Risk Perception of Cardiovascular Disease Among Saudi Women

Introduction

Cardiovascular diseases (CVDs) are non-communicable blood vessel, vascular, brain, and heart diseases (Shara, 2010). According to World Health Organization (WHO) (2012), in a year it is estimated that cardiovascular diseases cause over 17.4 million deaths, which translates to thirty percent of all deaths caused by non-communicable diseases. By the year 2030, cardiovascular disease will kill more than 23 million people annually (World Health Organization, 2015).CVDs are the number one cause of morbidity across the globe in the category of non-communicable diseases (WHO, 2012). The incidence of CVD among women has been increasing (WHO, 2012). According to Crocco, Pervez and Katz (2009), since 1984, more women than men have succumbed to CVD. The following research will focus on risk perception of cardiovascular diseases among Saudi women in relation to home cooking and intentions to consume to prepare a low-fat diet. The predominant causes of CVD are obesity, diabetes, smoking, hypertension, inadequate physical exercise, hypercholesterolemia, and intake of food above the recommended nutrient intake (Khatib, 2004). Many of these causes are prevalent among Saudi Arabian women.

Saudi Arabia has experienced significant economic growth fueled by earnings from oil (Hawazen, Patsy, & Robyn, 2012). The economic growth has, therefore, led to nutrition and epidemiological transition. Standards of living have increasingly changed and ushered in a more sedentary life. Saudi Arabians consequently have adopted energy-dense foods and urban lifestyles. The energy-dense foods contain a large number of calories per serving such as foods rich in fat (Escamilla et al., 2012). This lifestyle has resulted in increased non-communicable disease transmission as well as increased morbidity and mortality caused by CVD.

Non-communicable diseases are estimated to account for 78% of total deaths in the Saudi population (World Health Organization, 2014).CVD accounts for 46% of non-communicable disease deaths(World Health Organization, 2014). A study conducted by Brunner, Rees, Ward, Burke and Thorogood (2007), in South Eastern Saudi Arabia, found that CVD accounted for 26% of total deaths.

Socio-economic and environmental changes contribute to increased morbidity and mortality of cardiovascular diseases. With the changing lifestyle, the prevalence of overweight and obesity was high among males and females in Saudi Arabia (Albassam, Gawwad & Khanam & Costarelli, 2008). According to Albassam, Gawwad and Khanam & Costarelli (2008), Saudi women of childbearing age, frequently become overweight and obese due to their diets and reduced physical exercise. To reduce the morbidity resulting from CVD, it is prudent to educate people about the harm caused by lifestyle choices and dietary practices.

Dietary intake comprises different components that can increase or reduce the risk of cardiovascular disease. Most cardiovascular disease researchers in Saudi Arabia have focused on dietary and physical activity interventions. The researchers have not explored behavioral change based on perception as an integral factor in influencing dietary habits. This study will present an in-depth understanding of perceptions of cardiovascular disease among Saudi women. It is worth noting that women play a critical role in the nutrition of Saudi families. In addition, the prevalence of CVD in Saudi is higher than that of men. According to Al-Dkheel (2012) the type of diet, the cooking methods applied, and quantity can be used to determine whether individuals have adopted healthy eating lifestyles. Thus, perception of risk of cardiovascular disease and intentions to cook low-fat diets are critical to primary prevention.

Significance of the Study

The continuous rise in cardiovascular disease around the world necessitates health professionals to pay more attention to this lifestyle-related issue (Bovet & Paccaud, 2011). CVD continues to be the leading cause of death in the world (Kelly, Narula, &Fuster, 2012; Rohleder, 2012). It has reached overwhelming proportions in many countries around the world and Saudi Arabia is no exception. CVD has increased through the last decade in Saudi Arabia (Gaziano, Bitton, Anand, Abrahams-Gessel, & Murphy, 2010). Saudi Arabia has been identified as one place in the world where cardiovascular disease is at significantly high rates, especially those that result from high fat levels of foods (Ibrahim et al., 2014).CVD is a leading cause of death and morbidity in the Saudi population with a high prevalence rate among Saudi women (World Health Organization, 2014). In fact, cardiovascular disease is a prominent cause of mortality among women throughout the world, which has led the American Heart Association (AHA) to promote guidelines that specifically meet the needs of women (Berra, Fletcher, Hayman & Miller, 2013).

