Knowledge, Attitudes, and Practices Among Elderly CHD Patients Towards Self-Perceived Health Abilities

Introduction

Coronary heart disease (CHD) is a prevalent cardiovascular disorder characterized by the stenosis or occlusion of coronary arteries, resulting in insufficient blood supply to the heart. In China, the age-standardized prevalence of CHD was estimated at 2.23%.¹ The prevalence of CHD exhibited an upward trend with advancing age, particularly among individuals aged 50 years and above.¹ CHD often leads to reduced physical capabilities, limitations in daily activities, and a compromised sense of well-being among elderly.¹ Besides, elderly patients with CHD usually experience reduced exercise tolerance, and increased vulnerability to physical exertion.² Moreover, CHD can contribute to heightened psychological stress, increased healthcare utilization and decreased productivity, thereby imposing heavy public health burden.³ Therefore, preventive measures, early diagnosis, and effective treatment of CHD were crucial among elderly patients.

Self-perceived health abilities refer to an individual’s assessment of their own health status and their confidence in managing health-related tasks and challenges.⁴ This concept encompasses various aspects, including self-efficacy, perceived control over one’s health, and the ability to perform health-promoting behaviors. Specifically, in the prevention stage of CHD, self-perceived abilities involve maintaining a balanced diet, engaging in regular physical activity, and consistently monitoring blood pressure and cholesterol levels.^5–7 Following a CHD diagnosis, the abilities encompass adherence to routine health check-ups, medications (such as statins, antiplatelet agents, and beta-blockers), and participation in cardiac rehabilitation.^8,9 Additionally, awareness of self-perceived health abilities is essential for prompt healthcare seeking, and a lack of knowledge can impede treatment.¹⁰ Moreover, positive attitudes toward self-perceived health ability can significantly enhance adherence to regular follow-up appointments and bolster confidence in medical interventions.¹¹ However, knowledge, attitudes, and practices (KAP) regarding elderly CHD patients’ self-perceived health abilities were largely unknown.

This study aimed to explore the KAP among elderly CHD patients towards their self-perceived health abilities, and further identify influential factors. By elucidating these relationships, the findings of this research could contribute to the development of educational interventions aimed at enhancing the KAP among elderly CHD patients towards self-perceived health abilities.

Materials and Methods

Study Design and Participants

This cross-dimensional survey was conducted between April 2023 and September 2023 at Guang’anmen Hospital, China Academy of Chinese Medical Sciences. The study was approved by the Ethics Committee of Guang’anmen Hospital, China Academy of Chinese Medical Sciences (Approval No. 2022-KY-260) and informed consent was obtained from the study participants.

The inclusion criteria for this study were as follows: 1) aged 60 years or older. 2) diagnosed with CHD. 3) willing to sign an informed consent form, indicating voluntary participation in the study. Those who are currently undergoing inpatient treatment or residing in long-term care facilities are excluded from this study.

Questionnaire Design

The questionnaire was crafted under the guidance of the 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease¹² and pertinent literature on CHD.^13–15 The initial draft underwent revisions based on feedback from 3 senior experts specializing in cardiovascular disease and geriatrics. both holding the title of chief physician Subsequently, a preliminary trial was then conducted on a limited scale (n=34), resulting in a Cronbach’s alpha value of 0.887, indicating good internal consistency.

The final questionnaire was presented in Chinese and comprised four dimensions: demographics, knowledge, attitudes, and practices. The demographics dimension comprised 10 items. The knowledge dimension comprised 9 items, with 1 point for a correct answer and 0 points otherwise. The total knowledge dimension score ranged from 0 to 9. The attitude dimension consisted of 9 items, rated on a five-point Likert scale from “strongly agree” (5 points) to “strongly disagree” (1 point), with possible score ranged from 9 to 45. The practice dimension included 9 items, rated on a five-point Likert scale from “always” (5 points) to “never” (1 point). The total practice dimension score ranged from 9 to 45.

Data collection was conducted through online questionnaire on Sojump (http://www.sojump.com), and distributed across diverse social media platforms. Upon initiating the e-questionnaire, participants were required to indicate their consent before proceeding to answer questions. All the questions were mandatory for submission. Anonymity was maintained throughout data collection. To prevent duplicate submissions from a single IP address and ensure survey integrity, IP restriction was implemented.

