The Knowledge Assessment of Cardiovascular Disease Risk Factors: A Cross-Sectional Study

Introduction: Cardiovascular diseases (CVDs) are the primary cause of mortality worldwide. Numerous factors can indicate the likelihood of developing CVDs. Gaining a comprehensive understanding of these risk factors is the initial step towards implementing successful preventive measures to defy the prevalence of CVDs across all demographics. The aim of this study is to evaluate the Moroccan population's level of knowledge regarding cardiovascular risk factors (CVRF). Methods: This questionnaire-based cross-sectional study was conducted among 744 participants. Their knowledge of CVD risk factors was assessed by the Heart Disease Facts Questionnaire (HDFQ). Socio-demographic characteristics were collected and statistical analyses were performed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY). Results: Among 744 participants, 475 (63%) were male and 409 (55%) were young adults. The mean HDFQ score was 64.36%. Overall, 47.4% of the respondents were aware of CVD risk factors, 27% had moderate knowledge and 25.6% had poor knowledge. The most commonly identified factors were smoking (86.8%), obesity (85.6%), and aging (80.5%). Age was the only factor that showed a significant association with the awareness of CVD risk factors. Conclusion: The level of knowledge of CVRF is moderate among the Moroccan population. Effective health education about CVRF and adequate prevention measures is certainly essential to minimize the burden of CVD.


Introduction
The rising burden of cardiovascular diseases (CVDs) has become a major public health problem worldwide [1].CVDs are a group of diseases that predominantly impact the heart and blood vessels [1].These diseases are usually associated with atherosclerosis and an elevated risk of thrombosis due to blood clots [2].CVDs include diseases such as coronary heart diseases, peripheral vascular diseases, congenital heart diseases, pulmonary embolism, cerebrovascular diseases, and venous thrombosis [1].
Cardiovascular risk factors (CVRFs) have an important role in the development of almost all CVDs [3].They can be divided into two categories: modifiable factors, including hypertension, diabetes, high cholesterol, obesity, physical inactivity, and inadequate intake of fruits and vegetables [4]; and non-modifiable factors such as age, sex [4], family history and ethnicity [5,6].
CVDs remain the principal cause of death globally, with an estimation of 17.9 million deaths (32% of global deaths) each year reaching 23.3 million deaths by 2030, 85% of deaths are due to stroke and heart disease, and one-third of these fatalities are premature in adults under the age of 70 [1].As reported in various studies, the prevalence of these risk factors is on the rise across nearly all regions of Africa [7].According to the World Health Organization (WHO), "over three-quarters of CVD deaths take place in low-and middleincome countries" [1].
The Centers for Disease Control and Prevention report that a significant portion of deaths (six out of 10 deaths) caused by CVDs can be prevented [8].Previous studies have demonstrated that increasing knowledge about CVDs can effectively reduce an individual's actual risk of developing the disease [9].Hence, it is important to possess knowledge regarding the implications, signs, and potential factors that are linked to CVDs [10].A limited number of studies have addressed CVDs' level of knowledge worldwide [11].The reason why this study was conducted is to determine the level of knowledge regarding CVDs in the general population of Morocco.

Type and date of the study
A cross-sectional descriptive survey was carried out from May to August 2022 among the Moroccan population.

Sample size
An estimated sample size of 385 was calculated using a margin of error of 5% and a confidence level of 95% [12].A total of 744 adults aged more than 16 years were recruited from public places in various Moroccan cities (Figure 1).

FIGURE 1: Geographical distribution of regions included in the study
The image is created by the authors.
This study was randomly carried out every day from 9h00 to 18h00 in six regions of Morocco, in each region two recruitment sites were placed; one in a rural area and another in an urban area.A number of 62 participants were recruited from the weekly markets in villages while 62 participants were from downtown.

