Coronary Heart Disease Perception

Perception, Knowledge & Awareness of Coronary Heart
Disease among rural Australian women 25 to 65 years of age – A Descriptive Study

Rosanne Crouch
Submitted for Master of Nursing Science, October 2008
Discipline of Nursing, The University of Adelaide

Table of Contents
Index of Figures……………………………………………………………………...iii
Index of Tables ....................................................................................................... iii
Signed Statement .................................................................................................... iv
Acknowledgement ................................................................................................... v
Abstract ..................................................................................................................
vi
CHAPTER 1 - INTRODUCTION .......................................................................... 1
INTRODUCTION ................................................................................................................................ 1
CONTEXT OF THE STUDY .............................................................................................................. 1
PURPOSE OF THE STUDY ............................................................................................................... 2
RESEARCH QUESTION .................................................................................................................... 2
SIGNIFICANCE OF THE STUDY ..................................................................................................... 2
RURAL HEALTH................................................................................................................................ 3
CORONARY HEART DISEASE ........................................................................................................ 4
BURDEN OF CARDIAC RISK IN WOMEN ..................................................................................... 4
RISK FACTORS .................................................................................................................................. 5
LIFESTYLE AND CARDIOVASCULAR DISEASE......................................................................... 6
DIABETES........................................................................................................................................... 7
HYPERTENSION ................................................................................................................................ 8
CIGARETTE SMOKING .................................................................................................................... 9
NURTRITION AND HYPERLIPIDEMIA........................................................................................ 10
PHYSICAL ACTIVITY..................................................................................................................... 11
OBESITY ........................................................................................................................................... 11
ALCOHOL ......................................................................................................................................... 12
OUTLINE OF THE STUDY.............................................................................................................. 13
SUMMARY ....................................................................................................................................... 14

CHAPTER 2 – LITERATURE REVIEW.............................................................15
INTRODUCTION .............................................................................................................................. 15
SEARCH TIME SPAN AND DATABASES .................................................................................... 15
SEARCH TERMS .............................................................................................................................. 15
HEART DISEASE RISK ................................................................................................................... 15
A MAN’S DISEASE .......................................................................................................................... 16
THE FRAMINGHAM HEART STUDY ........................................................................................... 17
HEALTH BEHAVIOR....................................................................................................................... 17
WOMEN’S AWARENESS OF HEALTH......................................................................................... 19
YOUNG WOMEN AND THEIR AWARENESS OF HEART DISEASE ........................................ 22
IMPACT OF RISK FACTOR MODIFICATION .............................................................................. 22
INCIDENCE OF HEART DISEASE IN RURAL AUSTRALIA...................................................... 23
ECONOMIC BURDEN OF HEART DISEASE ................................................................................ 24
GAPS IN THE LITERATURE .......................................................................................................... 25
SUMMARY ....................................................................................................................................... 26

CHAPTER 3 - METHODS ....................................................................................27
INTRODUCTION .............................................................................................................................. 27
THE RESEARCH DESIGN ............................................................................................................... 27
STUDY SETTING ............................................................................................................................. 28
THE WELL WOMEN’S CLINIC ...................................................................................................... 28
RECRUITMENT STRATEGIES....................................................................................................... 29

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Process ........................................................................................................................................... 29
Sample ............................................................................................................................................ 30
INSTRUMENTS ................................................................................................................................ 30
PILOTING OF TOOL ........................................................................................................................ 31
INSTUMENT RELIABILITY AND VALIDITY.............................................................................. 31
ETHICAL ISSUES............................................................................................................................. 32
MEASURES....................................................................................................................................... 33
STATISTICAL ANALYSIS .............................................................................................................. 36
SUMMARY ....................................................................................................................................... 37

CHAPTER 4 - RESULTS ......................................................................................38
INTRODUCTION .............................................................................................................................. 38
STUDY POPULATION AND VARIABLES INVESTIGATED ...................................................... 38
DEMOGRAPHIC CHARACTERISTICS.......................................................................................... 39
SECTION ONE: Questions 1 – 3 WOMENS HEALTH ISSUES ..................................................... 40
PERCEPTIONS OF DISEASE ...................................................................................................... 40
SECTION TWO: Questions 4 - 30 HEART DISEASE KNOWLEDGE ........................................... 41
HEART DISEASE ......................................................................................................................... 41
SECTION THREE: Questions 32 - 52 HEALTH AND HEALTH RELATED BEHAVIORS ......... 43
PERSONAL HEALTH STATUS................................................................................................... 43
HEALTH HISTORY & MEDICATIONS ..................................................................................... 43
WEIGHT ........................................................................................................................................ 44
BLOOD PRESSURE...................................................................................................................... 45
EXERCISE ..................................................................................................................................... 45
CHOLESTEROL............................................................................................................................ 46
TOBACCO USE ............................................................................................................................ 46
ALCOHOL CONSUMPTION ....................................................................................................... 47
LIFESTYLE HABITS........................................................................................................................ 49
SUMMARY ....................................................................................................................................... 51

CHAPTER 5 - DISCUSSION ................................................................................52
INTRODUCTION .............................................................................................................................. 52
PURPOSE OF THE STUDY ............................................................................................................. 52
SUMMARY OF FINDINGS.............................................................................................................. 53
AWARENESS OF HEART DISEASE .......................................................................................... 53
HEART DISEASE KNOWLEDGE ............................................................................................... 54
BEHAVIOUR CHANGE ............................................................................................................... 55
SIGNIFICANCE OF FINDINGS....................................................................................................... 58
RESPONSE RATE......................................................................................................................... 58
IMPLICATIONS FOR PRACTICE ............................................................................................... 58
STUDY LIMITATIONS .................................................................................................................... 60
RECOMMENDATIONS FOR FURTHER INVESTIGATION ........................................................ 61
CONCLUSION .................................................................................................................................. 62

REFERENCES.......................................................................................................64
APPENDIX 1 ..........................................................................................................77
APPENDIX 2 ..........................................................................................................78
APPENDIX 3 ..........................................................................................................79

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Index of Figures
Figure 1 Flow chart of responses to questionnaire.....................................................39
Figure 2 Distributions of participants ' perceptions regarding the greatest health problem facing women today....................................................................................40
Figure 3 Weight assessment and high blood pressure................................................50
Index of Tables
Table 1 Age groupings of participants ......................................................................40
Table 2 Heart Disease Fact Questionnaire results......................................................42
Table 3 Top ranked correctly answered questions from Heart Disease Fact
Questionnaire ...........................................................................................................42
Table 4 Top ranked incorrectly answered questions from Heart Disease Fact
Questionnaire ...........................................................................................................42
Table 5 Participants general health ...........................................................................43
Table 6 Medical History ...........................................................................................44
Table 7 Participants self assessment of weight..........................................................45
Table 8 Blood Pressure.............................................................................................45
Table 9 Exercise.......................................................................................................46
Table 10 Women reported to have been told they have high cholesterol ...................46
Table 11 Current Smoking Status .............................................................................47
Table 12 Frequency of smoking................................................................................47
Table 13 Standard drinks drunk on a typical day.......................................................48
Table 14 Alcohol Consumption ................................................................................48
Table 15 Total Risk Factors......................................................................................49
Table 16 Heart disease knowledge and risk factors ...................................................49
Table 17 Comparison between risk factor and knowledge score ...............................50
Table 18 Blood Pressure checked .............................................................................51

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Signed Statement

The thesis contains no material which has been accepted for the award of any other degree or diploma in any university and that, to the best of my knowledge and belief, contains no material previously published or written by another person except where due reference is made in the text of the thesis.
I give consent to this copy of my thesis, when deposited in the Discipline library, being available for loan and photocopying.

Name:
Date:

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Acknowledgement
This research dissertation would not have been possible without the support and help of many people. I am sincerely thankful to everyone who supported and encouraged me during the period in which I have undertaken my Masters studies.
First, I would like to thank my supervisor, Dr Anne Wilson for continually supporting, and guiding me through this research. Anne was constantly positive, encouraging and constructive. I would also like to thank Dr Nancy Briggs who provided valuable comments and suggestions for interpreting the data. I am grateful to all the other staff in the Discipline of Nursing, University of Adelaide for their support and guidance.
I would like to thank the Port Pirie Regional Health Service for the continual support they provided to me throughout my studies. I would like particularly to thank the staff of the Well Women’s Clinic:

Viv London, Clinical Services Co-ordinator

(CSC), as well as Leanne Francis and Ros Mayfield. Their time and energies spent distributing the questionnaire was invaluable. I would also like to thank those staff of the health unit on night duty, who completed the pilot study. I would especially like to thank Margaret Neumeister for her time and support for this research.

