European Journal of Cardiovascular Nursing http://cnu.sagepub.com/
Knowledge of cardiovascular disease in Turkish undergraduate nursing students Aysel Badir, Kader Tekkas and Serpil Topcu Eur J Cardiovasc Nurs published online 30 June 2014 DOI: 10.1177/1474515114540554 The online version of this article can be found at: http://cnu.sagepub.com/content/early/2014/06/19/1474515114540554
Published by: http://www.sagepublications.com
On behalf of:
European Society of Cardiology
Additional services and information for European Journal of Cardiovascular Nursing can be found at: Email Alerts: http://cnu.sagepub.com/cgi/alerts Subscriptions: http://cnu.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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540554 research-article2014
CNU0010.1177/1474515114540554European Journal of Cardiovascular NursingBadir et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Paper
Knowledge of cardiovascular disease in Turkish undergraduate nursing students
European Journal of Cardiovascular Nursing 1–9 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114540554 cnu.sagepub.com
Aysel Badir1, Kader Tekkas2 and Serpil Topcu1
Abstract Background: Cardiovascular disease is the number one cause of death worldwide. However, there is not enough data exploring student nurses’ understanding, knowledge, and awareness of cardiovascular disease. Aims: To investigate knowledge of cardiovascular disease and its risk factors among undergraduate nursing students, with an emphasis on understanding of cardiovascular disease as the primary cause of mortality and morbidity, both in Turkey and worldwide. Methods: This cross-sectional survey assessed 1138 nursing students enrolled in nursing schools in Istanbul, Turkey. Data were collected using the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale and questions from the Individual Characteristics Form about students’ gender, age, level of education, and family cardiovascular health history, as well as smoking and exercise habits. Results: Respondents demonstrated a high level of knowledge about cardiovascular disease, with years of education (p < 0.001), gender (p < 0.001), and high school type (p < 0.05) all significantly associated with CARRF-KL scores. However, more than half of the students were not aware that cardiovascular disease is the primary cause of mortality and morbidity in Turkey and worldwide. The majority of the respondents’ body mass index (87%) and waist circumference values (females: 90.3%, males: 94.7%) were in the normal range and most were non-smokers (83.7%). However, more than half of the students did not exercise regularly and had inadequate dietary habits. Conclusions: Although students were knowledgeable about cardiovascular disease and associated risk factors, there were significant gaps in their knowledge; these should be addressed through improved nursing curricula. While students were generally healthy, they could improve their practice of health-promoting behaviors. Keywords Cardiovascular disease, nursing students, knowledge, health behaviors, risk factors Date received 27 March 2014; revised 21 May 2014; accepted 29 May 2014
Introduction Cardiovascular disease (CVD) is the number one health problem worldwide, accounting for 30% of all deaths.1 CVD is the main cause of death in Turkey and coronary artery disease (CAD) is the most prevalent in that category. While a decrease in the prevalence of the disease has been observed in developed countries where primary and secondary preventive measures have been successfully applied toward the risk factors, a general rise has been reported in Turkey for both genders in the past 20 years and is attributed to the lifestyle changes of the population based on the results of the Turkish Adult Risk Factor Study (TARF) study representing Turkey since 1990.2
Smoking, physical inactivity, unhealthy diet, and the excessive use of alcohol are the primary behavioral cardiovascular risk factors for CVD;3 CVD is preventable through reducing these behavioral risk factors.3,4 Even though Turkey has a young population compared to 1Koc
University School of Nursing, Istanbul of Washington School of Nursing, USA
2University
Corresponding author: Aysel Badir, Koc University School of Nursing, Guzelbahce Sk, No:20, Nisantasi 34365 Istanbul, Turkey. Email: [email protected]
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European Journal of Cardiovascular Nursing
other European countries, the CVD morbidity rate is higher.5 Since 1990, there has been an annual increase of 6.4% in CAD in the Turkish population, which is associated with lifestyle changes.2 Several screening studies on the prevalence of obesity in Turkey have shown that it is a major health problem, with increasing prevalence in younger age groups.2,6,7 While physical activity decreased (male: 2.3%, female: 6.3%) each year since 1990, hypertension incidence increased by 21.3% between 2003 to 2007.8 Moreover, prevalence of diabetes among individuals has increased from 7.2% to 13.7% in 10 years in Turkey.7,9 Besides the increasing hypertension and diabetes rates, smoking is an important concern in Turkey. According to the World Health Organization data, 33.4% of adult population was daily smokers (male: 50.6%; female: 16.6%).7–10 The effective management of CVD requires multidisciplinary cooperation in prevention and treatment as well as greater patient, family, and community involvement and a skilled, proactive, and diverse workforce.11,12 There is well-documented evidence as to the effectiveness of nurse-managed programs for CVD risk reduction, including individual, group, and community interventions.13–19 However, research has shown a lack of knowledge in