Results from INTERHEART global case-control study (Yusuf et al. 2004, Anand et al. 2008) concluded that the following nine potentially modifiable risk factors account for over 90% of the risk of an acute myocardial infarction (in order of highest to lowest population attributable risk for Southeast Asian and Japanese subgroup): dyslipidemia, abdominal obesity, hypertension, smoking, regular physical activity, regular alcohol consumption, psychosocial factors, diabetes mellitus, daily fruit and vegetable consumption. There are six established major risk factors for coronary heart disease: adverse diet, above-optimal levels of serum total cholesterol and blood pressure, overweight/obesity, diabetes mellitus and cigarette smoking (Stamler 2005).
Urban areas are defined as gazetted areas and their adjoining built-up areas with a combined population of 10 000 persons or more at the time of the consensus (Mahari et al. 2009). The fraction of rural population in Malaysia was 40.4 % in 2000 and an estimated 38.4 % in 2007, compared to Switzerland with 26.6 % in 2007 (UN Demographic Yearbook 2009).
The rapid urbanization of the world brings significant changes to lifestyles. Nowadays more than 50% of the world’s population is already living in urban areas, and and estimated 70% by 2050 (WHO 2010).
Epidemiology of cardiovascular disease risk factors
A major trend in developing countries is the epidemiological transition from communicable causes of death to non-communicable causes. Projections by Mathers et Loncar (2006) estimate that globally the proportions of deaths due to non-communicable diseases will rise from 59% in 2002 to 69% in 2030. According to Malaysia’s statistics of death, ischaemic heart disease and cerebrovascular disease are already considered the leading causes of death in 2007 (Department of Statistics Malaysia 2009).
Malaysia is strongly affected by the above mentioned health-transition. The National Health and Morbidity Survey (NHMS) III (2006) showed that the prevalence of obesity has more than tripled in a decade (from 4.4% in 1996 to 14.0% in 2006), the prevalence of hypertension has increased by about one third in 10 years (from 33% to 43%) and the prevalence of newly diagnosed and known diabetes has almost doubled in the same period. The prevalence of diabetes is significantly higher in urban areas, whereas the rural population is significantly more affected by hypertension and tobacco use.
Studies from other areas of the developing world show divergent results. A study from Vietnam (Pham et al. 2009) confirmed the higher prevalence of hypertension in the rural population of the Mekong Delta (rural male 27%, female 16%). On the other side a higher prevalence of hypertension in urban subjects was found in the National Nutrition and Health Survey 2002 in China (Wu et al. 2008) and a systematic review in Sub-Saharan Africa (Addo et al. 2007). Concerning smoking a recent study from China (Ho et al. 2010) revealed a higher prevalence of ever-smokers among urban young women.
In a semi-rural community, Chia and Srinivas (2009) found a high mean predicted coronary heart disease risk: 20-25% for men and 11-13% for women (mean age of the subjects 65.4 years(±8)). Studies from Vietnam (Pham et al. 2009), Brazil and Mexico (Ford et Mokdad 2008) revealed a higher prevalence of obesity in urban areas than in rural areas.
With a value of 11.6 % Malaysia has the second highest estimated comparative prevalence of diabetes mellitus in South East Asia for 2010 (with Singapore representing the highest prevalence), which is more than double of highly developed Japan (Sicree et al. 2006). Dietary imbalances in South-Asian populations are common: there is often a low intake of n-3 polyunsaturated fatty acids and fibre, and high intake of saturated fatty acids, carbohydrates and trans-isomer fatty acids (Isharwal et al. 2009, Misra et al. 2009).
Preventive programmes in Malaysia
In 2007 Malaysia’s Ministry of Health started a pilot study to test run a chronic care model called Community Based Multiple Risk Factors Intervention Strategy to Prevent Cardiovascular and Chronic Kidney Diseases (CORFIS) to assess how effective a multidisciplinary care team could manage hypertension, hyperlipidaemia and diabetes mellitus compared to routine care by a general practitioner. The CORFIS Phase I Report (2009) stated that CORFIS care demonstrated significant improvement in the management of above-mentioned chronic diseases. In managing diabetes mellitus CORFIS demonstrated significant improvement of HbA1c, blood glucose and medication adherence, in managing hypertension a significant reduction in systolic and diastolic blood pressure and achieving target blood pressure control and in management of hyperlipidaemia a significant improvement in both serum LDL-C reduction and achieving target LDL-C control.