Women in the Middle East, specifically in Saudi Arabia, are the most affected (Ibrahim et al., 2014). Previous literature has indicated various reasons why women in Saudi Arabia and other parts of the world are increasingly contracting cardiovascular diseases related to unhealthy eating and activity behaviors (Shara, 2010). Due to increased standards of living in Saudi Arabia lifestyle changes are evident in Saudi Arabia where many women have access to private chauffeured drivers, televisions, and housemaids (Rawas, Yates, Windsor, & Clark, 2012). This manner of living has increased sedentary behavior, causing many women to become obese, and as a result, has increased the rate of cardiovascular disease in the country among women (Nanita, 2012). Further, As a result of the global adoption of new technology and convenient eating habits, many women in Saudi Arabia now consume more fats, refined carbohydrates, and sugars than in the past (Al-Farwan, 2011; Ibrahim et al., 2014).

Even though cardiovascular disease morbidity and mortality are increasing among Saudi women, understanding and awareness of the disease are low (Shara, 2010). This lack of knowledge combined with lack of a proper exercise regimen not only puts the women of Saudi Arabia at risk, but also increases the susceptibility of cardiovascular disease amongst their families. These disturbing facts and statistics regarding the cardiovascular health of Saudi women justify the need for the implementation of effective initiatives to prevent cardiovascular disease among these women. Identifying and understanding the magnitude of risk factors contributing to cardiovascular disease, including high fat intake is an important aspect of creating targeted interventions for this particular population.

My study is based on Health Belief Model (HBM) construct that is applied in study of the risk perceptions. HBM explains and predicts behaviors that relate to health. The prediction of the behavior relates to the uptake of health services such as healthy dietary practices. HBM predicts that motivation, skill, and the presence of an enabling environment lead to behavioral change (Al Baghli, Al Ghamdi, Ahmad & Mohamood, 2010). Also, my study is based on Precaution Adoption Process Model (PAPM) to examine the readiness of participants to follow low fat diet preparation. PAPM describes the various stages that lead to behavioral change and provides tailors messages for the stages (Weinstein & Sandman, 2002).

The awareness of risk factors for cardiovascular disease is a crucial step in the implementation of preventive care programs (Khatib, 2004). There are no current data available on the prevalence of cardiovascular diseases in Saudi Arabia itself. However, smaller studies and data from health facilities point to a trend of increased CVD in urbanized towns. The trend of increased CVD has been made worse by the new roles of women in employment and socio-economic factors that have resulted to sedentary lifestyle and high carbohydrate diets (Bener et al., 2004). Research on the perception of risk factors of cardiovascular disease will enrich the existing research on cardiovascular diseases in Saudi Arabia. The findings of the research will be crucial in developing interventions to educate Saudi women on the prevention measures that relate to food preparation. In addition, the findings will help the Saudi women rediscover the importance the traditional foods and practices. The research will play an important role in providing a research-based framework for lowering risks for CVD based on the identified perceptions.

Women are responsible for the wellbeing of the family in the traditional setting of Saudi Arabian society. In Saudi Arabia’s religious and traditional setting, it is the mandate of women to plan and cook meals (Brunner et al, 2007). Many women are employed and their busy schedules make it difficult to meet the societal demands due to these changing environments (Mobaraki & Soderfeldt, 2007). The rapid economic growth resulted in increased purchasing power of many Saudi families, increased food supplies and varied meal patterns associated with a lifestyle of affluence. Al-Alwan, Badri, Al-Ghamdi, Aljarbouand Tamin (2013) noted that the per capita intake of calories increased from 1801 kcal in 1971 to a high of 3015 kcal in 2004. Fat intake also increased from 34-76.1 grams in a day.

The role played by women in ensuring that they prepare and cook food for the family, their perception towards risk factors associated with cardiovascular diseases and their intentions to provide a lower fat diet could be a crucial turning point for the cardiovascular health of these women and their families. The study will have great implications for the Saudi Arabia’s Directorate of Nutrition in developing an intervention that targets behavioral changes.

Rationale

The primary goal of this study is to examine the risk perception of cardiovascular disease among Saudi women. Perception of a given phenomena is usually hinged on the knowledge acquired and the expected outcome (Brunner et al., 2007). The implication of perception is that it acts as the determinant of the level of exposure towards a given phenomena (Vanhecke, Miller, Franklin, Weber & McCullough, 2006). In Saudi Arabia, both CVD morbidity and mortality has been increasing significantly. According to Vanhecke, Miller, Franklin, Weber and McCullough (2006), CVD is preventable by adoption of a healthy diet and increased physical activity. A balanced diet is necessary for a healthy circulatory system. Perception of risk factors and intention to adopt good dietary habits and cooking practices are important to a healthy lifestyle and reduced incidences of CVD.

