INTRODUCTION:

There is growing evidence that most cardiovascular disease (CVD) is preventable. Familial aggregation of coronary heart disease (CHD) is thought to account for 50% to 60% of total documented CHD before the age of 60 years.¹ First-degree relatives of people with premature CHD (proband) exhibit a risk that is 2 to 12 times greater than that of the general population.²

In this high-risk group for whom screening and intervention in first-degree relatives including children with a history of premature CVD (younger than 55 years in men and 65 years in women) may themselves have an increased risk of CVD, would be an important aspect of primary prevention (Pearson et al. 2002). In this respect a familial history of CHD is considered to reflect genetic, biochemical and behavioural components that may predispose an individual to be at higher risk of cardiovascular disease. While a positive family history is not modifiable, it can be used to identify individuals in whom a more intensified strategy of prevention by intervening on modifiable risk factors such as poor dietary habits, physical inactivity, obesity, hypertension, hypercholesterolemia or smoking should be developed.³ The importance of risk factor modification in high-risk individuals was underlined in the Joint Task Force of European and other Societies on Coronary Prevention, which advised that close relatives of patients with premature coronary heart disease (men <55 years and women <65 years) should be screened for coronary risk factors.

A decrease in coronary-prone behavior (and more detailed understanding of the barriers to change) is a priority for public health. Furthermore, the offspring of parents who suffer from premature coronary heart disease have a significantly higher risk of early cardiac death than controls. A genetic predisposition is compounded by a commonality of environmental risk factors within families.

Some research has suggested that having a family history could act either as a spur or a barrier to changing health behaviors⁴, although few studies have researched this link.⁵ The Reasons for lack of healthy behaviors based on family history are thought to exist at both the individual and provider levels. On the individual level, family members deny or are unaware of the familial aggregation of CHD and its risk factors. On the provider level, healthcare providers may not be engaged to identify high-risk families, conduct the teaching, and intervene with relatives.

Increasing awareness, early detection and modification of risk factors are essential components of an effective public health strategy to protect this highly vulnerable population. It has been argued that perceptions of familial tendencies to disease are common and important in decisions about health-related behaviours. Indeed, it has been suggested that the increased 'geneticization' of society may lead to an increased fatalism about health, which could undermine initiatives aimed at reducing coronary-prone behaviour. To date, much of the research on lay perceptions of inheritance has been based on people at high risk of particular genetic disorders or on qualitative research with small general population samples. Here we investigate perception of heart disease as the leading cause of death, identify health related behaviors in prevention of CHD, in first degree relatives of people with CHD, using quantitative techniques, to test hypotheses about the relationship between a perceived family history (PFH), coronary 'candidacy' and adherence to healthy behaviors which were raised by earlier anthropological work.

MATERIALS AND METHODS:

This quantitative, non-experimental, descriptive study was conducted during November- December 2012 in Jubilee Hrudhayalaya (JH), jubilee mission medical college and research institute (JMMC and RI), Thrissur district, Kerala, which is 1600 bedded hospital. JH is a 300 beds super specialty heart hospital, including 80 beds critical care unit, 4 operation theaters, 2 cath labs functioning 24x7. It caters to patients from the lower and lower-middle socio-economic strata of the population. The patients are mostly accompanied by their family members.

Using convenient sampling method 100 first degree relatives (individual's parents, full siblings, or children) of people with premature CHD (men under 55 years and women under 65 years) were selected accompanying the patients at out-patients and in-patient departments. Relatives in the age group of 18-60years, who were able to give adequate response to questionnaire, were included while relatives who refuse to participate in study and with a psychiatric or chronic physical illness were excluded from the study.

Data were collected using a demographic data sheet, and a structured interview schedule. It consisted of items on perception of heart disease and health related behaviors which were developed after thorough review of literature and in consultation with experts. This included common particulars such as age, gender, education religion, caste, income, and their area of living. Information regarding their perception of their greatest health problem and leading cause of death in India, self rated knowledge of heart disease, perception of personal risk getting heart attack when compared to the general population, concern for getting future heart attacks. A set of questions on important classes of behavioral risk factors viz., dietary habits, physical activity, smoking, alcohol consumption and mental stress were also included.