Her

suggestions were truly invaluable to me.
I wish to acknowledge the time and willingness of those women who participated in this study and did so without expectation or personal benefit.
In closing, I am deeply thankful to my family. To my husband, Michael for his loving support, constant encouragement, patience and understanding at all times. I would like to thank my children, Bethany, Jason and Nathan for their willingness to help at home when needed and their understanding when I was unable to spend time with them because of study commitments. Without their love and understanding, I would have been unable to complete this study.

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Abstract
Context:

Heart disease is the leading cause of morbidity and mortality in

Australian women. Traditionally, heart disease has been perceived as a man’s disease, where as women’s health issues have historically focused on menopause and breast cancer, leading women to believe that coronary heart disease is not an important health issue for them. Many Australian women fear cancer, although heart disease kills four times more women then breast cancer. The major risk factors for developing heart disease are the same for both men and women. These include hypertension, cigarette smoking, hyperlipidemia, diabetes, obesity, sedentary lifestyle, stress, age, heredity and race.

Purpose:

The purpose of this study was to:
a.

Assess rural women’s current level of awareness of heart disease as the leading cause of death in Australian women.

b.

Describe rural women’s current knowledge and perception of cardiovascular disease as well as actual risk of cardiovascular disease, and

c.

Evaluate whether heightened awareness and increased knowledge is associated with increased action to lower risk of heart disease.

Method:

A questionnaire combining questions from three existing questionnaires

used in numerous other studies was developed to collect data on perception, knowledge and awareness of heart disease of rural women. The questionnaire was pre-tested in a pilot study with participants recruited from the researcher’s workplace. The ethically approved and validated questionnaire was then distributed to rural women aged twenty five to sixty five attending a women’s health clinic in a regional hospital over a sevenweek period. Data analysis was performed using SPSS 15.0 for Windows.

Results:

The study included sixty five women participants. Only 13% (n=8) of

participants identified heart disease as the most significant health problem for women.
Sixty four percent of women participating in the study reported that breast cancer claims more lives than heart disease. Despite having an overall good knowledge of

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heart disease, there was an identified lack of health promoting behaviours by the women to reflect their knowledge. Less than half of the women who participated in this study recognised that they were at a higher risk of developing heart disease after menopause. Over half of the women participants of this study reported two or more lifestyle risk factors for heart disease. Self-reported risk factors such as hypertension, high cholesterol, cigarette smoking, alcohol use and obesity were consistent with national levels.

Recommendations:

Although health professionals have advocated primary

prevention of heart disease for many years, in general, are not heeding the message.
Women must be educated to the fact that cardiovascular disease kills. It is evident from this study that women are inadequately educated about the health problem heart disease is for women. Nurses can play a major role in educating both the public and other healthcare providers about the very real danger of heart disease in women.
Effective primary prevention of coronary heart disease requires early detection of risk factors, early intervention and communication of the relevance of the risk and the impact to women. Assessment and communication of risk is necessary as it can assist women in developing a more realistic perceived risk of coronary heart disease that, in turn, may motivate them to initiate and maintain healthy behaviours.
Conclusion: Women do not perceive heart disease as a substantial health concern.
Programs directed at young women to develop means to improve women’s perception of their risk for heart disease and to encourage them to act on their enhanced perception are required to reduce overall heart disease morbidity and mortality.
Changing the misperception women have about their health problems includes increasing their knowledge that favourable changes in lifestyle can reduce cardiovascular risk factors and prevent cardiovascular disease and coronary heart disease. Lifestyle modifications can substantially alter morbidity and mortality from coronary heart disease.

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CHAPTER 1 - INTRODUCTION

INTRODUCTION
This dissertation is the result of an investigation of Australian rural women’s perception, knowledge and awareness of coronary heart disease. This study focused on rural women’s awareness and perception of coronary heart disease and if this knowledge of risk factors influences lifestyle habits. This chapter introduces the reader to the study and specifies the research questions this study addressed. The significance of the study has been discussed along with an overview of the contents of each chapter.
CONTEXT OF THE STUDY
Diseases of the heart comprise a significant proportion of cardiovascular deaths.
Historically, coronary heart disease (CHD) has been perceived as a man 's disease.[1]
Perhaps this misperception stems from the lack of cardiovascular research on women, less public education directed toward female-specific cardiac risks, or an inherent bias against women within the health care system resulting in decreased access to diagnostic and therapeutic interventions in cardiology.

These convictions about

cardiovascular disease being a man’s disease have arguably permeated and impacted on nursing/midwifery education and subsequently the delivery of care by nurses and midwifes.[2] Women’s health issues historically focused on menopause and breast cancer, leading women to believe that coronary heart disease is not an important health concern for them. This has resulted in women not being adequately informed about the

disease.[3] Modification of cardiovascular risk factors requires a change in lifestyle habits and behaviours. Knowledge and awareness of risk factors is an essential component of behaviour change, however there is little information on rural
Australian women’s knowledge and awareness of cardiovascular risk factors.

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Many health care workers fail to discuss heart disease and associated risk factors with their female patients because they think it is primarily a man’s disease or is less serious in women.[4] Recognition of the subtle differences between men and women with heart disease have been slow to gain acceptance and these gendered assumptions have had other secondary effects, including reinforcing the perception among women themselves that they are immune from the risks of developing heart disease.[2]
PURPOSE OF THE STUDY
Cardiovascular disease is the leading cause of morbidity and mortality in women in
Australia,[5] yet prior research has shown a lack of awareness among women.[6] The purpose of this study was to evaluate the current awareness, perception and knowledge of heart disease among rural women aged twenty five to sixty five years.
A major objective was to evaluate if increased knowledge and awareness equates to women choosing better lifestyle choices to reduce their risk of heart disease.
The objectives of this study were to:
a. Assess rural women’s current level of awareness of heart disease as the leading cause of death in Australian women.
b. Describe rural women’s current knowledge and perception of cardiovascular disease as well as actual risk of cardiovascular disease, and
c. Evaluate whether heightened awareness and increased knowledge is associated with increased action to lower risk of heart disease.
RESEARCH QUESTION
The research questions were:
a. Are rural women aware of their risk of heart disease?
b. What knowledge of heart disease do rural women have?
c. Does an increased awareness and knowledge of the causes of heart disease relate to better lifestyle behaviour in rural women?
SIGNIFICANCE OF THE STUDY
The results of this study will be used to provide nurses with contemporary knowledge about cardiovascular risk factors in rural women. Heart disease develops gradually and can easily go undetected.[7] Risk management strategies for women at a younger age may have a significant impact on disease progression.[8] Results from this study

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will be useful in developing appropriate gender-specific messages to heighten heart disease risk awareness and to promote life-style changes to reduce risk.
RURAL HEALTH
Rurality can be described using the ‘Remoteness Structure’, based on the
Accessibility/Remoteness Index of Australia (ARIA), developed by the Australian
Department of Health and Ageing.[9] ARIA measures the remoteness of a point, based on the road distances to the nearest town (service centre) in each of five population size classes. The principles underpinning ARIA are that larger towns have more services than small towns, and that remoteness is a factor of distances travelled to obtain services.[10]
Approximately one-third of Australia’s total population of over twenty million live outside major urban centres.[10] The health disadvantages in rural Australia are welldocumented, particularly in terms of access and availability of health-care services.[11] Risk factors such as smoking, obesity, drinking and environmental dangers are more common in rural areas. Increased risk is also represented in high numbers of personal injury from accidents on farms, higher rates of hypertension, diabetes, asthma and high cholesterol.[12] The adverse effects of distance on access to services, lack of population growth in many communities, insufficient communication systems, response times, small population numbers and potential stigma from the greater visibility of circumstances exacerbate these risk factors.[13]
Australians living in regional and remote areas generally experience poorer health than their major city counterparts.[11] This is illustrated, most robustly, in measures of mortality. In 2002–04, death rates in regional and remote areas were between 10–
70% higher than in major cities.[14] Non-metropolitan areas of Australia have a significantly higher mortality from cardiovascular disease than metropolitan areas, after taking into account any differences in the proportion of elderly people through age standardisation.[14, 15] Furthermore, more people outside metropolitan areas are hospitalised for heart disease and related complications. Part of this excess risk may be due to a higher prevalence of cardiovascular disease risk factors.[16]

