Astoundingly, in the last 50 years, the death rate due to CVD decreased by 70% [25]. However, despite such educational campaigns, poor awareness about CVD is still prevalent, as revealed by various studies that aimed to assess the level of general CVD knowledge, attitude, practice (KAP), including one on obese Latina women [26], and others in Malaysia [27, 28] and Iran [29]. For instance, findings by Aminde et al. in Cameroon revealed that women had poor knowledge about CVD, and that high education level, high monthly income, having a family history of CVD, and being a former smoker were associated to moderate-to-good knowledge [30]. In Lebanon, a cross-sectional study conducted by Ghaddar et al. showed that individuals had a moderate-to-high degree of knowledge about cardiovascular risk factors, but a low-to-moderate level of adherence toward CVD management, such as physical exercise, weight loss, and smoking cessation [31].

Since KAP studies about CVDs are getting scant attention, specifically in Lebanon and in Arab countries, and that only one study was conducted to assess KAPs of CVD among non-cardiac Lebanese individuals [31], we recommend further research in this area. Consequently, this cross-sectional study aimed to assess KAP levels toward CVD among the Lebanese population with CVD subjects and non-CVD subjects (control), while identifying the factors affecting KAP CVD scores and the socio-demographic characteristics predicting these scores, in order to spread awareness and prevent CVDs.

Methods 1. Ethical information

Before we had started our study, we received an IRB waiver from the ethical committee of the Hayat Hospital (Reference Number: ETC-11-2021). This study was conducted in accordance with Good Clinical Practice ICH Section three, and the principles laid down by the 18th World Medical Assembly (Helsinki, 1964) and all applicable amendments. This study was confidential as each filled survey was associated with a number, thereby ensuring that all identities remain anonymous. Participants were asked to sign electronically an informed consent if they agree to participate voluntarily in our study. The study participants received detailed explanation of the background, objectives, risks, and advantages of the study and they were clearly informed of their right to withdraw at any time and that the information they provided was treated confidentially.

2. Study design

This study was a cross-sectional survey conducted from July 4th till August 4th 2021 to assess KAP towards CVD using an electronic survey (Google form) among CVD patients and the general Lebanese population. Eligible patients were ≥18-year-old, Lebanese CVD patient or non-CVD subjects from the general population, residing in Lebanon, and able to understand Arabic or English.

The population was targeted in all the eight governorates (Mohafazat) in Lebanon: Akkar, North, Beirut, Mount Lebanon, Bekaa, Baalbeck-Hermel, Nabatiyeh, and South. However, since the population is unequally distributed, we decided to regroup them into five governorates: Beirut, Mount Lebanon, Bekaa (Bekaa and Baalbeck-Hermel), North of Lebanon (North and Akkar), and South of Lebanon (South and Nabatieh).

3. Study population

The representative sample size of subjects with CVD was calculated using the Cochran formula n=Z2pqe2M1 \documentclass[10pt] \usepackage \usepackage[substack] \usepackage \usepackage \usepackage \usepackage[mathscr] \usepackage \usepackage \usepackage[Euler] \pagestyle \oddsidemargin -1.0in \begin \[ n = pq} \over }}} \] \end

, where Z2 is the square of the confidence interval considered, 95% in this case, which corresponds to (1.96)2, p is the estimated proportion of the Lebanese population which has CVD, q is (1-p), and e represents the p-value used which was set at 0.05. Therefore, a minimum of 355 patients suffering from CVD were required to participate in the study as a representative sample of the Lebanese population, based on the prevalence of CVD worldwide (36%) [7]. As for the group that included the general Lebanese population, a target of a minimum of 355 non-CVD subjects were required to fill out the questionnaire in order to be representative of the Lebanese general population. Data from 355 CVD patients and 355 non-CVD subjects (an average of 50 persons from 8 governates) was needed for analysis. Accordingly, 951 subjects were enrolled. 4. Procedures of data collection measurements 4.1. Data sources

Data was collected using a pre-validated structured questionnaire ]. It was uploaded on Google Form. Non-CVD participants were recruited from the general population across Lebanon, whereas CVD patients were recruited from dispensaries and private clinics, such as Srebta Health Center and Armenian Relief Cross Lebanon Center. Most of our CVD patients and non-CVD subjects (95%) were directly interviewed via face-to-face interaction or over phone calls. The questionnaire required no more than 10 minutes to be filled and was available in both English and Arabic languages. The questionnaire was translated from English to Arabic language using the inverted method of Fortin [32]. The authors first translated it from English to Arabic. Then, the Arabic version was translated into English by a healthcare professional/translator to compare the agreement of the instrument. A pre-test was carried out with ten persons who were not part of the sample to validate the understanding and clarity of the questionnaire items. At the end of the pre-test, the questionnaire was modified as necessary [32].

