Poor knowledge of peripheral arterial disease among the Saudi population: A cross-sectional study

Abstract

Peripheral arterial disease is a marker of severe atherosclerosis with a significantly higher risk of cardiovascular morbidity and mortality. It is often underdiagnosed and undertreated. Public and patients’ perception of peripheral arterial disease is influenced by their knowledge of the condition. In this study, we aimed to evaluate the Saudi public’s knowledge of peripheral arterial disease and its specific characteristics. We conducted an interview-based cross-sectional survey, and collected data on basic demographics, self-reported peripheral arterial disease awareness, and knowledge of clinical features, risk factors, preventative measures, management strategies, and potential complications of peripheral arterial disease. A total of 866 participants completed the survey (response rate, 94%); two-thirds were females. Only 295 (34%) of the surveyed participants indicated awareness of peripheral arterial disease. Overall peripheral arterial disease knowledge was low among the “peripheral arterial disease aware” group, particularly in the clinical features domain. Age > 40 years, female gender, and higher education were predictors of self-reported awareness of peripheral arterial disease. In conclusion, the Saudi public is largely unaware of peripheral arterial disease. Educational programs are important to address this critical knowledge gap.

Keywords

Peripheral arterial disease knowledge general population Saudi Arabia

Background

Peripheral arterial disease (PAD) is a manifestation of advanced systemic atherosclerosis. Much like coronary artery disease and cerebrovascular disease, risk factors for PAD include: advanced age, diabetes, hypertension, dyslipidemia, and smoking.^1,2 Patients with PAD have a significantly higher risk of cardiovascular morbidity and mortality compared to those who do not have PAD.^3–5 The prevalence of PAD is variable, and is highly dependent on the risk profile of populations and how the condition is diagnosed.⁶ In Saudi Arabia, the prevalence of PAD is about 12% for people aged 45 years or older, with two-thirds of them having at least two risk factors.⁷ The prevalence increases to nearly 25% among those with higher risk profiles.^8,9

Management of PAD risk factors has been shown to be effective in controlling the disease,^10–15 and this had led to multidisciplinary recommendations of initiating cardiovascular risk reduction treatment targeted to PAD patients at risk.¹⁶ Yet, multiple studies have shown that patients with PAD continue to receive suboptimal risk reduction therapy^17–19 – this may be due to a combination of physician and patient factors. For instance, lack of knowledge about PAD among physicians has been a well-documented concern in multiple studies.^20,21 Furthermore, patients’ own perception of the disease and its complications may contribute to suboptimal management,²² and general populations often have low overall knowledge about PAD.^23–25 Therefore, we sought to assess the Saudi public’s knowledge of PAD in this study to understand the magnitude of this problem in Saudi Arabia.

Methods

A descriptive cross-sectional interview-based survey was carried out during a two-phase educational campaign about PAD in September 2012 and April 2013. Campaign venues included the outpatient clinics building at King Khalid University Hospital in Riyadh, Saudi Arabia, and three large shopping centers in Riyadh, Saudi Arabia. Riyadh is the capital of the country with a population of nearly 4.3 million people.²⁶

We followed the principles of Declaration of Helsinki in designing our study protocol, which was approved by the King Saud University College of Medicine Research Ethics Committee. We modified a questionnaire that was previously used to test the knowledge of PAD among medical students.²⁷ Following modification, a cognitive pretest using the new questionnaire was conducted on a cohort of 20 persons who were not part of our sample. A final version was then used after minor edits (see Supplementary material). We did not need to translate our instrument as the data collection team members were trained to ask questions in both English and native Arabic languages. Following verbal consent to participate in the survey, basic demographic data on participants’ age, gender, and level of education were collected. Each participant was then asked if he or she had heard of PAD. The interview was concluded for subjects who responded “No” to this question, and they received written educational materials about PAD following interview conclusion. Participants who answered “Yes” were asked if they knew the risk factors, preventive strategies, clinical features, potential complications, as well as options to manage the disease using open-ended questions. No further questioning on a specific domain was done if a participant had no knowledge of that domain. No options or lists were provided to help participants guess answers. These participants also received similar education materials about PAD once the interview was concluded. Trained medical interns and medical students conducted the interviews.