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CORONARY HEART DISEASE
Coronary heart disease (also known as coronary artery disease or ischemic heart disease) is the most common form of heart disease and results from atherosclerosis, or the accumulation of fatty plaques in artery walls that cause narrowing of the artery lumen.[17] Coronary artery disease that includes coronary syndrome, atherosclerosis, and other forms of chronic ischemic disease, is responsible for many deaths.[18]
Chest pain, shortness of breath, heart attack or other symptoms can be caused by a blood clot or plaque rupture that blocks a narrowed artery leading to the heart.[19]
The term ‘cardiovascular disease’ includes coronary heart disease, stroke, peripheral vascular disease and heart failure.[20]
BURDEN OF CARDIAC RISK IN WOMEN
Cardiovascular disease remains the leading cause of mortality and morbidity in developed countries, despite recent advances in diagnostics and treatment.[21-24] The
Australian Institute of Health and Welfare[14] reports that coronary heart disease remains the leading cause of death in Australia. Heart disease has been a significant problem in terms of health and economic burden on individuals, communities and nations in spite of its steady decline since 1968.[14, 20]
Although the rate of cardiovascular deaths in men has declined over the last decade, the number of cardiovascular deaths in women remains unchanged or may even be increasing.[25] Women diagnosed with coronary heart disease experience higher morbidity and mortality than men.[26]

Coronary heart disease accounts for the

majority of cardiovascular deaths in women, disproportionately afflicts racial and ethnic minorities and is a prime target for prevention.[6] As coronary heart disease is often fatal, and nearly two thirds of women who die suddenly have no previously recognized symptoms, it is essential to prevent coronary heart disease.[6]
In 2006, 10,797 Australian women died of heart disease and 2,618 women died of breast cancer.[5] Australian women are four times more likely to die of heart disease than breast cancer and on average heart disease kills over two hundred women per week or thirty Australian women each day.[5] Although the onset of coronary heart disease in women typically starts ten to twenty years after it does in men, as the

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population continues to age, and women live longer than men, this disparity in mortality between the sexes will continue to grow.[25]
Studies show that although there has been a decline in the overall mortality for heart disease, the incidence in women has been steadily increasing.[27, 28] Along with the higher cardiovascular mortality among women, the outlook for women who do survive a coronary event is inferior to men.[29]

One explanation for this less

favourable outcome is that when women first experience a coronary event, they are older, and are more likely to have more co-morbidities, such as diabetes and hypertension, which in turn contribute to higher mortality rates.[26, 28]
The knowledge gap between women’s perceived and actual risk of cardiovascular disease, particularly for younger and minority women,[6] is perhaps another explanatory factor for the poorer cardiovascular outcomes observed in women following an acute coronary event.[29] An Australian study showed that only three percent of Australians are aware that heart disease is the leading cause of death in women.[30] Evidence shows that women perceive breast cancer as a greater risk than heart disease.[26] Although the benefits of early identification and modification of cardiac risk have been well defined, women must first receive and understand the actual risks before they can act to make the appropriate choices that will result in the reduction of the risks.[31] Misconceptions may lead women to underestimate their risk for heart disease so that they fail to seek early interventions to prevent unnecessary morbidity and mortality.[26] While research in the area of heart disease risk perception is not abundant, existing information suggests that women often incorrectly perceive their risk and lean toward an optimistic bias.[32]
RISK FACTORS
Recent scientific data supports the strong relationship between the way a person or population lives and their risk for developing or dying from Heart Disease.[33]
Genetics can be a major factor for some people, such as those with low-density lipoprotein cholesterol [LDL-C] receptor deficiency[34] and other risk factors such as increasing age and a family history of heart disease cannot be controlled. For most of the population, lifestyle is the major determinant of the risk of heart disease.[19] Data from the Framingham Health Study quantified risk on the basis of the presence of a

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range of factors for heart disease.[35] Although risk factors for heart disease are mostly the same for men and women, there are some differences.[36] Women, as well as men have a greater chance of developing heart disease when they have multiple risk factors.[37]
The major risk factors for developing heart disease are the same for both men and women. These include hypertension, cigarette smoking, hyperlipidemia, diabetes, obesity, sedentary lifestyle, stress, age, heredity and race.[17, 35] Women are more likely than men to have multiple risk factors for coronary heart disease.[38] Women’s awareness of risk for coronary heart disease is not proportionate to its seriousness, and women fail to follow heart-healthy lifestyle practices.[39]

Heart disease is a

multifactor process that is contributed to by a variety of biological and behavioural characteristics of the person.[34] Women with a father or brother who developed heart disease before age fifty five or a mother or sister who developed heart disease before age sixty five are at increased risk.[19]

Race is also a factor, with black

women more at risk of developing heart disease than white women.[19] The majority of factors that contribute to heart disease include a number of well established and emerging risk factors such as smoking, sedentary lifestyle, obesity and diet.[34, 40]
These factors can be controlled or modified by making simple changes in lifestyle and, if necessary, taking certain medications.[19] Women and health professionals need to recognise the existence of risk factors and the potential for developing future cardiovascular risk. Ongoing cardiovascular risk assessment should be a part of each female patient’s medical care.[41] Interventions aimed at lifestyle changes such as regular exercise, cholesterol-lowering dietary changes and smoking cessation are recommended to reduce the chance of having a first or recurrent heart attack.[23, 42]
LIFESTYLE AND CARDIOVASCULAR DISEASE
Starting as a child, many actions a person takes in daily life combine to establish much of their lifetime risk for developing heart disease.[34] Leon [43] found that even in uteri, exposure to the mother’s environment or lifestyle can influence the future risk of heart disease of the embryo or foetus. Many of these lifestyle factors are prevalent in Westernised or technologically advanced cultures, in which required daily physical activity is low because of widespread automation, calorie-dense but nutrient-poor food is readily available at a relatively low cost, psychological stress

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and social isolation is common and chronic exposure to cigarette smoke is still a common occurrence.[34]

While various lifestyle factors can initiate the

atherosclerotic process early in life,[44] long-term exposure leads to the clinical manifestations of coronary heart disease, peripheral vascular disease and stroke.[34]
Lifestyle interventions are a top priority for prevention of heart disease in women.[45]
All women should be encouraged not to smoke, to avoid environmental smoke and to get at least thirty minutes moderate exercise (ie brisk walking) on most and preferably every day. A heart-healthy diet is recommended, that incorporates a variety of fruits, vegetables, grains, fish and legumes and is low in saturated fat and cholesterol.
Weight control should be encouraged to achieve a body mass index (BMI) between
18.5 and 25 kg/m2 and a waist circumference < 80 cm for females.[23, 30, 45]
DIABETES
Diabetes increases the risk of heart disease in women more than it does in men.[46]
Data from the Framingham Heart Study[47] found that the relative impact of diabetes on cardiovascular mortality is greater in women than in men.
This represented a doubling of overall risk compared with men without diabetes and a fivefold increase for women.[48] This may be due to these women with diabetes more often having added risk factors, such as obesity, hypertension and high cholesterol.[49] Diabetes is more likely to be associated with elevations in both systolic and diastolic blood pressure in women than in men.[48] Weight gain, even of a modest degree, increases the risk for type 2 diabetes and heart disease in women.[48] The increase in coronary heart disease risk in women with diabetes has since been confirmed in other epidemiological studies.[50] There is in fact, concern that with the alarming increase in the prevalence of diabetes, the prevalence of coronary heart disease mortality is also increasing, particularly in women.[48]
The risk of developing coronary heart disease increases as well as the long term mortality is higher in women with diabetes, as diabetes eliminates the usual female advantage for coronary disease mortality.[49, 51-54]

Women with diabetes
also

experience more adverse outcomes after a vascular event as following a myocardial infarct, mortality is greater in diabetic women.[48]

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The rapid increase in the prevalence of type 2 diabetes and its occurrence at a younger age is primarily due to increased calorie intake and reduced energy expenditure and the resulting increase in adiposity.[55]

