Cardiovascular Disease Knowledge Amongst Jordanian Population: A Cross‐Sectional Study

TL;DR

This study assesses cardiovascular disease knowledge in Jordan and finds it to be low, potentially due to poor health literacy and socioeconomic factors.

Contribution

The study provides a comprehensive assessment of cardiovascular knowledge in Jordan using a large sample and identifies demographic and educational factors influencing it.

Findings

The Jordanian population has low cardiovascular knowledge across all assessed areas.

Females scored significantly higher in total cardiac knowledge than males.

Higher educational levels correlate with better dietary and risk factor knowledge.

Abstract

Cardiovascular diseases are the leading cause of death in both developed and developing countries, causing significant healthcare system disruptions due to inadequate access, high costs, and growing complications. This study aims to examine cardiovascular knowledge comprehensively among the Jordanian population.

A descriptive cross‐sectional design was used to recruit a total of 1,050 participants. A convenience sampling approach was used to gather data from accessible participants who meet the study criteria. A self‐administered questionnaire was used to comprehensively assess participants' knowledge of cardiac diseases composed of 30 questions about dietary knowledge, epidemiology, medical information, risk factors, and heart attack symptoms.

A total of 54.9% were female and 41.0% were employed. The vast majority of participants lived with their families (n = 929, 88.5%). Generally, the total scores of all cardiac items have a total score of (Mean = 18.8 out of 30, SD = 1.2), with a mean score of 3.8 out of 6 in dietary knowledge, 2.5 out of 4 in recognizing cardiac epidemiology, 4.0 out of 7 in knowing the cardiac medical information, 6.3 out of 9 in defining the main risk factors to develop cardiac diseases, and only 2.2 out of 4 in identifying the heart attack symptoms. The total score of cardiac knowledge is statistically significantly higher in females compared to males (t [1050] = 2.6, p > 0.001). The total score of dietary and cardiovascular risk factors are statistically significant with a higher educational level rather than school and less degree (t [1050] = 3.4, p > 0.001, and t [1050] = 2.9 [0.003]), respectively.

Jordan's population has a relatively low public cardiac knowledge score in all areas of heart disease, which may be a result of a lack of health literacy, a lack of educational programs about the further complications of heart disease, and poor socioeconomic conditions among Jordanians.

Tables

Table 1. Sample charachtristics (N = 1050).

Items	N (%)
Age
18–25 yrs.	542 (51.6)
26–50 yrs. > 50 yrs.	382 (36.4) 126 (12.0)
Sex
Male	474 (45.1)
Female	576 (54.9)
Marital status
Single	652 (62.1)
Married	398 (37.9)
Live with family
Yes	929 (88.5)
No	121 (11.5)
Educational level
School or less	176 (16.8)
Diploma or higher	874 (83.2)
Employment status
Yes	431 (41.0)
No	619 (59.0)
Chronic illnesses
Yes	135 (12.9)
No	915 (87.1)
DM
Yes	52 (5.00)
No	998 (95.0)
HTN
Yes	72 (6.90)
No	978 (93.1)
Smoking status
Yes	452 (43.0)
No	598 (57.0)
Physical activity
Inactive	851 (81.0)
Minimally active	91 (8.70)
HEPA active	108 (10.3)
BMI
Normal	554 (52.8)
Obese	331 (31.5)
Overweight	165 (15.7)

Table 2. Knowledge of public cardiovascular disease among the Jordanian population (N = 1050).

Knowledge domain	Min. score	Max. score	Total score ± SD
Cardiac dietary knowledge	0	6	3.8 ± 1.4
Cardiac epidemiology	0	4	2.5 ± 1.1
Cardiac medical information	0	7	4.0 ± 1.6
Cardiac risk factors	0	9	6.3 ± 1.8
Heart attack symptoms	0	4	2.2 ± 1.2
Total scores of heart knowledge	0	30	18.8 ± 5.3

Table 3. Demographic factors associated with cardiac knowledge scores (N = 1050).

