Thesis and Publications

[samehseef]

Dear all i would like to have your help fixing my thesis paper for publishing .
my langusge is not english and my skills will not be as someone with english langugae as mother tounge besides being expert like you.

preciating your help and support and waiting your reply

[samehseef]

part 1

What is killing? People’s knowledge about coronary heart disease, attitude towards prevention and main risk reduction barriers in Ismailia, Egypt (Descriptive cross sectional study)

Abstract

Background
Cardiovascular diseases are public health concern everywhere, especially ischemic or coronary heart diseases (CHD) which are on top of causes list of mortality and morbidity in both genders globally. From which nearly 80% can be due to modifiable risk factors. In Egypt, there is lack of studies concerning the knowledge of people about coronary heart diseases and its modifiable risk factors. So, this research reported here is designed to measure the dimensions of people knowledge about CHD and their attitude towards prevention, and to identify the main risk reduction barriers.
Methods
By using comprehensive cross-sectional, descriptive research design methodology, all adult individuals attending family health clinic at Suez Canal University Hospital were eligible for inclusion with total number 125 participants. An interview questionnaire was designed to collect data.
Results
the study revealed that (10.4%) of participants had a history of CHD, and (7.2%) had a family history of CHD. 79.2% had satisfactory total level of knowledge about CHD, and (94.4%) had a positive total attitude towards prevention. Risk reduction barriers were recognized as medical setting barrier (24%), patient related barrier (22.4%), and community and societal was almost the same as knowledge barrier, around (16%) and the least was the systemic and organizational barrier which considered being (9.6%).
Conclusion
It is concluded that the level of total knowledge about CHD was satisfactory, but lower than the level total of attitude. More effort is needed by the health system to improve the settings and engage patients in their plans and breaking related barriers, with development of structured health education programs based on needs assessment. Further studies are needed to investigate the reasons and follow up the process for changes.
Key words
Non-communicable, coronary heart disease, knowledge, attitude, risk, barriers, Egypt, morbidity, morbidity, Public health
Background
Cardiovascular diseases are public health concern everywhere, especially ischemic or coronary heart diseases (CHD) which are on top of causes list of mortality and morbidity in both genders globally (1). CHDs are greatly increased issues, and are the major causes of illness and deaths in the Middle East Region, responsible for 21% of deaths, from which nearly 80% can be due to modifiable risk factors (2).
Globally and within the region the sedentary life, high fat diet, high blood pressure, smoking, diabetes, obesity, dyslipidaemia and stress are the main risk factors leading to increased prevalence of CHD and especially in Egypt (2). The World health organization data have shown that, CHD is responsible for 10% of Disability-adjusted life years (DALY) lost in low- and middle-income countries. In Egypt it is responsible for 21% of fatality and 13 % of DALY (3).
The region countries are suffering from a tow fold burden, from both infectious and non-infectious diseases, where shortly the non-infectious diseases will be the most. And as shown from data that CHD will impose the highest with in the cardiovascular diseases and the countries burden of disease in men and women (4), (5). It is now an emerging major health problem in low and middle income countries. The incidence curve of CHD, among Egyptians, is rising in the last few decades. This is a general impression among Egyptian physicians repeatedly discussed in scientific meetings.
CHD mortality is affected by presence of the different risk factors especially high blood pressure, cholesterol level, smoking, physical inactivity , stress and diet , where up to 90% of mortality cases have one or more risk factors that are affected by people living style (4),(6).
Where in Egypt the major risk factor prevalence are as the following, the smoking prevalence is nearly 48% for men and 4% for women, the prevalence of hypertension is almost 31% (7), the prevalence of DM is 7.8% in urban areas, 5.6% in rural agricultural areas, and 2.5% in rural desert areas and the prevalence of obesity is 55.6 % (8).
And where is a relatively long time between exposure to a risk factor and development of disease, consequently there is a need to focus efforts on the risk factors that predict disease and the distribution of these risk factors within the population is the corner stone required for planning of prevention.
Preventive strategies are needed to focus on the population as a whole, and more specifically on the people at high risk of certain diseases. Prevention can be done but it is usually missed, and where more than half of deaths due to CHD occurred outside the health facilities, the role of primary prevention is increasing and risk factor identification and barriers to risk reduction is getting more valuable (7). Starting a healthy living style by stop smoking, losing weight and starting to be active is the base for prevention and treatment of heart disease (9).
Men, as well as women should be made more aware of their own risk of developing CHD and of the manifestations of CHD. Physicians should be encouraged to ask patients more deeply and comprehensively about their illnesses understanding, beliefs, and attitudes to check their knowledge (10), and define the barriers to risk reduction.
In Egypt, there is lack of studies concerning the knowledge of people about coronary heart diseases and its modifiable risk factors. So, this research reported here is designed to measure the dimensions of people knowledge about CHD and their attitude towards prevention, and to identify the main risk reduction barriers. It is hoped that this study will contribute to our knowledge in this field to put understand to the risk factors that we can prevent and control , and the current picture as a step for prevention and breaking down the barriers.
This study aims to identify People’s knowledge about coronary heart disease, their attitude towards prevention and main risk reduction barriers. This was to be achieved through measuring their knowledge and attitude towards CHD, its risk factors and identification of the main barriers for achieving risk reduction.