Data collection and instrument
Individuals who consented to participate in this study were interviewed through a pretested standard selfadministered questionnaire after obtaining written informed consent.The questionnaire consisted of three sections assessing the following items; The first section includes written consent of the participants, the sentence "Response to this questionnaire is voluntary and anonymous.The data collected will be used for scientific research purposes only.Do you give your consent to participate in this study?"was added at the top of the questionnaire form.The second section records demographic indicators (age, gender, marital status, academic level, profession) and tobacco consumption.The last section assesses the level of knowledge of CVRFs using the French-validated version of the 25-item Heart Disease Fact Questionnaire (HDFQ) [13] originally designed by Wagner et al. [14].
Participants were asked to respond to each statement by choosing a single option: "True", "False", or "I don't know" [15].Each correct response was scored "one" and each incorrect response or "I don't know" was scored "zero".
The total score ranges from 0% to 100%; it is calculated by multiplying the number of correct responses by four.A low level of knowledge is defined with a score of <50%, a moderate level of knowledge is defined with a score between 50% and 70% while a good level of knowledge includes the participants with an HDFQ score >70% [16].
The data were collected and transposed into an Excel spreadsheet (Microsoft® Corp., Redmond, WA), then analyzed using the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 26.0, Armonk, NY).The categorical variables were expressed in numerical form, along with their corresponding percentages.
To determine the factors linked to the level of knowledge, both univariate and multivariate logistic regression models were performed.P < 0.05 was taken as statistically significant.

Results
This study involved 744 participants, with the predominance of the female gender (63%).Participants' ages range from 16 to 84 years old.The categorical distributions for young adults, middle-aged adults, and oldaged adults were 55%, 30.6%, and 14.4%, respectively.In this study, 51.7% of the participants were single, while 41.9% were married.In terms of the participants' educational background, 58.1% were university graduates, and only 8.2% were illiterate.Regarding tobacco consumption, the majority of the participants (86.7%) were non-smokers, 9.9% were smokers, and only 3.4% were ex-smokers.The rest of the sociodemographic characteristics are displayed in Table 1.

Characteristics n (%) 95% Confidence Interval
Inf Sup  Concerning the 25 statements of the HDFQ, 10 questions were scored above 70%, 11 questions were scored between 50% and 70%, and four questions were scored below 50%.

Age
The mean knowledge total score was 64.36 ± 21.86 of which 47.4% have good knowledge (score over 70%) while 27% have moderate knowledge (score between 50 and 70%) and 25.6% have low knowledge (score less than 50%).
The majority also demonstrated adequate knowledge regarding several CVD prevention measures, such as regular physical activity (87.2%) and smoking cessation (78.5%).However, blood pressure control and diabetes were recognized by 68.7% and 64.5% of the participants, respectively.
In contrast, low high-density lipoprotein (HDL) cholesterol (35.6%) was not considered a CVRF.Also, 34.1% of the participants were not aware that people with diabetes are more likely to have high cholesterol and only 25% were able to know the relationship between diabetes and the tendency to have low HDL cholesterol.The participants' knowledge regarding CVRFs is displayed in Table 2. Nº

TABLE 2: Participants' knowledge regarding cardiovascular risk factors (n=744)
Statistical analysis disclosed a statistically significant association between the level of knowledge and age, marital status, profession, smoking status, prior knowledge of CVRFs, personal history of CVRFs, and family medical history.Whereas, no difference statistically significant in terms of the level of knowledge of CVRFs between groups of different educational levels and gender was found (Table 3).Logistic regression models to evaluate the association between participants' demographic characteristics and CVD awareness are presented in Table 4.The analyses of univariate regression showed that being oldaged (>45 years) (odds ratio (OR) = 2.08; P = <0.001);holding a university degree (OR = 1.927;P = 0.019), being a student (OR = 1.586;P = 0.022), divorced (OR = 0,559; P = <0.001),ex-smoker (OR = 2.413; P = 0.043), and having family medical history (OR = 0.621; P = 0.002) were significantly associated with CVRFs' level of knowledge.This indicates that old-aged participants have 2.08 times more knowledge than young adults, university degree participants have 1.927 times more knowledge than those with less educational level, and participants with a family medical history showed 37.9% less knowledge compared to those without a family medical history.In the multivariate logistic regression, the only factor that showed a significant association with knowledge of CVRFs was age (OR =2.122; P = 0.002), indicating that participants above 45 years have 2.08 times more knowledge than young adults.

TABLE 4: Results of multi-regression analysis of the association between CVD awareness and sociodemographic (n=744)
Variables with a p<0.2 in the univariate analysis were considered for the multivariable analysis.
Bold values indicate statistical significance at p<0.05.
* refers to the variable used as a reference in the univariate and multivariate regression analysis.

