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Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients
Heart & Lung 44 (2015) 183e188
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Care of Patients With or At-Risk for Cardiovascular Disorders
Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients Mona A. Abed, PhD, RN a, *, Amani A. Khalil, PhD, RN b, Debra K. Moser, RN, DNSc c, d a
Hashemite University, School of Nursing, Zarqa, Jordan The University of Jordan, School of Nursing, Amman, Jordan c University of Kentucky, School of Nursing, Kentucky, USA d University of Ulster, School of Nursing, Belfast, Ireland b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 August 2014 Received in revised form 24 February 2015 Accepted 27 February 2015 Available online 1 April 2015
Background: Poor awareness of modifiable risks for acute myocardial infarction (AMI) may explain the reported weak relationship between patients’ actual and perceived risk for AMI. Objectives: To assess the level of awareness of modifiable risks and perceived vulnerability for AMI among Jordanian patients, and to determine their independent association. Methods: This was a cross-sectional correlational study (N ¼ 231). Perceived risk, awareness of risk factors and risk profile were collected by self-reports and medical chart review. Results: Patients were mostly males (80%) and had a mean of 55.3 12.6 years for age. Perceived and actual AMI risks were not highly congruent even though patients had, on average, two modifiable risks and were knowledgeable of them. Awareness of risk factors independently explained 3.5% of the variance in perceived risk. Conclusions: The risk for developing AMI is underestimated among cardiac patients and it is only weakly linked with their awareness of AMI risk factors. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Knowledge Awareness Myocardial infarction Perception Risk factors
Introduction Acute myocardial infarction (AMI) is a serious health condition that is associated with high mortality and morbidity across the world. In Jordan, a middle income Middle-eastern country, AMI kills more than all respiratory disorders combined.1 In-hospital costs for AMI are about two times the average cost of other health conditions.2 Psychological co-morbidity after AMI is also common and involves depression, anxiety, and post-traumatic stress disorder.3,4 Although burdensome, AMI can be prevented by controlling known modifiable risk factors, such as hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, obesity and smoking. Preventative measures include exercising, eating a healthy diet low in fat and sodium, managing weight, and stopping smoking.5,6 Nevertheless, being at actual risk for an AMI neither encouraged patients, including Jordanians, to adopt healthy behaviors nor did it
* Corresponding author. Hashemite University, College of Nursing, Zarqa 13115, Jordan. Tel.: þ962 719 714 7206. E-mail address: [email protected] (M.A. Abed). 0147-9563/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2015.02.008
motivate them to call the emergency medical service when they developed chest pain.6e8 On the other hand, perceived risk or one’s belief about his/her likelihood of encountering a health threat, like AMI determines patients’ engagement in healthy lifestyle and adherence to treatment regimens, according to health behavior theories and previous research.9,10 Perceived risk is a fundamental part of the Health Belief Model, an important decision-making theory.9,11 Threat appraisal constitutes a major construct in the Health Belief Model. According to this theory, people evaluate their vulnerability or susceptibility for a health threat before deciding to adopt a recommended health behavior. The assumption is that perception of risk motivates people to act favorably for the purpose of minimizing a health threat. However, Weinstein demonstrated that individuals commonly underestimate their risk for a health threat for different purposes such as enhancing self-esteem or reducing anxiety.12,13 Individuals with optimistic bias tend to exaggerate expected benefits of their personal risk-reducing factors (e.g., heredity, environment) and minimize adverse impact of their risk-aggravating behaviors.12 This inaccurate risk perception raises the threshold for acting appropriately in the face of acute symptoms.14
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Perceived risk for AMI is associated with various factors such as gender, age, educational level, and cardiovascular health history.15e17 Females and young individuals were found to be optimistic regarding their perceived risk for AMI due to their belief that they are protected by their gender and physical fitness.15e17 Poorly educated individuals and those who did not have a personal or family history of cardiac events also tend to underestimate their risk for AMI.15,17e19 Actual risk profile for AMI, as determined by patients’ history of DM, HTN, hyperlipidemia, obesity, and smoking has frequently been found either to be not associated or weakly linked with patients’ perceived vulnerability for AMI.20e23 One possible explanation of the weak relationship between patients’ actual and perceived risk for AMI is poor awareness of the modifiable AMI risk factors. Understanding what modifies one’s risk is important for accurate estimate of one’s perceived risk. However, several investigators have documented that patients and the public are not knowledgeable about modifiable AMI risks.24e26 For example, a survey carried out in Thailand revealed that people believed drinking coffee and experiencing insomnia to be AMI risk factors more often than DM and obesity.27 Additionally, van Steenkisite and colleagues found that patients often determined their risk for AMI based on their cholesterol level only.18 Other patients believed that a decrease in nicotine level in the body after quitting smoking will actually increase their chance of developing AMI.18 Furthermore, some patients believed that their coronary interventions had eradicated their risk for AMI.15 The degree to which awareness of AMI risk factors heightens patients’ perceived risk for AMI is unknown. Thus, the first aim of the current study was to investigate the awareness of five modifiable risk factors (i.e., DM, HTN, hyperlipidemia, obesity, current smoking) and perceived vulnerability for AMI among Jordanian patients with a first-time AMI. The second aim was to determine whether such awareness is associated with patients’ perceived risk for experiencing AMI after controlling for their individual risk profile and demographic variables. Methods Design, sample and setting This was a cross-sectional correlational study. All patients hospitalized in one of 10 hospitals in Amman and Al Zarqa with a firsttime AMI were considered for recruitment if they were above 18 years old, clinically stable, had no comorbid psychiatric or mental illnesses and were fluent