Patient’S Knowledge of Cardiovascular Diseases Risk Factors and Associated Factors Among Adult Cardiac Patients in Selected Health Institutions; A Cross Sectional Study, Addis Ababa, Ethiopia 2021 G.C.

cardiovascular related disorders are a major public health challenge in globally as well as in Ethiopia. It is crucial to improve the life style of the community at the same time it is a key for health care policy to give emphasis for prevention by educating the community by different ways. Therefore, the current study patient’s knowledge about risk factors related to those diseases. A facility-based descriptive cross-sectional study design was conducted. 420 Participants selected by systematic random sampling technique from April 01, 2021 until Jun 28, 2021 and met the criteria were included. Data was collected by interviewer-administered questionnaire. Level of knowledge was assessed by the Heart Disease Fact Questions. Bivariate and multivariate logistic regression was done to identify factors associated with identied class of knowledge. P-value less than 0.05 was considered as to indicate statistical signicances.


Conclusion
The majority of participants had su cient knowledge regarding cardiovascular diseases risk factors. Maintaining good status, implementation of innovative interventions and structured, nurse-led lifestyle counseling would be required to effectively guide patients. Background Globally ,442.7million cases of cardiovascular Diseases(CVDs) were reported in 2015 including 17.9million cases of deaths from those diseases (1).This burden seems to get even worsen in developing countries as awareness of those disease among the population is limited (2).Among CVDs, increasing blood pressure, hypertension is considered as the mainly observed one (3).
Hypertension was diagnosed among 1.3billion people worldwide (4)in which 33% of adults were found to have this condition globally (5).This proportion of adults projected to get increased by 60% ,in 2025(6).In Sub-Saharan countries 125.5million individuals were estimated to get diagnosed with hypertension by the same year (7).
Ethiopia, were transition is being made from infectious disease to those non infection disease (8)this burden of CVDs are not found to have some mercy. Prevalence of hypertension among those population was reported to be 19.6% (9)which was highly documented among urban population, even though ischemic heart disease was reported to be leading cause of death among CVDs (12).
Scarcity of research regarding knowledge of patients about CVDs risk factors in developing countries has been mentioned (9).In Nigeria poor knowledge of patients about risk factors was observed (10) which was reported to get more worse in Cameroon (11).And also residency area and educational status were reported to associate with the health literacy of those patients (12,13).
Although knowledge of cardiovascular risk factors reported to be a back bone in the prevention of those diseases (14); researches to give input are scarce in developing countries, including Ethiopia. Therefore, this study will assess knowledge of CV risk factors among CVDs patients and its associated factors in two Hospitals which represents the country at whole.

Methods And Materials
Study Design, and setting Cross sectional study design was conducted at Tikur Anbessa Specialized Hospital (TASH) and St, Paul Referral Hospital (SPHMMC), Addis Ababa, Ethiopia. In Addis Ababa there are 12 governmental hospitals, from which 2 of them were selected for the study by lottery method. The selected hospitals are TASH and SPHMMC.420 participants were selected as they were presented at the center from April to June 2021.

Sample size determination and sampling technique
The sample size was calculated using a single-population proportion formula with 95% con dence intervals (CIs), a 5% margin of error, and 54% proportion of level of depression based on study done in Eastern part of the country(8). With 10% of non-response rate the nal total sample size was calculated to be 420.Participants who found to be meeting the criteria was selected until the required sample size was met. By using the formula for proportional allocation, i.e., n h = (Nh / N) * n ;280 patients from Tikur Anbessa Specialized Hospital (TASH), and 140 patients from St Paulo's Hospital were included in the study. A systematic random sampling method was employed to select a study participant.
To select the study participants, the total sample size was allocated proportionally based on the number of patients from each selected hospital. Again, proportional allocation was implemented for each selected hospital. Finally, from each hospital, patients were selected using simple random sampling with replacement method to attain the nal participants.

Data collection
The data extraction tool was developed from validated tool, the Heart Disease Fact Questions (HDFQs) (15) and international physical activity questionnaires. the HDFQ and international physical activity questionaries were translated into Amharic and were back translated into English by language experts to check reliability of the translations. Questionaries about sociodemographic status (age, sex, residency area, marital status, occupational status, educational status) of the participants were developed after rigorous literature review and were adopted to our context. Four clinical nurses were recruited as data collectors by principal investigator (PI). Those data collectors were well trained about the objective of the study. The PI monitored the data quality and supervise overall process.