[samehseef]

part 2

Methods
Study design: A comprehensive descriptive cross-sectional study was used to assess the knowledge, and attitude about CHD, and the possibly related variables and main risk reduction barriers.
Study Setting: This study was carried out in Egypt, Ismailia governorate. It has a population (including surrounding rural areas) of approximately 750,000. It is located on the west bank of the Suez Canal, approximately half way between Port Said to the north and Suez to the south.
Population and field work: All adult individuals, males and females, attending family health clinic at Suez Canal university hospital within the inclusion criteria, 18 and older and willing to participate during the time of the study. Upon obtaining the official permissions, and after preparation of the study tools, the process of data collection started. This was done 3 days per week for 3 weeks (clinic working days). The researcher approached eligible individuals according to inclusion criteria, and explained to them the purpose of the study. Then asked about their willingness to participate, and obtained their verbal consent. The participants interviewed using the questionnaire form, and the responses marked by the researcher. This was done for all participants, whether illiterate or educated, to avoid any bias in data collection.
Sampling: Through a comprehensive random sample within the determined time of the data collection, all individuals fulfil the inclusion criteria were included. Totally 125 participants 51 males and 74 females, where were no refusal for participating at the interview from all who been asked for.
Data Collection Tool: An interview questionnaire was designed by the researcher based on pertinent literature, and experts’ opinions (Appendix I). It consisted of Personal data: covered demographic characteristics, Socio-economic data, Medical history, Family history, and knowledge about coronary heart disease, Attitude towards prevention and lastly Barriers for risk reduction. With timing of 10-15 minutes to be marked.
Scoring: For the knowledge items scoring was carried out by evaluating the total knowledge for each individual responding to the 12 questions asking about the different aspects of knowledge the definition, disease presentation, main risk factors, fatality and seriousness early treatment and control, and lastly the main risk factors in relation to incidence of the disease, right or positive answer was given 2 points and wrong or negative answer was given 1 point. Resulted in a scale for weighting the total knowledge (lowest score was 12 and highest score was 24). Satisfactory level of knowledge chose to be over 75% of total score (>18 points)