The knowledge of nutritional implications and perceptions of Saudi women tasked with taking care of their nutrition, and that of their families will be a great milestone in establishing nutrition knowledge and link them with measures to reduce CVD. According to Vanhecke et al. (2006), lack of risk perception prevents people from adopting healthy lifestyles, and is the genesis of uncaring attitude towards what people consume. The established risk perception will significantly inform the type of nutrition interventions, preventive measures and behavior change campaigns that target dietary changes and cooking practices.

Previous work on CVD in Saudi Arabia

Many studies conducted in Saudi Arabia on CVD risk factors have concentrated on the general population and prevalence of cardiovascular diseases. The studies have also endeavored to establish causes of CVD among Saudi Arabia women. A study conducted by Pharaon (2004) pointed out significant changes in eating behaviors of people of Saudi Arabia. The research established that many Saudi Arabians consume foods that have a lot of sugar content and are high in fats. In a case study to examine the perception of body weight and eating behaviors among Saudi women, Yahya, Muhammad and Yossof (2012) found that there were misconceptions about eating habits.

In a similar study, Al-Alwan et al. (2013) examined the predisposing factors to CVD among Saudi women. The study found that Saudi women’s dietary and physical activity practices predisposed them to sedentary lifestyles and hence they were likely to be overweight compared to average European women. The increased obesity was due to adoption of unhealthy eating habits and the changes in socio-economic status, changes in traditional food cooking styles and the sedentary lifestyle. The study found that Saudi women prepare food for their family; the common ingredients include fats, meat, sugar, and spices. The current food preparation practices are influenced by Western food culture that has eroded the healthy cooking practices experienced in the traditional Arabian cooking methods and dietary practices. Pharaon (2004) noted that the new practices and ingredients are presumed to be proper. The presumption bars the Saudi women from cooking the traditional healthy foods. Kumosani, Alama and Iyer (2011) indicated that nutritional problems in Saudi Arabia are attributed to changes in eating habits, illiteracy and ignorance, rather than a shortage of food supply or low income. Diet is a core determinant of people’s health and contributes to the development of CVD. Studies conducted in Saudi Arabia by Al Nozha et al (2005) pointed to a high prevalence of cardiovascular diseases among women.

Fat Intake and Cooking Behaviors

The eating habits, cooking and behaviors in Saudi Arabia are significantly influenced by the Islamic religion (Pharaon, 2004). An example is the case of Muslims and their faith. They ought to exercise on regular basis and avoid alcohol. However, the Islamic teachings on healthy eating have been eroded by socio-cultural factors such as increased.

Economic activities, which have seen many women in employment (Pharaon, 2004). There are many traditional cuisines in Saudi Arabia. The traditional cuisines employ different types of cooking and reflect the customs and traditional cooking methods of Saudi people depending on the region (Hawazen, Patsy & Robyn, 2012).

Boiled vegetables and whole fruits were main ingredients in a typical Saudi Arabian dish. The traditional methods of cooking and the everyday dishes ensured a balanced diet with a lot of fiber, fat was used sparingly in cooking. However, with the globalization and cultural influence, Saudi Arabian cuisine has greatly changed; a lot of spices, highly refined foods and fast foods have been embraced (Hawazen, Patsy & Robyn, 2012). The typical Saudi diet is Al-kabsa. A lot of salads and spices are added to Al-kabsa, the accompaniments of the Al-kabsa are juices in which a lot of sugar is used.

Cardiovascular diseases pose a significant health challenge in Saudi Arabia just as in other developed countries in the western world. In Saudi Arabia, researchers have identified a trend of higher mortality and morbidity among women as compared to men. The differences of risks in relation to sex and gender are influenced by cultural differences; therefore, the differences in perception of risk factors have implications for primary prevention. Knowledge of nutrition best practices followed by dietary changes would help prevent CVD. Understanding the perception, knowledge, and behaviors that influence eating habits and activity patterns of Saudi women can be critical in the guidance of the intervention strategies to ensure energy balance and reduce the mortality and morbidity caused by CVD.

Research Question

  1. Is there a relationship between risk perception of cardiovascular disease among Saudi women and intentions to use low fat cooking methods?
  2. Do demographic characteristics such as age, educational level, and income affect the perception of cardiovascular disease risk in Saudi women?
  3. At what precaution adoption process model (PAPM) stage are Saudi women in terms of readiness for low fat cooking for the prevention of cardiovascular disease?