For fruit, Vegetable, fast foods, fatty foods and soft drinks consumption pattern items were graded as daily, 3-4 times in a week, 1-2times in a week, occasionally, and never as appropriate. Categories for Oil consumption were vegetable oil [refined/unhydrogenated], Vegetable oil (hydrogenated), Butter, ghee or none in particular. For the purpose of analysis, those who took vegetables and fruits less than once daily were considered as having unhealthy diet. Reuse of cooking oil, adding extra salt to food/salad/curd/rice/atta were graded as most of the times, sometimes<25%, and never.

A person was considered “inactive” if he/she has always been carrying out only light (sedentary) physical activities. Since work and leisure activities are the two important segments of daily life in which most time is usually spent, a composite index of ‘inactivity’ was defined by considering the respondent inactive at work if his/her work involve moderate/vigorous activity like brisk walking(or carrying light loads, heavy lifting, digging ) for atleast 10 minutes at a time. The level of activity during leisure was also studied by asking them to report the frequency and duration of each moderate-vigorous activities (brisk-walking/jogging/ cycling/aerobics/physically active games) they engaged if any carried out in the last week. Information regarding the practice of yoga was also obtained.

Collected Tobacco use related information include experimentation with tobacco, current use of tobacco, frequency of use if current smoker, exposure to passive smoking. Habit of alcohol consumption, frequency and quantity of use per week were also obtained. The study also attempted to obtain information on the level of mental stress and tension the respondents experienced. Respondents were asked whether they were feeling any stress or tension in their close environment. Stress was studied in six different areas job, family life, interaction with friends, financial problems, health and marital life (if married). The respondents were asked to score their level of stress in each of these six areas on a 7 point scale, (7 point Likert scale) ranging from -3 (extremely dissatisfied) to +3 (extremely satisfied), with zero if neutral. This scale is used to get some insight into the presence or absence of any stress, and not for quantifying its level. All the respondents with negative scores were considered stressed in the respective situations. For the purpose of analysis, the respondents were defined as stressed in life if they experienced stress in at least two of the above situations.

The correct responses given by each individual was converted to percentages with 100% denoting the correct responses.

After screening the subjects’ informed verbal consent was obtained before data collection. The interview schedule took around 15 minutes. Anonymity and confidentiality of the subjects was maintained during the study and they were given full autonomy to withdraw from the study at any time.

A pilot study was conducted among 20 subjects after establishing the validity and reliability of the tool to find out the feasibility of the study. No modifications were made in the tool or study protocol after the pilot study. The permission for data collection was obtained from the competent authorities in the Institute. The data were then transferred into SPSS 16.0 Version and was analyzed.

The total number of participants in the study was 100 people, 22 to 57 years (mean, 35.73±9.56 years). Of total number majority were female (66%), except 1%, all of them were literate, and more than one fourth possessed college or higher education qualifications. Among the participants, 24% were single, 64% were married, 5% were divorced, and 7% were widowed. More than half of the respondents (80%) were from the rural areas and had a monthly income (60%) of less than Rs.5000/month. 40% of the relatives noted cancer in general as their greatest health problem, whereas only 23% reported heart disease. When identifying the leading cause of death in India, 50% of all respondents reported road traffic accident whereas only 19% identified heart attack. With regard to the self perception of knowledge regarding heart disease majority 48% of people said they are only moderately informed,27% not at all informed,15% well informed, 5%very well informed and 5 % said they are not sure/don’t know. Interestingly, 19% recognized heart disease as the leading cause of death, but only 17% were concerned of getting future heart attacks and only 15% perceived their risk of getting heart attack is more than other people in the general population.

RESULTS:

Sample characteristics N=100

Socio Demographic Variables

Percentage

Age (in Years)

35.73±9.56

Gender

Male

Female

Marital status

Single

Married

Separated/divorced

widowed

Educational status

Professional degree/post graduate

Graduate

Secondary school

Upto primary school

Literate, no formal education

Illiterate

Occupation

Professional/big business

Clerical/medium business

Self employed/skilled

Unskilled/landless laborer

Home maker

Unemployed

Area of living

Rural

Urban

House hold income in a month

<5000

<15000

<30000

>30000

Note: all data are presented in % except age which is presented in mean ± SD.