Variables	Total scores	Dietary knowledge	Epidemiology	Medical information	Risk factors	Heart attack Symptoms
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)
Sex
Male	18.3 (5.7)	3.7 (1.5)	2.3 (1.2)	3.9 (1.7)	6.2 (1.9)	2.2 (1.2)
Female	19.1 (4.9)	3.9 (1.4)	2.6 (1.1)	4.1 (1.6)	6.3 (1.7)	2.3 (1.2)
t‐value (p‐value)	2.6 (0.002)	2.4 (0.042)	4.1 (0.001)	92 (0.525)	1.5 (0.016)	1.3 (0.587)
95% CI	1.497–0.210	0.388–0.038	0.425–0.152	0.294–0.106	0.379–0.052	0.237–0.051
Marital status
Single	18.5 (5.2)	3.7 (1.5)	2.5 (1.1)	3.9 (1.6)	6.1 (1.8)	2.3 (1.2)
Married	19.3 (5.4)	3.9 (1.4)	2.5 (1.1)	4.1 (1.7)	6.4 (1.8)	2.2 (1.2)
t‐value (p‐value)	2.3 (0.338)	2.5 (0.083)	0.90 (0.792)	2.2 (0.047)	2.6 (0.226)	0.693 (0.937)
95% CI	1.432–0.111	0.409–0.050	0.205–0.076	0.438–0.028	0.096–0.019	0.096–0.199
Living with family
Yes	18.8 (5.3)	3.8 (1.5)	2.5 (1.1)	4.0 (1.6)	6.3 (1.8)	2.2 (1.2)
No	18.6 (5.2)	3.8 (1.3)	2.5 (1.2)	3.9 (1.7)	6.1 (1.6)	2.3 (1.2)
t‐value (p‐value)	0.40 (0.688)	0.36 (0.039)	0.21 (0.047)	59 (0.602)	1.2 (0.087)	15 (0.338)
95% CI	0.801–1.21	0.323–0.223	0.237–0.191	0.134–0.537	0.218–0.407	0.241–0.207
Educational level
School or less	17.5 (5.9)	3.4 (1.6)	2.4 (1.1)	3.6 (1.7)	5.9 (2.1)	2.1 (1.3)
Diploma or higher	19.0 (5.1)	3.9 (1.4)	2.5 (1.1)	4.1 (1.6)	6.3 (1.7)	2.3 (1.2)
t‐value (p‐value)	3.6 (0.200)	3.4 (0.035)	0.73 (0.572)	3.8 (0.427)	2.9 (0.003)	1.4 (0.084)
95% CI	2.412–0.702	0.639–0.174	0.251–0.115	0.716–0.143	0.779–0.247	0.331–0.523
Employment status
Yes	18.6 (5.3)	3.8 (1.4)	2.4 (1.2)	4.1 (1.7)	6.2 (1.9)	2.1 (1.2)
No	18.9 (5.3)	3.7 (1.5)	2.5 (1.3)	4.0 (1.6)	6.3 (1.7)	2.3 (1.2)
t‐value (p‐value)	87 (0.830)	1.0 (0.231)	1.5 (0.742)	52 (0.686)	1.3 (0.100)	2.3 (0.500)
95% CI	0.941–0.365	0.086–0.268	0.247–0.030	0.358–0.078	0.149–0.256	0.329–0.039
Chronic illness
Yes	19.3 (5.5)	3.8 (1.4)	2.6 (1.2)	4.1 (1.7)	6.6 (1.8)	2.2 (1.2)
No	18.7 (5.3)	3.8 (1.5)	2.5 (1.1)	3.9 (1.6)	6.2 (1.8)	2.2 (1.2)
t‐value (p‐value)	1.1 (0.376)	0.09 (0.586)	0.69 (0.212)	0.27 (0.531)	2.6 (0.934)	0.12 (0.808)
95% CI	0.423–1.495	0.248–0.273	0.132–0.277	0.103–0.743	0.257–0.339	0.227–0.201
Smoking status
Yes	18.5 (5.3)	3.7 (1.5)	2.4 91.1)	4.0 (1.6)	6.2 (1.8)	2.2 (1.2)
No	18.9 (5.2)	3.9 (1.4)	2.6 (1.1)	3.9 (1.7)	6.3 (1.7)	2.2 (1.2)
t‐value (p‐value)	1.1 (0.977)	2.1 (0.056)	1.5 (0.657)	0.14 (0.577)	0.56 (0.420)	0.05 (0.520)
95% CI	1.234–1.727	0.396–0.409	0.134–0.497	0.284–0.706	0.481–0.439	0.462–0.198

Full text

Introduction

1

Cardiovascular diseases (CVD) are viewed as the leading cause of death in developed and developing countries causing devastating effects on the healthcare systems due to inadequate access to healthcare due to the cost and complications that tended to grow sharply among patients and healthcare institutions [1, 2]. Generally, CVD refers to any heart problems affecting cardiac muscle or blood vessels [3]. According to the World Health Organization (WHO), an estimated 17.9 million people died due to heart disease in 2023 representing about 32% of global deaths worldwide [4]. According to the Centers for Disease Control and Prevention (CDC), the top leading cause of death in Jordan was Ischemic Heart Disease (IHD) demonstrating 18% of the total deaths. However, stroke was responsible for 12% of the total death [5].