While heredity can influence a person’s

inclination to development of the disease, sedentary lifestyle and long term obesity are key triggering events for most people.[34]

Diabetes poses the greatest risk of

developing coronary heart disease than any other factor. Studies have shown that women with diabetes have seven times more cardiovascular events than other women, and approximately half died of coronary heart disease.[46, 56] Although women usually develop heart disease about ten years later than men, diabetes erases any premenopausal protection, so their risk of developing coronary heart disease equals that of men their age.[17] Half of all deaths in patients with type 2 diabetes are due to heart disease, with the majority of these being related to ischemia.[46] Health studies have shown that women with diabetes had a three to seven fold greater risk of cardiovascular events than did age-matched control subjects.[54, 57]

Preventing

diabetes in the first place is the ideal means of reducing coronary heart disease in women.[41, 46]
HYPERTENSION
Hypertension (elevated blood pressure) is a major modifiable risk factor for cardiovascular disease, cardiovascular events and death.[58] The relationship between blood pressure and cardiovascular disease control has been shown to be effective in reducing cardiovascular disease and morality, although below expectations from observational evidence.[59] Women with hypertension have a much greater risk of coronary heart disease than women or men with normal blood pressure.[17]
Hypertension is more common in women who take oral contraceptives, especially those who are overweight, and the prevalence of hypertension increases with age.[17,
46]
High blood pressure, especially high systolic blood pressure, is the best predictor of heart disease.[60] Optimal blood pressure for the general population is less than
120/80 mm Hg. In patients with proteinuria >1g/day with or without diabetes, the goal blood pressure is 125/75.[46, 60] Recent Australian studies have found that just over twenty five percent of Australian women twenty five years and over have high blood pressure.[61]

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CIGARETTE SMOKING
Cigarette smoking causes more preventable deaths from cardiovascular disease than any other modifiable risk factor.[32, 46, 49, 62] Cigarette smoke contains a number of components that contribute to the initiation or progression of atherosclerosis or trigger clinical events.[34] Cigarette smoking is the single most potent risk factor for atherosclerosis.[48] Nicotine increases myocardial oxygen demand by increasing heart rate and blood pressure as well as some increase in myocardial electrical instability. Carbon monoxide reduces the oxygen carrying capacity of the blood by binding to the oxygen receptors.[34] Other various chemicals appear to have a direct effect on the initiation and/or progression of the atherosclerotic process and contribute to increased platelet aggregation.

Smokers have low levels of high-density

lipoprotein cholesterol (HDL-C) which tend to increase by about ten percent soon after smoking cessation.[63] Along with lung cancer and chronic obstructive lung disease, the increased risk for heart disease contributed by cigarette smoke exposure is dose-dependent.[34] Women who smoke one or more packs of cigarettes daily have a coronary heart disease risk that is two to four times higher than that of nonsmokers.[62] Even women who smoke only a few cigarettes per day double their risk for heart disease compared with non-smoking women.[64] While many smokers may discount the increased personal risk they face from continued smoking, smokers who quit reduce their risk of CHD and prolong their lives substantially.[32, 46, 62]
Studies consistently show that smokers continue to deny their own personal health risks from smoking.[32, 65] Australian studies show that sixteen percent of women smoke daily.[66]
Women who spend a lifetime of smoking, even a few cigarettes a day, are at greater risk of coronary heart disease than men who do not smoke. Women who take oral contraceptives and smoke are more likely to have a Myocardial Infarction (MI) or stroke than those who do not.[17] Overall, the prevalence of smoking is declining, but more slowly in women than in men. In Australia, daily smoking rates for women are only marginally behind men, with the prevalence of daily smoking for men at
18.6% and women following closely with 16.3%.[67] Women should be encouraged and aided in their smoking-cessation efforts by whatever means are required. They need to understand that low-tar or low-nicotine cigarettes are unacceptable from a cardiac-health perspective.[46, 62] This is because most of the health damage caused

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by smoking comes from the non nicotine constituents, carbon monoxide.[68]
Smoking cessation reduces the risk for heart disease substantially after only one to two years of abstinence, and after ten to fifteen years of abstinence, the risk approaches that of a non-smoker.[64]
NURTRITION AND HYPERLIPIDEMIA
A person’s diet appears to play a central role in their long-term risk of heart disease.
Much of the focus from the 1950s to the 1990s was on the contribution diet made to the levels of total cholesterol or LDL-C, however it is now realized that this relationship is only one aspect of the contribution of diet to heart disease.[34]
Beneficial components in the diet include dietary fibre (especially water-soluble fibre), a wide range of antioxidants, B vitamins (B6, B12, and Niacin), folic acid, omega-3 fatty acids, calcium and potassium. Minimizing intake of foods high in saturated fat, trans-fatty acids, calories and sodium are also beneficial.[69]

An

important foundation for heart disease prevention and management includes an eating pattern that contains a high proportion of calories from a wide variety of vegetables, whole grains, fruits, and nuts and frequent consumption of fatty fish, with limited intake of high-fat animal products and processed foods containing trans-fats.[34]
Oestrogen helps to protect a woman from heart disease by increasing HDL (‘good’) cholesterol and decreasing LDL (‘bad’) cholesterol.[46] After menopause, women have higher concentrations of total cholesterol than men, although this does not entirely explain the sudden rise in heart disease risk after menopause.[70] Elevated triglycerides are an especially powerful contributor to cardiovascular risk in women.
Low LDL and high triglycerides appear to be the only factors that increase the risk of death from heart disease in women over age 65.[71] The Framingham Heart Study
(ongoing since 1948) has shown that women with high total cholesterol levels are twice as likely to develop coronary heart disease as other women.[33] Large amounts of cholesterol in the LDL fraction were atherogenic, whereas that in the high-density lipoprotein (HDL) fraction was protective. Low levels of HDL cholesterol (HDL-C) and high triglyceride levels are a stronger predictor of coronary heart disease mortality in women than men.[17, 46] Oestrogens affect lipids and other risk factors therefore hormonal protection for heart disease wanes as women move into their postmenopausal years. As a result, heart disease risk in women gradually increases to

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equal that of men.[46]

Since levels of HDL-C may drop, and those of LDL

cholesterol (LDL-C) may rise, greater vigilance for dyslipidemia is warranted.[71]

PHYSICAL ACTIVITY
Along with good nutrition and not smoking, maintaining a physically active lifestyle appears to be a core component in the prevention of heart disease.[34] Studies have reported that more physically active or fit men and women have a substantially lower risk of heart disease and all-cause mortality than do their less active counterparts.[7274]

Physical activity impacts upon metabolic and other pathways which affect

cardiovascular risk factors. It improves plasma lipid profile, reduces body weight, lowers blood pressure, reduces platelet aggregation, increases fibrinolytic activity, improves cardiac function, improves cardio-respiratory fitness and lowers the resting heart rate. [48, 75, 76] Studies have also shown that exercise training improves endothelium–dependent vasodilation, as well as increasing urinary sodium excretion and insulin sensitivity. [77, 78]

Physical activity also positively affects the

psychosocial well being of the individual.[79] A Finnish study [75] showed that regardless of other risk factors that may be present, moderate levels of physical activity were associated with a reduced risk of premature cardiovascular disease and mortality. Physical activity can decrease a woman’s risk by half and may significantly decrease the risk of a second MI in a post-menopausal woman who has already had one event.[17] In 2004-2005, Australian women were more likely than men to report being sedentary or having very low levels of physical activity.[80] The Australian
Heart Foundation recommends that light to moderate activity, such as walking 30 minutes several (at least three) days a week, can decrease a women’s risk of heart disease.[23] Multiple short (10 minute) bouts of exercise in the form of brisk walking produces similar changes in cardio respiratory fitness and weight loss to that achieved with regimens involving longer, less frequent intervals.[48]
OBESITY
Obesity research today is in its infancy, at a stage comparable to lipid research twenty years ago.[81] Obesity is the most obvious manifestation of the global epidemic of sedentary lifestyles and excessive energy intake.[82, 83] Epidemiological studies

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have shown that obesity is a serious risk factor for heart disease, on a par with cigarette smoking, physical inactivity and high blood pressure.[82, 84]