in Arabic. By considering perceived vulnerability for AMI as the outcome variable of principal interest, sample size was calculated using G-Power V.3.1.28 A sample of 200 was considered sufficient based on an effect size of 0.30, power of 0.80 and a two-tailed level of significance of 0.05. We increased the sample size to 230 to compensate for missing data. Procedure The institutional review board of the Hashemite University and the participating hospitals approved the current study and the investigation conformed to the principles in the Declaration of Helsinki.29 The study aims, inclusion criteria and data collection plan were explained to research assistants who held master’s degrees in nursing and were familiar with the assigned hospital. In order to recruit patients, research assistants checked medical records of all patients hospitalized for AMI during the study period and determined their eligibility. They explained the study aims, and patient’s rights as research participants. Patients were also informed that their choice to participate was risk-free and had no
impact on their medical care. Patients who agreed to participate signed an informed consent document prior to providing any information to the research assistants. Patients were interviewed within 72 h of their admission to the hospital. Study questionnaires were read to patients and their answers were recorded by research assistants. Medical records were reviewed after the interviews with patients to complete the data collection process. Anonymity was preserved for all patients. During the study period the primary investigator randomly selected 10% of medical records to verify the accuracy of collected data, and no errors were detected. Measurement Awareness of AMI risk factors scale A five-item scale was developed to measure patients’ awareness of five modifiable risk factors for AMI (DM, HTN, hyperlipidemia, obesity, and current smoking). For each item, patients were asked to indicate their level of agreement regarding whether the risk factor increases the chance of experiencing AMI. There were four possible response options for each item: 1 ¼ definitely disagree, 2 ¼ disagree, 3 ¼ agree, 4 ¼ definitely agree. The total score is the sum of scores for the five items and can range between five and 20. A higher score indicates higher awareness about modifiable AMI risk factors. Construct validity of the awareness scale was supported by demonstrating a significant positive correlation with years of education (r ¼ 0.31, P < 0.001). Cronbach alpha of the awareness scale within the current study was 0.78. Perceived vulnerability for AMI Perceived vulnerability or risk for AMI was measured using a four-point Likert question; “prior to your current diagnosis of AMI and compared to other people, how did you evaluate your personal risk of having an AMI during your lifetime?” There were four possible response options: 1 ¼ at no risk, 2 ¼ at low risk, 3 ¼ at moderate risk, and 4 ¼ at high risk. A higher score indicated higher perceived vulnerability for AMI. Construct validity of the perceived vulnerability for AMI scale was tested by examining the association of the scale with patients’ beliefs about first cause of death in Jordan. We expected this association based on theoretical and empirical evidence30,31 that one’s perceived risk becomes higher when he/she believes that the health threat is frequent and common. Results of chi-square test supported the construct validity of the perceived risk scale (X2 ¼ 4.7, P ¼ 0.03). Patients who thought that cardiac disease is the first cause of Jordanian deaths were more likely to perceive themselves at high risk for AMI than those who thought of other causes or did not know. Demographic variables and risk factors for AMI The variables age, gender, marital status, education level, insurance, income, smoking and family history of AMI were collected by patient self-report. Height and weight were not routinely recorded in medical records and therefore they were collected by self-report in order to calculate patients’ body mass index (BMI). Patients were considered obese if their calculated BMI was 30. History of angina, HTN, DM and hyperlipidemia were collected by medical record review. Analysis The software SPSS version 17.0 was used for analysis. Data were checked for errors and assumptions of tests were verified. The sample was described using means, standard deviations, and frequency distributions. At the bivariate level, chi-square tests and Spearman rho were used to examine the relationship of perceived vulnerability for AMI with regard to gender, education, first degree
M.A. Abed et al. / Heart & Lung 44 (2015) 183e188
relative with AMI, angina, modifiable AMI risk factors (history of HTN, DM and hyperlipidemia, smoking, and obesity) and number of modifiable risks and awareness of AMI risk factors. For chi-square tests, patients were categorized into mild versus high perceived vulnerability for AMI using the median score of the perceived vulnerability scale. To describe the extent to which awareness of AMI risk factors explains the variance in perceived risk for AMI after controlling covariates, we did a two-step multiple hierarchical regression analysis. In the first block we entered the demographic variables and actual risks (age, gender, education level, family history of AMI, history of angina, HTN, DM and hyperlipidemia, current smoking and obesity) and in the second block we entered awareness of AMI risk factors. Results As summarized in Table 1, the majority of recruited patients (N ¼ 231) were males and married. The sample average was 55.3 12.6 years for age, 10.2 5.7 years for education and 27.9 5.6 for BMI. The prevalence of the five conventional risk factors in descending order were smoking followed by HTN, DM, hyperlipidemia and finally obesity. Only 7% had none of the five conventional risk factors. Awareness of AMI risk factors was high and averaged 17.2 2.6 with a median score of 17.0. Close to onehalf (48%) of patients considered themselves at no risk for developing AMI during their lifetime while 25%, 17% and 10% perceived their risk as low, moderate and high, respectively. Different variables were significantly linked with perceived vulnerability for AMI (Fig. 1). Patients with angina or with firstdegree relatives who had an AMI were more likely to perceive themselves at high risk for AMI than their counterparts ([X2 ¼ 4.2, P ¼ 0.04], [X2 ¼ 5.36, P ¼ 0.02], respectively). Risk perception for AMI was significantly associated with hypertension (X2 ¼ 4.2, P ¼ 0.04) and obesity (X2 ¼ 8.5, P ¼ 0.04) but not with current smoking (X2 ¼ 1.9, P ¼ 0.17), hyperlipidemia (X2 ¼ 2.5, P ¼ 0.11) or DM (X2 ¼ 0.0, P ¼ 0.91). By Spearman rho, there was a positive and weak relationship of perceived vulnerability for AMI to both the cumulative number of modifiable risk factors (r ¼ 0.20, P ¼ 0.005) and awareness of AMI risks (r ¼ 0.17, P ¼ 0.009). Age (r ¼ 0.07, P ¼ 0.32), gender (X2 ¼ 0.15, P ¼ 0.69) and education (r ¼ 0.04, P ¼ 0.58) were not associated with perceived risk for AMI. To examine whether awareness of AMI risk factors added significantly to patients’ perceived vulnerability for AMI after controlling for demographic variables and risk profile, two-step multiple hierarchical regression analysis was performed. At the Table 1 Sample characteristics (N ¼ 231). Variable
