Abstract
Objective:
Awareness of heart disease as the leading cause of death in women has increased over the past 10 years, but little is known about the awareness level of college students. This study evaluated the level of awareness and knowledge of heart disease in women among college students.
Methods and Results:
Using a cross-sectional design, a sample of 320 women from a private university was queried. A 13-item survey assessed demographic information and awareness of cardiovascular disease (CVD). The mean age was 23 years; the majority were single and of Hispanic ethnicity. Almost one third believed breast cancer was the greatest problem facing women. One half recognized CVD as the leading cause of death among women. Students aged 18–24 years were significantly less likely to identify heart disease/heart attack as the leading cause of death in women compared with students aged 25–34 years. Significant ethnic differences in perceptions of risk were found. Family history and obesity were seen as major contributors to CVD; less than a fourth ever discussed CVD with their healthcare provider. Information was gained primarily from television, magazines, and the Internet. Exercise and maintenance of healthy blood pressure were viewed as priorities in prevention of CVD.
Conclusions:
Results add to the body of research on CVD risk and the need for intervention to increase awareness and knowledge of heart disease risk among younger and ethnically diverse young women and raises questions about the role of colleges and universities in promotion of student health. Colleges and universities may provide the last opportunity to reach youth as a group to affect lifestyle changes.
Introduction
Preventive healthcare depends, in part, on awareness and perception of personal risk. 1 Awareness of heart disease as the leading cause of death in women showed a steady increase from 30% in 1997 to 46% in 2003 and 57% in 2006 among women aged 25–65 years. 2 This gradual increase in awareness among women can be attributed in part to two national campaigns by the National Heart, Lung and Blood Institute (NHLBI) and the American Heart Association (AHA). Four national telephone surveys 3 –5 commissioned by the AHA during the past two decades examined views of women aged ≥25 years. Little is known, however, about the awareness of cardiovascular disease (CVD) of college-age students; ethnic and gender differences among this age group are also understudied. This article describes the level of awareness and knowledge of heart disease in women based on a survey conducted in spring 2008 among diverse college students within the context of a campuswide Red Dress Day event.
The Red Dress is one of the symbols of the nation's effort to increase awareness of heart disease as the leading cause of death in women. 6 –8 A university nursing research team, engaged in research on heart health issues among youth, collaborated with faculty and students in fashion design and implemented the first of now five annual Red Dress Day events for the campus community (Table 1 shows major focus and activities by year). The campus Red Dress Day event, held on a day in February, takes place in the student center and combines a health fair concept with a fashion show of student-designed red dresses. Educational booths on nutrition, exercise, lifestyle, and heart health allow participants to sample healthy snacks, have blood pressure measured, and receive information on a broad number of lifestyle issues, including exercise and stress management. A guest speaker on heart health and the student fashion show are the highlights of the event. The Red Dress Day events receive support from campus administration, faculty, and staff and the local AHA.
Little was known about the awareness level of students regarding a woman's risk for heart disease and effective strategies to reach students with heart health promotion information. To answer these questions, the research team conducted a student survey to assess awareness and knowledge of heart disease in women following the approach used by Mosca et al. 9
Materials and Methods
Design and subjects
Using a cross-sectional design, the setting for the study was a private, federally designated Hispanic-serving Catholic university in south Texas. A sample of 440 student volunteers was recruited from graduate and undergraduate courses in the spring semester. Of these, 335 were complete datasets; 115 (26%) were male and 320 (73%) were female. This analysis examines the 320 female student volunteers. A majority of female students were from nursing (95, 30%) and pharmacy (98, 31%), with the rest in wellness and kinesiology (33, 10%), education (11, 3%), and liberal arts (83, 26%).
Survey methods
The 13-item survey developed for this study was based on the AHA national telephone survey on awareness and perception of heart disease and stroke among women. 2,10,11 A copy of the telephone survey and permission to use the questions were obtained from the author (L. Mosca, personal communication, November 13, 2007). Eight questions specific to awareness and knowledge of CVD were selected from the original survey and developed into a scannable format for self-administration. Content and wording of the individual questions were unchanged from the original document. Of the eight questions, four allowed participants to choose as many answers as applicable about their knowledge of CVD risk factors, warning signs of a heart attack and stroke, and risk prevention methods for CVD. Two questions asked participants about their sources for information about CVD. The remaining two were forced-choice questions that assessed the greatest health problem facing women and the leading cause of death for all women. Four additional questions taken from the original AHA survey assessed demographic information on age, gender, ethnicity, and marital status. Researchers added one demographic question on grade level.
The University Institutional Review Board for Protection of Human Subjects approved the study. Permission to access classes for approximately the first 15 minutes of class was received from a convenience sample of faculty for 21 classes; all faculty approached agreed to participate. Surveys were anonymous and administered during a 2-week period. Students were given a brief overview of the research goals, and surveys were distributed by the researchers to students who volunteered to participate. Less than 1% of students declined to participate.
