Knowledge about cardiovascular disease in Portugal

www.revportcardiol.org

Revista

Portuguesa

de

Cardiologia

Portuguese

Journal

of

Cardiology

ORIGINAL

ARTICLE

Knowledge

about

cardiovascular

disease

in

Portugal

Nelson

Andrade

_,

_Elisabete

_Alves

_,

_Ana

_Rute

_Costa

_,

Pedro

Moura-Ferreira

,

Ana

Azevedo

,

Nuno

Lunet

b_{UniversidadedoPorto,FaculdadedeMedicina,DepartamentodeCiênciasdaSaúdePúblicaeForenseseEducac¸ãoMédica,}

Porto,Portugal

c_{InstituteofSocialSciences,UniversityofLisbon,Lisbon,Portugal}

Received12September2017;accepted8October2017 Availableonline25July2018

KEYWORDS Cardiovascular disease; Healthinformation management; Healthknowledge; Primaryprevention Abstract

Objectives: Tocharacterizespecificknowledgeoncardiovasculardisease,particularlystroke andmyocardialinfarction(MI),anditsrelationshipwithsociodemographicfactors,health lit-eracyandclinicalhistory,amongthePortuguesepopulation.

Methods:In across-sectional studyconducted in2012, atotalof1624Portuguese-speaking residentsofmainlandPortugal,agedbetween16and79years,wereassessedthrough face-to-faceinterviewsusingastructuredquestionnaire.

Results:Around30%ofparticipantswereunabletoestimatetheriskofMIorstroke.Onaverage, those whoresponded estimatedthat 34.2%and 35.6%of Portuguesewillsuffer astroke or MI,respectively,duringtheirlifetime.‘‘Notsmoking’’(36.8%)anda‘‘healthydiet’’(32.8%) wereidentifiedasthemostimportantbehaviorsforpreventionofcardiovasculardisease,and lessthanhalfoftheparticipantsrespondedthatthemostappropriateoptioninthepresence ofacutecardiovascularsignsorsymptomswastocall theemergencynumber.‘‘Dependence on daily activities’’ (90.7%)and‘‘impaired speech’’(89.8%)were frequently recognized as consequencesofstroke,while‘‘heartfailure’’(86.4%)and‘‘dependenceondailyactivities’’ (85.3%) werethe mostfrequently identifiedconsequences of MI.Overall, participantswith adequatehealthliteracyrevealedmoreappropriatecardiovascularhealth-relatedknowledge. Conclusions: Thereareimportantgapsincardiovascularhealth-relatedknowledgeinthe Por-tuguese population. Health education strategies and practices should be sensitive to the differences in health literacy described herein, in order to improve cardiovascular health knowledgeamongthePortuguesepopulation.

© 2018SociedadePortuguesade Cardiologia.Publishedby ElsevierEspa˜na,S.L.U.Allrights reserved.

∗_{Correspondingauthor.}

E-mailaddress:[email protected](E.Alves). 1 _{Equallycontributingauthors.}

https://doi.org/10.1016/j.repc.2017.10.017

670 N.Andradeetal.

PALAVRAS-CHAVE

Doenc¸as

cardiovasculares; Gestãodainformac¸ão emsaúde;

Conhecimento emsaúde;

Prevenc¸ãoprimária

Conhecimentosobreadoenc¸acardiovascularemPortugal

Resumo

Objetivos: Caracterizar o conhecimento específico sobre a doenc¸a cardiovascular (DCV), nomeadamenteoacidentevascularcerebral(AVC)eoenfarteagudodomiocárdio(EAM),da populac¸ãoportuguesa,deacordocomfatoressociodemográficos,literaciaemsaúdeehistória clínica.

Métodos: Numestudotransversalrealizadoem2012,foramavaliados1624residentesem Por-tugal continental,entre16 e79 anos, através de entrevistaspresenciais comquestionário estruturado.