Discussion
To the best knowledge of the authors, the assessment of the level of knowledge of CVDs using the HDFQ instrument is conducted for the first time in Morocco.The major outcome of this study revealed that, out of 744 participants, just under half had good awareness of CVRFs and only two participants could correctly identify all the risk factors.
In our study, age, smoking status, marital status, profession, prior knowledge of CVRFs, and family medical history were significantly associated with the total score of CVRF knowledge.On the HDFQ scale, our study highlighted a gap in Moroccan young adults' CVRF knowledge, knowing that among young adults, 60.6% have an inadequate level of knowledge.
Regarding risk factors, eight out of 10 of the study participants were aware that physical inactivity, smoking, and obesity are risk factors for CVDs, whereas low HDL cholesterol and diabetes were less frequently identified as risk factors [17].Participants' awareness about CVRFs was significantly greater among females compared to males, these results are in concordance with former studies conducted in Kuwait [18] and Iran [19], contrary to a study conducted in Saudi Arabia [20].
However, their educational level was not significantly associated with the level of knowledge of CVRFs which was compatible with a Nigerian study [3].In opposition, participants with a higher educational level were more likely to have a higher level of knowledge in Saudi Arabia [20] and Spain [16].
Our findings stated smoking as the most well-known CVRF in accordance with studies conducted in North America, the Middle East, and South Asian countries [18,[21][22][23][24]. Smoking cessation was also known by most participants as an indispensable aspect of CVD prevention, as mentioned in Ali S. Alghamdi et al. study [10].
Participants' knowledge about the relationship between controlling blood pressure and reducing the chances of developing heart disease was at best moderate, although most participants were aware that hypertension is a CVRF.These findings were supported by a similar study conducted in Nigeria [3].
The majority of the study participants were also aware that constant physical activity will reduce a person's chance of getting heart disease, as well as activities such as walking and gardening.Furthermore, our study showed a higher knowledge related to regular physical activity, compared to the figures in Nigeria [3].
The final aspect of the HDFQ reflects the level of knowledge of diabetes and its relationship with heart disease.In our study, this level was averagely moderate.In comparison with other studies, our findings are similar to a study conducted in Oman [21].Moreover, it was higher in Nigeria [22] and lower in Indonesia [4].
It is known that modifiable risk factors are responsible for more than 90% of the likelihood of developing CVDs.The burden of CVDs can be considerably diminished by emphasizing preventive measures and adopting healthy lifestyle behaviors [23].As shown in numerous studies, physical activity has proved its efficacy in decreasing the risk of developing CVD by maintaining good physical functioning and improving the quality of life [23,24].
Dietary habits are also considered an important healthy behavior, as expanding confirmations reinforce their powerful modulatory effects on health status and CVRF [25].
Additionally, poor sleep is under-recognized as a CVRF [26].Numerous studies offer valuable insights into the correlation between the duration of sleep, cardiometabolic risk factors, and significant cardiovascular outcomes [27].Another study found a U-shaped relationship between sleep duration and CVD outcomes [23].Therefore, most guidelines recommend seven to eight hours of sleep per night for optimal results [23].
This research highlights the importance of raising awareness of CVRFs among the Moroccan population, especially young adults whose level of knowledge was low.Thus, with the aim of adopting and ensuring a positive healthy lifestyle, and preventing themselves and their families from developing CVRFs such as hypertension, obesity, hypercholesterolemia, and eventually CVDs.

Limitations of the study
This study has certain limitations that must be acknowledged.It was a cross-sectional study based on a hardcopy questionnaire.This may represent a limitation, as papers are more likely to be damaged or lost, given that a number of copies were not completed.However, this problem was overcome by the large sample size, which represents the robustness of the study.

Conclusions
The moderate knowledge regarding CVD among the general population of Morocco is a call for action to the necessity of adopting adequate educational programs to raise awareness regarding CVDs in Morocco.The present study emphasizes that high awareness regarding CVDs will lead to adequate behaviors to prevent the onset of preventable diseases especially among young adults.In addition, the implementation of massive and cost-effective health education is essential to minimize cardiovascular morbidity and mortality in Morocco.

TABLE 1 : Socio-demographic characteristics of the study population (n=744)
CVD: cardiovascular disease