Statistical methods
Survey data were entered into an Excel spreadsheet for data cleaning and then moved to SPSS release 13.0 for analysis. Data were analyzed using descriptive statistics, including percentages, means, and standard deviations (SD). Chi-square statistics and odds ratios (OR) were computed to assess the association between knowledge of the leading cause of death or perception of the greatest health problem facing women today and gender, age group, class, or ethnicity. For the ethnicity variable comparisons, Caucasians were used as the reference category. The 95% confidence interval (CI) was used, and the level of significance for the study was set at 0.05. A Bonferroni correction was used for the chi-square analyses to control for type I error inflation, p < 0.007 (i.e., 0.05/7).
Results
Characteristics of respondents
Table 2 describes the demographic characteristics of the sample by ethnic category. The mean age was 23 years (SD 3.6, range 18–34 years). A majority (225, 70%) was of diverse ethnic/racial backgrounds, reflecting the composition of the university. Over three fourths (251, 78%) were juniors or seniors or graduate students.
n (%).
Awareness related to CVD
Table 3 presents responses to questions relating to cause, warning signs, and prevention of CVD. Major causes of heart disease were identified as family history (87%) and being overweight (84%), followed by high cholesterol (78%), high blood pressure (78%), and not exercising (68%).
A large majority of students identified chest pain (92%), tightness of the chest (85%), radiating pain (81%), and shortness of breath (77%) as signs associated with heart attack. Participants recognized physical exercise (93%) as the number one activity for prevention or reduction of heart disease. Maintaining healthy blood pressure (85%) and cholesterol level (84%) and losing weight (83%) were selected as activities for prevention or reduction of heart disease. Quitting smoking (82%) was also identified as an activity toward prevention/reduction of CVD.
Table 4 presents ethnic comparisons on perceptions of risk by ethnic group. In response to the forced-choice question, As far as you know, what is the leading cause of death for all women? 55% of students identified heart disease/heart attack. Breast cancer was chosen by 19% of the students as the leading cause. When analyzed by comparing each ethnic group to Caucasians, all ethnic groups, with the exception of African Americans, had significantly lower odds of identifying heart disease/heart attack as the leading cause of death in women. The odds of Hispanics correctly identifying heart disease/heart attack as the leading cause of death for all women was 0.33 times the odds of Caucasians correctly identifying heart disease/heart attack as the leading cause of death for all women (CI 0.19-0.58). The odds of Asian/Pacific Islanders correctly identifying heart disease/heart attack as the leading cause of death for all women was 0.36 times the odds of Caucasians (CI 0.17-0.77).
Chi-square = 25.795, df = 4, p < 0.001.
Nine students did not answer this question.
Chi-square = 18.156, df = 4, p < 0.001.
Four students did not answer this question.
Slightly less than one third (32%) of students chose breast cancer as the response to the forced-choice question, What do you think is the one greatest health problem facing women today? Heart disease/heart attack was chosen by 37% of the students. When analyzed comparing each ethnic group to Caucasians, differences were found. The odds of Hispanics choosing heart disease/heart attack as the greatest health problem facing women today was 0.34 times the odds of Caucasian students choosing heart disease/heart attack as the greatest problem facing women today (CI 0.20-0.37). Similarly, the odds of Asian/Pacific Islander students selecting heart disease/heart attack as the greatest health problem facing women today was 0.19 times the odds of Caucasians selecting heart disease/heart attack as the greatest health problem facing women today (CI 0.08-0.46). Table 5 presents findings from the analyses of age, class, and perceived leading causes of death and greatest health problems facing women. Data were categorized to examine the relationship among students in health professional (nursing and pharmacy) and nonhealth professional classes (wellness and kinesiology, education, liberal arts). Students enrolled in health professional classes differed from nonhealth professional students in perceptions of the leading cause of death for women. The odds of nonhealth professional students selecting heart disease/heart attack as the leading cause of death for women was 0.25 times the odds of students enrolled in health professional classes selecting heart disease/heart attack as the leading cause of death for women (CI 0.16-0.41).
All findings evaluated based on Bonferroni adjustment, p < 0.007.
Significant per Bonferroni adjustment.
Similar findings for the question on greatest health problem facing women emerged. The odds of students in nonhealth professional classes choosing heart disease/heart attack as the greatest health problem facing women today was 0.40 times the odds of students enrolled in health professional classes (CI 0.25-0.66).
Awareness of heart disease/heart attack as the leading cause of death in women and perception of the greatest health problem facing women were analyzed among younger vs. older female students. Students aged 18–24 years were significantly less likely to identify heart disease/heart attack as the leading cause of death in women compared with students aged 25–34 years (OR 0.48, CI 0.29-0.80). There were no significant differences by age group related to perception of the greatest health problem facing women (Table 5).
Sources of information on CVD
Student sources of information on heart disease in women are summarized in Table 6. One third (35%) of students had not seen, heard, or read material about women and heart disease within the past 12 months. When asked to determine sources of information related to CVD, the participants identified television (39%), most frequently followed by magazines (33%) and the Internet (26%). Greater than three fourths (81%) of students responded negatively to the question, Have any of your doctors ever discussed heart disease with you when discussing your health? As presented in Table 6, no significant differences in sources of information about CVD by age group were identified. The chi-square analysis for age on this item was not significant following the Bonferroni adjustment (OR 0.48, CI 0.26-0.91).