In The same principal as for scoring the total knowledge, the total attitude was scored as the following .1 point was given to the answer (insignificant), and 5 points were given to the answer (very Important) , 4, 3 and 2 points were given to the answers (important ,average importance ,less important) respectively , answering the 5 questions reflecting the attitude aspect. Resulted in a scale for weighting the total attitude towards prevention (lowest score was 5 and highest score was 25). Positive attitude chose to be over 75% of total score (>18.75=19 points)
Ethical considerations and Human Rights: A verbal consent was taken from all the studied individuals before the beginning of the study. Complete confidentiality of the data ensured. The investigator provided counselling to participants in case of need or upon request. And participants had the right to leave and stop the questionnaire at any time.
Data analysis: Statistical analysis carried out by using SPSS -V18.0 statistical software packages.
Frequencies and cross tabulations were generated and A chi-square test was used to see if there is a relationship between the categorical variables. Chi-square test assumes that the expected value for each cell is five or higher and statistical significance was considered at p-value <0.05.
Results
The socio-demographic characteristics of study participants are described in table 1. It indicates that more than 75% were less than 45 years old, with more females (59.2%). More than half of the participants (56 %) were either housewives or unemployed, (56.8%) were rural residents, and the majority was married and has children (76.8%). As regards education, the highest percentage (41.6%) were illiterate and only (6.8%) were highly educated. Only (7.2%) were current smokers.
Income was enough for (69.6%) of study participants and not enough for living for (24%).
As shown in table 2, (10.4%) had a history of CHD, whereas (7.2%) had a family history of CHD. The table also reflected a positive history of other chronic diseases (Diabetes Mellitus, hypertension) among (15.2%) of the participants, and among (36.8%) of their families.
Table 3 illustrates the knowledge about CHD among participants. (39.2%) did not know what the meaning of CHD is, but (59.2%) considered chest pain as disease presentation. (50.4%) defined most of risk factors and (30.4%) considered smoking as a risk factor and its cessation as a preventive measure (95.2%). Conversely,(0.8%) defined diabetes mellitus as risk factor by itself. Overall, (20.8%) of participants had unsatisfactory knowledge about CHD. Figure 1
As regards participants’ attitudes towards prevention of CHD, table 4 shows that the great majority of them had positive attitudes towards all preventive measures. Ranging from (94.4%) for stopping smoking to (73.6%) for control of diabetes mellitus, with total positive attitude (94.4%). Figure 2
The main barriers preventing from achieving risk reduction as in table 5 considered to be mainly medical setting barriers (24%) followed by patient related barriers (22.4%) and systemic and organizational barriers listed to be the least (9.6%).
The association between the total knowledge and socio-demographic characteristics of study participants as in table 6 reflected that there were associations between total knowledge and both of marital status and educational level. And for the associations between the total knowledge and medical and family histories table 7 demonstrated only association to family history of other chronic diseases.
Table 8 showed the association between the total attitude and socio-demographic characteristics of study participants which reflected association between total attitude and all of marital status, job and special habits, but for the association between the total attitude and medical and family histories table 9 demonstrated only association to family history of chronic heart disease. And there was an association between the total knowledge and total attitude as reflected from table 10.

[samehseef]