nurses,20,21 nursing students,22–24 and both groups combined regarding CVD and associated risk factors.20,25,26 Wilt et al. found that most nurses agreed that counselling patients about CVD risk factors should be their responsibility, but only 1% reported that they were currently involved in this activity.20 Another study reported that, although most Chinese nursing professionals and students could identify common risk factors for CAD and had positive attitudes towards reducing the risks, less than 58% could correctly answer questions about evidence-based recommendations.26 A self-administered survey of nursing and medical students found that healthy lifestyle behaviors were independently associated with positive attitudes toward CVD prevention.23 Similarly, Irazusta et al. evaluated and compared physical exercise habits, physical fitness, and diet in a group of female nursing students. Most did not exercise regularly.22 Despite the need for nurses to provide education to help reduce CVD-related morbidity and mortality in Turkey, no studies have been published of nursing students’ knowledge and personal health behaviors related to CVD and related risk factors. This knowledge gap prevents constructing a study with a priori hypothesis. For this reason, our overall aim was to investigate knowledge CVD and associated risk factors among undergraduate nursing students, with an emphasis on their understanding of CVD as the primary cause of mortality and morbidity in Turkey and worldwide to form a base for the further studies.
Objectives The objectives of this study were to (1) evaluate students’ knowledge of CVD and associated risk factors; (2) identify associations between students’ knowledge of CVD and individual characteristics; (3) evaluate students’ knowledge of CVD as the primary cause of mortality and morbidity in Turkey and worldwide; and (4) investigate nursing students’ personal health behaviors of exercise, diet, and smoking.
Methods Design This cross-sectional study was conducted at three public and three private undergraduate nursing schools in Istanbul, Turkey, from December 2009 to March 2010.
Participants A total of 1814 students were invited to participate in the study (530 first-year, 474 second-year, 461 third-year, and 349 fourth-year students); 1138 of the students responded, achieving an overall response rate of 62.73%.
Ethical concerns This study was approved by the Koc University School of Nursing Institutional Research Ethics Board, which is consistent with the principles outlined in the Declaration of Helsinki.27
Data collection Information was gathered on students’ knowledge of CVD and risk factors, personal health behaviors associated with CVD, and knowledge of CVD as the primary cause of mortality and morbidity. The data were collected using a two-stage process. First, the 28-item Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale, developed by Arıkan et al.,28 was used to evaluate knowledge of CVD and risk factors, as defined by previous studies.29–35 Arıkan et al. tested the validity and reliability of the scale, achieving a Cronbach’s alpha of 0.77. 28 Our study also achieved a Cronbach’s alpha of 0.77. All items were true/false statements, with possible responses of ‘Yes’, ‘No’, or ‘Do not know’. Each correct answer was awarded one point; six items were false, and therefore inversely scored. A mean score was calculated for each participant and the maximum total score was 28 points. A high total score on the CARRF-KL is positively correlated with better knowledge of CVD risk factors.28 The data for the second stage were collected by using a questionnaire consisted of four open-ended questions that
Downloaded from cnu.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
3
Badir et al. assessed knowledge related to the primary causes of mortality and morbidity in men and women. An example of open-ended questions is “What is the primary cause of morbidity in women in Turkey and in the World?”. The questionnaire also included items assessing demographic characteristics and health behaviors which were defined as ‘any activities undertaken to maintain, attain, or regain good health and prevent CVD’.36,37 Students’ nutritional patterns were evaluated based on dietary guidelines published by the Turkish Ministry of Health. These guidelines recommend two servings of protein, six servings of carbohydrates, and at least five servings of fruits and vegetables daily.38 For this study, we measured individual weight (kg), height (cm), and waist circumference (cm). We calculated body mass index (BMI), weighing students after they removed heavy clothing. Participants were classified as underweight (BMI ≤ 18.5), normal weight (BMI = 18.5–24.9), or overweight (BMI ≥ 25.0). Waist circumference was measured on a horizontal plane, midway between the inferior margin of the ribs and the superior border of the iliac crest at the end of gentle expiration.37 Based on International Diabetes Federation and Turkish Heart Association guidelines, healthy waist circumference were defined as ≤80 cm for women and ≤ 94 cm for men.2,39
Data analysis Data were analyzed using IBM SPSS Statistics 19.0. CARRF-KL total mean scores were compared using independent sample t-tests for independent groups and one-way analysis of variance (ANOVA; Tukey’s HSD for further analysis) for independent groups. To examine the effects of various factors on CARRF-KL total mean scores, the following factors were considered as independent variables for multiple regression analysis: year of undergraduate education, gender, educational background, BMI, exercise, waist circumference, CVD history in first degree male or female relatives, smoking. Significance was set at p < 0.05.