Where

previously, obesity was thought to augment other risk factors, in the past ten years, obesity has been included as a major risk factor.[81] The effects of obesity on cardiovascular health and disease are many – in particular hypertension.[84]
Estimates from population studies suggest that seventy five percent of hypertension can be directly attributed to obesity.[85]
In Australia, the prevalence of obesity has more than doubled in the past twenty years.[82] Seventeen percent of Australian women are reported to be obese,

compared to sixteen percent of men.[86]

The Australian Heart Foundation

recommends that a health waist circumference is less than 80 cm in women and less than 94cm in men.[60] The optimal BMI is 1 risk factors)

37

81.51

10.17

When examining the relative frequencies of women in the weight categories, it is clear that those in the overweight category have more often been informed that they are hypertensive than those in the normal weight category (Figure 3). Of the thirty two women who assessed their weight as acceptable or healthy, 7 (22%) also reported to have high blood pressure. Of the thirty women who reported to be overweight, 15
(50%) also reported to have high blood pressure. While younger women reported a higher percentage of being overweight, this same age group was more likely not to have had their blood pressure checked in the last twelve months (Table 18).
Have been told have high Blood Pressure
Yes
No

Percent

60.0%

40.0%

20.0%

0.0%
Underweight

Acceptable or healthy

Weight

Figure 3 Weight assessment and high blood pressure

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Overweight

Table 18 Blood Pressure checked
Blood Pressure checked
Yes
Age

Total

No

25-34 years

14

5

19

35-44 years

7

3

10

45-54 years

12

3

15

55-65 years

19

1

20

52

12

64

Total

SUMMARY
This study explored the perceptions, knowledge and awareness of coronary heart disease in rural women. A questionnaire containing 52 questions was distributed to
93 rural women attending a women’s health clinic over a 7 week period. A total of 65
(70%) questionnaires provided data for analysis. The results are presented in this chapter, in three sections. Section one presents the results of women’s awareness of heart disease as the greatest health problem and common cause of death in women.
Findings indicate that rural women do not recognise heart disease as the leading cause of death in women and perceive breast cancer as a greater health problem. Section two presents results of women’s knowledge of heart disease with the application of questions from the Heart Disease Fact Questionnaire.[131, 133] Overall, women’s knowledge of heart disease is quite good although women’s knowledge of cholesterol and diabetes did not rate well. Women also did not recognise that age and menopause increases their risk of heart disease, particularly women in the 55-65 year age group.
Section three reported on women’s health and health promoting behaviours. A little less than half of the participants reported that they were overweight. Women in all the age groups reported that they had been told by a health professional they had high blood pressure and a little over half reported that they had smoked at least 100 cigarettes in their life. Younger women were smoking more frequently than older women. The majority of women reported that they had exercised in the past month.
Only half the women reported having had their cholesterol checked and of those, women in the 55-65 year age group were more likely to have been told they had high cholesterol. Women were also reporting large amounts of alcohol consumption in one session. These results suggest that while women have a good knowledge of heart disease, they are not aware of their risk of heart disease.

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CHAPTER 5 - DISCUSSION

INTRODUCTION
This chapter interprets the findings of the study within the context of the available literature about women and heart disease. The methods used to conduct the study have been taken into account. The discussion begins with a brief overview of how the study was conducted and the purpose of the study. This has been followed by a summary and evaluation of the main results.

These are presented within three

headings; awareness of heart disease, heart disease knowledge and behaviour change.
A discussion of the significance of the findings that included the implications in and on practice for nurses will follow with respect to education for women about coronary heart disease. Limitations of the study are discussed along with recommendations for further research.

PURPOSE OF THE STUDY
The study was conducted to evaluate the current awareness, perception and knowledge of heart disease among rural women aged twenty five to sixty five years.
A self reported questionnaire was distributed by nursing staff to women aged 25-65 years attending a well women’s clinic in a rural health centre in South Australia over seven weeks of the study period. Participants completed the questionnaire in their own time and place and then returned the completed questionnaire via Australia post to the researcher using a stamped self-addressed envelope provided. The purpose of this study was to
a.

Assess rural women’s current level of awareness of heart disease as the leading cause of death in Australian women.

b.

Describe

rural

women’s

current

knowledge

and

perception

of

cardiovascular disease as well as actual risk of cardiovascular disease and
c. Evaluate whether heightened awareness and knowledge is associated with increased action to lower risk of heart disease.

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SUMMARY OF FINDINGS
The findings of this study indicate that rural women are unaware of their risk of heart disease as the leading cause of death. The findings of this study also suggest that the majority of women do not perceive heart disease as a threat, but believe breast cancer poses a greater threat to their health.

The results of this study also found that

women’s overall knowledge of heart disease was good. Nevertheless, there were two areas of knowledge that were suboptimal. These were women’s knowledge of age and menopause as risks of heart disease, as well as cholesterol. This knowledge though did not relate to positive action to minimise their own risks, with over half of women participants having two or more lifestyle risk factors for heart disease.
AWARENESS OF HEART DISEASE
The results of women’s lack of awareness of heart disease and their fear of breast cancer as a greater threat are consistent with other studies. [90, 103, 104] National survey work for the Pfizer Australia Health Report and Australian Heart Foundation uncovered the staggering statistic that ninety seven percent of people were unaware that heart disease is the leading cause of death for women.[144] While American
Heart Association studies [6, 62, 90] show that women are becoming more aware of the problem of heart disease, this is not evident in the current study of Australian women. These perceptions differ from the actual statistics for the leading causes of death for women in Australia in 2005.[145] According to the Australian Bureau of Statistics, ischemic heart disease is the leading cause of death in Australian women. In 2005
109,000 women died of heart disease and twenty seven thousand women died of breast cancer. Ischemic heart disease is the number one cause of death of Australian women, followed by cerebral vascular diseases, then dementia and Alzheimer 's disease. Breast cancer is rated as the fourth cause of death in Australian women.
More than 12,000 Australian women die from heart disease each year, which is 4.5 times higher than deaths from breast cancer.[144]
A possible reason that women underestimate the importance of coronary heart disease risk may be that this issue is not often discussed. An American Heart Association survey [39] found that only 38% of medical officers discussed heart disease with their

- 53 -

female patients and that only 20% of the female patients surveyed reported that a healthcare professional gave them information on heart disease in the past twelve months. A possible explanation for the lack of communication between health

providers and their patients may be that there is a general focus on traditional women’s healthcare issues, such as breast disease and gynaecologic problems.[146]
Other health care providers fail to discuss heart disease or its risk factors with their female patients because they think of heart disease primarily a man’s disease, or as less serious in women. This thinking leads to less aggressive treatment or even no treatment at all.[4] Considering the impact of coronary heart disease on women, this lack of communication and low level of awareness of the disease in women are problematic. The increased awareness of breast cancer may be related to the uniquely female aspect of the disease and to the excess of information on breast cancer that is targeted to women.[104] Breast cancer awareness is everywhere, particularly with recent high profile women who have been diagnosed with breast cancer. Televised dramas and documentaries do not help with raising awareness, as they tend to misrepresent heart disease as a disease afflicting men. Women’s magazines, by contrast, have many columns devoted to losing weight, exercise and reducing fat intake. These concepts are never presented in terms of preventing heart disease, but packaged around aesthetic looks and slimness.[2] From this perspective, heart disease in women is not driving the health agenda. In addition, health pages in women’s magazines tend to discuss various forms of cancer and in particular breast cancer, and offer tips on how to minimise the risks. Since breast cancer affects many young women and invades the organs connected with femininity and reproduction, it is the topic that is emotionally loaded, which presumably attracts a wide readership.[2] Although the awareness of breast cancer has led to earlier detection and increased survival, the heightened concern surrounding breast cancer may overshadow other important healthcare issues.[146] Breast cancer has many renowned women who have come out and spoken about their personal story and recovery story.
HEART DISEASE KNOWLEDGE
The results of this study show that while women may not acknowledge heart disease as the greatest health problem or the leading cause of death, they generally had a high

