Study design and sample recruitment
A descriptive, cross-sectional study was conducted among adult Saudi women attending PCCs in a university hospital in Riyadh, Saudi Arabia, from January to June 2016. The sample size was calculated using the FluidSurveys© (2014) software (Sample Size Calculator, 2017), with a CI of 95% with an error margin of 0.05 . A non-random convenience sample of 503 women was selected from 600 women who attended the PCCs for a regular appointment and who qualified for the study. The questionnaire used sequential steps, starting with a survey, followed by physical measurements, biochemical measurements, and a CVD score calculation using FRS.
Data collection instrument and process
A survey was conducted utilizing face-to-face interviews using a structured questionnaire, and individual medical records were reviewed, after appropriate hospital permission was obtained.
The questionnaire consisted of 40 questions divided into 4 parts: socio-demographic profile; healthy behaviour; history of CVDs; and socio-cultural factors.
The socio-demographic information included age, level of education, marital status, occupation, income, and behavioral habits, including tobacco use, fruit and vegetable (FV) consumption and physical activity (PA).
Data extracted from each participant’s medical record included cardiovascular risk factor details and prescribed medication for blood pressure or cholesterol. A recent lipid profile was obtained and medical parameters such as blood pressure, height, weight, hip and waist ratio (WHR), body mass index (BMI)and HbA1c were gathered. The participants’ 10-year estimated risk was calculated based on the assumptions underlying the FRS .
Pictures were provided in the questionnaire, specifically in the FV question, to enrich the quality of the interviews by prompting the memory and reducing misunderstandings .
The Health Belief Related to CVD (HBCVD) Scale is a 25-item self-reported scale. Each item includes five response options (strongly agree, agree, neutral, disagree, and strongly disagree) to measure the perceptions of susceptibility, severity, benefits and barriers. Item-response-weighted scores indicate the following: 0=neutral, 1=strongly disagree, 2=disagree, 3=agree and 4=strongly agree; higher scores indicate a higher level of perception.
A cross-cultural translation and adaptation process was used to translate the HBCVD questionnaire into Arabic and underwent back-translation to ensure the accuracy of the translation .
Inclusion/exclusion criteria and ethical considerations:
The inclusion criteria were the following: (1) Saudi women, (2) aged 15 and above (3) attending the primary health care clinics (4) with regularly updated medical records (5) who expressed interest in participating in the study. Women with pre-existing CVD were excluded. Ethical approval was obtained from the Institutional Review Board (IRB) of the university hospital. The participants signed an informed consent form and agreed to participate in the study. All information taken from the subjects was coded and kept confidential.
Data management and statistical analysis
Descriptive and inferential statistical data analyses were conducted using SPSS, version 25. Missing data were transcribed or excluded from the analysis. The study results were checked for normality of distribution and were found to be a symmetrical bell-shaped curve. Skewness was within the range of ±2 and kurtosis within the range of ±7. The Chi-Square test was used for categorical data, and Pearson’s correlation and ANOVA were used for continuous data such as the mean of Framingham scores. A Pearson correlation test was run to gauge the association between the mean FRS and the four subscales of health beliefs . Descriptive statistics, one sample T-test, measures of central tendency, frequencies, and standard multiple regression were used for statistical analyses.
Cohorts were sub-divided according to their Framingham scores into three categories: low-risk (<10%), intermediate (10–20%) and high-risk (>20%) . Health beliefs about CVD were measured by 25 health belief questions divided into four subscales: perceived susceptibility (5 items), perceived severity (5 items), perceived benefits (6 items), and perceived barriers (9 items). The responses to the questions in the HBM subscales were combined into three groupings: Disagree (a combination of Strongly Disagree and Disagree), Neutral, and Agree (a combination of Agree and Strongly Agree) to determine the overall intensity of the pattern of responses. Perceived susceptibility measured participants’ beliefs about their susceptibility to CVD; the higher the score, the greater the tendency to see themselves as susceptible to CVD. Perceived severity measured participants’ beliefs about the seriousness of developing CVD; the higher the score, the greater the tendency to perceive CVD as serious. The perceived benefit scale measured participants’ beliefs about the benefits of healthy behaviours to prevent CVD; the higher the score, the greater the tendency to perceive benefits in preventing CVD. Perceived barriers measured participants’ beliefs about the barriers to health-promoting behaviours preventing CVD; the higher the score, the higher the barriers.
The results of this study need to be considered in light of various strengths and limitations. This quantitative study used a cross-sectional, descriptive and correlational survey design. Although it is difficult to derive causal relationships from cross-sectional analysis, it allows the research investigators to measure the outcome and the exposures in the study participants at the same time. In addition, it is an instrument that saves time and money and is useful for public health planning, monitoring and evaluation .
This study was conducted in only one of the primary care centres in the capital, and most of the participants were older than 45 years of age, which can limit the generalizability of the findings. The study sample was a non-randomized convenience sample, resulting in the risk of selection bias. The main limitation of the study is the recall bias that could have occurred, especially in measuring behaviours like FV consumption. Many responses depended on the participant’s memory. Nevertheless, responder bias can be unintentional due to poor or incomplete memory recall. Last but not least, this study is questionnaire based.