Public Knowledge of Cardiovascular Diseases and its Risk Factors in Jeddah City, Saudi Arabia

Introduction: Cardiovascular diseases (CVDs) are one of the critical yet preventable non-communicable diseases. Based on the World Health Organization (WHO) reports on non-communicable conditions in 2010, millions of people were killed by non-communicable diseases in 2008, resulting in deaths that occurred before the age of 60 (1). Our aim in this study is to provide descriptive epidemiology and to estimate the public’s knowledge towards CVD types, risk factors, and warning symptoms of heart attack or stroke. Methodology: The study was approved by Ibn Sina National College of Medical Sciences research committee in November of 2019.This is a cross-sectional analytic study conducted among the Saudi community in Jeddah City, Saudi Arabia from November 2019 to April 2020. A total of 635 respondents contributed to fill the self-administered questionnaire. Statistical package for social sciences (SPSS) version 20 was used. The degree of association was tested using Chi-square. A statistically significant association was taken at P<0.05. Results: Participants who agreed to participate consisted of 228(35.9%) males and 407(64.1%) females. Hypertension is the highest disease diagnosed with a total of 111(17.5%) and highest among females with 71(64.0%). Most of the participants identified chest pain and discomfort (76.4%) and shortness of breath (73.7%) as symptoms of heart attack. Compared with other symptoms such as pain or discomfort in the arm or shoulder (57.3%), weakness in the arm or leg on one side of the body (55.6%), and weakness lightheaded and fainting (51.2%). Conclusion: The study participants show low knowledge in CVS. There is a need to increase public awareness and to establish basic knowledge to the general and targeted individuals.


Introduction
Cardiovascular diseases (CVDs) are one of the critical yet preventable non-communicable diseases. Based on the World Health Organization (WHO) reports on non-communicable conditions in 2010, millions of people were killed by noncommunicable diseases in 2008, resulting in deaths that occurred before the age of 60 [1] . Public knowledge of cardiovascular diseases and its risk factors is of great importance since it includes a diversity of disorders like coronary heart disease, cerebrovascular disease and deep vein thrombosis. CVDs are the leading cause of death globally, with more than 17.3 million deaths/per year [1] . Based on the WHO and Saudi Ministry of Health (MOH), CVDs caused 42 % of deaths in 2010 in the Kingdom of Saudi Arabia (KSA). Numbers in reports also show a higher number of male patients with cardiac diseases than female patients [2] .
A cross-sectional study was conducted in 2016 in Jeddah, Saudi Arabia on the prevalence of undiagnosed cardiovascular risk factors in 507 participants aged between 20-40 years which reported that men showed a higher prevalence of high blood pressure of 10.6%, while females on the other hand only showed 0.8% [3] . Another study was done at King Abdul-Aziz University hospital regarding the physical attributes of cardiovascular risk factors among high-risk individuals that attend general practice, indicated that obesity is a crucial cause of CVDs [4] . Tobacco smoking is another leading cause of CVD, especially waterpipe smoking which has been known among people as a better alternative to cigarettes, which in fact contains an equivalent harmful chemical substances and pathologic effects [5] . Educating people about obesity and its tributaries to CVDs will make a massive difference in the number of high-risk people.
To our knowledge, data that assess public knowledge of cardiovascular diseases in Jeddah, Saudi Arabia are very limited. Our aim in this study is to provide descriptive epidemiology and to estimate the public's knowledge towards CVD types, risk factors, and warning symptoms of heart attack or stroke.

Methodology
The study was approved by Ibn Sina National College of Medical Sciences research committee in November of 2019.This is a cross-sectional analytic study conducted among the Saudi community in Jeddah City, Saudi Arabia from November 2019 to April 2020. A total of 635 respondents (aged 20 years and older) contributed to fill the self-administered questionnaire anonymously after taking a verbal consent either directly in public places or indirectly through an online link. The target sample size was a minimum of 377 that was calculated using Raosoft [6] .
A validated electronic questionnaire was taken from a study conducted in Nigeria that was used to know the public knowledge [7] . The survey is written in both English and Arabic languages, and the accuracy of the translation was checked. The questions included in the study are demographic characteristics of the respondents, such as gender, marital status, age, employment, educational level, and lifestyle. Other important questions that provide information about the participant's health status and knowledge. Statistical package for social sciences (SPSS) version 20 was used and descriptive analysis was conducted. The degree of association was tested using Chi-square. A statistically significant association was taken at P<0.05.