n (%)
Male gender Married Monthly income 351 JOD With medical insurance Current smoking Obese (n ¼ 206) History of angina Hypertension Diabetes mellitus Hyperlipidemia (n ¼ 228) Number of risk factors (n ¼ 203) Zero One risk Two risks Three risks Four risks Five risks
185 208 131 153 128 56 42 123 104 65
(80) (90) (57) (66) (55) (24) (18) (53) (45) (28)
14 67 58 40 23 2
(7) (33) (28) (20) (11) (1)
185
first step, age, gender, education level, first-degree relative with AMI, history of angina and the five conventional risk factors to AMI (HTN, DM, hyperlipidemia, current smoking and obesity) explained 15.0% of the variance in perceived vulnerability for AMI (P < 0.001). After entry of awareness of AMI risks at step two the total variance explained by the model as a whole was 18.5% (P < 0.001). Awareness of AMI risk factors explained as additional 3.5% of the variance in perceived risk for AMI (P ¼ 0.005). In the final model, smoking, history of angina, HTN, obesity and awareness of AMI risk factors were statistically significant (Table 2). Discussion Among Jordanian patients with a first-time AMI, we examined patients’ awareness of five modifiable risk factors (HTN, DM, hyperlipidemia, current smoking, and obesity) and their perceived vulnerability for AMI. We demonstrated that patients tended to underestimate their risk although they had on average two modifiable risks and were highly aware of AMI risk factors. Awareness of modifiable risk factors was weakly correlated with perceived vulnerability for AMI and explained a small amount of the variance in risk perception. Only 7% of patients in the current study had none of the five conventional risk factors while 60% had two or more. More than 50% were currently smokers and hypertensive and close to onehalf, one-third and one-quarter of patients were diabetic, hyperlipidemia and obese, respectively. These proportions confirm the reported high prevalence of AMI modifiable risks among Jordanians, especially those with a history of cardiac events.20,32 Smoking, HTN, DM, hyperlipidemia, and obesity induce unfavorable alterations in body functions including coagulation and inflammation processes, endothelial condition, and cardiac autonomic status.33e35 The chance of developing AMI increases by at least 1.5 times when AMI risk factors exist alone6 and close to four times when they occur together.32,36 In addition, individuals with more than one modifiable risk factor are more likely to have sudden cardiac death after AMI.37 This emphasizes the importance of controlling risk factors in order to decrease the incidence and complications of AMI. Consistent with previous investigations, having a specific modifiable risk to AMI does not necessarily raise one’s perceived risk. In the current study, HTN, current smoking and obesity, but not DM or hyperlipidemia were independently associated with AMI risk perception. According to a qualitative study, diabetic patients thought there is no direct relationship of DM or cholesterol to the development of AMI.38 In addition, only 17% of patients with DM considered heart disease as a serious complication of their illness.39 Poor appreciation of the role that either DM or hyperlipidemia could play in changing health outcomes may explain the common suboptimal blood sugar and cholesterol control among patients.40,41 Therefore, health care providers have to clearly communicate with their patients the increased risk for AMI that DM or hyperlipidemia engender. Though smoking was positively lined with perceived risk for AMI in our regression model, it is should be highlighted that more than half (69%) of smokers had the perception that their risk of AMI was low. Other studies conducted in Jordan confirmed the high prevalence of smoking among patients with ischemic heart disease (61%)36 and among health care providers (39%).42 It is possible that patients become less appreciative of the role of smoking in developing AMI or they may feel that it is accepted to smoke when their health care providers are actually smokers. Thus, health care providers have to act as a role model by stopping smoking. While the majority of enrolled patients in the current study were at a considerable risk for AMI and their awareness of AMI risks
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Fig. 1. Perceived vulnerability for acute myocardial infarction according to patients’ risk profile. AMI ¼ acute myocardial infarction. *p < 0.05.
was shown to be high, close to three quarters perceived themselves at low or no risk for AMI. Also, the relationship between an increased number of the modifiable risks and risk perception was weak. These results confirm previous reports43e44 that patients’ perceived and actual risk of AMI are not highly congruent and that patients, in general, tend to underestimate their vulnerability to health threats, including AMI. The results also suggest that being aware of modifiable AMI risk factors is one component needed to increase an individual’s perceived risk for AMI, but it is insufficient to match one’s perceived risk with the actual one. Other investigators have found that high knowledge of risk factors did not help vulnerable patients to properly determine their AMI risk.41 The poor contribution of risk factors awareness to risk perception may mean that vulnerable patients must be educated about other salient aspects of AMI, such as seriousness and incidence, to properly correct their risk perception for AMI. The weak relationship between risk perception and awareness in our study also confirms previous conclusions that cognitive aspects do not entirely govern one’s risk perception. Emotions such as feelings of anxiety and worry do affect one’s risk perception.12 In Jordan, health campaigns are mostly employed in raising awareness about cancer and this may result in less concern among Jordanians about cardiac health problems. Perception of low risk for cardiac events has a negative impact on practicing a healthy lifestyle.45 This may explain why Jordanians adults with and without ischemic heart disease were found to be poorly adherent to a healthy life-style that included physical activity and diet control. On the other hand, educational interventions that corrected patients’ misconceptions, including risk perception, showed a modest improvement in patients’ commitment to healthy life.45,46 Low risk perception for AMI among our patients could be possibly linked with cultural or religious factors. Islam the religion of the majority in Jordan has a large impact on Jordanians’ health beliefs and practices.47 Jordanians in general believe that illness is God’s will and it is a way to clear their sins. This belief may make some less appreciative of the importance of risk profile in determining their AMI vulnerability. Also, secondary to Islamic practices, such as praying five times every day (praying includes physical activity like standing, bowing, prostrating and sitting) and fasting one month a year during Ramadan, some Jordanians may believe that they are actually controlling their risk profile and therefore their risk for AMI is low. Vulnerable patients may dismiss risk communication messages delivered by health campaigns when they have low risk perception