- 54 -

level of knowledge of heart disease. There were a few deficits in women’s knowledge of heart disease and these related to menopause, age and cholesterol. Less than half the women who participated in this study recognised that women are at a higher risk of heart disease after menopause, or that their risk of heart disease increases with age.
This was also found in an American study of women and heart disease.[3] In general, symptoms of coronary heart disease are first observed approximately ten years later in women than in men.[146] The delayed onset is often credited to the protective effect of female sex hormones.[147] This theory is consistent with the findings of increased morbidity and mortality from heart disease after menopause.[146]
While women in this study were able to recognise that high cholesterol is a risk factor for developing heart disease, and were able to correctly find that ‘good’ cholesterol
(HDL) is not a risk for heart disease and ‘bad’ (LDL) cholesterol is a risk for heart disease, they were not able to recognise that a person with diabetes tends to have low
HDL cholesterol. This may be because while participants understood that one type should be high and the other low, their greater familiarity with the generalized term
‘cholesterol’ and their recognition that high (total) cholesterol levels are unhealthy result in confusion about cholesterol being both good and bad, with goals for high and low numbers.[148] This may also indicate that while women may know their total cholesterol number, many may not be aware of their HDL and LDL levels.
BEHAVIOUR CHANGE
The results of this study found no relationship between knowledge of cardiovascular disease and risk-reducing behaviours. Greater knowledge of heart disease was not an indication that women were engaging in better lifestyle behaviour. These results are similar to other studies. [3] The data examined were based on self-reported risk factor status and were dependent on the individuals’ awareness of their risk factor status.
Trends in awareness of risk factor status may be different from trends in actual risk factor status. Eighty one percent of women surveyed reported having had their blood pressure checked in the past twelve months. Thirty five percent of women were told they had high blood pressure, only half of these women were taking medication for hypertension. Similar results were shown for women with high cholesterol levels.
There has been a significant decline in the proportion of people with high blood pressure (and/or receiving treatment) since the 1980s, yet there is thought to have

- 55 -

been little change in blood cholesterol levels in the Australian population in the same period.[149] Cigarette smoking is the single most preventable cause of morbidity and mortality in
Australia.[144] The results of this study found that 24% of women reported they were currently smoking, reflecting National Health results.

The Australian Bureau of

Statistics reports that the proportion of adults who are current smokers has changed marginally over time dropping from 24% in 2001 to 23% in 2004-05 (age adjusted).[150] Smoking cessation markedly reduces overall cardiovascular risk. The risk of myocardial infarction is two to six times higher in people who smoke than in non smokers.[60]
Thirty six percent of women who participated in this study were found to be drinking above the recommended levels for prevention of heart disease. Excessive alcohol consumption, including binge and heavy drinking has been linked to injuries and deaths from accidents. Long-term heavy drinking increases the risk for high blood pressure, heart arrhythmias and stroke.[137]

The National Heart Foundation

recommends that alcohol intake should be limited to one standard drink per day for women.[60] Obesity is an important determinant of coronary heart disease.

Overweight and

obesity are highly prevalent in rural areas of Australia and post significant risks to health. Overweight and obesity increases the risks for hypertension, heart disease and diabetes.[137] Results from this study found that women who reported being

overweight are more likely to also have been told that they have high blood pressure.
This is consistent with risk estimates from population studies suggest that 75% of hypertension can be directly attributed to obesity.[84] In the last 20 years there has also been a significant increase in the proportions of overweight and obese
Australians.[82]
Interestingly, there were no women who reported having diabetes or were taking medication for diabetes. Australian studies have shown that self-reported diabetes has more than doubled from 1.3% in 1989-90 to 2.9% in 2001.[151] These figures may be underestimated though, as it has been found that when undiagnosed cases are
- 56 -

included, it is estimated that nearly one million Australians aged twenty five and over
(7.6% of the population) have diabetes.[82] Diabetes is the sixth leading cause of death in Australia, and contributes to significant disability. Diabetes involves high rates of health service utilisation, with morbidity and mortality increasing markedly with age.

People with diabetes are two to four times more likely to develop

cardiovascular disease.[152] Diabetes shares risk factors with, and is itself a risk factor for coronary heart disease, stroke and peripheral vascular disease. People with diabetes are more likely to have a clustering of risk factors such as high blood cholesterol, overweight and high blood pressure, associated with the metabolic syndrome. Over half of women participants in this study reported having two or more lifestyle risk factors for heart disease. This was despite having a good knowledge of heart disease. This is consistent with other studies that found that women’s perception of their personal susceptibility to heart disease was not related to their knowledge about heart disease risk.[110, 137] Consequently, this study demonstrates that women may know about heart disease risk factors, nevertheless they may be unaware of their susceptibility to heart disease in relation to the risk factors. Without an awareness of personal susceptibility, women may be less likely to take action to reduce the risk of heart disease.
Greater awareness and knowledge is associated with increased action to lower risk of heart disease. Prevention of coronary heart disease also contributes to decreased morbidity and mortality from other chronic illnesses such as diabetes, cancer, depression, chronic renal disease, respiratory disorders and musculoskeletal disorders.
In fact, prevention of heart disease involves a healthy lifestyle that includes diet modifications, exercise, weight control, limiting alcohol and smoking cessation. This information, when introduced at a young age, will result in increased quality of life and less chronic illness for women. Therapies and behaviour modification that delay disease onset will markedly reduce overall disease prevalence, whereas therapies to treat existing disease will alter the proportion of cases that are mild as opposed to moderate/severe. The public health impact of such changes would likely involve both the amount and type of health services needed.[153]

- 57 -

SIGNIFICANCE OF FINDINGS
RESPONSE RATE
The present study achieved a response rate of 73% (68 out of 93 questionnaire returned). The achieved response rate was more than the researcher’s expectations of
50%, which was estimated from literature data on survey studies.[89] The response rate varies and depends on many factors, such as subjects demographic profile, technique of conducting the survey and clarity of the questionnaire items.[128] There is not a standard response rate to survey studies and therefore the response rate should be evaluated within the context of each study individually and compared with similar studies. Other published studies investigating women’s perception, knowledge and awareness of coronary heart disease have not included postal surveys, but telephone surveys, making it difficult to compare response rates.[6, 90, 104] The target population of the current study was relatively small and therefore relying solely on the retaining percentage to evaluate the success in recruiting subjects might be misleading.
IMPLICATIONS FOR PRACTICE
Coronary heart disease in women will continue to be a public health priority as significant numbers of aging women are at increased risk for morbidity and mortality related to heart disease. Healthcare systems need to begin to shift paradigms to emphasize healthy lifestyles for young women. This approach will help prevent development of risk factors and minimize the need to manage them at a later time.[62]
Even though most heart disease is manifested in adults, the disease process can begin at a young age.[7] Because of the magnitude of the problem of heart disease in women and the evidence that risk can be decreased by a healthy lifestyle, there is an obligation to action before women show symptoms of myocardial infarction.
Educational programs targeting younger women emphasizing the role of diet, exercise, smoking cessation and regular blood cholesterol measurements should be stressed in preventing heart disease.[37] Programs that focus on heart disease risk reduction may have a profound effect on disease progression because pathogenesis begins early in life.[8] Studies have linked fatty streaks to atherosclerotic disease suggesting that awareness of heart disease risk at a young age may have an effect on the rate of disease development in the subsequent 20-40 years.[154, 155]