Results Demographic characteristics A total of 1138 students (overall mean age was 20.92±1.98 (20.81±1.91 years female; 21.41±2.49 years male) responded. Of these, 91.2% (n = 1038) were female, 52.7% (n = 600) attended a private university, 47% (n = 538) a public university. Nearly all students had graduated from high school 92.5% (n = 1046); 7.5% (n = 85) had graduated from four-year vocational health schools, which can grant nursing diplomas in Turkey. In total, 28% (n = 319) were first-year students, 23.6% (n = 269) second-year, 26.4% (n = 301) third-year, and 21.9% (n = 249) fourth-year.
The students’ CARRF-KL scores and individual characteristics The total mean CARRF-KL score was 22.47±3.38 out of a maximum of 28 (female = 22.63±3.31; male = 20.82±3.57). As shown in Table 1, 87% of students did not know that heart disease could be identified based on common signs and symptoms. About half of the students (50.4%) did not know what constitutes an exercise; for example, they considered slow walking and wandering as exercise. Nearly all students (94.2%) knew that ‘hypertension is a risk factor for heart disease’ and 87.3% knew that ‘blood pressure control reduces the risk of heart disease’, but only 46.4% knew that ‘hypertension medications should be used for a lifetime’. Although 93.6% knew that ‘high cholesterol is a risk factor for heart disease’, 35.4% did not know that ‘there is a risk of a heart disease if good (HDL) cholesterol level is low’ and 35.3% did not know that ‘CAD can be prevented’. In examining the relationship between CARRF-KL mean scores and individual characteristics, we found statistically significant difference (all p < 0.001) between years of undergraduate education and CARRF-KL mean scores; first-year students’ knowledge level was significantly lower than that of students’ knowledge level in later years. Logically, fourth-year students’ knowledge level was significantly higher than those of lower classes. Students who graduated from vocational health schools had higher mean CARRF-KL scores as compared to those who graduated from high schools. A t-test indicated that female students’ knowledge level was higher than that of the male students (p < 0.001, Table 2).
CVD as a primary cause of mortality and morbidity in Turkey and worldwide Students answered four open-ended questions on the primary causes of mortality and morbidity in men and women in Turkey and worldwide. Only 16.5% of female and 14% of male students reported that heart disease was the primary cause of morbidity in women, and only 39.7% of female and 31% of male students reported that heart disease was the primary cause of morbidity in men. Only 20.4% of female and 20% of male students reported that heart disease was the primary cause of mortality in women in Turkey and worldwide; 43.4% of female and 36% of male students reported that heart disease was the primary cause of mortality in men in Turkey and worldwide (Table 3).
Personal health behaviors associated with CVD Waist circumference was within the normal range for 74.5% of the students; 90.3% of the female respondents’ measurements were ≤80 cm, and 94.7% of the male
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European Journal of Cardiovascular Nursing
Table 1. The Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale scores. Correct 1. A person always realizes if she/he has a heart disease. 2. A family history of CVD increases your risk of having heart disease. 3. Elderly people are at a higher risk for heart diseases. 4. CAD can be prevented. 5. Smoking is a preventable cause of death and diseases in our country. 6. Smoking is a risk factor for heart diseases. 7. The risk of developing heart disease is reduced when smoking is stopped. 8. It is beneficial to eat 2-3 portions of fruit and 2 portions of vegetable daily. 9. It’s harmful to eat red meat more than 3 times a week. 10. Eating salty leads to increase in blood pressure. 11. Fatty meals do not increase the cholesterol level in blood. 12. Fats that are solid at room temperature are beneficial for heart health. 13. A low carbohydrate and low fat diet is beneficial for heart health. 14. Overweight individuals have higher risk of heart disease. 15. Regular exercise reduces the risk of heart disease. 16. Risk can be reduced by exercising only in gym. 17. Slow walking and wandering are also considered as exercise. 18. Stress, sorrow, and burden increase the risk of heart disease. 19. Blood pressure increases under stressful conditions. 20. High blood pressure is a risk factor for heart disease. 21. Blood pressure control reduces the risk of heart disease. 22. Hypertension medications should be used for a lifetime. 23. High cholesterol is a risk factor for heart disease. 24. There is a risk of heart disease if good cholesterol (HDL) is high. 25. There is a risk of heart disease risk if bad cholesterol (LDL) is high. 26. Every person with high cholesterol level is given medicine. 27. Diabetes is a risk factor for heart disease. 28. The risk can be reduced in diabetic patients with glucose control. aT