for health threat or when they feel that the threat is irrelevant to them.48 It is possible that health care providers in Jordan are not giving effective individualized risk communication that helps vulnerable patients comprehend their risk for AMI. Effective risk communication requires careful incorporation of standardized risk assessment tools in practice. It also needs attention not only to the content of risk message but also to how the message is framed and how it may interact with the receipt’s characteristics and beliefs.49 Though some papers suggested strategies regarding efficient methods to communicate uncertainty and probability (“numerical risk”) to the public,50 we lack research that guides risk communication for the Jordanian population. If, for example, patients believe that one’s risk for developing AMI is tied with God’s will and no one knows the future except Him, then the risk message will be perceived skeptically no matter how it is formulated. We need more studies to understand how Jordanians rate their risk for AMI and how we can develop effective risk communication that addresses Jordanians’ health literacy and beliefs. It is notable that in the current study none of the demographic variables, including age, gender and education, was associated with risk perception. Although similar findings have been reported in other studies,21,41 our results could be related to the limited
Table 2 Two-step multiple hierarchical regression analysis to predict perceived risk for acute myocardial infarction (N ¼ 203). Variable
Age Gender Education Having first-degree relative with myocardial infarction Current smoking Angina Diabetes mellitus Hypertension Hyperlipidemia Obesity Awareness of modifiable myocardial infarction risk factors 2 R 2 R change
Model I (F [10, 193] ¼ 3.39, P < 0.001)
Model II (F [11, 192] ¼ 3.95, P < 0.001 )
b
b
P-value
P-value
0.05 0.03 0.04 0.13
0.52 0.71 0.63 0.07
0.06 0.03 0.02 0.12
0.44 0.73 0.82 0.08
0.16 0.17 0.08 0.14 0.04 0.25
0.05 0.02 0.36 0.09 0.62 <0.001
0.17 0.16 0.08 0.17 0.04 0.24 0.20
0.03 0.02 0.33 0.04 0.58 <0.001 0.005
0.15 0.15
0.185 0.035
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variability of these variables in the current investigation, which require further research for confirmation. As with all studies, results should be evaluated after consideration of limitations. One drawback of our study is that patients’ awareness of AMI risk factors was measured by a rating scale rather than an open-ended question. Health rating scales and agreement questions may overestimate subjects’ knowledge as the answers are, in some way, introduced in the questions. Thus, we are unsure if our patients would have responded differently if they were asked to list the risk factors. Also, we remain uncertain if patients were actually knowledgeable of their risk profile as we depended mainly on medical records for data extraction. However, the routine in Jordan hospitals is that patients receive screening for comorbidities (HTN, DM, hyperlipidemia) on admission and they are usually informed of results. Other limitations include the retrospective nature of the study, the non-probability sampling method and the primary focus on the awareness of AMI risk factors and risk profile to understand how patients rated their risk for AMI. In conclusion, patients do not necessarily perceive their risk for AMI based on their actual risk profile. Furthermore, we cannot assume that vulnerable patients appropriately perceive their risk for AMI even when they demonstrate high awareness of AMI risk factors. AMI can be prevented if patients know their risk and how to modify it. Health care providers are usually perceived as the most trusted and credible source of information and thus they are in are in an excellent position to openly discuss with their patients how they comprehend their vulnerability for AMI and what can be done to reduce it. Such conversation provides an excellent chance to correct patients’ misconceptions about AMI risk. In addition, incorporation of cultural or religious factors in interventions may make them more persuasive to certain audiences. For example, integrating Islamic teachings that address one’s accountability for health and illness prevention in risk communication could be very compelling to Jordanians. Also, because some Jordanian male patients still believe that female physicians are less competent than their counterparts, the type of physician-patient dyad (mixed or same gender) may be important when communicating risk to patients. Acknowledgment This study was funded by the Hashemite University in Jordan. References 1. Mortality Data in Jordan, 2010. Ministry of Health. Available from: http://www. moh.gov.jo/EN/Pages/Periodic-Newsletters.aspx; Accessed 02.02.14. 2. Costs for Hospital Stays in the United States, 2010. Statistical Brief #146. Agency for Healthcare Research and Quality. Available from: http://www. hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf; Accessed 02.02.14. 3. Bankier B, Januzzi JL, Littman AB. The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease. Psychosom Med. 2004;66:645e650. 4. Carney RM, Freedland KE. Depression in patients with coronary heart disease. Am J Med. 2008;121:S20eS27. 5. Hoevenaar-Blom MP, Spijkerman AM, Boshuizen HC, Boer JM, Kromhout D, Verschuren WM. Effect of using repeated measurements of a Mediterranean style diet on the strength of the association with cardiovascular disease during 12 years: the Doetinchem Cohort Study. Eur J Nutr. 2014;53:1209e1215. 6. Lanas F, Avezum A, Bautista LE, et al. Risk factors for acute myocardial infarction in Latin America: the INTERHEART Latin American study. Circulation. 2007;115:1067e1074. 7. Eshah NF. Lifestyle and health promoting behaviours in Jordanian subjects without prior history of coronary heart disease. Int J Nurs Pract. 2011;17: 27e35. 8. Al-Safi SA, Alkofahi AS, El-Eid HS. Public response to chest pain in Jordan. Eur J Cardiovasc Nurs. 2005;4:139e144. 9. Webster R, Heeley E. Perceptions of risk: understanding cardiovascular disease. Risk Manag Healthc Policy. 2010;3:49e60. 10. Wendt SJ. Perception of future risk of breast cancer and coronary heart disease in female undergraduates. Psychol Health Med. 2005;10(3):253e262.