Measurements
Respondents were asked 29 knowledge-based questions to assess their knowledge toward CVD Risk factors and they were categorized in to two groups based on their score (Su cient knowledge and Insu cient knowledge). Total cumulative knowledge level was determined out of 29 and mean level of knowledge was determined to be 19.9. Hence mean and above (i.e, >=20) is considered "Su cient knowledge" while the rest was considered "Insu cient knowledge".

Data analysis
The collected data were checked daily for completeness and rechecked again by the principal investigator before data entry. Data were entered into EpiData 3.1 (EpiData Association, Odense, Denmark), and transferred to SPSS version 25.0 (IBM Corp., Armonk, NY, USA) for farther analysis. The entered data were explored for errors and missing values were checked before analysis.
Descriptive statistics were used to summarize the data in both tables and graphs. In order to identify associated factors, bivariate logistic regression analysis was done for each independent variable and signi cant variables were included in the nal multiple logistic regression model. Standard coe cients with 95%CI were presented using tables.

Socio-Demographic Characteristics of participants
The response rate was 100%.255 (60.7%) of participants were females. The mean age was 48.7 (SD=13.05). The minimum total of study participants 374 (89%) were urban residents. 240 (57.1%) participants were married and most participants 125 (29.7%) acquire tertiary level of education. Majority 131 (31.2%) of the study participants are enrolled in private sector. (Table1). Knowledge of cardiovascular risk factors 90.5% of the participants did know that obesity (over-weight) increases the risk for heart diseases while only 44% of participants did know that family history of heart disease is risk factor for developing one( Table 2). Findings of this study revealed that the majority of patients who participated in this study had su cient knowledge score, 300 (71.4%) (Figure 1).  This discrepancy might be due to lack of health awareness trainings on area of CVD which is a routine procedure among CVD patients in our study setting, socio-demographic differences, study time gap and study setting difference.
Studies from Africa reported mean knowledge of patients towards CVD risk factors to be 32.1%, 49.4% while a systematic review from Sub Saharan Africa revealed a mean knowledge level ranging from 4.4%-68.1% (13,19,20)which are signi cantly lower than our study. These differences can be due to different measurement tools, difference in socioeconomic background, lack of awareness creation events, poor patient counseling, lack of effective communication with physicians and absence of independent CVD units equipped to deal with sustainable Cardiovascular patient care in the former studies.
Studies from Eastern and Northern Ethiopia reported mean Knowledge of 54% and 32.2% respectively(8, 21). The observed difference could be due to the fact that our participants are largely urban dwellers located in the capital city compared with the formers.
Our rates of CVD risk factors literacy echoes ndings of previous studies from Tanzania (22), South Africa (23), and Iran (24) where ndings were 80%, 75% and 78.7% respectively. This observed similarity in literacy rates could be explained by the education-level similarities among study participants and similarity of tools used for knowledge assessment, similarity of study setting Among individual risk factors related knowledge observed from literatures, smoking (17,23,25) mentioned to constitute 36.2-93.2% of participants, alcohol intake in excess explained by 40.7%(26) and by 65% (27) (17,25,27) while hypertension (17,25,27) was explained by 6.2-94%.In addition, diabetes (17,23,27)  bene ts and potential risk of the study. Con dentiality and anonymity of the participants was kept private.

Consent for publication
Not applicable.
Availability of data and material The dataset used for the study is not publicly available in order to maintain data security but is available from corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests Funding This study is supported by Department of Nursing and Midwifery, College of Health Sciences, Addis Ababa University. The funding body didn't get involved in the design of the study and collection, analysis and interpretation of data and in writing the manuscript.
Authors' Contribution BD, YT, KB and SW worked in the conception and design of the study. BD collected, analyzed interpreted the data. SW drafted the manuscript. YT and KB monitored and evaluated the data. YT, KB and SW critically revised and edited the manuscript. All authors read and approved the manuscript.