Ta T T T T T T T T T Fb F T T T F F T T T T T T F T F T T
Incorrect
n
%
n
%
148 1089 986 736 869 1101 1050 1070 872 1042 1029 959 902 1097 1092 944 564 1079 1053 1072 994 610 1065 735 951 726 796 942
13.0 95.7 86.6 64.7 76.4 96.7 92.3 94.0 76.6 91.6 90.4 84.3 79.3 96.4 96.0 83.0 49.6 94.8 92.5 94.2 87.3 53.6 93.6 64.6 83.6 63.8 69.9 82.8
990 49 152 402 269 37 88 68 266 96 109 179 236 41 46 194 574 59 85 66 144 528 73 403 187 412 342 196
87.0 4.3 13.4 35.3 23.6 3.3 7.7 6.0 23.4 8.4 9.6 15.7 20.7 3.6 4.0 17.0 50.4 5.2 7.5 5.8 12.7 46.4 6.4 35.4 16.4 36.2 30.1 17.2
(True), bF (False).
Table 2. Association between students’ individual characteristics and CARRF-KL scores. Characteristics Year of undergraduate education First year (n = 319) Second year (n = 269) Third year (n = 301) Fourth year (n = 249) Educational background Vocational health school (n = 85) High school (n = 1053) Gender Female (n = 1038) Male (n = 100)
CARRF-KL total score (X ± SD)
Statistical test
20.28 ± 3.53 23.34 ± 2.86 22.79 ± 3.08 23.96 ± 2.57
F (82.41)
23.68 ± 3.23 22.37 ± 3.37
t (3.45)
22.63 ± 3.31 20.82 ± 3.58
t (5.18)
respondents were ≤94 cm. The majority of students had no first degree family history of CVD in either a first-degree male or female relative. A majority (63.6%) of the students
p value 0.001
0.001 0.001
were not aware of their blood pressure, and (0.8%) had diabetes mellitus type 2. 83.7% of students were nonsmokers, and 85.5% reported not taking exercise in the
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5
Badir et al. Table 3. The knowledge of the students that CVD is the primary reason for mortality and morbidity in Turkey and in the world. Female students Primary morbidity reason in women in Turkey and the world (n = 1018) Cancer Cardiovascular diseases Do not know Diabetes Mellitus Gynecological diseases Other Primary morbidity reason in men in Turkey and the world (n = 1038) Cancer Cardiovascular diseases Do not know Diabetes Mellitus Other Primary mortality reason in women in Turkey and the world (n = 1038) Cancer Do not know Cardiovascular diseases Gynecological diseases Other Primary mortality reason in men in Turkey and the world (n = 1018) Cardiovascular diseases Cancer Do not know Other
Male students
%
n
n
%
561 171 128 70 31 77
54.0 16.5 12.3 6.7 3.0 7.4
46 14 22 10 0 8
46.0 14.0 22.0 10.0 0 8.0
430 412 165 14 17
41.4 39.7 15.9 1.3 1.6
36 31 29 2 2
36.0 31.0 29.0 2.0 2.0
512 212 233 35 46
49.3 24.0 22.4 3.4 4.4
39 31 20 3 7
39.0 31.0 20.0 1.0 7.0
451 337 202 48
43.4 32.5 19.5 4.6
36 26 27 11
36.0 26.0 27.0 11.0
preceding six months (defined as exercising 2–3 times per week for at least 40 minutes; Table 4). As shown in Table 4, the majority of the students (93.2%) did not consume the recommended daily amounts of fruit, vegetables, or carbohydrates, and approximately half (44.8%) consumed less than the recommended daily amount of protein. More than half of the students (58.7%) reported preferring unsaturated fats (e.g. vegetable oil); 39.5% liked both saturated (e.g. margarine) and unsaturated fats, and only 1.4% preferred saturated fat in cooking. A multiple regression analysis was run to predict CARRF-KL total score from educational year, gender, educational background, BMI, exercise, waist circumference, CVD history in first degree male or female relatives, and smoking. Three variables were revealed in the multiple
Table 4. Characteristics of the students associated with CVD. %
n BMI (n = 1129)
Knowledge of cardiovascular disease in Turkish undergraduate nursing students Aysel Badir, Kader Tekkas and Serpil Topcu Eur J Cardiovasc Nurs published online 30 June 2014 DOI: 10.1177/1474515114540554 The online version of this article can be found at: http://cnu.sagepub.com/content/early/2014/06/19/1474515114540554
Published by: http://www.sagepublications.com
On behalf of:
European Society of Cardiology
Additional services and information for European Journal of Cardiovascular Nursing can be found at: Email Alerts: http://cnu.sagepub.com/cgi/alerts Subscriptions: http://cnu.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Jun 30, 2014 What is This?
