INTRODUCTION

The changes caused by scientific and technological development had an effect on the population’s living conditions, which led to an increased life expectancy and the risk of developing Chronic Noncommunicable Diseases (CNCDs). CNCDs are the leading causes of death worldwide, and, in 2016, their estimates were 71% of the 57 million deaths that occurred worldwide. Of which 17.9 million were caused by Cardiovascular Diseases (CVD), representing 44% of all deaths from CNCDs and 31% of total deaths overall^1,2.

The increasing prevalence of CVD is directly related to urbanization and lifestyle changes in society that contribute to the adoption of behavioral risk factors such as smoking, inadequate nutrition, sedentary lifestyle and alcoholism^3,4. The presence of these risk factors can trigger the development of some diseases such as systemic arterial hypertension, diabetes mellitus, dyslipidemia, obesity and metabolic syndrome, representing high cardiovascular risk for the affected individual⁵.

The morbidity and mortality from CVD can be reduced by controlling and preventing risk factors. Health education with the incorporation of health technologies contribute to knowledge, stimulating healthy living practices and empowering individuals in the exercise of their autonomy, becoming a relevant method for public health^6,1.

In this context, evaluation instruments are resources often used in educational programs in the health area, as they enable measuring the effects of the teaching and learning process, in addition to possible changes in attitudes about the disease in question⁷.

Thus, the aim of this study was to identify and describe the instruments for assessing knowledge about risk factors and prevention of CVD.

METHODS

This is an integrative literature review. The construction of this review was based on the following steps: 1) elaboration of the guiding question; 2) search in the literature; 3) categorization of primary studies; 4) evaluation of the studies included in the integrative review; 5) interpretation of the results; 6) analysis and synthesis of the knowledge of the studies⁸.

The elaboration of the research guiding question was based on the acronym PICo (participants, phenomenon of interest and context of the study)⁹, where “P”- individuals in general; “I”- validated instruments; “Co”- knowledge about risk factors and prevention measures for CVD. Thus, the research was based on the following question: “What are the validated instruments for the evaluation of individuals’ knowledge about risk factors and prevention measures for cardiovascular diseases?”

The searches were conducted in May 2019 and updated in July 2020 at the Latin American and Caribbean Health Sciences Literature (LILACS), Medical Literature Analysis and Retrieval System Online (MEDLINE) databases via PubMed and the Scientific Electronic Library Online (SciELO). The articles were surveyed with the following descriptors: knowledge, cardiovascular diseases, risk factors, prevention of diseases and validation studies, indexed in Health Sciences Descriptors (DeCS) and Medical Subject Headings (MeSH). The searches were directed by descriptors combined with Boolean operators (AND and OR), with different strategies in each database, as shown in Chart 1.

Chart 1.  Presentation of the search strategies used in the selection process of the articles. Teresina/PI, Brazil, 2020. 

The sample included instrument validation studies published from 2005 to May 2019, available in the Portuguese, English and Spanish, which answered the guiding question established in this integrative literature review. Review articles, reflection, case study, incomplete texts, theses and dissertations were not included. Duplicate articles were excluded.

To collect data from the articles, an instrument was elaborated, which contains the following items: authors of the article, place/year of the study, objective, type of validation, type of instrument, cardiovascular disease, target audience of the instrument, instrument title, description of the instrument. The information was synthesized and analyzed through a critical and detailed evaluation, seeking to make comparisons and conclusions with the pertinent literature.

RESULTS

Of the 77 articles initially identified, four were excluded because they were repeated. Thus, titles and/or abstract of 73 articles were read. After this stage, 12 articles were selected for full reading and chosen to form the basis of analysis of this study, according to the sequematic flowChart described in Figure 1.

Figure 1.  FlowChart of the search and selection stages of the analyzed articles. Teresina/PI, Brazil, 2020. 

Regarding the year of publication, there was a higher frequency in 2009^10,11, 2010^12,13 and 2014^7,14. Seven were performed in Brazil^{7)(12)(13)(14)(15)(16)(17}, two in the United States^18,19, two in the United Kingdom^11,20 and one in Turkey¹⁰. Five^{10)(11)(14)(18)(20} studies developed and validated instruments to assess knowledge about CVD in general and the other studies focused on the evaluation of a specific CVD, with Coronary Artery Disease (CAD) being the most evaluated pathology^{12)(13)(15)(17}. Regarding the type of validation, nine^{7)(10)(11)(13)(14)(16)(18)(19)(20} studies developed the instrument and performed content and construct validation, while three^12)(15)(17) performed translation, adaptation and validation of instruments to be used in Brazil (Chart 2).