4.2. Variables

The questionnaire consisted of the following sections:

– Sociodemographic and other patient’s related characteristics: this section included 10 questions concerning the patient’s gender, age group, occupation, marital status, residency, education, personal monthly income, smoking status, alcohol drinking, presence of CVD, presence of medical illnesses, source of information about CVD. – Knowledge about CVD: this section included 40 questions assessing how knowledgeable the patients are about CVD and their consequences of CVD, symptoms of coronary heart disease (CHD), risk factors of CVD, CVD risk levels (desirable values of high-density lipoprotein cholesterol (HDL-c), low-density lipoprotein cholesterol (LDL-c), fasting glycemia, normal blood pressure (BP) ranges, Normal BMI). – Attitude and Practice toward CVD: These sections were comprised of 17 and 12 questions, respectively related to attitude and practice covering regular measuring of lipid profile, glycemia, and BP, diet plan, salt consumption, adherence to treatment, maintenance of normal body weight, and exercise. – For KAP assessment, the widely adopted Bloom’s cutoff points are the following: 80–100% (good KAP), 60–79% (moderate KAP), and less than 60% (poor KAP) [33, 34, 35]. In this study, we used the Median of the scores and a modified Bloom’s cutoff values with the subcategories of ‘Poor’ and ‘Fair’ scores grouped under the category ‘limited KAP’ about CVD and subcategories of ‘Good’ and ‘Excellent’ scores grouped under the category of ‘adequate KAP’ about CVD. These cutoff values were also based on previously published KAP studies [36, 37].

Computed scores were graded into categories and subcategories, as shown in Table 1.

Table 1

Grading of Knowledge (K), Attitude (A), and Practice (P) scores about CVD into Categories ‘Limited and Adequate’ and Sub-Categories ‘’Poor, Fair, Good, and Excellent’.

CATEGORIES SUB-CATEGORIES KNOWLEDGE ATTITUDE PRACTICE /40 % /85 % /9 % • LIMITED • POOR ≤26 ≤65 ≤55 ≤64.7 ≤6 ≤66.66 • FAIR [27, 28, 29, 30, 31, 32] [67.5–80] [56–69] [65.88–81.17] 7 77.77 • ADEQUATE • GOOD [33, 34, 35, 36, 37, 38] [82.5–95] [70–82] [82.8–97.1] 9 88.88 • EXCELLENT [39, 40] [97.5–100] [83–85] [97.64–100] 9 100 5. Data analysis

Collected data was inserted and analyzed using Statistical Package for Social Sciences (SPSS) software (version 25). The cumulative replies to each question were reported along with their respective percentages. Data were represented as frequencies and proportions for the nominal variables and as mean (±SD) for the continuous variables. Scores of KAP were computed. As such, 40 items were included for knowledge score, 17 for attitude score, and 9 for practice score. Sections of the knowledge and practices were scored in such a way that every correct answer was granted 1 point and each wrong answer a 0. Concerning the attitude section, a 5-point Likert scale was adopted in which ‘strongly disagree’ was given 1 point and ‘strongly agree’ was given 5 points for all items. The overall KAP score was calculated from the sum of the points granted where the cut-off value was the median for each section.

Descriptive analysis was used for the representation of the sample characteristics and the KAP data. Normality distribution was checked via the data representation on histograms and QQ plots and showed that the three scores were normally distributed. KAP scores and continuous variables were represented by mean, standard deviation, minimum and maximum. Categorical variables will be presented by their frequency and percentage. Bivariate analysis was conducted in order to test the correlation between the KAP scores and the demographic characteristics in the two study groups (CVD and non-CVD). Tests used were Student t-test and ANOVA test. In addition, the correlation was tested between the three KAP scores using Pearson correlation test. A multivariate analysis was enrolled in order to test factors affecting each of the three scores in the population. Significance level was set at 5%.