Cognitive aspects of cardiovascular risk factors
A national study of 16440 subjects in the whole of Malaysia (Rampal et al. 2007) concluded that the prevalence of hypertension in Malaysia is high, but there are low levels of awareness and treatment, and poor control of hypertension. In primary care patients in Kelantan, a largely rural area of northeastern Peninsular Malaysia, knowledge about obesity was to be found low since a substantial minority of the subjects does not regard obesity as unhealthy and doesn’t associate it with diet or lack of exercise (Jackson et al. 1996). Two studies from Penang (Yun et al. 2007) and Seremban (Ding et al. 2006) concluded that patients with diabetes mellitus were significantly more knowledgeable about their disease than healthy subjects and education and income were the predominant predictive factors of knowledge about diabetes. The International Tobacco Control-South-East Asia survey (Siapush et al. 2008) revealed that male Malaysian smokers with a high income had a higher self-efficacy to quit smoking. It was also stated that being employed was associated with higher cigarette consumption (which differs from results found in high-income countries). In a study among Malaysians age 18 and above Lim et al. (2009) found that smokers were less knowledgeable about the dangers of smoking and had more positive attitudes towards smoking. Another result of this study was that education and female gender were associated with a negative attitude. Jackson et al. (2004) asked patients in Kelantan (Northeast Malaysia) about safe ways to smoke: Common beliefs were that drinking water or taking sour fruit can “clean away” the effect of smoking. Manaf et Shamsuddin (2008) studied smoking among young urban Malaysian women (university students) and found associations with individual (slim image, monthly allowance, car ownership), family (smoking brothers, parental marital status) and environmental factors (having more smoker friends, perceiving female smoking as normal).
Data from rural parts of Turkey showed that there seems to be a low level of knowledge about heart disease, cardiovascular risk factors and the importance of protection from those risk factors (Metintas et al. 2009). Goldman et al. (2006) confirmed inadequate knowledge and awareness about cholesterol and the associated CVD risk in New England. A study by Kalra et al. (2004) conducted in Asian Indian communities in Northern California revealed that awareness for several risk factors for CVD was present, and awareness of risk factors increased when someone, that the participants knew, was suffering from the disease.
Problem statement and justification
In consideration of the world’s fast pace of urbanization with associated changes of lifestyles, the growing importance of cardiovascular diseases as leading causes of death in middle-income countries and the rapid surge of cardiovascular disease risk factors in Malaysia over the last decade, a better understanding of the underlying health beliefs, attitudes and perceptions of potentially preventable cardiovascular disease risk factors is important. The results gained from studying knowledge, attitudes and perception of these risk factors could help to formulate more effective cardiovascular prevention policies and programmes. To my knowledge, few qualitative studies in Malaysia have examined the cognitive aspects of cardiovascular risk factors: Ching et al. (2009) showed that many overweight and obese participants perceived themselves as ugly and feeled ashamed and frustrated, were less effective at work and had negative attitudes towards themselves because of excess weight; Jackson et al. (2004) reported about lay beliefs about smoking that included safe ways of smoking, e.g. taking sour fruit, smoking after food, exercising and using a filter.
Understand health beliefs, knowledge and perception of – in particular preventable and modifiable – cardiovascular risk factors to help in the planning of prevention programmes of cardiovascular disease.
Evaluate knowledge, perception and attitudes of cardiovascular disease and associated major modifiable risk factors in urban Malaysians attending an outpatient clinic.
Understand what are the main sources of information about cardiovascular disease and risk factors for the study population.
Understand how cultural factors could influence perception of cardiovascular risk.
Help to identify cardiovascular prevention programs’ priorities.
Help to understand what kind of barriers limit the adaptation of preventive measures.
Understand personal health priorities in the study setting.
This study uses quantitative and qualitative methods (in-depth open-ended interviews and rank-order methods).
Study location and population
It is planned to randomly select from the outpatient clinic of University of Malaya Medical Centre, Kuala Lumpur, 20 patients suffering from cardiovascular disease and 20 patients not suffering from this condition. To be included in the study, participants have to have a minimum age of 18 years and must be able to speak Bahasa Malaysia, Mandarin or English.
In-depth open-ended interviews with patients will be used to collect the main data. In addition to the interviews, the subjects will be asked to rank-order cardiovascular risk factors and common causes of death in Malaysia. Interview questions will be pilot-tested before the actual research is being performed. Written consent will be obtained before starting the interview. The interviews will take place at the outpatient clinic of University of Malaya Medical Centre. A local research assistant fluent in English, Malay and Mandarin will be trained to assist in the interviews. During interview notes will be taken and the interviews will be audio recorded. Transcriptions of the interviews based on audio recordings will be performed and later on translated into English. The study duration is approximately 3 months, from May to Juli 2010 and data collection planned to start in May 2010. Ethical clearance will be obtained from the ethical committee of University of Malaya, Kuala Lumpur.
For qualitative data content analysis will be used to categorize textual data from the transcripts of the interviews. Analysis of the data sets produces codes that later translate into themes (Given 2008).