Research Hypotheses

  1. There is a relationship between risk perception of cardiovascular disease among Saudi women and intentions to use low fat cooking methods.
  2. Demographic characteristics such as age, educational level, and income affect the perception of cardiovascular disease risk in Saudi women.
  3. The majority of Saudi women will be classified in the PAPM stage of high-fat cooking related to cardiovascular risk but not engaged in low fat cooking.

Study Methodology

The study will entail a survey of the women living in selected urban towns in Saudi Arabia. Quantitative research methods will be used to obtain required data from the sampled women. The risk perception will be predicted by use of HBM and PAPM models. The sampling of women will entail combination of simple random and purposive sampling procedures. Structured questionnaires and interviews will be used to collect data.

Operational Definition of Terms

Energy dense foods: The term energy dense food is used to describe the number of calories per unit measure (Farley, Baker, Futrell & Rice, 2010). The measure is a bite, ounce or a gram. According to Farley et al. (2010), foods described as energy dense have very high concentration of carbohydrates per unit measure.

Traditional cooking in Saudi Arabia: the term refers to the foods and cooking methods that formed the daily diet of Saudi Arabians before the influences from western world and other outside cultures.

Precaution Adoption Process Model (PAPM): PAPM is a model used to predict the process of health behavior change.

Health Belief Model (HBM): HBM is a model that is applied in health researches to study the risk perceptions that relate to adoption of healthy actions.

Conclusion

Cardiovascular diseases present a significant health challenge in the Kingdom of Saudi Arabia. Hypertension, atherosclerosis, diabetes and ischemic heart diseases are common in Saudi (Khan, 1997). Unfortunately, the etiology presents a trend in which women show high prevalence compared to their male counterparts. Changes in dietary patterns, the cooking styles, and reduced physical exercise are the main risk factors for CVD among the Saudi women. The overview of CVD and its implication and Saudi Arabia dietary recommendations that relate to risk perception of cardiovascular disease among Saudi women in relation to home cooking and intentions to low fat cooking are discussed in the next chapter.

Overview of the Chapters

Chapter two (2) of the research will review the literature on the dietary practices in Saudi Arabia. The review will cover the recommended dietary allowances in Saudi Arabia and the Health Food Palm. Further, the study will explore the history of dietary changes in Australia. Literature on Precaution Adoption Process Model (PAPM) and Health Belief Model (HBM) will be reviewed and synthesized. Chapter three (3) will include the study methodology to be employed in the research. This chapter will include a discussion of data collection and analysis, procedures in sampling as well as the quantitative research design.

References

Al-Alwan, I., Badri, M., Al-Ghamdi, M., Aljarbou, A. and Tamim, H. (2013). Prevalence of Self-reported cardiovascular risk factors among Saudi physicians: A Comparative Study. International Journal of Health Sciences, 7(1), 13-38.

Al-Baghli, N., Al-Ghamdi, A., Khalid, A., Ahmad, G. and Mahmood, M. (2010). Awareness of cardiovascular disease in eastern Saudi Arabia. Journal of Family Community Medicine, 17(1), 15–21.

Albassam, R., Gawwad, E., Khanam, L. (2007). Weight management practices and their relationship to knowledge, perception and health status of Saudi females attending diet

clinics in Riyadh City. Journal of Egypt Public Health Association, 82(1), 23-67.

Al-Farwan, W. M. (2011). Perceived personal, social, and environmental barriers to healthy eating among young overweight and obese Saudi women. Middle East Journal of Family Medicine, 9(10), 3-9.

Al-Nozha, M., Abdullah, M., Arafah, M., Khalil, M. and Khan, N. (2007). Hypertension in Saudi Arabia. Saudi Medical Journal, 28 (1), 77- 84.

Al-Nozha, M., Al-Mazrou, Y., Al-Maatouq, M., Arafah, M., and Khalil, M. (2005). Obesity in Saudi Arabia. Saudi Medical Journal, 26 (5), 824-829.

Benner, A., Al-Suwaidi, J., Al-Jaber, K., Al-Marri, S., Dagash, M. and Elbagi, I. (2004). The prevalence of hypertension and its associated risk factors in a newly developed country. Saudi Medical Journal, 25 (1), 918-922.