Downloaded from cnu.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
540554 research-article2014
CNU0010.1177/1474515114540554European Journal of Cardiovascular NursingBadir et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
Original Paper
Knowledge of cardiovascular disease in Turkish undergraduate nursing students
European Journal of Cardiovascular Nursing 1–9 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1474515114540554 cnu.sagepub.com
Aysel Badir1, Kader Tekkas2 and Serpil Topcu1
Abstract Background: Cardiovascular disease is the number one cause of death worldwide. However, there is not enough data exploring student nurses’ understanding, knowledge, and awareness of cardiovascular disease. Aims: To investigate knowledge of cardiovascular disease and its risk factors among undergraduate nursing students, with an emphasis on understanding of cardiovascular disease as the primary cause of mortality and morbidity, both in Turkey and worldwide. Methods: This cross-sectional survey assessed 1138 nursing students enrolled in nursing schools in Istanbul, Turkey. Data were collected using the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale and questions from the Individual Characteristics Form about students’ gender, age, level of education, and family cardiovascular health history, as well as smoking and exercise habits. Results: Respondents demonstrated a high level of knowledge about cardiovascular disease, with years of education (p < 0.001), gender (p < 0.001), and high school type (p < 0.05) all significantly associated with CARRF-KL scores. However, more than half of the students were not aware that cardiovascular disease is the primary cause of mortality and morbidity in Turkey and worldwide. The majority of the respondents’ body mass index (87%) and waist circumference values (females: 90.3%, males: 94.7%) were in the normal range and most were non-smokers (83.7%). However, more than half of the students did not exercise regularly and had inadequate dietary habits. Conclusions: Although students were knowledgeable about cardiovascular disease and associated risk factors, there were significant gaps in their knowledge; these should be addressed through improved nursing curricula. While students were generally healthy, they could improve their practice of health-promoting behaviors. Keywords Cardiovascular disease, nursing students, knowledge, health behaviors, risk factors Date received 27 March 2014; revised 21 May 2014; accepted 29 May 2014
Introduction Cardiovascular disease (CVD) is the number one health problem worldwide, accounting for 30% of all deaths.1 CVD is the main cause of death in Turkey and coronary artery disease (CAD) is the most prevalent in that category. While a decrease in the prevalence of the disease has been observed in developed countries where primary and secondary preventive measures have been successfully applied toward the risk factors, a general rise has been reported in Turkey for both genders in the past 20 years and is attributed to the lifestyle changes of the population based on the results of the Turkish Adult Risk Factor Study (TARF) study representing Turkey since 1990.2
Smoking, physical inactivity, unhealthy diet, and the excessive use of alcohol are the primary behavioral cardiovascular risk factors for CVD;3 CVD is preventable through reducing these behavioral risk factors.3,4 Even though Turkey has a young population compared to 1Koc
University School of Nursing, Istanbul of Washington School of Nursing, USA
2University
Corresponding author: Aysel Badir, Koc University School of Nursing, Guzelbahce Sk, No:20, Nisantasi 34365 Istanbul, Turkey. Email: [email protected]
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European Journal of Cardiovascular Nursing
other European countries, the CVD morbidity rate is higher.5 Since 1990, there has been an annual increase of 6.4% in CAD in the Turkish population, which is associated with lifestyle changes.2 Several screening studies on the prevalence of obesity in Turkey have shown that it is a major health problem, with increasing prevalence in younger age groups.2,6,7 While physical activity decreased (male: 2.3%, female: 6.3%) each year since 1990, hypertension incidence increased by 21.3% between 2003 to 2007.8 Moreover, prevalence of diabetes among individuals has increased from 7.2% to 13.7% in 10 years in Turkey.7,9 Besides the increasing hypertension and diabetes rates, smoking is an important concern in Turkey. According to the World Health Organization data, 33.4% of adult population was daily smokers (male: 50.6%; female: 16.6%).7–10 The effective management of CVD requires multidisciplinary cooperation in prevention and treatment as well as greater patient, family, and community involvement and a skilled, proactive, and diverse workforce.11,12 There is well-documented evidence as to the effectiveness of nurse-managed programs for CVD risk reduction, including individual, group, and community interventions.13–19 However, research has shown a lack of knowledge in nurses,20,21 nursing students,22–24 and both groups combined regarding CVD and associated risk factors.20,25,26 Wilt et al. found that most nurses agreed that counselling patients about CVD risk factors should be their responsibility, but only 1% reported that they were currently involved in this activity.20 Another study reported