Results
In this study we aimed to provide descriptive epidemiology and to estimate the public's knowledge towards CVD types, risk factors, and warning symptoms of heart attack or stroke.
A total of 635 questionnaires were distributed to the participants directly in shopping centers and indirectly through electronic platform during the period from November 2019 to April 2020. Data were collected anonymously via a selfadministered questionnaire. No missing value was recorded. Table 1 illustrates the characteristics of the study participants. Participants who agreed to participate consisted of 228 (35.9%) males and 407 (64.1%). The majority of the participants had a relatively stressful lifestyle of 278 (43.8%), 447 (70.4%) are not smokers, and 294 (46.3%) don't exercise. Only 372 (58.6) reported eating fruits or vegetables sometimes, and 252 (39.7) reported eating fast foods. Those reported having high blood pressure were 111(17.5%) and of those only 22(19.9%) measure it regularly. Diabetes was reported in 65 (10.2%) of those only 31(47.7%) monitor their blood sugars regularly. Table 2 reveals to us the conditions diagnosed with the participants. Hypertension is the highest disease diagnosed with a total of 111 (17.5%) and highest among females with 71 (64.0%). The second most upper disease diagnosed is obesity, with 110 (17.3%) and highest among females as well, with 71 (64.5%). High cholesterol is the third highest with 80 (12.6%) and highest among females with 52 (65.0%) followed by those diagnosed with diabetes mellitus with 65 (10.2%), which is also highest among females with 34 (52.3%). Prior heart attack or heart disease are reported by 16 participants (12.5%). Females have the highest percentage of diagnosed conditions except in prior stroke as it is identical in both sexes. Table 3 shows the respondent's knowledge about the symptoms of a heart attack. The majority of the participants identified chest pain and discomfort (76.4%) and shortness of breath (73.7%) as symptoms of a heart attack compared with other symptoms such as pain or discomfort in arm or shoulder (57.3%), weakness in the arm or leg on one side of the body (55.6%), and weakness lightheaded and fainting (51.2%). A reasonably high response rate of participants who did not know whether some symptoms were for heart attack. When asked which symptoms were of heart attack shortness of breath 468(73.7) was reported the highest and trouble seeing in one or both eyes was reported the least. None reached statistical significance (p<0.05) except "weakness in the arm or leg in one side of the body" with a p-value of (0.005), "pain or discomfort in arm or shoulder" with p-value (0.001), and "shortness of breath" with a p-value of (0.001). Table 4 shows the participants' knowledge of heart attack risk factors. The majority 496(78.1%) of the participants identified smoking as the highest risk factor, excess salt intake being the lowest at 318(50.1%). None of the risk factors reached statistical significance (p> 0.05).

Discussion
This is the first known study to be conducted in Saudi Arabia, Jeddah, to comprehensively demonstrate the current level of public knowledge about CVD's warning symptoms and risk factors. This study's objectives were to characterize the symptoms and factors related to CVD knowledge in the Saudi population. A very worrisome finding in the current study was the respondents' low knowledge of CVD symptoms. The first sign is chest pain, which was the most common reported (76.4%), which is close to that found in Nigeria (67%) and Beijing (64%) but higher than that reported in Kuwait (50%), Pakistan (36%), and Nepal. People's awareness of chest pain and their relationship to CVD was acceptable, but it requires more education about the symptoms associated with CVD [7,8,9,10,11] . Saudi society awareness about Shortness of breath was recognized by (73.7%) of the study population, which is consistent with that reported in Nigeria (62%), but higher than that in Canada (39%), Pakistan (24%), Kuwait (48%), and Nepal (13%) [7,9,10,11,11] . Pain in arms or shoulder was identified by (56%) of respondents, which is higher than that reported by studies from Nigeria (28%) and Kuwait (48%) [9,10,11,11] . followed by numbness or weakness of the face, arm, or leg (55%). Feeling weak, light-headed, or faint was recognized by (51.2%) of participants, close to that reported in Nigeria (41%), and lower than in Kuwait (25%) [7,9,10,11] . Knowledge about Symptoms of Heart Attack in CVD was significantly p <0.05 different in weakness in the arm or leg on one side of the body, chest pain, discomfort, pain in arms or shoulder, and shortness of breath.
Respondents' knowledge about the risk factors of heart attack of a heart attack in CVD was better than the symptoms of a heart attack. This increased understanding of CVD risk factors is related to their significant representation in mass media and promotions, as opposed to CVD's warning. Respondents' higher knowledge about these risk factors, may be related to the statistic, and the questions were taken through the mall. Its visitors are mostly intellectuals; their awareness and education are high because most of them are aware of some heart attack causes. Therefore, they know how dangerous these risk factors are related to CVD in addition to the intensive representation in mass media campaigns as opposed to a symptom of a heart attack, which were identified less frequently by the study population. Factors significantly associated with CVD are diabetes mellitus with p value 0.037 When comparing our results to those of Northern Ireland and Jorden studies, it must be pointed out that Northern Ireland was higher with p value 0.117 and Jordan was lower with p value 0.013 [14,15] .
Some limitations during this study; firstly, this is a cross sectional study and the data represented are in one point of time and therefore does not reflect any change in respondent's knowledge about CVS. Secondly, this is a self-administered questionnaire and cardiac examinations are needed. Thirdly, this study was only conducted in Jeddah therefore we can't generalize the results. These present findings highlighted the need for further improvement of the public knowledge regarding symptoms and causes of CVD among the Saudi population.
Lack of knowledge of symptoms of heart attacks can increase the delay in seeking early medical care, leading to worse therapeutic outcomes.

Conclusion
This study demonstrates the baseline levels of knowledge about CVD types, warning symptoms of heart attack or stroke, and CVD risk factors among the general population in Jeddah, Saudi Arabia. The study participants show low knowledge in CVS. There is a need to increase public awareness and to establish basic knowledge to the general and targeted individuals.

Funding
This research received no funding