There was a variation in the target audiences of the instruments. Four^{12)(13)(15)(17} instruments are intended for patients with CAD, and three^12)(13)(17 of these are specific to be used in coronary patients in Cardiac Rehabilitation (CR). Three^10)(14)(20 instruments are applied to healthy individuals, one¹⁴ specific for use in schoolchildren. Four are aimed at people with diabetes¹⁸, Rheumatoid Arthritis (RA)¹¹, Systemic Arterial Hypertension (SAH)¹⁹, Heart Failure (HF)⁷, and one¹⁶ for people with SAH in CR (Chart 2).

Chart 2.  Characterization of studies on knowledge assessment instruments on risk factors and preventive measures for cardiovascular diseases. Teresina/PI, Brazil, 2020. 

Source: the authors, 2020. CVD: Cardiovascular Diseases; CAD: Coronary Artery Disease; SAH: Systemic Arterial Hypertension; HF: Heart Failure; CR: Cardiac Rehabilitation.

Ten^{7)(11)(12)(13)(14)(15)(16)(17)(18)(20} studies developed and validated questionnaires and the other studies constructed and validated scales^13,19. The number of items of the instruments ranged from 12 to 31 questions. Regarding the objectives and characteristics of the instruments, six^{10)(11)(14)(18)(20} sought to evaluate knowledge about CVD in general, further investigating risk factors and lifestyle; three^12)(13)(17 questionnaires evaluated coronary patients’ knowledge about CAD, risk factors and physical exercise; two^16,19 instruments sought to evaluate the knowledge of hypertensive patients about their disease and self-management of hypertension; and one⁷ questionnaire sought to evaluate the knowledge of patients with heart failure about this pathology, risk factors and treatment (Chart 3).

Chart 3.  Description of knowledge assessment instruments on risk factors and preventive measures for cardiovascular diseases. Teresina/PI, Brazil, 2020. 

Source: authors, 2020. CVD: Cardiovascular Diseases; CAD: Coronary Artery Disease; SAH: Systemic Arterial Hypertension; HF: Heart Failure; CR: Cardiac Rehabilitation.

DISCUSSION

Most of the instruments were questionnaires that addressed cardiovascular risk factors and lifestyle. Four of the instruments analyzed are intended for people diagnosed with CAD and were created to investigate users’ knowledge about their disease, medical condition, cardiovascular treatment, risk factors, lifestyle, among others^{12)(13)(15)(17}.

The considerable number of instruments for people with CAD can be explained by representing one of the most relevant forms of presentation of CVD, which is the main cause of death in Brazil and worldwide²¹. Based on estimates from the Global Burden of Disease study²², there was a reduction in mortality from CVD in recent decades in Brazil; however, the same did not occur with its morbidity, which is the reason for the greatest impact on the cost of hospitalizations at the national level²³.

Thus, it is important to control risk factors to reduce CVD, and, in this sense, health professionals should add efforts, with interventions that ensure an improvement in quality of life and control of the incidence of these diseases in the population. Therefore, the applicability of these instruments can support the individualized treatment of patients with CAD, contribute to health education practices, plan, propose and evaluate educational interventions in CR programs and clinical practice^{12)(13)(15)(17}.

The Heart Disease Fact Questionnaire (HDFQ) proved to be valid and reliable to assess knowledge about the risk of heart disease among people with diabetes, and can be used in the adaptation of health education to meet the users’ needs, in research and clinical care¹⁸. The use of this instrument¹⁸ is relevant, since diabetes mellitus is an important cause of morbidity and mortality worldwide, representing a public health problem. The main cause of death and disability among people with diabetes is CVD, accounting for approximately half of diabetes mortality in most countries²⁴.

In general, individuals with diabetes have other associated comorbidities, such as obesity, SAH and dyslipidemia that also contribute to increase cardiovascular risk²⁵, thus, such risk factors are addressed in the questionnaire. Moreover, there are questions about the importance of ceasing tobacco use, performing physical activity and having a healthy diet to reduce the risk of developing heart disease ¹⁸.

The evaluation of knowledge about the risk factors associated with diabetes and the importance of control through health promotion measures can contribute to reduce the incidence of the disease and its complications, as well as to reduce the costs generated on the health system²⁶.

The HDFQ¹⁸ questionnaire was used to develop and validate two other instruments: a scale to measure the level of knowledge of adults about risk factors for CVD (Cardiovascular Disease Risk Factors Knowledge Level-CARRF-KL)¹⁰ and two parallel versions of the Heart Disease Fact Questionnaire-Rheumatoid Arthritis (HDFQ-RA)¹¹, which measures the knowledge of heart disease in patients with Rheumatoid Arthritis (RA).

CARRF-KL was considered reliable, valid, easy to fill and effective to identify the impact of education programs on the prevention of CVD risk factors and can be applied to high-risk individuals attending primary health care and individuals in the general population¹⁰.

