Awareness and knowledge of cardiovascular disease and their associations with the lifestyles of 8-16-year-old girls: a perspective from Saudi Arabia | BMC Public Health

The results of this study show that the awareness and knowledge of CVD and its risk factors among 8- to 16-year-old Saudi girls are inadequate and that the girls’ knowledge level is dissociated from their lifestyle, with a high prevalence of unhealthy traits, including obesity and hypertension. The majority of the participants rated cancer (61%) as the most dangerous disease in adult life, followed by CVD (50.3%), and only 71.2% considered CVD very dangerous. Knowledge about major CVD risk factors was low, and individual risk factors were, on average, identified by one-quarter of the participants. Overall, knowledge levels significantly improved with increasing age and school grade in girls and in those with a family history of CVD. Conversely, no significant favorable associations between the participants’ knowledge scores and lifestyle factors, including exercise, sedentary time, diet or maintaining a healthy BMI, were observed.
Alarmingly, an increasing prevalence of unhealthy traits was observed. Approximately 44.1% were overweight or obese, whereas 32.2% was the reported value five years ago in a sex- and age-matched population in Riyadh [24]. Moreover, the dietary intakes of fruits/vegetables, milk/cheese and important proteins for most participants were below or just at the minimal servings recommended by the American Academy of Pediatrics [25]. Moreover, almost half were identified as hypertensive, which is a higher prevalence than in a previous report from Jeddah, Saudi Arabia [26], although a single measurement was obtained from most participants, and different diagnostic cutoffs were applied in our study. In particular, there is an immediate need for the management and primary prevention of childhood obesity to combat the health hazard and socioeconomic burden of CVD from its development in childhood to its manifestation in adulthood in an effective and timely manner [27].
Awareness of CVD among women, female adolescents and female children
Our results for girls 8–16 years of age add to the available data on the awareness of CVD among women of all ages and confirm that misinformation starts in childhood and should be targeted early in life [10]. The misconception that cancer is the most life-threatening disease in adulthood followed by CVD, and the awareness levels observed in our study mirror those reported among women ≥ 25 years of age, where the awareness of CVD as the leading cause of death ranged between 44% and 56% [3, 6]. In another study that evaluated the awareness of CVD and prevention efforts among women 15 to 24 years of age, only 10.0% correctly identified CVD as the leading cause of death in women, and most participants worried little or not at all about CVD (39.2% and 38%, respectively) [4]. There have been calls to extend the American Heart Association’s “Go Red for Women” initiative, which aims to promote awareness and heart-healthy behaviors among women, to female teens [4]. The campaign should also include female children if primordial prevention of CVD in women is to be achieved.
In recent decades, substantial efforts have been made to assess, improve and track the awareness of CVD among women of adult and teenage age [4, 28, 29], with a much lesser focus on females who are early teens or children. These age groups should receive similar if not more attention to reduce the future risk of CVD among women. Furthermore, as observed in our study, young individuals are rarely devoid of CVD risk factors or have ideal cardiovascular health [30]. The escalating pro-atherogenic profile observed among the girls in this study is expected to further aggravate their risk of CVD upon reaching adulthood [30].
Prior studies on children’s and adolescents’ awareness and knowledge of CVD and its risk factors
A limited number of studies have evaluated the knowledge and awareness of CVD and its risk factors among children and adolescents worldwide [12,13,14,15,16], and very few reported on gender differences between young participants [14, 15]. Similar to our findings, inadequacies in knowledge have been detected despite a notably high prevalence of risk factors [13, 15, 16]. Our results are in accordance with those reported previously among 9th and 10th grade boys and girls in the rural district of West Midnapore, India, where the awareness of CVD and its risk factors was far from optimal, with a mean score of 41.1% [16]. Similarly, in a study from Delhi involving 6th-8th-grade children, only 15.3% were aware that coronary artery disease refers to blockage of the coronary artery, while 25.4% had adequate knowledge regarding CVD risk factors. A high prevalence of risk factors was similarly reported in that study, particularly in relation to exercise, dietary habits, and family history of CVD [13]. In a study in Michigan in the U.S., involving high school students (mean age of 15.6 years), only a minority (16.6%) considered CVD the greatest lifetime health risk, which was thought to be the greatest health threat for men at 42.3% compared with 14.0% for women [15].