Statistical Methods

STATA 17.0 (Stata Corporation, College Station, TX, USA) was used for statistical analysis. The continuous variables were expressed as mean±SD, and the categorical variables was expressed as n (%). The continuous variables conformed to a normal distribution were tested by the t-test or ANOVA. In multivariate analysis, 50% of the total score was used as the cut-off value. The structural equation model (SEM) of knowledge, attitudes and practices among elderly CHD patients toward self-perceived health abilities was constructed with AMOS 24.0 (IBM, NY, United States). The hypotheses as following: 1) knowledge had direct effects on attitudes, 2) knowledge had direct effects on practices, and 3) attitudes had direct effects on practices. The model fitting was evaluated with CMIN/DF (Chi-square fit statistics/degree of freedom), RMSEA (root mean square error of approximation), IFI (incremental fix index), TLI (Tucker-Lewis index) and CFI (comparative fix index). In this analysis, P<0.05 was considered statistically significant.

Results

A total of 679 questionnaires were initially collected. However, 21 of these exhibited apparent logical inconsistencies and were subsequently discarded. Furthermore, 90 responses were excluded due to the participants indicating “not sure” for all items within the knowledge dimension. As a result, a final count of 568 valid questionnaires was retained for further analysis.

The mean age of participants was 65.97±5.50 years. A considerable proportion of participants were female (52.46%), with a body mass index (BMI) within 18.5–23.9 kg/m² (51.41%), residing in urban areas (56.87%), and married (85.74%). Notably, 51.06% had Grade II heart function, and the majority (86.27%) had not undergone interventional therapy. Furthermore, 81.69% of participants took 2 or fewer coronary heart disease-related medications (Table 1). More than half (54.40%) of participants had comorbid hypertension, followed by hyperlipidemia (29.75%), diabetes (18.31%), and other conditions (13.03%) (Figure S1).

Table 1 Demographic Characteristics and KAP Scores

The mean scores for knowledge, attitudes, and practices were 6.34±2.29 (possible range: 0–9), 35.24±4.99 (possible range: 9–45), and 27.79±10.09 (possible range: 9–45), respectively. Notably, urban residents exhibited higher scores (P<0.001). Higher attitude scores were observed among urban residents (P=0.019), individuals with Grade I heart function (P=0.007), and those prescribed 3–4 coronary heart disease-related medications (P=0.014). Additionally, higher practice scores were observed among male participants (P=0.039), individuals with Grade I heart function (P=0.035), those with a history of interventional therapy (P=0.014), and those taking 3–4 coronary heart disease-related medications (P=0.003) (Table 1).

The correct rate in the knowledge dimension ranged from 28.35% to 83.10%. The three knowledge items with the highest correctness rates were as follows: “Patients with higher self-perceived health ability tend to adopt more positive coping strategies” (K6) with a correctness rate of 83.10%, “Generally, the stronger the belief in the curability of the disease among patients, the higher their self-perceived health ability” (K8) with a correctness rate of 79.58%,

Lack of energy or a lack of knowledge about the disease will make it difficult for patients to engage in disease control and negatively impact their self-perceived health ability (K7)

with a correctness rate of 79.05%. The three items with the lowest correctness rates were:

The probability of developing coronary heart disease is the same for individuals with risk factors such as hypertension, hyperlipidemia, diabetes, hyperuricemia, obesity, smoking, alcohol consumption, psychological factors like anxiety, depression, stress, or a lack of physical activity as for those without these issues (K3)

with a correctness rate of 28.35%,

Self-perceived health ability is typically assessed using a Health Competence Perception Scale, which consists of 8 items and is divided into two dimensions: behavioral expectations and outcome expectations. Higher scores indicate higher self-perceived health ability (K9)

with a correctness rate of 68.13%,

Commonly used medications for treating coronary heart disease include aspirin and/or clopidogrel bisulfate, statins, metoprolol succinate, metoprolol tartrate, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, calcium channel blockers, nitrates, and traditional Chinese medicines like Compound Salvia Droplets, Quick-Acting Cardiovascular Pills, and Musk Cardiac Bolus (K4)

with a correctness rate of 70.25% (Table 2).

Table 2 Knowledge

In the attitudes dimension, positive response rates, encompassing both “Strongly Agree” and “Agree”, varied from 44.37% to 84.33%. A significant majority (84.33%) of participants exhibited positive attitudes towards seeking advice from their attending physician towards their self-perceived health ability (A3). Similarly, most participants (82.75%) agreed that they were willing to adjust their mindset and lifestyle habits based on the results of their self-perceived health ability to improve their condition (A9). In contrast, only 44.37% concurred with the notion that, due to feeling physically and mentally exhausted from coronary heart disease, they were unwilling to further focus on their own health (A5) (Table 3).