Berra, K., Fletcher, B., Hayman, L., L., & Miller, N., Houston. (2013). Global cardiovascular disease prevention. Journal of Cardiovascular Nursing, 28(6), 505-513.

Bovet, P., &Paccaud, F. (2011). Cardiovascular disease and the changing face of global public health: A focus on low and middle income countries. Public Health Reviews, (2), 399.

Brunner, E., Rees, K., Ward, K., Burke, M., and Thorogood, M. (2007). Dietary advice for reducing cardiovascular risk. Cochrane Database of Systematic Reviews,1(4), p. 1-16.

Crocco, M. S., Pervez, N., and Katz, M. (2009). At the Crossroads of the World: Women of the Middle East. Social Studies, 100(3), 107-114.

Farley, T., Baker, E., Futrell, L., & Rice, J. (2010). The Ubiquity of Energy-Dense Snack Foods: A National Multicity Study. Am J Public Health, 100(2), 306-311.

Gaziano, T. A., Bitton, A., Anand, S., Abrahams-Gessel, S., & Murphy, A. (2010). Growing epidemic of coronary heart disease in low- and middle-income countries. Current Problems in Cardiology, 35(2), 72-115.

Hawazen, O., Patsy, A. and Robyn, C.(2012) Cultural challenges to secondary prevention: Implications for Saudi women. Journal of the Royal College of Nursing Australia,19(1), 51-57.

Homko, C.J., Santamore, W. P., Zamora, L., Shirk, G., Cross, R., Kashem, A., Petersen, S. (2008). Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease. Journal of Cardiovascular Nursing, 23(4), 332-337.

Ibrahim, N. K., Mahnashi, M., Al-Dhaheri, A., Al-Zahrani, B., Al-Wadie, E., Aljabri, M.,…Bashawri, J. (2014). Risk factors of coronary heart disease among medical students in king Abdulaziz University, Jeddah, saudiarabia. England: BioMed Central.

Kelly, B. B., Narula, J., & Fuster, V. (2012). Recognizing global burden of cardiovascular disease and related chronic diseases. The Mount Sinai Journal of Medicine, New York, 79(6), 632-640.

Khanam, S. and Costarelli, V. (2008). Attitudes towards health and exercise of overweight women. The Journal of the Royal Society for the Promotion of Health, 128(1), 26-30.

Khatib, O. (2004). Non-communicable diseases: Risk factors and regional strategies for prevention and care. East Mediterranean Health Journal, 10(6), 778-788.

Kumosani, T., Alama, M. and Iyer, A. (2011). Cardiovascular diseases in Saudi Arabia. Journal of Prime Research on Medicine, 1 (10), 1-6.

Mobaraki, A. H., and Soderfeldt, B. (2007). Gender inequity in Saudi Arabia and its role in public health. EMHJ, 16(1), 3-15.

Nanita, A. K. S. (2012). Impact Of Dietary Advice On Overweight Children-Randomized Control Trail (Doctoral dissertation, Kle University, Belgaum, Karnataka,). College of Cardiology (JACC), 57(12), 1404-1423.

Pharaon, N. A. (2004). Saudi women and the Muslim state in the twenty-first century. Sex Roles, 51(5), 349-366.

Rawas, H., O., Yates, P., Windsor, C., & Clark, R., A. (2012). Cultural challenges to secondary prevention: Implications for Saudi women. Collegian, 19(1), 51-57.

Rohleder, P. (2012). Critical issues in clinical and health psychology. Sage.

Shara, N. M. (2010). Cardiovascular disease in Middle Eastern women. Nutrition, Metabolism and Cardiovascular Diseases, 20(6), 412-418.

Vanhecke, E., Miller, W., Franklin, A., Weber, E., McCullough, P. (2006). Awareness, knowledge, and perception of heart disease among adolescents. European Journal of Cardiovascular Prevention & Rehabilitation, 13(5), 718-723.

Weinstein, N. D., & Sandman, P. M. (2002). The Precaution Adoption Process Model and its application: Strategies for Improving Public Health. San Francisco: Jossey-Bass.

World Health Organization. (2015). Cardiovascular disease. Web.

World Health Organization (WHO). (2012). Cardiovascular disease (CVD). Web.

World Health Organization. (2014).Non-communicable Diseases (NCD) Country Profiles.

Yahya, R., Muhammad, R., and Yusoff, M. (2012). Association between knowledge, attitude and practice on cardiovascular disease among women in Kelantan. International Journal of Collaborative Research on Internal Medicine & Public Health, 4 (8), 12-32.