Cardiovascular Risk Behaviour and Health Literacy among Patients with Cardiovascular Disease in Ethiopia

Abstract

Cardiovascular diseases (CVD) are becoming more prevalent globally. Increased urbanisation and life expectancy accompanied by a lack of CVD prevention policies in developing countries, is predicted to escalate the burden of CVD in the future. Moreover, low- and middle income countries are facing a high burden of CVD in a context of limited resources and lack of evidence-based prevention policies. In addition, research indicates significant gaps in knowledge of CVD and its risk factors among patients with CVD and in the general population. Despite the growing burden of CVD in developing countries, there is limited data available to improve awareness of this area. This study was conducted in two phases, and the overall aim was to assess cardiovascular (CV) risk behaviours and related health literacy among patients with cardiovascular conditions in Ethiopia. In study 1, a hospital-based cross-sectional survey was conducted in two referral hospitals in eastern Ethiopia. Patients with a confirmed diagnosis of CVD such as heart failure, hypertension and myocardial infarction were recruited from the follow-up units of the hospitals, which provide treatment for CVD and counselling of patients to achieve healthy lifestyles. Convenience sampling was used to select the study participants from each hospital. Data were collected through face-to-face interviews with patients using three validated tools: the World Health Organisation STEPs instrument, an international physical activity questionnaire and a heart disease fact questionnaire. The primary aims of the study were assessment of cardiovascular risk behaviours and knowledge of cardiovascular risk factors among patients with cardiovascular conditions. The data were entered on Epidata version 3.0 and was checked for completeness and consistency. Then, it was exported to SPSS version 24 for analysis. Multivariable linear regression was used to examine the relationship between knowledge of CV risk factors and explanatory variables. A total of 287 CVD patients were recruited, of which 56.4% were females and 90.2% were urban residents. Most patients had inadequate consumption of fruit and vegetables, 51.6% were physically inactive, 20% were current khat chewers, 19% were current alcohol drinkers and only 1% were current smokers. Approximately one-third (30%) of the patients had one of these risk behaviours, more than half (51.9%) had two, 15% had three and 3.1% had four risk behaviours. The majority (70%) of the patients had multiple risk behaviours. The prevalence of multiple risk behaviours did not significantly vary with sex, residence and educational level differences, (p > 0.05). More than half of the patients (54%) had a good knowledge of cardiovascular risk factors (scored > 70%), whilst 46% demonstrated suboptimal knowledge levels in this area. Urban residents had 12.84 units higher mean knowledge scores than rural residents (β = 12.84, 95% CI 6.91 to 18.77; P < 0.001). Those who had no formal education had -18.80 units lower mean knowledge score compared to those who completed college or university (β = -18.80, 95% CI -24.76 to -12.85; P < 0.001). In addition, those who attained less than primary school education had -12.02 units less knowledge scores compared to those who completed college or university (β = -12.02, 95% CI -17.63 to -6.40; P < 0.001). Those who were never married had -14.01 units lower mean knowledge scores than those who were currently married (β = -14.01, 95% CI -20.71 to -7.29; P < 0.001). However, there was no statistically significant association between knowledge of cardiovascular risk factors and actual cumulative risk behaviour (p > 0.05). In study 2, qualitative in-depth interviews were employed to collect data. The study participants were patients with hypertension who attended follow-up care. Data were collected through face-to-face in-depth interviews. The study is presented in line with consolidated criteria for reporting qualitative reserach. Audio recorded data were transcribed verbatim, and data analysis was guided by the Braun and Clarke steps of thematic analysis and using Nvivo 12 software. A total of 18 patients with hypertension were interviewed. The findings of this study revealed many patients had a poor understanding of heart disease, were not concerned about developing heart disease in the future and did not know that hypertension predisposes to heart disease. Barriers to fruit and vegetable consumption were poor access, cost and sociocultural factors. Whereas, being busy, poor physical health, and lack of access to an exercise facility were barriers to physical activity. The participants with CVD maintained unhealthy lifestyles even though they attended follow-up care with a specific focus on risk management. The findings of this study demonstrate the high prevalence of physical inactivity, alcohol consumption and inadequate fruit and vegetable consumption in a developing country. The emerging increase of CVD and the continuation of unhealthy lifestyle in patients is somewhat comparable with western countries, indicating this as a global problem. The burden of CV risk behaviours is increasing whilst the patients’ understanding of associated risk factors is limited. Almost half of CVD patients had suboptimal knowledge regarding CVD risk factors, and they had multiple unhealthy behaviours though they attended chronic follow up care clinics. Lower education, rural residence and single marital status were associated with lower knowledge of CVD risk factors. Despite being at high risk for heart disease, patients with hypertension had an inadequate understanding of heart disease and they had deficient understanding that hypertension predisposes to heart disease. However, they were aware that smoking, drinking alcohol, inadequate consumption of fruit and vegetables and physical inactivity causes heart disease. Results indicated that education level influences participants’ understanding of heart disease and the risk factors. This study provides evidence for policy makers that health services reform is required to promote healthy lifestyle behaviours. Implementation of lifestyle support programs should be considered for the disease prevention policy agenda in Ethiopia. In line with intensive patient counselling and education to improve awareness of CVD risk factors, implementation of multidisciplinary, innovative interventions and systematic nurse-led lifestyle counselling is important to assist CVD patients to adopt healthy lifestyles. Healthcare workers need to identify and consider patients’ understanding of health behaviours in planning secondary prevention strategies. Moreover, implementation of CVD prevention programs should be considered for disease prevention policy in Ethiopia.