that, although most Chinese nursing professionals and students could identify common risk factors for CAD and had positive attitudes towards reducing the risks, less than 58% could correctly answer questions about evidence-based recommendations.26 A self-administered survey of nursing and medical students found that healthy lifestyle behaviors were independently associated with positive attitudes toward CVD prevention.23 Similarly, Irazusta et al. evaluated and compared physical exercise habits, physical fitness, and diet in a group of female nursing students. Most did not exercise regularly.22 Despite the need for nurses to provide education to help reduce CVD-related morbidity and mortality in Turkey, no studies have been published of nursing students’ knowledge and personal health behaviors related to CVD and related risk factors. This knowledge gap prevents constructing a study with a priori hypothesis. For this reason, our overall aim was to investigate knowledge CVD and associated risk factors among undergraduate nursing students, with an emphasis on their understanding of CVD as the primary cause of mortality and morbidity in Turkey and worldwide to form a base for the further studies.
Objectives The objectives of this study were to (1) evaluate students’ knowledge of CVD and associated risk factors; (2) identify associations between students’ knowledge of CVD and individual characteristics; (3) evaluate students’ knowledge of CVD as the primary cause of mortality and morbidity in Turkey and worldwide; and (4) investigate nursing students’ personal health behaviors of exercise, diet, and smoking.
Methods Design This cross-sectional study was conducted at three public and three private undergraduate nursing schools in Istanbul, Turkey, from December 2009 to March 2010.
Participants A total of 1814 students were invited to participate in the study (530 first-year, 474 second-year, 461 third-year, and 349 fourth-year students); 1138 of the students responded, achieving an overall response rate of 62.73%.
Ethical concerns This study was approved by the Koc University School of Nursing Institutional Research Ethics Board, which is consistent with the principles outlined in the Declaration of Helsinki.27
Data collection Information was gathered on students’ knowledge of CVD and risk factors, personal health behaviors associated with CVD, and knowledge of CVD as the primary cause of mortality and morbidity. The data were collected using a two-stage process. First, the 28-item Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale, developed by Arıkan et al.,28 was used to evaluate knowledge of CVD and risk factors, as defined by previous studies.29–35 Arıkan et al. tested the validity and reliability of the scale, achieving a Cronbach’s alpha of 0.77. 28 Our study also achieved a Cronbach’s alpha of 0.77. All items were true/false statements, with possible responses of ‘Yes’, ‘No’, or ‘Do not know’. Each correct answer was awarded one point; six items were false, and therefore inversely scored. A mean score was calculated for each participant and the maximum total score was 28 points. A high total score on the CARRF-KL is positively correlated with better knowledge of CVD risk factors.28 The data for the second stage were collected by using a questionnaire consisted of four open-ended questions that
Downloaded from cnu.sagepub.com at TEXAS SOUTHERN UNIVERSITY on October 28, 2014
3
Badir et al. assessed knowledge related to the primary causes of mortality and morbidity in men and women. An example of open-ended questions is “What is the primary cause of morbidity in women in Turkey and in the World?”. The questionnaire also included items assessing demographic characteristics and health behaviors which were defined as ‘any activities undertaken to maintain, attain, or regain good health and prevent CVD’.36,37 Students’ nutritional patterns were evaluated based on dietary guidelines published by the Turkish Ministry of Health. These guidelines recommend two servings of protein, six servings of carbohydrates, and at least five servings of fruits and vegetables daily.38 For this study, we measured individual weight (kg), height (cm), and waist circumference (cm). We calculated body mass index (BMI), weighing students after they removed heavy clothing. Participants were classified as underweight (BMI ≤ 18.5), normal weight (BMI = 18.5–24.9), or overweight (BMI ≥ 25.0). Waist circumference was measured on a horizontal plane, midway between the inferior margin of the ribs and the superior border of the iliac crest at the end of gentle expiration.37 Based on International Diabetes Federation and Turkish Heart Association guidelines, healthy waist circumference were defined as ≤80 cm for women and ≤ 94 cm for men.2,39
Data analysis Data were analyzed using IBM SPSS Statistics 19.0. CARRF-KL total mean scores were compared using independent sample t-tests for independent groups and one-way analysis of variance (ANOVA; Tukey’s HSD for further analysis) for independent groups. To examine the effects of various factors on CARRF-KL total mean scores, the following factors were considered as independent variables for multiple regression analysis: year of undergraduate education, gender, educational background, BMI, exercise, waist circumference, CVD history in first degree male or female relatives, smoking. Significance was set at p < 0.05.