Results 1. Demographic characteristics

A total of 921 participants filled our questionnaire form and were distributed over different governorates. Most of CVD patients were from Mount Lebanon (47.6%). A proportion of 52.6% of CVD patients were males, while non-CVD participants were 47.7% of males. No statistically significant differences were observed between groups in term of gender. The mean age of the participants was 47.3 ± 18.3 years old. CVD patients (58.3 ± 13.7 years old) were significantly older than non-CVD participants (36.3 ± 15.4 years old) (p < 0.001). A significantly greater proportion of CVD patients were married compared to non-CVD subjects, (77.6% vs 47.7%, respectively), while other CVD patients were widowed (11.1%), single (8.5%), and divorced (2.8%), p < 0.001.

Smoking was prevalent in 36.7% of our total population. Smoking has been found associated with CVD with a p value <0.001. For instance, 44.1% of CVD patients were smokers, while 55.9% were not. Conversely, only 29.3% of non-CVD participants were smokers while 70.7% were not (p < 0.001). In term of medical history, diabetes mellitus, hypercholesterolemia, obesity thyroid disease, and stroke were found associated with CVD with a p value <0.001. Indeed, CVD patients had a higher prevalence of diabetes compared to non-CVD participants (32.4% vs 5.9%), as well as of hypercholesterolemia (48.7% vs 7.6%), obesity (28.5% vs 7.8%), thyroid disease (13.9% vs 4.8%), and stroke occurrence (6.5% vs 0.4%). Other details about demographics can be found in Table 2.

Table 2

Bivariate analysis of demographics and other characteristics of the enrolled subjects (CVD patients vs Non-CVD participants) (N = 921).

STUDY GROUPS TOTAL P.VALUE NON-CVD CVD Governorate Beirut 73 80 153 <0.001 15.8% 17.4% 16.6% North Lebanon 89 43 132 19.3% 9.3% 14.3% South Lebanon 92 75 167 20.0% 16.3% 18.1% Mount Lebanon 105 219 324 22.8% 47.6% 35.2% Beqaa 102 43 145 22.1% 9.3% 15.7% Gender Male 220 242 462 0.138 47.7% 52.6% 50.2% Female 241 218 459 52.3% 47.4% 49.8% Age <45 318 60 378 <0.001 69.0% 13.0% 41.0% 45 – 65 118 253 371 25.6% 55.0% 40.3% >65 25 147 172 5.4% 32.0% 18.7% Age Mean (SD) 36.3 (15.4) 58.3 (13.7) 47.3 (18.3) <0.001 Min – Max 18–86 19–90 18–90 Marital status Single 219 39 258 <0.001 47.5% 8.5% 28.0% Married 220 357 577 47.7% 77.6% 62.6% Divorced 10 13 23 2.2% 2.8% 2.5% Widowed 12 51 63 2.6% 11.1% 6.8% Occupation Not working 136 86 222 <0.001 29.5% 18.7% 24.1% Working as healthcare professional 70 24 94 15.2% 5.2% 10.2% Working as non-healthcare professional 192 197 389 41.6% 42.8% 42.2% Household 63 153 216 13.7% 33.3% 23.5% Educational level No formal education 12 24 36 <0.001 2.6% 5.2% 3.9% Elementary class 11 93 104 2.4% 20.2% 11.3% Complementary 35 91 126 7.6% 19.8% 13.7% Secondary 71 98 169 15.4% 21.3% 18.3% University level 266 118 384 57.7% 25.7% 41.7% Postgraduate 66 36 102 14.3% 7.8% 11.1% Personal Monthly income 0–750,000LL 157 124 281 <0.001 34.1% 27.0% 30.5% 751,000–1,500,000LL 116 91 207 25.2% 19.8% 22.5% 1,501,000–3,000,000LL 97 91 188 21.0% 19.8% 20.4% 3,001,000–4,500,000LL 39 59 98 8.5% 12.8% 10.6% More than 4,500,000LL 52 95 147 11.3% 20.7% 16.0% Smoking (Are you a current smoker?) No 326 257 583 <0.001 70.7% 55.9% 63.3% Yes 135 203 338 29.3% 44.1% 36.7% Medical History Diabetes mellitus 27 149 176 <0.001 5.9% 32.4% 19.1% High Cholesterol 35 224 259 <0.001 7.6% 48.7% 28.1% Obese 36 131 167 <0.001 7.8% 28.5% 18.1% Thyroid disease 22 64 86 <0.001 4.8% 13.9% 9.3% Stroke 2 30 32 <0.001 0.4% 6.5% 3.5% Source of Information Healthcare worker 221 353 574 <0.001 47.9% 76.7% 62.3% TV and radio 300 284 584 0.293 65.1% 61.7% 63.4% Newspapers or general magazines 128 97 225 0.018 27.8% 21.1% 24.4% Specialized health journals 177 72 249 <0.001 38.4% 15.7% 27.0% By watching medical conferences 132 42 174 <0.001 28.6% 9.1% 18.9% Through the experience of cardiac patient 219 294 513 <0.01 2. CVD-Related KAP 2.1. KAP Scores about CVD according to categories and subcategories

