The eligibility criteria were: female sex, age 45 to 60 years, with one or more CV risk factors [overweight or obesity, i. e. body mass index (BMI) ≥ 25 kg/m2, and/or central obesity – waist circumference ≥ 88 cm, high blood pressure (systolic blood pressure ≥ 140 mm Hg and/or diastolic blood pressure ≥ 90 mm Hg), high blood cholesterol (≥ 5.2 mmol/L) and active smoking]. The participants on antihypertensive therapy were also included in the study.
All eligible participants were followed for 3 months after the educational intervention, and qualitative data we collected at 6 months.
The study participants first completed the Pre-study questionnaire (Questionnaire 1), which included: a) demographic data (Supplement 1), b) attitudes and knowledge questionnaire about CV risk factors (17) (Supplement 1), c) decisional conflict scale (DCS) (12, 18), d) integrative hope scale (IHS) (13, 19), and e) eating habits questionnaire (EPAT) (20).
Attitudes and knowledge questionnaire about CV risk factors was created according to the model of “Ottawa Decision Support Tutorial” (17).
The DCS consist of 16 items rated in a 5-point Likert-type response format, and measures individual's uncertainty toward a course of action. There are five subscales: uncertainty, informed, values clarity, support and effective decision. The scores on the total scale and subscales are calculated as a sum of items, divided by the number of items and multiplied by 25, allowing for a score range from zero (no decisional conflict) to 100 points (extreme decisional conflict) (12). The Croatian version of the scale was previously validated (18).
The IHS is 23-items scale, a self-rating instrument with items being rated on a six‐point Likert scale from 1, strongly disagree, to 6, strongly agree. It provides an overall score and four dimension scores, obtained by summing up the individual item scores, with negative items being rated inversely. This produces possible overall hope scores ranging from 23 to 138 with higher scores representing higher hopefulness. The scores for the sub‐dimensions vary according to the number of items (13). The Croatian version of the scale was previously validated (19). Hope to be healthy at 70 and hope to reduce CV risk was assessed by a visual analogue scale from 0 to 100.
EPAT is a simple, quick, self-administered tool using an easy scoring method for accurately assessing fat and cholesterol intake. It is a reliable and valid substitute for more time-consuming food records. EPAT also provides an efficient way to monitor eating patterns of patients over time and is arranged to provide an educational message that reinforces the consumption of recommended types and numbers of servings of low-fat foods (20). The questionnaire was translated into Croatian by the authors and then back translated by an independent language expert to confirm the translation validity.
Ten-year risk of fatal CVD was estimated using the ACC/AHA (American College of Cardiology/American Heart Association) guidelines (21), based on the following data collected from the study participants: age, gender, race, total and HDL (high-density lipoprotein) cholesterol, systolic blood pressure, data about antihypertensive therapy, diabetes mellitus and smoking status.
Immediately after the lecture, the participants filled the Post-lecture questionnaire (Questionnaire 2), which included: a) attitudes and knowledge about CV risk factors (17) (Supplement 2), b) decisional conflict scale (DCS) (12, 18) and c) integrative hope scale (IHS) (13, 19).
Three months after the lecture, the participants filled in the last questionnaire (Questionnaire 3), which included: a) attitudes and knowledge about CV risk factors (17) (Supplement 3), b) decisional conflict scale (DCS) (12, 18), c) integrative hope scale (HIS) (13, 19) and d) eating habits questionnaire (EPAT) (20). Ten-year risk of fatal CVD was also calculated at this time point.
BMI, waist and hip circumference, systolic and diastolic blood pressure, blood cholesterol, triglycerides, physical activity and smoking status were measured at each of three time points.
Thematic analysis of answers from post-intervention survey
Six months after the intervention, we contacted the participants for the final assessment, along with their feedback on the intervention in general and their personal opinions on further improvements in their lifestyle. This feedback was in the form of post-intervention survey conducted by the authors. The survey included 13 structured questions and 4 open-ended questions (Supplement 4).
We preformed the thematic analysis of the answers, grouping them into theme categories. Categorization of the answers was made by the two independent assessors. After determining the categories, each answer was marked s 1 if matching to specific category or as 0 if not. Answers were used as predictors in further analysis.
After the study, we grouped the participants into those who reduced the CV risk and those that did not. We used logistic regression for all parameter we measured to identify factors contributing to the reduction in CV risk.