Results Demographic characteristics A total of 1138 students (overall mean age was 20.92±1.98 (20.81±1.91 years female; 21.41±2.49 years male) responded. Of these, 91.2% (n = 1038) were female, 52.7% (n = 600) attended a private university, 47% (n = 538) a public university. Nearly all students had graduated from high school 92.5% (n = 1046); 7.5% (n = 85) had graduated from four-year vocational health schools, which can grant nursing diplomas in Turkey. In total, 28% (n = 319) were first-year students, 23.6% (n = 269) second-year, 26.4% (n = 301) third-year, and 21.9% (n = 249) fourth-year.
The students’ CARRF-KL scores and individual characteristics The total mean CARRF-KL score was 22.47±3.38 out of a maximum of 28 (female = 22.63±3.31; male = 20.82±3.57). As shown in Table 1, 87% of students did not know that heart disease could be identified based on common signs and symptoms. About half of the students (50.4%) did not know what constitutes an exercise; for example, they considered slow walking and wandering as exercise. Nearly all students (94.2%) knew that ‘hypertension is a risk factor for heart disease’ and 87.3% knew that ‘blood pressure control reduces the risk of heart disease’, but only 46.4% knew that ‘hypertension medications should be used for a lifetime’. Although 93.6% knew that ‘high cholesterol is a risk factor for heart disease’, 35.4% did not know that ‘there is a risk of a heart disease if good (HDL) cholesterol level is low’ and 35.3% did not know that ‘CAD can be prevented’. In examining the relationship between CARRF-KL mean scores and individual characteristics, we found statistically significant difference (all p < 0.001) between years of undergraduate education and CARRF-KL mean scores; first-year students’ knowledge level was significantly lower than that of students’ knowledge level in later years. Logically, fourth-year students’ knowledge level was significantly higher than those of lower classes. Students who graduated from vocational health schools had higher mean CARRF-KL scores as compared to those who graduated from high schools. A t-test indicated that female students’ knowledge level was higher than that of the male students (p < 0.001, Table 2).
CVD as a primary cause of mortality and morbidity in Turkey and worldwide Students answered four open-ended questions on the primary causes of mortality and morbidity in men and women in Turkey and worldwide. Only 16.5% of female and 14% of male students reported that heart disease was the primary cause of morbidity in women, and only 39.7% of female and 31% of male students reported that heart disease was the primary cause of morbidity in men. Only 20.4% of female and 20% of male students reported that heart disease was the primary cause of mortality in women in Turkey and worldwide; 43.4% of female and 36% of male students reported that heart disease was the primary cause of mortality in men in Turkey and worldwide (Table 3).
Personal health behaviors associated with CVD Waist circumference was within the normal range for 74.5% of the students; 90.3% of the female respondents’ measurements were ≤80 cm, and 94.7% of the male
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European Journal of Cardiovascular Nursing
Table 1. The Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale scores. Correct 1. A person always realizes if she/he has a heart disease. 2. A family history of CVD increases your risk of having heart disease. 3. Elderly people are at a higher risk for heart diseases. 4. CAD can be prevented. 5. Smoking is a preventable cause of death and diseases in our country. 6. Smoking is a risk factor for heart diseases. 7. The risk of developing heart disease is reduced when smoking is stopped. 8. It is beneficial to eat 2-3 portions of fruit and 2 portions of vegetable daily. 9. It’s harmful to eat red meat more than 3 times a week. 10. Eating salty leads to increase in blood pressure. 11. Fatty meals do not increase the cholesterol level in blood. 12. Fats that are solid at room temperature are beneficial for heart health. 13. A low carbohydrate and low fat diet is beneficial for heart health. 14. Overweight individuals have higher risk of heart disease. 15. Regular exercise reduces the risk of heart disease. 