Results showed that the 921 participants (CVD group and non-CVD) had an overall limited knowledge, attitude, and practice toward CVD. Specifically, the participants showed poor level of knowledge (25.05 ± 6.84 over 40 [62.62%]), fair level of attitude (62.34 ± 11.40 over 85 [73.34%]), and poor to fair levels of practice (6.15 ± 1.99 over 9 [68.33%]) concerning CVD. ‘Limited’ knowledge, attitude, and practice about CVD were reported in 89.9%, 70.5%, and 71.1% of the participants (n = 921), respectively (Table 3).

Table 3

Bivariate analysis of KAP scores about CVD and participants distribution (N) (CVD vs Non-CVD) according to subcategories (Poor, Fair, Good, Excellent).

STUDY GROUPS TOTAL P.VALUE NON-CVD CVD Knowledge
(Subjects’ distribution) Poor 283 202 485 <0.001 61.4% 43.9% 52.7% Fair 132 211 343 28.6% 45.9% 37.2% Good 43 46 89 9.3% 10.0% 9.7% Excellent 3 1 4 0.7% 0.2% 0.4% Knowledge
score Mean (SD) 23.5 (7.9) 26.6 (5.2) 25.0 (6.8) <0.001 Min – Max 0 – 40 5–39 0–40 % Mean over 40 58.75% 66.50% 62.50% Attitude (Subjects’ distribution) Poor 140 98 238 0.006 30.4% 21.3% 25.8% Fair 188 224 412 40.8% 48.7% 44.7% Good 133 136 269 28.9% 29.6% 29.2% Excellent 0 2 2 0.0% 0.4% 0.2% Attitude score Mean (SD) 61.4 (12.4) 63.3 (10.2) 62.3 (11.4) <0.001 Min – Max 21–82 29 – 83 21–83 % Mean over 85 72.23% 74.47% 73.29% Practice (Subjects’ distribution) Poor 224 267 491 <0.001 48.6% 58.0% 53.3% Fair 63 101 164 13.7% 22.0% 17.8% Good 84 60 144 18.2% 13.0% 15.6% Excellent 90 32 122 19.5% 7.0% 13.2% Practice score Mean (SD) 6.3 (2.2) 6.0 (1.7) 6.1 (2.0) <0.001 Min – Max 1–9 2–9 1–9 % Mean over 9 70.00% 66.66% 67.77%

When each sub-population was analyzed separately, the mean CVD knowledge score in CVD patients was significantly higher than the one of non-CVD subjects (26.6 ± 5.2 over 40 [66.50%] poor to fair level vs 23.5 ± 7.9 over 40 [58.75%] poor level, respectively, p < 0.001) (Table 3 and Figure 1A). In addition, the mean CVD attitude score in CVD patients was significantly higher than the one of non-CVD subjects (63.3 ± 10.2 over 85 [74.47%] fair level vs 61.4 ± 12.4 over 85 (72.74%) fair level, respectively, p < 0.001) (Table 3 and Figure 1B). Furthermore, the mean CVD practice score in CVD patients was significantly lower than the one of non-CVD subjects (6.0 ± 1.7 over 9 [66.67%] poor to fair level vs 6.3 ± 2.2 over 9 [70.00%] poor to fair level, respectively, p < 0.001) (Table 3 and Figure 1C).