Statistical analysis

Demographic data are presented in numbers and percentages, and grouped according to age range (less than 20 years old; 20 to 40 years old; 40 to 60 years old; more than 60 years old), gender (male or female), and level of education (primary; intermediate; high school; higher education). Data about the knowledge of each PAD domain, and the elements within each domain are presented in percentages. A multiple logistic regression analysis was done to predict the likelihood of respondents being aware of PAD based on demographic characteristics. Results are presented in odds ratios (ORs) and 95% confidence intervals (CIs) with age less than 40, male sex, and no higher education as reference groups.

Significance was set at the 0.05 level, and all p values are two-tailed. All statistical analyses were conducted using SAS 9.4 (SAS Institute Inc., Cary, NC, USA).

Results

Of the 923 invited participants, 866 (94%) completed the study questionnaire, and 66% of those were females. Nearly 85% of subjects were within the age range of 20–60 years, and about 85% held high school degrees or higher (Table 1).

Table 1.

Demographic characteristics of respondents.

Characteristic	N	%
Total sample	866	100
Age
Less than 20 years old	134	15.5
20 to 40 years old	497	57.4
40 to 60 years old	220	25.4
More than 60 years old	15	1.7
Gender
Male	295	34.1
Female	571	65.9
Level of education
Primary	41	4.7
Intermediate	96	11.1
High School	230	26.6
Higher Education	499	57.6

Only 295 (34%) of the surveyed participants indicated awareness of PAD (Figure 1). This “PAD aware” cohort’s self-reported knowledge of PAD domains was as follows: 63% for symptoms, 85% for risk factors, 83% for preventative measures, 63% for treatment options, 24% for local complications, and 53% for systemic complications (Figure 2). When further asked about the specific elements within each PAD domain, participants had poor overall knowledge. A total of 91% of those who reported familiarity with PAD symptoms did not know that it can be asymptomatic, and more than half did not know that it could present as intermittent claudication. Moreover, except for high cholesterol, every PAD risk factor was identified by less than 45% of those who reported awareness of PAD risk factors. The majority of participants with reported knowledge of preventative measures did not know that smoking cessation, diabetes and hypertension control, as well as pharmacological therapy are important in preventing PAD. Table 2 shows the percentages of participants who identified specific elements of PAD in each domain. Finally, multiple logistic regression analysis showed that the following factors were associated with greater awareness of PAD: female gender (OR 1.67, 95% CI 1.22–2.29; p = 0.001), those with higher education (OR 1.57, 95% CI 1.15–2.14; p = 0.005), and those aged 40 years or older (OR 1.63, 95% CI 1.21–2.19; p = 0.001) (Table 3).

Figure 1.

Proportion of respondents who expressed that they were aware of PAD (n = 866). PAD: Peripheral arterial disease.

Figure 2.

Self-reported knowledge of specific PAD domains among respondents who indicated awareness of PAD (n = 295).

Table 2.

Proportion of participants that correctly identified specific characteristics of PAD.

Knowledge domain	%
Symptom (n = 187)
Asymptomatic	9.1
Claudication	49.2
Rest pain	20.9
Ulcers	12.8
Coldness	26.2
Numbness	52.4
Paralysis	20.9
Risk factor (n = 252)
Old age	3.4
Smoking	44.8
Diabetes	38.9
Hypertension	40.1
High cholesterol	78.2
Male gender	13.5
Personal/Family History	17.5
Preventative measure (n = 244)
Smoking cessation	40.6
Dietary changes	81.6
Lifestyle changes	69.7
Diabetic control	23.0
Hypertension control	27.5
Medications	21.7
Treatment (n = 187)
Surgical	12.8
Medical	41.7
Both	45.5
Local complication (n = 72)
Tissue loss	70.8
Amputation	70.8
Systemic complication (n = 155)
Myocardial infarction	68.4
Stroke	71.6
Renal artery stenosis	16.1

Table 3.

The likelihood of respondents being aware of peripheral arterial disease based on demographic characteristics.

Variable	OR	95% CI	p-value
Age greater than 40 years	1.67	1.22–2.29	0.001
Female sex	1.57	1.15–2.14	0.005
Higher education	1.63	1.21–2.19	0.001

OR: odds ratio; CI: confidence interval.