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Care of Patients With or At-Risk for Cardiovascular Disorders
Awareness of modifiable acute myocardial infarction risk factors has little impact on risk perception for heart attack among vulnerable patients Mona A. Abed, PhD, RN a, *, Amani A. Khalil, PhD, RN b, Debra K. Moser, RN, DNSc c, d a
Hashemite University, School of Nursing, Zarqa, Jordan The University of Jordan, School of Nursing, Amman, Jordan c University of Kentucky, School of Nursing, Kentucky, USA d University of Ulster, School of Nursing, Belfast, Ireland b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 30 August 2014 Received in revised form 24 February 2015 Accepted 27 February 2015 Available online 1 April 2015
Background: Poor awareness of modifiable risks for acute myocardial infarction (AMI) may explain the reported weak relationship between patients’ actual and perceived risk for AMI. Objectives: To assess the level of awareness of modifiable risks and perceived vulnerability for AMI among Jordanian patients, and to determine their independent association. Methods: This was a cross-sectional correlational study (N ¼ 231). Perceived risk, awareness of risk factors and risk profile were collected by self-reports and medical chart review. Results: Patients were mostly males (80%) and had a mean of 55.3 12.6 years for age. Perceived and actual AMI risks were not highly congruent even though patients had, on average, two modifiable risks and were knowledgeable of them. Awareness of risk factors independently explained 3.5% of the variance in perceived risk. Conclusions: The risk for developing AMI is underestimated among cardiac patients and it is only weakly linked with their awareness of AMI risk factors. Ó 2015 Elsevier Inc. All rights reserved.
Keywords: Knowledge Awareness Myocardial infarction Perception Risk factors
Introduction Acute myocardial infarction (AMI) is a serious health condition that is associated with high mortality and morbidity across the world. In Jordan, a middle income Middle-eastern country, AMI kills more than all respiratory disorders combined.1 In-hospital costs for AMI are about two times the average cost of other health conditions.2 Psychological co-morbidity after AMI is also common and involves depression, anxiety, and post-traumatic stress disorder.3,4 Although burdensome, AMI can be prevented by controlling known modifiable risk factors, such as hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, obesity and smoking. Preventative measures include exercising, eating a healthy diet low in fat and sodium, managing weight, and stopping smoking.5,6 Nevertheless, being at actual risk for an AMI neither encouraged patients, including Jordanians, to adopt healthy behaviors nor did it
* Corresponding author. Hashemite University, College of Nursing, Zarqa 13115, Jordan. Tel.: þ962 719 714 7206. E-mail address: [email protected] (M.A. Abed). 0147-9563/$ e see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hrtlng.2015.02.008
motivate them to call the emergency medical service when they developed chest pain.6e8 On the other hand, perceived risk or one’s belief about his/her likelihood of encountering a health threat, like AMI determines patients’ engagement in healthy lifestyle and adherence to treatment regimens, according to health behavior theories and previous research.9,10 Perceived risk is a fundamental part of the Health Belief Model, an important decision-making theory.9,11 Threat appraisal constitutes a major construct in the Health Belief Model. According to this theory, people evaluate their vulnerability or susceptibility for a health threat before deciding to adopt a recommended health behavior. The assumption is that perception of risk motivates people to act favorably for the purpose of minimizing a health threat. However, Weinstein demonstrated that individuals commonly underestimate their risk for a health threat for different purposes such as enhancing self-esteem or reducing anxiety.12,13 Individuals with optimistic bias tend to exaggerate expected benefits of their personal risk-reducing factors (e.g., heredity, environment) and minimize adverse impact of their risk-aggravating behaviors.12 This inaccurate risk perception raises the threshold for acting appropriately in the face of acute symptoms.14
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Perceived risk for AMI is associated with various factors such as gender, age, educational level, and cardiovascular health history.15e17 Females and young individuals were found to be optimistic regarding their perceived risk for AMI due to their belief that they are protected by their gender and physical fitness.15e17 Poorly educated individuals and those who did not have a personal or family history of cardiac events also tend to underestimate their risk for AMI.15,17e19 Actual risk profile for AMI, as determined by patients’ history of DM, HTN, hyperlipidemia, obesity, and smoking has frequently been found either to be not associated or weakly linked with patients’ perceived vulnerability for AMI.20e23 One possible explanation of the weak relationship between patients’ actual and perceived risk for AMI is poor awareness of the modifiable AMI risk factors. Understanding what modifies one’s risk is important for accurate estimate of one’s perceived risk. However, several investigators have documented that patients and the public are not knowledgeable about modifiable AMI risks.24e26 For example, a survey carried out in Thailand revealed that people believed drinking coffee and experiencing insomnia to be AMI risk factors more often than DM and obesity.27 Additionally, van Steenkisite and colleagues found that patients often determined their risk for AMI based on their cholesterol level only.18 Other patients believed that a decrease in nicotine level in the body after quitting smoking will actually increase their chance of developing AMI.18 Furthermore, some patients believed that their coronary interventions had eradicated their risk for AMI.15 The degree to which awareness of AMI risk factors heightens patients’ perceived risk for AMI is unknown. Thus, the first aim of the current study was to investigate the awareness of five modifiable risk factors (i.e., DM, HTN, hyperlipidemia, obesity, current smoking) and perceived vulnerability for AMI among Jordanian patients with a first-time AMI. The second aim was to determine whether such awareness is associated with patients’ perceived risk for experiencing AMI after controlling for their individual risk profile and demographic variables. Methods Design, sample and setting This was a cross-sectional correlational study. All patients hospitalized in one of 10 hospitals in Amman and Al Zarqa with a firsttime AMI were considered for recruitment if they were above 18 years old, clinically stable, had no comorbid psychiatric or mental illnesses and were fluent in Arabic. By considering perceived vulnerability for AMI as the outcome variable of principal interest, sample size was calculated using G-Power V.3.1.28 A sample of 200 was considered sufficient based on an effect size of 0.30, power of 0.80 and a two-tailed level of significance of 0.05. We increased the sample size to 230 to compensate for missing data. Procedure The institutional review board of the Hashemite University and the participating hospitals approved the current study and the investigation conformed to the principles in the Declaration of Helsinki.29 The study aims, inclusion criteria and data collection plan were explained to research assistants who held master’s degrees in nursing and were familiar with the assigned hospital. In order to recruit patients, research assistants checked medical records of all patients hospitalized for AMI during the study period and determined their eligibility. They explained the study aims, and patient’s rights as research participants. Patients were also informed that their choice to participate was risk-free and had no