16. Risk can be reduced by exercising only in gym. 17. Slow walking and wandering are also considered as exercise. 18. Stress, sorrow, and burden increase the risk of heart disease. 19. Blood pressure increases under stressful conditions. 20. High blood pressure is a risk factor for heart disease. 21. Blood pressure control reduces the risk of heart disease. 22. Hypertension medications should be used for a lifetime. 23. High cholesterol is a risk factor for heart disease. 24. There is a risk of heart disease if good cholesterol (HDL) is high. 25. There is a risk of heart disease risk if bad cholesterol (LDL) is high. 26. Every person with high cholesterol level is given medicine. 27. Diabetes is a risk factor for heart disease. 28. The risk can be reduced in diabetic patients with glucose control. aT
Ta T T T T T T T T T Fb F T T T F F T T T T T T F T F T T
Incorrect
n
%
n
%
148 1089 986 736 869 1101 1050 1070 872 1042 1029 959 902 1097 1092 944 564 1079 1053 1072 994 610 1065 735 951 726 796 942
13.0 95.7 86.6 64.7 76.4 96.7 92.3 94.0 76.6 91.6 90.4 84.3 79.3 96.4 96.0 83.0 49.6 94.8 92.5 94.2 87.3 53.6 93.6 64.6 83.6 63.8 69.9 82.8
990 49 152 402 269 37 88 68 266 96 109 179 236 41 46 194 574 59 85 66 144 528 73 403 187 412 342 196
87.0 4.3 13.4 35.3 23.6 3.3 7.7 6.0 23.4 8.4 9.6 15.7 20.7 3.6 4.0 17.0 50.4 5.2 7.5 5.8 12.7 46.4 6.4 35.4 16.4 36.2 30.1 17.2
(True), bF (False).
Table 2. Association between students’ individual characteristics and CARRF-KL scores. Characteristics Year of undergraduate education First year (n = 319) Second year (n = 269) Third year (n = 301) Fourth year (n = 249) Educational background Vocational health school (n = 85) High school (n = 1053) Gender Female (n = 1038) Male (n = 100)
CARRF-KL total score (X ± SD)
Statistical test
20.28 ± 3.53 23.34 ± 2.86 22.79 ± 3.08 23.96 ± 2.57
F (82.41)
23.68 ± 3.23 22.37 ± 3.37
t (3.45)
22.63 ± 3.31 20.82 ± 3.58
t (5.18)
respondents were ≤94 cm. The majority of students had no first degree family history of CVD in either a first-degree male or female relative. A majority (63.6%) of the students
p value 0.001
0.001 0.001
were not aware of their blood pressure, and (0.8%) had diabetes mellitus type 2. 83.7% of students were nonsmokers, and 85.5% reported not taking exercise in the
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Badir et al. Table 3. The knowledge of the students that CVD is the primary reason for mortality and morbidity in Turkey and in the world. Female students Primary morbidity reason in women in Turkey and the world (n = 1018) Cancer Cardiovascular diseases Do not know Diabetes Mellitus Gynecological diseases Other Primary morbidity reason in men in Turkey and the world (n = 1038) Cancer Cardiovascular diseases Do not know Diabetes Mellitus Other Primary mortality reason in women in Turkey and the world (n = 1038) Cancer Do not know Cardiovascular diseases Gynecological diseases Other Primary mortality reason in men in Turkey and the world (n = 1018) Cardiovascular diseases Cancer Do not know Other
Male students
%
n
n
%
561 171 128 70 31 77
54.0 16.5 12.3 6.7 3.0 7.4
46 14 22 10 0 8
46.0 14.0 22.0 10.0 0 8.0
430 412 165 14 17
41.4 39.7 15.9 1.3 1.6
36 31 29 2 2
36.0 31.0 29.0 2.0 2.0
512 212 233 35 46
49.3 24.0 22.4 3.4 4.4
39 31 20 3 7
39.0 31.0 20.0 1.0 7.0
451 337 202 48
43.4 32.5 19.5 4.6
36 26 27 11
36.0 26.0 27.0 11.0
preceding six months (defined as exercising 2–3 times per week for at least 40 minutes; Table 4). As shown in Table 4, the majority of the students (93.2%) did not consume the recommended daily amounts of fruit, vegetables, or carbohydrates, and approximately half (44.8%) consumed less than the recommended daily amount of protein. More than half of the students (58.7%) reported preferring unsaturated fats (e.g. vegetable oil); 39.5% liked both saturated (e.g. margarine) and unsaturated fats, and only 1.4% preferred saturated fat in cooking. A multiple regression analysis was run to predict CARRF-KL total score from educational year, gender, educational background, BMI, exercise, waist circumference, CVD history in first degree male or female relatives, and smoking. Three variables were revealed in the multiple
Table 4. Characteristics of the students associated with CVD. %
n BMI (n = 1129)