Factors influencing participants’ knowledge levels
We found that the knowledge levels of the participants were positively influenced by increases in girls’ ages and school grades. Additionally, in comparison with our results, higher knowledge levels have been reported among secondary school students [31]. These findings highlight the importance of schools as a source of knowledge among young people. School-based educational programs significantly improve the awareness of CVD and its risk factors among children and adolescents [16] and help popularize healthy lifestyle habits.
Conversely, we found no association between the participants’ microenvironment, including parents’ occupation and number of siblings, and their CVD knowledge level, which contrasts with the observations of Notara et al., who reported that a lower number of siblings and higher parental education had a positive effect on participants’ knowledge [32]. Nonetheless, the higher knowledge scores observed in participants with a family history of CVD may still point to a family role in improving the children’s knowledge of CVD health, subject to improved awareness of the family members themselves. Data indicate that the factors affecting the home environment are complex and involve educational, financial, and other elements [33]. Further studies that explore the homes of children in detail, particularly parents’ knowledge of CVD specifically and their lifestyle habits, are warranted.
Impact of knowledge level on participants’ lifestyles
We found that the knowledge scores of the girls were not related favorably to their lifestyle. In particular, significantly higher knowledge scores were recorded among those who preferred fast and carbohydrate-rich foods. One potential explanation is that, among the risk factors for CVD, knowledge of dietary factors specifically is low [31] or that they are difficult to control. In one study, despite a high awareness of CVD risk factors, only approximately half of the participants knew what constituted healthy food, and two-thirds doubted that they could change their eating habits [34]. A lack of motivation is another potential explanation. In one study involving healthy undergraduate female students in Al-Madinah, SA, 55.8% of the participants were aware of the health consequences of excessive intake of added sugar, but only 32.6% reported making an effort to reduce their intake [35].
A high level of knowledge of CVD and its risk factors is likely not sufficient to improve health risks among young people [36], possibly because they tend to underestimate the impact of poor health behaviors. Tran et al. reported that while college students may be knowledgeable about CVD risk factors, they do not perceive themselves to be at risk of CVD, as they have not experienced the consequences of their behaviors [36]. Not foreseeing oneself to be at risk has been reported by other investigators among young individuals [4, 15], particularly women, and was cited as the first and main barrier to engaging in prevention behaviors [4]. While very limited data have suggested that women may occasionally be better informed about CVD and its risk factors than their male counterparts are [37], the myth that CVD is a disease affecting men may lead to underestimation of their risk. Furthermore, a focus on young women and schoolgirls, in particular, is warranted, as they are largely unaware of the risk CVD imposes on their health [4].
Studies evaluating the awareness of CVD in Saudi Arabia
To our knowledge, this is the first study to investigate the awareness and knowledge of CVD among Saudi children and adolescents and its effects on participants’ lifestyles. Few studies involving adults in Saudi Arabia exist [38–43]. A recent cross-sectional study from Riyadh reported that only 47.1% of the participants had good awareness, with men having better awareness than women in that study [38]. Limited knowledge levels were also reported in Al-Qassim Province [42, 43] and Jeddah [40, 41]. Overall, the respondents seem less likely to be aware of the role of the individual’s sex, age, family history, diabetes, and hypertension as causative factors for CVD and are better informed about the role of smoking, obesity, hyperlipidemia, unhealthy diet, and physical inactivity [38–40, 43]. There are not enough data on the predictors of knowledge level or its impact on participants’ lifestyles. In one study, following a healthy diet was an independent predictor of good CVD awareness [38].
Strengths and limitations
There was no direct question regarding smoking in the questionnaire. This is due to ethical concerns from the authors since the study included 8-year-old children who may not have been informed properly about smoking, which is both a risk factor and a bad habit. The participants, however, were given the option to enumerate any other risk factors they may know of. Nonetheless, the level of awareness of smoking, cannot be compared with the other studied risk factors. The possibility of bias from self-report questionnaires is another well-known limitation. Additionally, the study included girls with an 8-year age difference, which may have created a challenge in the questionnaire application. However from the age of 7 onward, children can be interviewed via structured questionnaires or complete self-reports, particularly if short questions, and simple terms are used [18, 19]. This age difference, has the advantage of permitting comparisons of child and teen participants’ knowledge, and adds to the continuum of data on CVD awareness among females of different ages which we were interested in studying. Although increasing age was significantly associated with better knowledge in our study, the difference in the mean knowledge score was not large, and the observed knowledge levels mirrored those of female teens and women. While the study was carried out among girls in Riyadh, the results are in accordance with those reported from other parts of the world among children in general and women, and point to the globalization of unhealthy diets and traits, and low awareness of this important disease.
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