Experimentation with tobacco was found to be in 24% and 18% were currently using tobacco in any form. 22% were exposed to passive tobacco smoke at home or workplace regularly. 18% were using alcohol on regular basis.

The proportion of individuals physically inactive during work (job) was 65% per cent. The inactivity was 85% during leisure time. The average duration of moderate –vigorous activity among physically active people was 238minutes/week. Very few (7%) were practicing activities like yoga.

Most of the respondents (91%) were not in the habit of taking fruits adequately (at least once daily). As regards vegetables, 63 per cent of the respondents were said to have not taken vegetables at a satisfactory level, i.e., at least once daily. Choice of cooking oil was hydrogenated vegetable (81%) in most of them while only 8% use hydrogenated vegetable oil and 11% use none in particular.44 percentage were in a habit of taking snacks atleast 1-2 times per day while 7% snaked 3-4 times in day, and snacking was not seen in 49 percentage. About 19% of respondents were not all taking fast foods of any kind, while 4% take daily, 18% take 3-4 times in a week, 29%, 1-2 times /week, 30% occasionally. Regarding consumption of fatty food, 21% were taking daily, while 36% 3-4times weekly, 27% 1-2 times/day 13% occasionally and 3%not in a habit of taking any fatty food.

Finance was the major source of mental stress, followed by health/illness. The proportion of people with stress from one or more sources was found to be 84 per cent.

DISCUSSION:

A family history of premature CHD is widely recognized as a strong risk factor of CHD. In the present study cancer in general as the greatest health problem and road traffic accidents was ranked as the leading cause of death and in India. These perceptions are contrasted against the actual statistics for the leading causes of death in India. According to 2012 statistics coronary heart disease is the leading cause of death in the world and in India. Road traffic accident is rated only as the tenth cause of death⁶. Poor awareness towards the coronary heart disease is considered to be a serious issue, which not only affects the public recognition towards disease but also delays the process of timely diagnosis and treatment. This may be due to the fact that major sources of information are TV and Newspapers which give publicity of commonly occurring cancers and road traffic accidents diabetes but no structured and targeted IEC activities are promoted through programmatic efforts towards coronary heart disease.

Very few first degree relatives (15%) perceived that their risk of getting heart attack is more than other people in the general population and well informed about prevention of heart disease. Relatives appear to underestimate their own risk. A possible reason that first degree relatives underestimate the possible risk of coronary heart disease may be is that, it is often not discussed by the health care professional⁷.Risk perception is a complex process that has been studied in relation to an individual’s adherence to health behaviors. According to the Health Belief model, individuals who recognize their risk for disease will not take action unless they perceive the illness to have serious consequences. Hunt and colleagues suggest that even people with a large number of relatives affected by heart disease are not likely to recognize a positive family history and that the level of recognition can depend on the proband’s sex, social class, and age at death.

Prevalence of different classic cardiac risk factors were high in relatives and offspring of patients with premature CHD. A comparison with the general population or previous studies on patients with premature CHD is difficult since we used self-reported risk factors and since age and gender matched groups of patients are not easily found in literature. Considering the impact of coronary heart disease among first degree relatives of people with CHD, this lack of awareness coupled with a substantially high rate of prevalence behavioral risk factors among adults in the community, especially physical inactivity and smoking is going to be problematic. The study further showed that the dietary habits of the majority of the respondents were not healthy. The relationship between the inadequate intakes of high -fiber foods such as vegetables and fruits, stress and the occurrence of coronary heart diseases is well documented. Physical activities are of prime importance for lowering the levels of cholesterol and blood pressure, even in a population with dietary practices similar to that of Western countries.

CONCLUSION:

The higher prevalence of such risk factors and poor perception of heart disease as a health concern in the present study suggests a high potential for acquiring high morbidity among first degree relatives of people with CHD and they form an ideal target population for primary prevention of CHD in high-risk patients.

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Received on 28.04.2013 Modified on 15.05.2013

Asian J. Nur. Edu. and Research 3(3): July-Sept., 2013; Page 192-195