- 58 -

It is

therefore beneficial for the entire population, including children and adolescents, to have an awareness of the risk factors associated with heart disease and the education necessary to modify risk factors as needed on an individual basis. Future health education for adolescents and young adults should be focused on prevention of heart disease, because prevention of heart disease is important to this population.[7]
Cardiovascular disease is primarily a lifestyle disease, and is amenable to changes.
Research shows that coronary heart disease can be slowed significantly or progression halted when preventive programs have been instituted at the beginning stages of the disease.[140] Effective primary prevention of coronary heart disease requires early detection of risk factors, communication of individual risk to women and benefits of early intervention. Assessment and communication of risk is necessary as it can assist women to have insight into the impact and by developing a more realistic perceived risk of coronary heart disease that, in turn, may motivate them to initiate and maintain healthy behaviours.[95] Health professionals have advocated primary prevention of heart disease for many years, however it seems that women in general are not heeding the message.[140] Nurses can play a major role in educating both the public and other healthcare providers about the very real danger of heart disease in women.
Heart disease is not a man’s disease. It is an equal-opportunity disease. The media, through the Heart Foundation has launched a huge campaign to educate the public about this potentially lethal disease, however, the myth still exists.[37]
The findings of this study indicate the need for heart disease education programs for all women. New strategies for educating women about coronary heart disease should be explored by nurses. Nurses need to be aware that women tend to recognize smoking, obesity and inactivity as risk factors nevertheless are less aware of factors such as hypertension, diabetes, age and hyperlipidemia. Many women have never had their cholesterol tested and women need to be taught the importance of knowing their cholesterol levels and how to improve their cholesterol profile. Nurses can lead multidisciplinary team members in delivering care that decreases risks and increases knowledge for their patients. Nurses interested in cardiovascular disease in women could organize and offer educational sessions in local schools, churches and at sites where women work. Collaborating with the National Heart Foundation and Country
Health in educating women may be appropriate. By increasing women’s knowledge,
- 59 -

their actual risk may change and thus improve their chance to live free of cardiovascular disease or have it later in life or to a lesser extent.[156]
There are many situations open to nurses for providing either planned or opportunistic verbal information, which could be supplemented by written materials that specifically focus on the needs and priorities of women at risk of heart disease.[2]
Nurses need to look for those risk factors that may be more specific to women, such as diabetes, depression, post menopause, and thyroid dysfunction. The importance of testing for diabetes, thyroid disease, depression and lipid levels needs to be stressed.[37] In a survey of one hundred and twenty women between the ages of 35 and 60 years with no history of heart disease, it was found that nurse practitioners were ideally suited to decrease the mortality and morbidity associated with heart disease through education strategies and attention to individual barriers women face when attempting to incorporate coronary heart disease risk factor modification into their lives.[157] Nurses play an important role, whether in the hospital or community setting as they have the closest contact with women, whether as female patients, daughters, mothers, carers or partners. There are many situations open to nurses for providing either planned or opportunistic verbal information, which could be supplemented by written materials that specifically focus on the needs and priorities of women with coronary heart disease.[2]
STUDY LIMITATIONS
Participation in this study was limited to women who were able to read English.
Generalisation of the result to non-English speaking groups, including Aboriginal women are limited, as they did not participate in the study. Participants were not required to disclose their ethnicity so generalisations of the results to women of race other then Caucasian cannot be made. Data related to socioeconomic status was not collected for individual participants so it is unknown if socio-economic status affected women’s perception, knowledge and awareness of heart disease. Due to the specific characteristics of this particular sample (e.g. convenience sampling was used and the sample was limited in diversity regarding race), results should not be generalized to the greater population of rural women.[134] However, the findings of this study lead to implications for nurses, particularly for those practicing in rural communities.

- 60 -

In efforts to maintain participants’ anonymity the researcher did not have control over the distribution of the questionnaires. Hospital employed nursing/midwifery staff were responsible for the distribution of the questionnaires to women and a clear criteria was provided. These staff members had the opportunity to act in a gate keeper role and had the potential to restrict who received the questionnaires. There is no evidence however, to show that this occurred.
Data examining health history was unable to be included in the discussion of this study as it was thought to be inaccurate. Many of the completed questionnaires had numerous responses to the question about health history and it is thought by the researcher that many of the women interpreted this question as family history rather than personal history.
Other risk factors have not been addressed in this study. Depression, menopausal status and thyroid abnormalities have been linked to coronary heart disease in women.[37] Information about the participants’ menopausal status and knowledge of hormone replacement therapy as a preventive strategy would have been useful.
RECOMMENDATIONS FOR FURTHER INVESTIGATION
More research is needed to develop means to improve women’s perception of their risk for heart disease and to encourage them to act on their enhanced perception and thereby reduce overall heart disease morbidity and mortality. Women’s perception and awareness of risk requires quantification by empirical studies that should be done on an ongoing basis to evaluate changes in heart disease knowledge in women over time. Future studies should focus on exploring in detail the specific areas of

knowledge deficits so that education can be provided in a more focused manner.
Further study also needs to be done on the effects of risk modification by women.
Few clinical or public health interventions for primary prevention have targeted women, despite the high prevalence of risk factors and morbidity and mortality from cardiovascular disease in women.[158]

For the most part, the effects of

cardiovascular health interventions have been understudied in women. Much work needs to be done to improve cardiovascular health in women and to learn the best ways of helping women to adopt and sustain healthy lifestyle behaviours.

- 61 -

CONCLUSION
Coronary heart disease in women will continue to be a public health priority as increasing numbers of aging women are at increased risk for heart disease morbidity and mortality. Given the frequent occurrence of multiple risk factors in women, a multifactorial approach to primary prevention and risk factor reduction should be encouraged to help reduce the prevalence and burden of heart disease among women in Australia.
Few women appreciate that cardiovascular disease is their major health problem. This gap between fact and perception highlights the need to increase women’s awareness about their vulnerability to coronary heart disease.

Although deaths from heart

disease is 4.5 times higher than deaths from breast cancer, women perceive breast cancer as their major health problem.[144] Changing the misperception of women about their health problems includes increasing their knowledge that favourable changes in lifestyle can reduce cardiovascular risk factors and prevent cardiovascular disease and coronary heart disease.
Cardiovascular disease is a serious epidemic in the female population. Almost two thirds of women who die suddenly of coronary heart disease had no previous symptoms of their illness. The fact that coronary risk factors predict sudden cardiac death provides a further rationale for coronary risk reduction for women.[27]

It is

essential for health workers to increase their awareness of sex-based differences in risk factors, lipid profiles and treatment response to effectively refocus cardiovascular care for women. Cardiovascular risk factors should be assessed in women starting much earlier than menopause and should then be treated as aggressively in women as men.[41] Any woman can benefit from increased awareness of the risks, and the younger women who adopt healthy lifestyle behaviours now may avoid developing heart disease later in life.
The results of this study revealed that many women are at risk of developing heart disease. This research recommends aggressive risk factor education among women associated with risk factor modification programs. The use of a risk factor assessment instruments to provide individual scores for each women’s risk for cardiac disease can facilitate development of individual plans for risk factor modification. Women at

- 62 -

high risk for heart disease would benefit for a collaborative, multidisciplinary approach. - 63 -

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APPENDIX 1
DISCIPLINE OF NURSING

SCHOOL OF POPULATION HEALTH & CLINICAL
PRACTICE
FACULTY OF HEALTH SCIENCES
LEVEL 3, ELEANOR HARRALD BUILDING
ROYAL ADELAIDE HOSPITAL
THE UNIVERSITY OF ADELAIDE
SA 5005
AUSTRALIA
TELEPHONE [phone]
FACSIMILE [phone]

Dear Madam,
I am a candidate in the Master of Nursing Science at the Discipline of Nursing in the
School of Population Health at The University of Adelaide. I am currently investigating the understanding women aged between 25 and 65 years have of heart disease. I would appreciate it if you could complete the enclosed questionnaire and deposit it in the box provided in the waiting area or post it to me in the reply paid envelope provided. It will take you between 15-20 minutes to complete the questionnaire. Your participation is voluntary and if you do not wish to complete the questionnaire, your future medical treatment will not be affected in any way.
It is hoped that this study will provide doctors and nurses with a better understanding of women’s knowledge of Coronary Heart Disease. The results of this study may be published, but all participants will remain anonymous.
If you have any queries, please contact Rosanne Crouch, Ward A, Port Pirie Regional
Health Service 86364500 extension 84526. Alternatively, you may wish to contact my supervisor, Dr Anne Wilson, University of Adelaide, [phone]. Information on the complaints procedure is also enclosed in case you wish to discuss any issues about the way in which this study is conducted with an independent person.
I wish to thank you in advance for your assistance.
Rosanne Crouch

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APPENDIX 2
THE UNIVERSITY OF ADELAIDE
HUMAN RESEARCH ETHICS COMMITTEE
CONTACTS FOR INFORMATION ON
COMPLAINTS PROCEDURE

PROJECT AND INDEPENDENT

The Human Research Ethics Committee is obliged to monitor approved research projects. In conjunction with other forms of monitoring it is necessary to provide an independent and confidential reporting mechanism to assure quality assurance of the institutional ethics committee system. This is done by providing research participants with an additional avenue for raising concerns regarding the conduct of any research in which they are involved.
The following study has been reviewed and approved by the University of Adelaide
Human Research Ethics Committee:
Project title:
Perception, Knowledge & Awareness of Coronary Heart Disease among rural
Australian women 25 to 65 years of age – An Exploratory Descriptive Study
1.