impact on their medical care. Patients who agreed to participate signed an informed consent document prior to providing any information to the research assistants. Patients were interviewed within 72 h of their admission to the hospital. Study questionnaires were read to patients and their answers were recorded by research assistants. Medical records were reviewed after the interviews with patients to complete the data collection process. Anonymity was preserved for all patients. During the study period the primary investigator randomly selected 10% of medical records to verify the accuracy of collected data, and no errors were detected. Measurement Awareness of AMI risk factors scale A five-item scale was developed to measure patients’ awareness of five modifiable risk factors for AMI (DM, HTN, hyperlipidemia, obesity, and current smoking). For each item, patients were asked to indicate their level of agreement regarding whether the risk factor increases the chance of experiencing AMI. There were four possible response options for each item: 1 ¼ definitely disagree, 2 ¼ disagree, 3 ¼ agree, 4 ¼ definitely agree. The total score is the sum of scores for the five items and can range between five and 20. A higher score indicates higher awareness about modifiable AMI risk factors. Construct validity of the awareness scale was supported by demonstrating a significant positive correlation with years of education (r ¼ 0.31, P < 0.001). Cronbach alpha of the awareness scale within the current study was 0.78. Perceived vulnerability for AMI Perceived vulnerability or risk for AMI was measured using a four-point Likert question; “prior to your current diagnosis of AMI and compared to other people, how did you evaluate your personal risk of having an AMI during your lifetime?” There were four possible response options: 1 ¼ at no risk, 2 ¼ at low risk, 3 ¼ at moderate risk, and 4 ¼ at high risk. A higher score indicated higher perceived vulnerability for AMI. Construct validity of the perceived vulnerability for AMI scale was tested by examining the association of the scale with patients’ beliefs about first cause of death in Jordan. We expected this association based on theoretical and empirical evidence30,31 that one’s perceived risk becomes higher when he/she believes that the health threat is frequent and common. Results of chi-square test supported the construct validity of the perceived risk scale (X2 ¼ 4.7, P ¼ 0.03). Patients who thought that cardiac disease is the first cause of Jordanian deaths were more likely to perceive themselves at high risk for AMI than those who thought of other causes or did not know. Demographic variables and risk factors for AMI The variables age, gender, marital status, education level, insurance, income, smoking and family history of AMI were collected by patient self-report. Height and weight were not routinely recorded in medical records and therefore they were collected by self-report in order to calculate patients’ body mass index (BMI). Patients were considered obese if their calculated BMI was 30. History of angina, HTN, DM and hyperlipidemia were collected by medical record review. Analysis The software SPSS version 17.0 was used for analysis. Data were checked for errors and assumptions of tests were verified. The sample was described using means, standard deviations, and frequency distributions. At the bivariate level, chi-square tests and Spearman rho were used to examine the relationship of perceived vulnerability for AMI with regard to gender, education, first degree
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relative with AMI, angina, modifiable AMI risk factors (history of HTN, DM and hyperlipidemia, smoking, and obesity) and number of modifiable risks and awareness of AMI risk factors. For chi-square tests, patients were categorized into mild versus high perceived vulnerability for AMI using the median score of the perceived vulnerability scale. To describe the extent to which awareness of AMI risk factors explains the variance in perceived risk for AMI after controlling covariates, we did a two-step multiple hierarchical regression analysis. In the first block we entered the demographic variables and actual risks (age, gender, education level, family history of AMI, history of angina, HTN, DM and hyperlipidemia, current smoking and obesity) and in the second block we entered awareness of AMI risk factors. Results As summarized in Table 1, the majority of recruited patients (N ¼ 231) were males and married. The sample average was 55.3 12.6 years for age, 10.2 5.7 years for education and 27.9 5.6 for BMI. The prevalence of the five conventional risk factors in descending order were smoking followed by HTN, DM, hyperlipidemia and finally obesity. Only 7% had none of the five conventional risk factors. Awareness of AMI risk factors was high and averaged 17.2 2.6 with a median score of 17.0. Close to onehalf (48%) of patients considered themselves at no risk for developing AMI during their lifetime while 25%, 17% and 10% perceived their risk as low, moderate and high, respectively. Different variables were significantly linked with perceived vulnerability for AMI (Fig. 1). Patients with angina or with firstdegree relatives who had an AMI were more likely to perceive themselves at high risk for AMI than their counterparts ([X2 ¼ 4.2, P ¼ 0.04], [X2 ¼ 5.36, P ¼ 0.02], respectively). Risk perception for AMI was significantly associated with hypertension (X2 ¼ 4.2, P ¼ 0.04) and obesity (X2 ¼ 8.5, P ¼ 0.04) but not with current smoking (X2 ¼ 1.9, P ¼ 0.17), hyperlipidemia (X2 ¼ 2.5, P ¼ 0.11) or DM (X2 ¼ 0.0, P ¼ 0.91). By Spearman rho, there was a positive and weak relationship of perceived vulnerability for AMI to both the cumulative number of modifiable risk factors (r ¼ 0.20, P ¼ 0.005) and awareness of AMI risks (r ¼ 0.17, P ¼ 0.009). Age (r ¼ 0.07, P ¼ 0.32), gender (X2 ¼ 0.15, P ¼ 0.69) and education (r ¼ 0.04, P ¼ 0.58) were not associated with perceived risk for AMI. To examine whether awareness of AMI risk factors added significantly to patients’ perceived vulnerability for AMI after controlling for demographic variables and risk profile, two-step multiple hierarchical regression analysis was performed. At the Table 1 Sample characteristics (N ¼ 231). Variable