CVD include several types of health conditions including ischemic heart disease, cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, arrhythmias, congenital heart disease, heart failure, cardiomyopathy, and valvular heart disorders [6, 7]. Sometimes, cardiac disorders could be silent and can be no longer detected with no specific signs and symptoms until the patient experiences a heart attack or heart failure with symptoms including chest discomfort, heartburn, indigestion, shortness of breath, palpitation, swellings in the feet, ankle, and abdomen [8]. Therefore, adequate act for detecting and assessing people at risk of CVD is essential to initiate the primary prevention strategies [2].

The most important risk factors of CVD are preventable since they are modifiable [9]. An unhealthy diet, physical inactivity, and tobacco use are the main risk factors that represent rising blood pressure, lipids, high sugar levels, and being overweight [10]. Besides, about 7 out of 10 people who experience a heart attack have high blood pressure [11]. Around 74.6% of participants had hypercholesterolemia, 37.4% with high blood pressure readings, 32.5% were obese, 31.4% were smokers, and 21.5% with high random blood sugar.

This indicates that risk factors of heart diseases were extremely relevant among the Jordanian population alarming the situation of constant increasing of heart diseases and their complications [12].

Nurses play a crucial role in assessing the public's knowledge of cardiac diseases [13]. They are often on the frontline of healthcare and are in direct contact with patients and the community [14]. Public health initiatives and campaigns in Jordan have focused on raising awareness about CVD risk factors, prevention, and early detection [15]. The Jordanian Ministry of Health, along with various healthcare organizations and non‐governmental organizations, have been working to educate the population about the importance of a healthy lifestyle and regular health check‐ups [16, 17, 18].

It's significant to highlight that people and communities in Jordan can have different levels of public understanding and awareness about CVD. An accurate and current assessment of the population's knowledge and comprehension of CVD in Jordan can be obtained by conducting a cross‐sectional survey. A more knowledgeable population reflects a healthier lifestyle, more recognition of the main risk factors of CVD, and adoption of positive health‐seeking behaviors [19]. Unfortunately, the high burden of CVD among the Jordanian population revealed a limited understanding of the disease knowledge, which is supported by a study that was conducted by Mukattash et al. [20] who found that the general public in Jordan knows nothing about and is unaware of CVD, and they recommend to create and promote efficient and easily available services if they hope to have a beneficial impact on CVD management and prevention. Hence, the purpose of this study is to examine cardiovascular knowledge comprehensively among the Jordanian population.

Materials and Methods

2

Study Design

2.1

A descriptive cross‐sectional design was used.

Study Population, Sample Size, and Sampling

2.2

The study participants were residents of Amman city since it was the highest population density city in Jordan. The sample size was calculated using G*power which shows that the minimum required sample was 1000 participants; based on α = 0.05, power = 0.80, and moderate effect size = 0.30 [21]. However, a larger number of participants were collected to compensate for the attrition rate that could happen during the data collection process. A random sample of different areas in Amman was drawn to form the study cluster. Participants' locations were obtained from the Department of Statistics, which provides free copies of statistical bulletins upon request. They print hundreds of copies of each bulletin, making the data easily accessible. Amman has a total of 4,430,700 population with a density of 584.6 inhabitants/km² which forms 42.0% of the total Jordanian governorate [22]. The statistical bulletins provided by the Department of Statistics (DOS) include detailed demographic information including population size, distribution by district, neighborhood boundaries, and occasionally socioeconomic indicators. These bulletins were used to identify and randomly select different geographic areas within Amman for inclusion in the study cluster. The mention of multiple bulletins being available was intended to highlight the accessibility and comprehensiveness of this data, which supported an unbiased area selection process. In the selected areas, a random sample of 1050 participants was obtained. The inclusion criteria were (1) All Jordanians who were living in Amman, (2) aged more than 18 years, and (3) informed consent on participating in this study. The study was authorized by Al‐al Bayt University Ethics Committee (number: #119/2837/1, date of approval: 4‐1‐2023) and carried out in compliance with the Declaration of Helsinki's standards. Every individual taking part in the study gave their informed consent. After being informed about the purpose and methods of the study.