If you have questions or problems associated with the practical aspects of your participation in the project, or wish to raise a concern or complaint about the project, then you should consult the project co-ordinator:
Name: Dr Anne Wilson
Senior Lecturer
Discipline of Nursing
University of Adelaide
Telephone: [phone] email: [e-mail]

2.

If you wish to discuss with an independent person matters related to making a complaint, or raising concerns on the conduct of the project, or the University policy on research involving human participants, or your rights as a participant

Contact the Human Research Ethics Committee’s Secretary on phone [phone]

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APPENDIX 3

QUESTIONNAIRE

This questionnaire contains three sections relating to women’s health issues, your personal health and heart disease. It should take between 10-15 minutes to complete.

Section 1
Please provide your response to the following questions by circling one answer only.
Women’s Health Issues
1. Which of the following do you consider the greatest health problem for women?
a. Cancer (generally)
b. Heart Disease/heart attack
c. Diabetes
d. Breast Cancer
e. Cervical Cancer
2. Coronary heart disease is the most common cause of death in women in Australia?
a. True
b. False
3. In Australia, breast cancer claims more lives than heart disease?
a. True
b. False

Section 2
Please provide your response to the following questions by circling one answer only.
Heart Disease
4. Heart disease develops gradually over many years and can easily go undetected.
a. True
b. False
5. If you have a family history of heart disease, you are at risk for developing heart disease. a. True
b. False
6. The older a person is, the greater their risk of having heart disease.
a. True
b. False

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7. Smoking is a risk factor for heart disease.
a. True
b. False
8. A person who stops smoking will lower their risk of developing heart disease.
a. True
b. False
9. High blood pressure is a risk factor for heart disease.
a. True
b. False
10. Keeping blood pressure under control will reduce a person’s risk for developing heart disease. a. True
b. False
11. High cholesterol is a risk factor for developing heart disease.
a. True
b. False
12. Eating fatty foods does not affect blood cholesterol levels.
a. True
b. False
13. If your ‘good’ cholesterol (HDL) is high you are at risk for heart disease.
a. True
b. False
14. If your ‘bad’ cholesterol (LDL) is high you are at risk for heart disease.
a. True
b. False
15. Being overweight increases a person’s risk for heart disease.
a. True
b. False

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16. Regular physical activity will lower a person’s chance of getting heart disease.
a. True
b. False
17. Only exercising at a gym or in an exercise class will lower a person’s chance of developing heart disease.
a. True
b. False
18. Walking and gardening are considered exercise that will help lower a person’s chance of developing heart disease.
a. True
b. False
19. Diabetes is a risk factor for developing heart disease.
a. True
b. False
20. High blood sugar puts a strain on the heart.
a. True
b. False
21. If your blood sugar is high over several months it can cause your cholesterol level to go up and increase your risk of heart disease.
a. True
b. False
22. A person who has diabetes can reduce their risk of developing heart disease if they keep their blood sugar levels under control.
a. True
b. False
23. People with diabetes rarely have high cholesterol.
a. True
b. False

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24. If a person has diabetes, keeping their cholesterol under control will help lower their chance of developing heart disease.
a. True
b. False
25. People with diabetes tend to have low HDL (good) cholesterol.
a. True
b. False
26. A person who has diabetes can reduce their risk of developing heart disease if they keep their blood pressure under control.
a. True
b. False
27. A person who has diabetes can reduce their risk of developing heart disease if they keep their weight under control.
a. True
b. False
28. Men with diabetes have a higher risk of heart disease than women with diabetes?
a. True
b. False
29. Women are a higher risk of heart disease after menopause?
a. True
b. False
30. A person always knows when they have heart disease.
a. True
b. False
Section 3
Personal Health Status
31. Which of the following groups does your age fit?
a. 25-34 years
b. 35-44 years
c. 45-54 years
d. 55-65 years
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32. Would you say that your general health is:
a. Excellent
b. Very Good
c. Good
d. Fair
e. Poor
33. Do you have a history of the following illnesses (Please circle all the responses that apply to you).
a. Heart Disease

f. Stroke

b. Diabetes

g. Heart Attack

c. Cancer

h. Angina

d. Mental Health problem

i. Hypothyroidism

e. Heart Failure

j. Respiratory illness

34. Are you taking any prescription medication?
a. Yes
b. No
35. Please list the medication (both prescription and over the counter) that you take
Name

Dose

Frequency

1.__________________________________________________________________________
2.__________________________________________________________________________
3.__________________________________________________________________________
4.__________________________________________________________________________
5.__________________________________________________________________________
6.__________________________________________________________________________
7.__________________________________________________________________________
Please provide your response to the following questions 36-38 by circling one answer only.

Weight
36. How would you assess your own weight?
a. underweight
b. acceptable or healthy
c. overweight

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37. What means do you use to assess your weight?
a. Comparison to others
b. Clothing size
c. Clothing fit (loose or tight)
d. Body mass index scales
e. How you feel
f.

Opinion of others

g. Other ________________________________(Please State)
38. Has your weight changed in the last 12 months?
a. increased
b. decreased
c. no change

Blood Pressure
39. Have you had your blood pressure checked in the last 12 months?
a. yes
b. no
40. Have you EVER been told by a doctor, nurse or other health professional that you have high blood pressure?
a. yes
b. no
41. Are you currently taking medication for your high blood pressure?
a. yes
b. no

Exercise
42. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, callisthenics, golf, gardening, or walking for exercise? a. Yes
b. No

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Cholesterol
Blood cholesterol is a fatty substance found in the blood.
43. Have you EVER had your cholesterol checked?
a. Yes [go to question 44]
b. No [Go to question 46]
44. How long has it been since you last had your blood cholesterol checked?
a. Within the past year (anytime less than 12 months ago)
b. Within the past 2 years (1 year but less than 2 years)
c. Within the past 5 years (2 years but less than 5 years ago)
d. 5 or more years ago
45. Have you EVER been told by a doctor, nurse or other health professional that your blood cholesterol is high?
a. Yes
b. No

Tobacco Use
46. Have you smoked at least 100 cigarettes in your entire life?
Note: 5 packs = 100 cigarettes
a. Yes [Go to question 47]
b. No [Go to question 49]
47. Do you now smoke cigarettes every day, some days, or not at all?
a. Every day
b. Some days
c. Not at all [Go to Question 49]
48. During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking?
a. Yes
b. No

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Alcohol Consumption
In Australia, one standard drink is equivalent to 10g alcohol. Each of the drinks pictured below is one standard drink. Before answering the next questions, please refer to the diagram below. It shows examples of a standard drink.

NOTE:
This figure is included on page 86 of the print copy of the thesis held in the University of Adelaide Library. www.dassa.sa.gov.au OTHER EXAMPLES OF STANDARD DRINK QUANTITIES:
1 bottle(750ml) = 7 standard drinks

Wine

1 cask (4 litres = 38 standard drinks
1 can or stubby of beer = 1.5 standard drinks

Full Strength Beer

1 bottle of beer (750ml) = 3 standard drinks
1 six –pack o0b beer = 9 standard drinks
1 six-pack of light beer = 5 standard drinks

Light Beer

1 case or slab of light beer = 20 standard drinks

Other drinks

1 stubby of cider (375ml) = 1.5 standard drinks
1 bottle of spirits (750ml) = 24 standard drinks

49. During the past 30 days, have you had a least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
a. Yes [Go to question 50]
b. No [Go to question 51]
50. How often do you have a drink containing alcohol?
a. Monthly or less
b. 2 to 4 times a month
c. 2 to 3 times a week
d. 4 or more times a week

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51. How many standard drinks do you have on a typical day when you are drinking?
a. 1 or 2
b. 3 or 4
c. 5 or 6
d. 7 to 9
e. 10 or more
52. How often do you have 6 or more drinks on one occasion?
a. Never
b. Less than monthly
c. Monthly
d. Weekly
e. Daily or almost daily

Thank you for completing this survey.
Please return the questionnaire in the envelope provided and place in the box in the Well
Women’s Clinic.
Alternatively, post to:
Rosanne Crouch
Ward A
Port Pirie Regional Health Service
PO Box 546
PORT PIRIE 5540

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