All findings evaluated based on Bonferroni adjustment, p < 0.007.
Discussion
Findings from this study of predominantly younger, diverse college women suggest that age and ethnicity may be significant factors in awareness and knowledge of heart disease in women. Younger students aged 18–24 years were less likely than older students 25–34 years to identify heart disease as the leading cause of death for women.
What is striking about these findings, however, is the proportion of all students who have gaps in awareness and knowledge, irrespective of their level of education. Slightly more than half of the total sample of students, for example, reported that heart disease/heart attack was the leading cause of death, and less than one third recognized it as the greatest health problem facing women. Of interest is that 48% of women aged 25–34 years in the 2006 survey by the AHA 2 cited heart disease as the leading cause of death in women; in our study, 67% of college women aged 25–34 years cited heart disease as the leading cause of death. In the same age category of 25–34 years, 32% of women in the AHA survey cited breast cancer as the greatest health problem facing women. In this current study of college women, 28% of women aged 25–34 years selected breast cancer as the greatest health problem facing women. This suggests there is a need for clear messages to increase awareness.
The ethnic differences in awareness of heart disease as the leading cause of death in this study are consistent with 9-year trends in awareness among older women reported by Christian et al. 2 In their analyses, older black and Hispanic women had significantly lower awareness levels than had white women. Younger women (25–34 years) were more likely than older women (45–64 years) to cite breast cancer as the leading cause of death in women. A strength of the current study is the large number of students of Hispanic origin, but the small number of students of African American and relatively small number of students of Asian American descent limit generalization.
Responses to the question on sources of information for this sample of college students indicate that television, magazines, and the Internet predominate. Physicians were not reported by students in this study as a source of information or counseling. The question, Have any of your doctors ever discussed heart disease with you in discussing your health? may have resulted in incomplete information, as some study participants may receive their care from nurse practitioners or physician assistants, who may have provided teaching. Another limitation may have been that three items on the questionnaire relating to major causes and management of heart disease did not specify “in women.” The inconsistency may have been confusing and may have elicited inaccurate responses.
Perception of risk for heart disease in women was found to be the primary reason associated with CVD prevention recommendations in a study of physicians. 12 For young men and women, access may be an issue. Unless there is a heart health issue, CVD may not be discussed with this population, as young adults do not routinely access healthcare for CVD screening. When they do access the healthcare system, their immediate concern or presenting symptom receives priority. Godfrey, in a conversation with experts on women's health issues, calls for primary care providers to help women see health as a priority, to update their knowledge on current guidelines for care, and to “catch every opportunity” to counsel on lifestyle changes early to prevent chronic heart disease. 13
It is well documented that risk factors for heart disease are rooted in the young. 14 –16 Research conducted among college student populations has also documented a population at risk for cardiac disease. 17 –19 Two studies of college students using objective measures of blood pressure, blood lipids, height, and weight found that almost half of college students were in the overweight or obese category, and almost one third were prehypertensive or hypertensive. Two thirds consistently reported a family history of hypertension or diabetes. 20,21
In the current study, high proportions of students knew the causes of heart disease and were also aware of the basic warning signs associated with a heart attack. These findings are consistent with other studies regarding specific knowledge among older adults. 22 At issue may be whether young adults, despite general knowledge of cause, prevention, and early signs of heart attack, actually perceive they are at risk. Green et al. 23 examined 470 undergraduates at two public universities in Texas; the mean age of the sample was 22 years, and 86% were white. They found that perceptions of personal risk of heart disease were low. Taken together with our findings of sources of information, electronic media and popular cultural icons may be more effective in increasing awareness of heart disease risk in younger populations.
Men also are an understudied group in awareness of heart disease risk among women. Analysis of the subsample of 115 male students in the larger sample of college students showed that proportionately fewer male students recognized that heart disease is a major health problem facing women today and the leading cause of death in women. The odds of male students choosing heart disease/heart attack as the leading cause of death for all women was 0.35 times the odds of female students choosing heart disease/heart attack as the leading cause of death for all women (CI 0.22-0.56). Similarly, the odds of male students selecting heart disease/heart attack as the greatest health problem facing women today was 0.21 times the odds of female students selecting heart disease/heart attack as the greatest health problem facing women today (CI 0.11-0.40). These findings suggest a need for further study.
Conclusions
Results of this study add to the growing body of research on awareness and knowledge of heart disease risk and the need for educating youth and young adults, particularly women and people of diverse racial/ethnic backgrounds. Health in most colleges and universities is marginalized in favor of emphasis on mainstream coursework, as evidenced by reductions in funding for health programs. 24 Colleges and universities may provide the last opportunity to reach youth as a group with knowledge that positively affects their health and our nation's future.
Footnotes
Acknowledgments
We thank Dr. David Fike for his patience and guidance with data analysis for this article.
Disclosure Statement
The authors have no conflicts of interest to report.