Table 3 Attitudes

Practice adherence rates, covering both “Always” and “Often”, ranged from 32.75% to 45.95%. The majority (45.95%) of participants affirmed actively acquiring knowledge related to CHD and self-perceived health ability through various channels such as books, the internet, newspapers, and more (P1). However, only 32.75% of participants actively participated in filling out the self-perceived health ability assessment scale (P4) (Table 4).

Table 4 Practices

Pearson correlation analysis revealed significantly positive correlations between knowledge and practice (r=0.215, P<0.001), as well as attitude and practice (r=0.396, P<0.001) (Table 5). In the multivariate logistic analysis, age (OR=1.043, 95% CI: 1.010–1.079, P=0.012) and urban residence (OR=1.463, 95% CI: 1.040–2.058, P=0.029) were independently associated with knowledge (Table 6). Knowledge (OR=1.392, 95% CI: 1.280–1.520, P<0.001) and heart function classification of Grade II were independently associated with attitudes (OR=0.526, 95% CI: 0.355–0.774, P=0.001) (Table 7). Furthermore, attitudes (OR=1.133, 95% CI: 1.085–1.185, P<0.001), education level of college and above (OR=1.574, 95% CI: 1.008–2.470, P=0.047), and a history of interventional therapy (OR=2.197, 95% CI: 1.223–4.073, P=0.010) were independently associated with practices. However, obesity (OR=0.425, 95% CI: 0.181–0.978, P=0.046) and taking 5 or more CHD-related medications (OR=0.325, 95% CI: 0.115–0.842, P=0.025) displayed negative associations with practice scores (Table 8).

Table 5 Pearson Correlation Analysis

Table 6 Univariate and Multivariate Analysis of Knowledge

Table 7 Univariate and Multivariate Analysis of Attitudes

Table 8 Univariate and Multivariate Analysis of Practices

The fitting index of the structural equation model (SEM) outperformed the respective threshold value, signifying that the data satisfactorily fit the structural model (RMSEA=0.000, SRMR=0.012, TLI=1.028, CFI=1.000) (Table 9). Elderly CHD patients’ knowledge directly affects attitudes and practices, with path coefficient of 0.93 (P<0.001) and 0.39 (P=0.033), respectively. Moreover, attitudes play an intermediary role between knowledge and practices with path coefficient of 0.75 (P<0.001). Furthermore, residence directly affects knowledge with path coefficient of 0.67 (P<0.001), cardiac function directly affects knowledge with path coefficient of −0.97 (P<0.001) and history of interventional therapy directly affects practice with path coefficient of 4.23 (P<0.001) (Table 10 and Figure 1).

Table 9 Model Fitness Indices for the KAP Structural Equation Model

Table 10 The Estimates of Structural Equation Model

Figure 1 Structural equation model.

Discussion

Elderly CHD patients possessed sufficient knowledge, positive attitudes, and proactive practices towards self-perceived health abilities. Moreover, positive relationships were identified among their KAP scores. These results provided significant insights into targeted educational interventions to improve the KAP levels of CHD patients towards self-perceived health abilities.

Consistent with our findings, cardiovascular disease patients in Iran had high levels of knowledge and positive attitudes towards the condition.¹⁶ Similarly, another Indian study revealed satisfying KAP scores among ischemic heart disease patients towards their medications.¹⁷ This suggests that patients with cardiovascular conditions across different regions possess adequate knowledge, maintain positive attitudes, and engage in proactive practices related to their health management. Therefore, CHD education through community programs and doctor-patient communication can be warranted to maintain and promote the KAP scores among the affected elderly.