For the quantitative part of data analysis, frequency distribution will be calculated to summarize relevant data obtained from the interviews and Pearson’s Chi-squared test to test for statistical significance in the comparison of proportions of different categories (e.g. patients with cardiovascular disease (CVD) vs. patients without CVD; male vs. female).
Since smokers seem to be less knowledgeable about smoking (Lim et al. 2009), our study is expected to confirm limited knowledge about the dangers of smoking in our subjects. Similar to the study by Jackson et al. (2004) additional understanding can be gained from asking the participants about safe ways to smoke. Jackson et al. (1996) described the low knowledge of patients from a rural area about the causes and health effects of obesity and we expect our results to be alike. Studies from the western part of the world revealed a low level of knowledge about heart disease, cardiovascular risk factors and the importance of protection from those risk factors (Metintas et al. 2009) and inadequate knowledge and awareness about cholesterol and the associated CVD risk (Goldman et al. 2006). Little is known about knowledge, perception and attitudes of other risk factors, e.g. physical inactivity, hypertension, adverse diet and psychosocial stress in Malaysians. Thus results from our proposed thesis should help fill in the gaps.
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Open-ended Interview guide
Establish rapport, give explanations of study, explain anonymity/confidentiality, explain note-taking/recording, obtain written consent. Hand out patient information leaflet.
Sources of information
“I’d like to start off by asking you about information about health topics.”
“What kinds of information about health do you like to have?”
“Where do you get information about health topics from?”
“Which source of information do you trust the most?”
Understanding of health risks and knowledge of cardiovascular risk factors
“I’d like to start off by asking you about what is called ‘health risks’.”
“When you hear the term ‘health risk’, what do you think of?”
“What are some examples of what you consider being a high risk for your health?”
“Do you ever talk to your family or friends about risks to health? What kinds of things do you talk about?”
“When you hear the term ‘heart disease’ or ‘cardiovascular disease’, what do you think of?”
“What do you think makes people more likely to get a heart attack?”
Understanding of high blood pressure and effect of high blood pressure
“What do you think of when you hear the term ‘high blood pressure’?”
“Do you consider high blood pressure being a disease?”
“What kinds of things can happen to your health if your blood pressure is too high?”
“Do you know your blood pressure?”
“Can you think of any reasons why people suffer from high blood pressure?”
“What do you think people can do to avoid getting high blood pressure?”
Understanding of cholesterol and effect of cholesterol
“What do you think of when you hear the word ‘cholesterol’?”
Probe for understanding of different kinds of cholesterol, e.g. LDL and HDL, or ‘good and bad cholesterol’.
“What kind of food do you consider containing a lot of cholesterol?”
“Do you consider high cholesterol being a disease?”
“Do you know your cholesterol level?”
Understanding of diabetes mellitus and effect of diabetes mellitus
“What do you think of when you hear the word ‘diabetes’?”
“Do you consider high blood sugar being a disease?”
“What kinds of things can happen to your health if your blood sugar is too high?”
“Can you think of any reasons why people suffer from high blood sugar?”
“Do you know your blood sugar level?”
“What could you do to keep your blood sugar low?”
Understanding of obesity, overweight and healthy diet
“What do you think of when you hear the word ‘obesity’?
“How do you know whether somebody is overweight?”
“Do you consider obesity a disease?”
“What kinds of things can happen to your body if you are obese”?
“In your opinion, what is the cause of overweight and obesity?”
“Can you give me some examples of food that is healthy for your heart?
“Do you eat fruits and/or vegetables every day?”
Understanding of the importance of physical activity
“Can you think of any reasons why physical activity/exercise is important for your health?”
“What kinds of things can happen to your body if you have a lack of exercise?”
“Do you do moderate (e.g. walking, cycling and gardening) or strenuous exercise (e.g. running, football and swimming) for 4 h or more a week?”
Understanding of the effects of smoking
“Do you consider smoking a danger for your health?”
“What kinds of things can happen to your health if you smoke?”
“Do you know any safe ways to smoke?”
“Do you smoke?”
Understanding of psychosocial stress
“What do you think of, if you hear the word ‘stress’?”
“What kinds of things can happen to your health if you have too much stress?”
“Do you often feel stressed?”
“Among all the things you do in your life, how important is it to you to do things to stay healthy?”
“What kinds of things do you do to stay in good health?”
Rank ordering cardiovascular risk factors
“On these cards are written 10 factors that could be a health risk for your heart and blood vessels. Please order the factors in order of highest to lowest risk.”
10 cards of cardiovascular risk factors are presented to the subjects for rank-ordering.
“On these cards are written 10 diseases that cause death in Malaysia. Please order the death causes in order of most common to least common.”
10 cards with common causes of death in Malaysia are presented to the subjects for rank-ordering.
Write down: age, gender, ethnicity, profession and education level.