Figure 1 

Percentage (%) of CVD patients versus Non-CVD subjects with Knowledge (A), Attitude (A), and Practice (P) scores represented in categories (Limited/Adequate) and sub-categories (Poor/Fair/Good/Excellent).

2.2. CVD-Related Knowledge

Among all participants in the study, 45.9% correctly recognized that CVD are the leading cause of death in Lebanon, 48.4% knew that most CVD cases are hereditary [38], and only 35.5% were aware that CVD are the primary cause of death in diabetic patients. Moreover, 91% knew that hypertension is a CVD risk factor, and 32% that cancer are CVD risk factors. Detailed responses to the knowledge section are provided in Table S1.

2.3. CVD-Related Attitude

Attitude towards CVD included 17 items following a Likert scale from 1 (strongly disagree) to 5 (strongly agree). The top three attitude items for which participants showed the best scores were ‘Take treatment as recommended by doctor’ (4.9 ± 1.16 over 5 [98%]), ‘Should know blood pressure level’ (4.12 ± 1.22 over 5 [82.4%]), and ‘Should know blood sugar level’ (4.0 ± 1.27 over 5 [80%]). On the other hand, the bottom three items for which participants showed the worst scores were ‘Willingness to take hormone replacement therapy (HRT)’ (2.11 ± 1.28 over 5 [42.2%]), ‘Eat with restriction as feel well’ (3.19 ± 1.47 over 5 [63.8%]), ‘Change eating habit easily’ (3.39 ± 1.42 over 5 [67.8%]), Attitudes items are set in Table S2.

2.4. CVD-Related Practice

Among all participants, 55.4% performed exercise more than 20 min 3x/week, 75.7% were taking fatty food more than three times/week, 81% maintained normal weight, 63.5% tried to reduce stress, 65.4% were nor smokers and used to be passive smokers, 91.9% took treatment as recommended by doctor, 69.4% visited doctor for advice regularly, only 38.4% took omega3 for heart disease prevention, and 73.9% increased knowledge about CVD through mass media or internet, as shown in Table S3.

3. Correlation among kap score parameters

Results of the Pearson correlation test revealed that knowledge in the non-CVD group was positively correlated with attitude (p-value < 0.001, r = 0.182) and practice (p-value = 0.011, r = 0.118). In addition, attitude was positively correlated with practice (p-value < 0.001, r = 0.332).

As for the CVD group, results of the Pearson correlation test revealed that knowledge was positively correlated with attitude (p-value < 0.001, r = 0.312) and practice (p-value <0.001, r = 0.244). In addition, attitude was positively correlated with practice (p-value < 0.001, r = 0.441).

4. Socio-demographiic characteristics of cvd patients & Non-cvd participants with poor knoweldge, poor attitude, and poor practice scores

Percentages of Lebanese CVD patients and non-CVD subjects with Poor Knowledge score (K: ≤26 over 40 so ≤65.0%), Poor Attitude score (A: ≤55 over 85 so ≤64.7%), and Poor Practice score (P: ≤6 over 9 so ≤66.66%) regarding CVD according to socio-demographic status are represented in Table 4.

Table 4

Percentage (%) of Lebanese CVD patients and non-CVD subjects (Control) with Poor Knowledge, Poor Attitude, and Poor Practice regarding CVD according to socio-demographic status.

% POOR
KNOWLEDGE % POOR
ATTITUDE % POOR
PRACTICE GENDER MALE NON-CVDNon-CVD 60.0% 35.9% 59.5% CVD 42.1% 21.9% 57.0% FEMALE NON-CVDNon-CVD 62.7% 25.3% 38.6% CVD 45.9% 20.6% 59.2% AGE <45 NON-CVDNon-CVD 57.2% 27.7% 46.9% CVD 45.0% 16.7% 55.0% 45–65 NON-CVD 71.2% 34.7% 55.1% CVD 40.7% 28.6% 56.5% >65 NON-CVD 68.0% 44.0% 40.0% CVD 49.0% 21.3% 61.9% MARITAL STATUS SINGLE NON-CVD 53.0% 26.0% 44.3% CVD 35.9% 23.1% 46.2% MARRIED NON-CVD 67.7%