part 3

Discussion
This study aimed to identify people’s knowledge about coronary heart disease, their attitude towards prevention and main risk reduction barriers. In disagreement with the study prevalence findings for CHD and risk factors in participants, an American report in 2003 indicated that a high proportion of the US population had multiple risk factors for heart disease (11). Moreover, a study in Jordan reported that more than half of the sample had a family history of hypertension and diabetes mellitus (12). These figures are much higher than those within the present study. The differences between these studies might be due to the different prospective of each study, the targeted population, and the methods of data collection and interpretation.
In studying the knowledge of the studied sample, in the present study, about the risk factors related to CHD, smoking was the most recognized factor by the majority of the studied participants. Moreover, the great majority of them had positive attitudes towards smoking cessation as a preventive measure for CHD. This may be due to the increased preventive measures targeting smoking and spreading awareness among the population all over the country through all mass media also another explanation can be due to high female participants in the present study which are mostly non-smokers.
As regards to the knowledge about the modifiable risk factors of CHD among the present study participants, the studied factors were recognized by about half of the participants each of them and total knowledge scored to be satisfactory by the majority of the participants. Moreover, the data shows that the great majority of them had positive attitudes towards all preventive measures. However, the study also reported several barriers to prevention and achieving risk reduction. In this context, surveys of CHD prevention-related services such as smoking cessations advice, measurement and treatment of lipid disorders, and physical activity assessment and counselling are disappointing (13). We should also note that individuals expect a lot from the system, and less from their own selves’ which affect their actions and decisions and consequently their lives (14)
Knowledge about the disease presentation was correct among the great majority of the participants in the present study. This high awareness might be due to that chest pain, which is one of the most important symptoms in CHD, and the most feared symptom. The high level of awareness about this symptom is quite expected, and is line with the current trends that any patient with a recent onset of chest pain, especially when the symptoms are ongoing, should be transported immediately to the emergency (15).
Also in agreement with the present study findings, the data reported on the signs and symptoms of heart attack and stroke in New York State 2003 had demonstrated that recognition of symptoms ranged from 42% to 93 %. Chest pain or discomfort was the most often recognized symptom (93%) (16) Furthermore, and in accordance with this present study finding, data from the 2001 study of the CDC showed that 95% of respondents recognized chest pain as a heart attack symptom (17), compared to (88.8%) in the present study.
Although a good percentage of the studied participants, in the present study, recognized the disease presentation, only slightly more than half of them recognized the seriousness of the disease, whereas the majority of the participants recognized the importance of early treatment and control. This discrepancy might lead to the delay in time to treatment. It should be kept in mind that knowing the disease presentation is not the only factor that affects the time to treatment. Other factors also need to be considered (16).
Within this study, a satisfactory total knowledge level about CHD was revealed among four fifths of the participants. Moreover, the great majority of them had positive total attitude. These figures are higher than the corresponding ones in other studies. Surveys conducted by the AHA between 1997 and 2003 have shown that the awareness of heart disease ranges from 30% in 1997 to 46% in 2003. Excellent awareness was reported by less than half of the population (18).
As regards to attitudes towards CHD, in 1997, a telephone survey of 1000 US households found that only 8% of population respondents identified heart disease as their greatest health concern; less than one third identified heart disease as the leading cause of death (19). Another international survey revealed a considerable degree of indifference to coronary heart disease, despite the possession of a reasonable level of knowledge of the risks involved, even among patients who had suffered a myocardial infarction (20). These findings are in disagreement with the present study results where the attitude was much higher than the knowledge about CHD among participants.
According to the present study findings, the association between attitude towards prevention among participants and their personal and family histories revealed no association except from the association to the family history of coronary heart disease. This is in disagreement with the claim that patients who did not experience chest pain during the acute event had significantly different attitudes than those who did (21).
In the present study, it is evident that the total knowledge score was associated to marital status and educational level. Moreover, it was not associated to age, gender and income level. The latter which in contrast with 2003 results which emphasized that people from lower income and certain age groups appear to lag behind the rest in their recognition of these symptoms and should be considered for targeted health education efforts (16).
The findings are also in line with the results of a study done in two New England communities where knowledge was higher among more educated individuals (22). Similar findings were reported in three population-based cross-sectional surveys in two northern California cities were conducted between 1980 and 1990 (23), and in Pakistan (24). Differences or similarities between these studies might be due to the prospective of each study, the targeted population, and the methods of data collection and interpretation.
In the present study, the relation between participants’ attitude towards prevention and their socio-demographic characteristics pointed that there was no association between attitude and gender. As well as between age and total attitude, where there was no association. These findings are in contrast with the results of 2005 which had also suggested that educating women and interpreting the symptoms of CHD remain significant obstacles in reducing decision time (15). Also, older age, female sex, low education level, low socioeconomic status, and black race were reported to be associated with increased delays in seeking treatment as reported by Moser 2006 (25).
These discrepancies between the results of the previous studies and the current study might be explained by individual characteristics, social, psychological and cultural differences.
The data of the present study showed that there was an association between knowledge about CHD and attitude towards prevention among participants in the current study. This means that increased knowledge would lead to improved attitude. This is in line with the findings that has emphasized that interventions based on simple messages, for example knowledge about diseases presentations and dealing with it are still being recommended (26).
Lastly, self-reported information subjected to recall and social desirability biases (27), inability to examine neither the actual cardiovascular risk factors nor the actual control of the participants, besides unawareness of some of them about their risk factors (high cholesterol, diabetes, or high blood pressure .etc), and unequal access to the health care services due to any possible obstacles, are the most probably limitations of the current study.
Finally, this study only examined modifiable risk factors and did not include other established risk factors, e.g., age, gender and family history of coronary heart disease (9), (17).
Conclusion
It is concluded that the level of satisfactory knowledge about CHD and positive attitude towards prevention were higher than expected, but with no statistical significant related to gender or education. There were a high reported percentage of medical setting related barriers and patient related barriers that were preventing from achieving the risk reduction actions. Therefore, it is recommended to strength the role of physicians in development and application of health prevention and promotion programs towards CHD and engage patients and families into the risk reduction plans. Further in depth studies are needed for more accurate results and confirming the findings and cover the limitations of the quantitative studies, by using focus group discussions or interviews and using qualitative methods as well.

[Tdol]

A work of this length and specialisation should be submitted to a professional proofreader in this area- we are a language discussion forum and not a free proofreading service.