In the knowledge dimension, the majority (83.10%) agreed that individuals with higher self-perceived health ability are inclined to adopt positive coping strategies. This indicated a prevailing awareness of the psychological impacts of self-perceived health. The result aligned with previous assumption that self-perceived health ability played a role in managing chronic conditions like CHD.^18,19 On the contrary, the low concurrence rate (28.35%) regarding the likelihood of CHD among individuals with risk factors such as hypertension²⁰ and psychological stress²¹ raised concerns about the participants’ awareness of the multifactorial nature of CHD. Consistent with the Ethiopian study, 46% of patients with cardiovascular conditions exhibited inadequate knowledge concerning cardiovascular risk factors.²² Patient education should focus on raising awareness about the interplay of different risk factors, the importance of comprehensive risk assessment, and the potential benefits of preventive measures such as lifestyle modifications, medication adherence, and regular health screenings. Moreover, 68.13% of participants concurred that self-perceived health ability is typically assessed using a Health Competence Perception Scale. This suggested the recognition of subjective health assessment among elderly CHD patients. Prior research has explored the significance of subjective questionnaires in capturing the psychosocial dimensions, including cardiovascular conditions.²³

The positive attitude expressed by a majority (84.33%) towards seeking advice from attending physicians regarding self-perceived health abilities underscored the perceived importance of medical guidance in managing one’s health. This positive inclination aligned with the established role of healthcare professionals in providing essential information, guidance, and support for individuals with CHD.^24,25 Similarly, 82.75% of participants with the willingness to adjust mindset and lifestyle habits based on their self-perceived health ability indicated a proactive viewpoint towards health management. Aligned with studies highlighting the patient engagement in self-management behaviors, the finding could inform tailored interventions according to patients’ intrinsic motivations.²⁶ However, 44.37% of participants were unwilling to focus on their health due to physical and mental exhaustion from CHD. Previous researches across various chronic illnesses have highlighted the disease burden as barriers in health management.^27,28 Therefore, targeted interventions are warranted to address the multifaceted challenges faced by CHD participants.

In the practice dimension, 45.95% of participants expressed their enthusiasm to obtain knowledge related to CHD and self-perceived health ability through various channels, which underscored the significance of information-seeking behaviors. This aligned with the principles of patient empowerment and health literacy, emphasizing the importance of actively seeking health-related information to make informed decisions about their well-being.^29,30 Conversely, the lower percentage (32.75%) of participants actively participating in filling out the self-perceived health ability assessment scale raised considerations about the willingness in structured self-assessments. Several factors might contribute to this discrepancy, including perceived time constraints, discomfort with self-assessment tools, or a potential lack of awareness regarding the benefits of such assessments.³¹

The positive relationships of KAP scores towards self-perceived health abilities among CHD patients were in accordance with health behavior theories.³² Essentially, individuals possessing knowledge of self-perceived health abilities are inclined to harbor positive attitudes, subsequently translating into proactive practices for the prevention and management of the condition. Influential factors of KAP scores were further identified. Firstly, the positive associations of age and urban residence with knowledge scores were observed. Older individuals might accumulate knowledge through increased exposure to health information or experiences with the healthcare system.³³ Urban residents, with potentially greater access to healthcare resources and information, might also exhibit higher knowledge scores.³⁴ Secondly, the negative association between Grade II heart function and attitude scores suggested that individuals with more severe cardiac impairment could harbor negative attitudes. This finding highlighted the psychological and emotional burdens of advanced heart disease on CHD patients.³⁵ Thirdly, higher education levels and interventional therapy were positively associated with practice scores. Individuals with higher education levels could possess enhanced health literacy, enabling them to engage more actively in health-promoting behaviors.³⁶ Similarly, those with interventional therapy might adhere to practices for better health outcomes. Fourthly, the negative associations of obesity and taking ≥5 CHD-related medications with practice scores indicated barriers to adopting health practices. Obesity could be related to challenges in maintaining a healthy lifestyle. Besides, a higher medication burden might pose challenges in adherence to recommended practices due to complex treatment regimens.

Several limitations should be acknowledged. Firstly, the cross-dimensional design posed challenges in establishing causality, and the limited sample size impacted the generalizability of our findings. Secondly, self-reported data could cause social desirability bias, potentially inflating scores.³⁷

Conclusion

Sufficient knowledge, positive attitudes, and proactive practices towards self-perceived health abilities were determined among elderly CHD patients. Knowledge is positively associated with attitudes and practices, wherein attitudes play a mediating role. This finding suggests that guiding knowledge and attitudes can foster practices in self-perceived health abilities. Although the KAP scores were generally high in the study population, the research identified certain deficiencies. Educational interventions should be initiated to emphasize the risk factors of CHD, address physical and mental exhaustion and improve participation in self-assessment. Caution should be paid to elderly with lower ages and education levels, those residing in rural areas, those without interventional therapy, those experiencing obesity, and those taking a higher number of CHD medications.