HDFQ-RA also demonstrates reliability and validity. It was developed in response to the clinical need to address the risk of CVD associated with RA and can be applied in clinical and research environments. The use of the two parallel versions are appropriate to evaluate a new educational intervention or the progress of a participant in a health education course¹¹.

The approach of cardiovascular risk factors in patients with RA is relevant, because the presence of RA increases about 30 to 60% the chance of developing CVD, which is the most important cause of morbidity and mortality in patients with RA²⁷.

Another disease that represents an important risk factor for CVD is SAH, which is characterized by a multifactorial clinical condition associated with functional, structural and metabolic alterations, with consequent association with fatal and non-fatal cardiovascular events, such as sudden death, cerebrovascular accident, acute myocardial infarction, heart failure, peripheral arterial disease and chronic kidney disease²⁸.

Two of the studies analyzed developed and validated instruments to assess knowledge about SAH in hypertensive people. In the study by Schapira et al. (2012)¹⁹, the Hypertension Evaluation Lifestyle and Management Knowledge Scale was developed and validated in order to be used to evaluate studies of effectiveness of interventions to improve the treatment of chronic diseases. The Instrument to assess knowledge about their disease in hypertensive patients participating in CR programs (HIPER-Q)¹⁶ is a valid, useful and easy-to-understand questionnaire that allows establishing educational strategies aimed at the patients’ real needs. It assists health professionals in the evaluation and planning of health education practices for hypertensive patients in CR programs, aiming at controlling the disease and reducing cardiovascular comorbidities¹⁶.

Another instrument that was developed and validated to be applied to patients in CR programs was the Knowledge Questionnaire for Patients with Heart Failure, which seeks to evaluate patients’ knowledge about the subjects that the CR program encompasses in its educational process, such as basic information on the pathophysiology of their disease, relationship of the disease with physical exercise, mechanisms of action of drugs and reformulation of life habits⁷.

The analysis of the studies presented revealed the importance of applying specific instruments to measure the patient’s knowledge about his/her pathology, considering that patients’ inadequate understanding about their disease and risk factors can cause emotional changes, non-adherence to treatment and disease progression⁷.

Thus, using instruments to assess knowledge about CVD allows pointing out the needs of individuals and intensifying health prevention, control and education programs on risk factors associated with the disease, contributing to the dissemination of knowledge, behavior change and reduction of the burden of morbidity and mortality from CVD²⁹.

Two of the twelve instruments analyzed are intended to audiences who do not have any diagnosis of CVD and aim to prevent the occurrence of these diseases^16,20.

One of these questionnaires was constructed and validated with the objective of verifying the knowledge of students aged seven to 11 years about healthy habits and risk factors for CVD (CARDIOKID), which is brief and easily applicable, and may contribute to the elaboration of preventive strategies and evaluation of the effectiveness of intervention programs¹⁴.

The use of these instruments for children and adolescents is relevant since the determination of risk factors for CVD may start in childhood, as a result of lifestyle and personal habits that are learned and initiated at this stage of life, influencing the onset of these diseases³⁰. Therefore, it is important to measure the knowledge of this population about the determinants that influence the development of CVD to allow the development of early effective disease prevention measures.

The ABCD Risk Questionnaire²⁰ was developed and validated to assess the accuracy of perceived risk and general knowledge of CVD and the intention to change behavior in relation to diet and exercise among participants of the cardiovascular preventive program of the National Health Service Health Check. This program aims to asses and manage the risk for CVD in England and aims to increase knowledge about cardiovascular risks among adults at high risk for CVD. The application of this questionnaire helps determine whether the program is effective to enable users to make informed choices about their lifestyle and health²⁰.

The analysis of the studies showed that the use of these instruments are indispensable strategies to measure the level of knowledge of individuals, direct interventions to the needs detected, support the clinical treatment of patients, plan and evaluate the effectiveness of health educational programs and actions.

CONCLUSION

The integrative review allowed identifying validated instruments available in the literature that assess knowledge about risk factors and prevention of CVD. Most instruments are intended to evaluate the knowledge of individuals diagnosed with some CVD, emphasizing the evaluation of patients’ knowledge about the management of their disease, risk factors and the behavior changes necessary to prevent the progression of cardiovascular problems.

There is a need to develop validation studies of instruments aimed primarily at populations that have not yet been diagnosed with these diseases, especially for children and adolescents, aiming to evaluate health programs and technologies that are developed to promote cardiovascular health education.

These findings show that the development and use of these knowledge assessment instruments can contribute to preventing and reducing risk factors and morbidity and mortality from CVD in the population.

A limitation of this study is the absence of a detailed description of the items that make up the instruments in some studies, hindering in-depth investigations of the main risk factors and disease prevention measures that are being evaluated. Even with this limitation, this study describes the instruments for evaluating knowledge on risk factors and prevention of cardiovascular diseases validated with publication carried out between 2005 and 2019, contributing to consolidating the information on the subject.