n (%)
Male gender Married Monthly income 351 JOD With medical insurance Current smoking Obese (n ¼ 206) History of angina Hypertension Diabetes mellitus Hyperlipidemia (n ¼ 228) Number of risk factors (n ¼ 203) Zero One risk Two risks Three risks Four risks Five risks
185 208 131 153 128 56 42 123 104 65
(80) (90) (57) (66) (55) (24) (18) (53) (45) (28)
14 67 58 40 23 2
(7) (33) (28) (20) (11) (1)
185
first step, age, gender, education level, first-degree relative with AMI, history of angina and the five conventional risk factors to AMI (HTN, DM, hyperlipidemia, current smoking and obesity) explained 15.0% of the variance in perceived vulnerability for AMI (P < 0.001). After entry of awareness of AMI risks at step two the total variance explained by the model as a whole was 18.5% (P < 0.001). Awareness of AMI risk factors explained as additional 3.5% of the variance in perceived risk for AMI (P ¼ 0.005). In the final model, smoking, history of angina, HTN, obesity and awareness of AMI risk factors were statistically significant (Table 2). Discussion Among Jordanian patients with a first-time AMI, we examined patients’ awareness of five modifiable risk factors (HTN, DM, hyperlipidemia, current smoking, and obesity) and their perceived vulnerability for AMI. We demonstrated that patients tended to underestimate their risk although they had on average two modifiable risks and were highly aware of AMI risk factors. Awareness of modifiable risk factors was weakly correlated with perceived vulnerability for AMI and explained a small amount of the variance in risk perception. Only 7% of patients in the current study had none of the five conventional risk factors while 60% had two or more. More than 50% were currently smokers and hypertensive and close to onehalf, one-third and one-quarter of patients were diabetic, hyperlipidemia and obese, respectively. These proportions confirm the reported high prevalence of AMI modifiable risks among Jordanians, especially those with a history of cardiac events.20,32 Smoking, HTN, DM, hyperlipidemia, and obesity induce unfavorable alterations in body functions including coagulation and inflammation processes, endothelial condition, and cardiac autonomic status.33e35 The chance of developing AMI increases by at least 1.5 times when AMI risk factors exist alone6 and close to four times when they occur together.32,36 In addition, individuals with more than one modifiable risk factor are more likely to have sudden cardiac death after AMI.37 This emphasizes the importance of controlling risk factors in order to decrease the incidence and complications of AMI. Consistent with previous investigations, having a specific modifiable risk to AMI does not necessarily raise one’s perceived risk. In the current study, HTN, current smoking and obesity, but not DM or hyperlipidemia were independently associated with AMI risk perception. According to a qualitative study, diabetic patients thought there is no direct relationship of DM or cholesterol to the development of AMI.38 In addition, only 17% of patients with DM considered heart disease as a serious complication of their illness.39 Poor appreciation of the role that either DM or hyperlipidemia could play in changing health outcomes may explain the common suboptimal blood sugar and cholesterol control among patients.40,41 Therefore, health care providers have to clearly communicate with their patients the increased risk for AMI that DM or hyperlipidemia engender. Though smoking was positively lined with perceived risk for AMI in our regression model, it is should be highlighted that more than half (69%) of smokers had the perception that their risk of AMI was low. Other studies conducted in Jordan confirmed the high prevalence of smoking among patients with ischemic heart disease (61%)36 and among health care providers (39%).42 It is possible that patients become less appreciative of the role of smoking in developing AMI or they may feel that it is accepted to smoke when their health care providers are actually smokers. Thus, health care providers have to act as a role model by stopping smoking. While the majority of enrolled patients in the current study were at a considerable risk for AMI and their awareness of AMI risks
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Fig. 1. Perceived vulnerability for acute myocardial infarction according to patients’ risk profile. AMI ¼ acute myocardial infarction. *p < 0.05.
was shown to be high, close to three quarters perceived themselves at low or no risk for AMI. Also, the relationship between an increased number of the modifiable risks and risk perception was weak. These results confirm previous reports43e44 that patients’ perceived and actual risk of AMI are not highly congruent and that patients, in general, tend to underestimate their vulnerability to health threats, including AMI. The results also suggest that being aware of modifiable AMI risk factors is one component needed to increase an individual’s perceived risk for AMI, but it is insufficient to match one’s perceived risk with the actual one. Other investigators have found that high knowledge of risk factors did not help vulnerable patients to properly determine their AMI risk.41 The poor contribution of risk factors awareness to risk perception may mean that vulnerable patients must be educated about other salient aspects of AMI, such as seriousness and incidence, to properly correct their risk perception for AMI. The weak relationship between risk perception and awareness in our study also confirms previous conclusions that cognitive aspects do not entirely govern one’s risk perception. Emotions such as feelings of anxiety and worry do affect one’s risk perception.12 In Jordan, health campaigns are mostly employed in raising awareness about cancer and this may result in less concern among Jordanians about cardiac health problems. Perception of low risk for cardiac events has a negative impact on practicing a healthy lifestyle.45 This may explain why Jordanians adults with and without ischemic heart disease were found to be poorly adherent to a healthy life-style that included physical activity and diet control. On the other hand, educational interventions that corrected patients’ misconceptions, including risk perception, showed a modest improvement in patients’ commitment to healthy life.45,46 Low risk perception for AMI among our patients could be possibly linked with cultural or religious factors. Islam the religion of the majority in Jordan has a large impact on Jordanians’ health beliefs and practices.47 Jordanians in general believe that illness is God’s will and it is a way to clear their sins. This belief may make some less appreciative of the importance of risk profile in determining their AMI vulnerability. Also, secondary to Islamic practices, such as praying five times every day (praying includes physical activity like standing, bowing, prostrating and sitting) and fasting one month a year during Ramadan, some Jordanians may believe that they are actually controlling their risk profile and therefore their risk for AMI is low. Vulnerable patients may dismiss risk communication messages delivered by health campaigns when they have low risk perception