Data Collection

2.3

Data was collected between May and July 2023 by the researchers utilizing a standard predesigned questionnaire for assessing cardiac knowledge among Jordanians [23]. Bilingual professionals translated the instrument from English to Arabic and then reversed it from Arabic to English. Additionally, the researcher tested its accuracy and applicability by having professionals pilot it. A panel of three experts assessed the instrument's content validity, and changes were made as a result.

Demographical data were obtained from the participants including age, sex, educational level, nationality, marital status, living with family, employment status, poor socioeconomic status, presence of chronic diseases, height, and weight to calculate the body mass index (BMI) based on the following formula (kg/m^2^).

Physical activity is measured using the International Physical Activity Questionnaire (IPAQ) – Short Form that classifies the levels of physical activity into three categories, namely, inactive, minimally active, and HEPA active [24], and smoking status.

The questionnaire was developed by Bergman et al. [23]. It consists of 30 questions divided into five primary domains dietary knowledge (six items), epidemiology (four items), medical information (seven items), risk factors (nine items), and heart attack symptoms (four items). The answers were in the form of True/False questions addressing patients' beliefs and knowledge about various aspects of heart disease. If participants were not sure about the correct answer, they were instructed to choose‚ “Don't know.”

For each subdomain and the complete questionnaire, the scoring of the questions was summarized. Each correct answer was given one scoring point. The total score of this questionnaire ranged between 0 and 30.

Data Management and Analysis

2.4

Using SPSS software (version 26.0), the gathered data was processed and examined. When presenting quantitative data, regularly distributed continuous variables are represented by mean ± standard deviation. Nominal variables are defined as percentages and absolute numbers (n). Inferential statistics, specifically parametric tests, are used to make conclusions about a population based on sample data. A t‐test was utilized to evaluate whether the observed differences were statistically significant. In every analysis, a two‐tailed p‐value < 0.001 was considered statistically significant.

Results

3

Demographics

3.1

The study recruited 1050 participants, where about half of the participants were younger adults aged between 18 and 24 years (n = 542, 51.6%). A total of 54.9% were female and 41.0% were employed. The vast majority of participants lived with their families (n = 929, 88.5%). approximately, half of the participants had a problem of obesity and overweight 31.5% and 15.7, respectively Table 1.

Public Knowledge of Cardiovascular Diseases

3.2

A summary of participants' scores on the comprehensive cardiac knowledge questionnaire is shown in Table 2. Generally, the total scores of all cardiac items have an average (M = 18.8 out of 30, SD = 1.2), with a total score of 3.8 out of 6 in dietary knowledge, 2.5 out of 4 in recognizing the cardiac epidemiology, 4.0 out of 7 in knowing the cardiac medical information, 6.3 out of 9 in defining the main risk factors to develop cardiac diseases, and only 2.2 out of 4 in identifying the heart attack symptoms.

Demographical Factors Mean Difference in Public Cardiac Knowledge

3.3

An independent sample t‐test was used to analyze the mean difference of variables including sex, marital status, living status, educational level, employment status, presence of chronic diseases, and smoking status. Males had significantly lower mean scores than females in diet (18.3 vs. 19.1, p > 0.002, 95% CI for the mean difference [female–male]: 0.21–1.49), epidemiology (3.7 vs. 3.9, p = 0.042, 95% CI: 0.04–0.39), and medical knowledge (2.3 vs. 2.6, p = 0.001, 95% CI: 0.15–0.43). No significant differences were found in risk perception (p = 0.525), symptom awareness (p = 0.016), or total scores (p > 0.587). Married participants scored significantly higher than single participants in risk perception (4.1 vs. 3.9, p > 0.001, 95% CI for the mean difference [married–single]: 0.03–0.44). No significant differences were observed in diet, epidemiology, medical knowledge, symptoms, or total scores (p > 0.05 for all). No significant differences were found in any category except epidemiology (p = .039, 95% CI: 0.223–0.323) and medical knowledge (p > 0.001, 95% CI: 0.19–0.24), where those not living with family scored slightly higher.

Participants with a diploma or higher had significantly higher scores in Epidemiology (3.9 vs. 3.4, p > 0.001, 95% CI: 0.17–0.64) and symptoms knowledge (6.3 vs. 5.9, p = 0.003, 95% CI: 0.25–0.78). No significant differences were observed in diet, medical knowledge, risk perception, or total scores. Table 3.