Discussion

To the best of our knowledge, this is the first study to assess the knowledge of PAD among a sample of the Saudi population. We found the majority (66%) of study subjects were unaware of the disease. This is considerably more than those who have not heard about stroke in Saudi Arabia (22%).²⁸ Surveys from other countries have also attempted to assess the public knowledge of PAD in their populations. Lovell et al.²⁴ reported similar familiarity with PAD (33%) among 501 Canadian adults, whereas only 26% reported familiarity with PAD among 2501 adults surveyed in the United States.²³ These studies, however, utilized a different methodology than our study, as they used a telephone-based survey and sampled only those who were 50 years old or above. When we asked detailed questions about PAD to individuals who indicated familiarity with PAD, they expressed limited knowledge of the condition across all knowledge domains. Intermittent claudication is the most common symptom of PAD, and only about a third of PAD patients present with symptoms.^29,30 In this study, however, we found that only half of the “symptoms-aware” group identified intermittent claudication in their responses, and less than 10% recognized that PAD could be asymptomatic.

Diabetes, hypertension, and dyslipidemia are noncommunicable diseases that put patients at a significantly higher risk of PAD and its complications.^1,3,4 These factors are very prevalent in the Saudi population, reaching up to 67%, 73%, and 71% prevalence among retired patients in primary care settings, respectively.^31,32 In the present study, dyslipidemia was identified by 78% of subjects who indicated they knew risk factors for PAD, but identification of diabetes and hypertension was much lower (39% and 40%, respectively) despite their strong association with PAD among Saudi patients.⁹ In addition, only a minority of participants identified control of diabetes and hypertension as PAD preventative measures (23% and 28%, respectively). Furthermore, despite the acceptable recognition rate of dyslipidemia, medical therapy was identified as a risk reduction factor by only 22% of the cohort. Interestingly, the surveyed subjects did generally better in the recognition of PAD complications, as ulceration or tissue loss, amputation, myocardial infarction, and stroke were correctly identified by about 70% of the participants (Table 2).

Strengths and limitations

This project has important strengths. It is the first study to specifically address public knowledge of PAD in the nation, and it has an excellent (94%) response rate. Also, the interview-based design and open-ended questions helped limit the effect of information bias on study results. In addition, our sample consisted of mostly young participants, as only 27% were older than 40 years old. This percentage is consistent with the national data that shows that only 26.5% of the entire Saudi population is above 40 years of age.²⁶ It is important, however, to consider the limitations of this study when discussing its findings. First, although this convenient sampling is often used with community education projects in the country,^28,33 it resulted in underrepresentation of the older population in our study sample; only 1.7% participants were older than 60 years compared to the national proportion of 4.7%.²⁶ Furthermore, two additional groups were overrepresented in the study: females (66%), and those with higher education (58%). National data indicate that women represent approximately 50% of the Saudi population, and only 15% of Saudis are enrolled in or hold higher education degrees.²⁶ As female gender and higher education were associated with increased familiarity with PAD (Table 3), their overrepresentation in our study sample may have caused an overestimation of actual PAD knowledge among the Saudi population. Thus, generalizing our data to the general population should be done with caution. Second, due to the relatively uncommon nomenclature of PAD, the data collection team was trained to ask the main question of the study (“Have you heard about PAD?”) using all possible terms in Arabic and English languages. These terms included: PAD, peripheral vascular disease, claudication, atherosclerosis of the leg, leg cramps with walking, and arterial blockages in the legs. However, even with these various descriptions, assessment of participants’ recognition of such terms is not feasible—this limitation is consistent with other previously reported surveys of PAD.^23,24 Finally, we did not collect data about participant occupation, past history of PAD, or if they knew someone with the disease. These factors have been found to be predictors of increased awareness of PAD.^23,24

Conclusions

This study demonstrates a significant knowledge gap about PAD among the Saudi public despite the high prevalence of the disease and its risk factors. Our findings may help explain the suboptimal levels of recognition, diagnosis, and treatment of PAD, particularly in asymptomatic patients. Local and national educational activities are warranted to manage this gap and avoid missed opportunities in preventing cardiovascular morbidity and mortality.

Footnotes

Acknowledgements

The authors would like to thank all the medical students who collected the data, and all members of the public who participated in the survey.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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