for health threat or when they feel that the threat is irrelevant to them.48 It is possible that health care providers in Jordan are not giving effective individualized risk communication that helps vulnerable patients comprehend their risk for AMI. Effective risk communication requires careful incorporation of standardized risk assessment tools in practice. It also needs attention not only to the content of risk message but also to how the message is framed and how it may interact with the receipt’s characteristics and beliefs.49 Though some papers suggested strategies regarding efficient methods to communicate uncertainty and probability (“numerical risk”) to the public,50 we lack research that guides risk communication for the Jordanian population. If, for example, patients believe that one’s risk for developing AMI is tied with God’s will and no one knows the future except Him, then the risk message will be perceived skeptically no matter how it is formulated. We need more studies to understand how Jordanians rate their risk for AMI and how we can develop effective risk communication that addresses Jordanians’ health literacy and beliefs. It is notable that in the current study none of the demographic variables, including age, gender and education, was associated with risk perception. Although similar findings have been reported in other studies,21,41 our results could be related to the limited
Table 2 Two-step multiple hierarchical regression analysis to predict perceived risk for acute myocardial infarction (N ¼ 203). Variable
Age Gender Education Having first-degree relative with myocardial infarction Current smoking Angina Diabetes mellitus Hypertension Hyperlipidemia Obesity Awareness of modifiable myocardial infarction risk factors 2 R 2 R change
Model I (F [10, 193] ¼ 3.39, P < 0.001)
Model II (F [11, 192] ¼ 3.95, P < 0.001 )
b
b
P-value
P-value
0.05 0.03 0.04 0.13
0.52 0.71 0.63 0.07
0.06 0.03 0.02 0.12
0.44 0.73 0.82 0.08
0.16 0.17 0.08 0.14 0.04 0.25
0.05 0.02 0.36 0.09 0.62 <0.001
0.17 0.16 0.08 0.17 0.04 0.24 0.20
0.03 0.02 0.33 0.04 0.58 <0.001 0.005
0.15 0.15
0.185 0.035
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variability of these variables in the current investigation, which require further research for confirmation. As with all studies, results should be evaluated after consideration of limitations. One drawback of our study is that patients’ awareness of AMI risk factors was measured by a rating scale rather than an open-ended question. Health rating scales and agreement questions may overestimate subjects’ knowledge as the answers are, in some way, introduced in the questions. Thus, we are unsure if our patients would have responded differently if they were asked to list the risk factors. Also, we remain uncertain if patients were actually knowledgeable of their risk profile as we depended mainly on medical records for data extraction. However, the routine in Jordan hospitals is that patients receive screening for comorbidities (HTN, DM, hyperlipidemia) on admission and they are usually informed of results. Other limitations include the retrospective nature of the study, the non-probability sampling method and the primary focus on the awareness of AMI risk factors and risk profile to understand how patients rated their risk for AMI. In conclusion, patients do not necessarily perceive their risk for AMI based on their actual risk profile. Furthermore, we cannot assume that vulnerable patients appropriately perceive their risk for AMI even when they demonstrate high awareness of AMI risk factors. AMI can be prevented if patients know their risk and how to modify it. Health care providers are usually perceived as the most trusted and credible source of information and thus they are in are in an excellent position to openly discuss with their patients how they comprehend their vulnerability for AMI and what can be done to reduce it. Such conversation provides an excellent chance to correct patients’ misconceptions about AMI risk. In addition, incorporation of cultural or religious factors in interventions may make them more persuasive to certain audiences. For example, integrating Islamic teachings that address one’s accountability for health and illness prevention in risk communication could be very compelling to Jordanians. Also, because some Jordanian male patients still believe that female physicians are less competent than their counterparts, the type of physician-patient dyad (mixed or same gender) may be important when communicating risk to patients. Acknowledgment This study was funded by the Hashemite University in Jordan. References 1. Mortality Data in Jordan, 2010. Ministry of Health. Available from: http://www. moh.gov.jo/EN/Pages/Periodic-Newsletters.aspx; Accessed 02.02.14. 2. Costs for Hospital Stays in the United States, 2010. Statistical Brief #146. Agency for Healthcare Research and Quality. Available from: http://www. hcup-us.ahrq.gov/reports/statbriefs/sb146.pdf; Accessed 02.02.14. 3. Bankier B, Januzzi JL, Littman AB. The high prevalence of multiple psychiatric disorders in stable outpatients with coronary heart disease. Psychosom Med. 2004;66:645e650. 4. Carney RM, Freedland KE. Depression in patients with coronary heart disease. Am J Med. 2008;121:S20eS27. 5. Hoevenaar-Blom MP, Spijkerman AM, Boshuizen HC, Boer JM, Kromhout D, Verschuren WM. Effect of using repeated measurements of a Mediterranean style diet on the strength of the association with cardiovascular disease during 12 years: the Doetinchem Cohort Study. Eur J Nutr. 2014;53:1209e1215. 6. Lanas F, Avezum A, Bautista LE, et al. Risk factors for acute myocardial infarction in Latin America: the INTERHEART Latin American study. Circulation. 2007;115:1067e1074. 7. Eshah NF. Lifestyle and health promoting behaviours in Jordanian subjects without prior history of coronary heart disease. Int J Nurs Pract. 2011;17: 27e35. 8. Al-Safi SA, Alkofahi AS, El-Eid HS. Public response to chest pain in Jordan. Eur J Cardiovasc Nurs. 2005;4:139e144. 9. Webster R, Heeley E. Perceptions of risk: understanding cardiovascular disease. Risk Manag Healthc Policy. 2010;3:49e60. 10. Wendt SJ. Perception of future risk of breast cancer and coronary heart disease in female undergraduates. Psychol Health Med. 2005;10(3):253e262.
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