One‐way ANOVA was also run to assess whether differences between groups exist among the BMI and age groups with the total scores of cardiac knowledge. The results found that there are no association among the age groups (F (3, 1047) = 1.19, p > 0.001), and for the body mass index, it was (F (3, 1047) = 3.8, p > 0.001).

Discussion

4

The current study aims to assess the public cardiac knowledge among the Jordanian population using a comprehensive tool that measures different domains including their knowledge about dietary habits, epidemiology of cardiac diseases, risk factors, medical information, and heart attack symptoms. Generally, it could be judged that the Jordanian population had insufficient or poor knowledge about CVDs in all domains of items. The results of this study were consistent with a study conducted by Omoronyia et al. [25], which found that the Iranian population had unsatisfactory knowledge of cardiac diseases and all aspects assessed. Also, another study using the same questionnaire used in this study found poor cardiac knowledge among their participants with poor perception of the main risk factors of CVD and its related risk factors [26]. Poor cardiac knowledge among the participants could be contributing to the lack of awareness about the importance of primary prevention strategies for the complications of CVD among the population. Besides, promoting cardiac knowledge among the population is a crucial priority that could affect the population positively in changing their lifestyle and adopting the healthiest practices which will help in preventing chronic diseases [27].

In this study, females had a higher level of knowledge in all domains of cardiac scores generally with significant results in the aspects of epidemiological and risk factors aspects specifically. In line with this, Omoronyia et al. [25] found that females had a higher cardiac knowledge compared with males and this could be contributing that females are more interested in getting health information that obtained from different sources of information including their frequent visiting maternity clinics and more access to health care services rather than males. Furthermore, this study found that participants with higher educational levels had a higher cardiac knowledge which is consistent with a study that was conducted by Chukwuemeka et al. [28] who revealed that knowledge of cardiac risk factors is increased with increasing their educational level.

The current study showed that there is no significant result between the body mass index of participants and the total score of cardiac knowledge which is inconsistent with a study performed by Michaëlsson et al. [29, 30]who outlined that obese individuals did not experience higher cardiac knowledge scores while those who have normal BMI adhere to a healthy diet program to maintain a low risk of mortality.

Strengths and Limitations of the Study

4.1

The study has limitations even though it has a large sample size and a generally homogeneous socioeconomic setting across different Jordanian governorates, which increases the findings' potential generalizability. First, it is difficult to prove causality or shifts in knowledge over time due to the cross‐sectional design. Second, there may have been selection bias since those who consented to participate may have been better educated or more health‐conscious than the general population, which could have resulted in an overestimation of knowledge about CVD. Furthermore, although using a thorough CVD knowledge questionnaire improves the evaluation, self‐reported answers could be skewed by social desirability or recollection bias. Furthermore, even though this is the first study in Jordan that has been recognized to thoroughly evaluate public understanding of CVD, the results should be interpreted cautiously when extrapolating to populations with alternative cultural or health system contexts.

Implication of Study

4.2

Nursing professionals serve as educators and public health activists since they can take part in community outreach initiatives, health fairs, and workshops where they disseminate knowledge about cardiac illnesses, risk factors, management, and prevention. Besides, collaboration with other healthcare providers is another implication to coordinate complete treatment for people with cardiac problems because nurses work closely with doctors, dietitians, and other healthcare providers. Nurses work with these professionals to produce and provide accurate, scientifically sound instructional materials in a public context.

Conclusion

5

It is concluded that the Jordanian population has a low public cardiac knowledge score in all aspects of heart diseases including dietary habits, epidemiology of cardiac diseases, risk factors, medical information, and heart attack symptoms. This could be attributed to the lack of educational programs about the further complications of CVD, poor health literacy, poor socioeconomic conditions among the Jordanian population, and lack of system training programs to educate the general population.

Author Contributions

Ahmed Mohammad Al‐smadi: conceptualization, formal analysis, writing – original draft. Salam Bani Hani: data curation. Hossam Alhawatmeh: data curation. Rula Amr: data curation. Omar gammoh: writing – original draft, writing – review and editing, supervision, formal analysis. Abedalmajeed Shajrawi: writing – review and editing, writing – original draft. Ala Ashour: writing – review and editing. Rani Shatnawi: data curation, investigation. Donna Fitzsimons: writing – review and editing. Albara Alomari: visualization, project administration, writing – review and editing.

Funding

The authors received no specific funding for this work.

Conflicts of Interest

All authors declare no conflicts of interest.

Transparency Statement

The lead author Albara Alomari affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.