Resultados: Cercade30%dosparticipantesnãoconseguiramestimaroriscodeAVCeEAM.Em média,osqueresponderamestimaramque34,2%e35,6%dosportuguesessofrerãoumAVCou um EAM durantea suavida, respetivamente.«Não fumar»(36,8%) euma «dietasaudável» (32,8%) foramidentificados como os comportamentos mais importantespara prevenc¸ão da DCV e menos de metade dos participantes respondeu«telefonar para o 112» como opc¸ão correta perante a presenc¸a de sinais ou sintomas de eventos cardiovasculares agudos. A «dependêncianasatividadesdiárias»(90,7%)eas«perturbac¸õesdafala»(89,8%)foram fre-quentementereconhecidascomo consequênciasdeAVC,enquantoa«insuficiênciacardíaca» (86,4%)e«dependêncianasatividadesdiárias»(85,3%)foramasconsequênciasdeEAM iden-tificadas com maiorfrequência. Em geral, participantes comliteracia em saúde adequada revelaramumconhecimentoemsaúdecardiovascularmaisapropriado.

Conclusões:Verificaram-se importantes lacunas noconhecimento específico sobreadoenc¸a cardiovasculardapopulac¸ãoportuguesa.Asestratégiasepráticasdeeducac¸ãoemsaúdedevem sersensíveisàsdiferenc¸asdescritasdeacordocomoníveldeliteraciaemsaúde,deformaa melhoraroconhecimentoemsaúdecardiovasculardapopulac¸ãoportuguesa.

©2018SociedadePortuguesadeCardiologia.PublicadoporElsevierEspa˜na,S.L.U.Todosos direitosreservados.

Introduction

Cardiovascular disease (CVD) is the main cause of death worldwide and is projected to remain among the most important contributors to mortality up to 2030.1

World-wide,approximately17.3millionpeoplediedfromCVDin

2013,representingnearlyone-thirdoftheoverallnumberof

deathsand45%ofthoseduetonon-communicablediseases.2

Amongthese,8.1milliondeathswereduetocoronaryheart

disease(CHD) and 6.4 million tostroke, which constitute

the leading and third leading causes of disability

world-wide,respectively.2 _{In Europe,CVD isresponsible for 45%}

ofalldeathseachyear, with2.8milliondeathsattributed

to CHD and stroke.3 _{In Portugal, CVD is the main cause}

ofmortality,withstroke andCHDaccountingfor6.1%and

6.0%,respectively, oftotaldisability-adjustedlifeyearsin

2015.4

Despitethehigh burdenofCVD, therehasbeen a

con-siderable decline in mortality in recent decades.5 _These

reflect downward trends in exposure to behavioral risk

factors such as smoking, as well as increasing use of

evidence-basedpharmacologicaltreatmentsfor controlof

hypertension and cholesterol levels, and interventional

therapiesandtechniquesforbettermanagementofpatients

in the acute phase.6---9 _{However, patterns of variation in}

mortalityareheterogeneous,5_{withmanycountries,}

includ-ing Portugal, still presenting considerable potential for

further decreases in morbidity and mortality from stroke

and CHD,5,10 _{through both ‘high-risk’ and ‘population’}

strategies.11

Behaviors that increase the risk of CVD are

mod-ulated by individuals’ health-related knowledge and

risk perception,12 _{and therefore understanding}

limita-tions in specific knowledge is essential to develop

strategies aimed at the empowerment of the

popula-tion for self-care and better use of available health

resources.13,14

Wethereforeaimedtocharacterizespecific knowledge

onthefrequency,prevention,controlandconsequencesof

cardiovascular disease,particularlystroke andmyocardial

infarction(MI),anditsrelationshipwithsociodemographic

factors,historyofCVDandhealthliteracy,amongthe

Por-tuguesepopulation.

Methods

Thisanalysisisbasedonacross-sectionalstudyconducted

between January and May 2012, withthe primary

objec-tive of assessing knowledge and health behaviors in a

representativesample ofPortuguese-speaking residentsof

mainlandPortugal,agedbetween16and79years,as

previ-ouslydescribedindetail.15_{Briefly,astratifiedprobabilistic}

sampling procedure was used to select 150 geographical

units, among which a total of 585 starting points were

designated for the selection of households through

stan-dardrandomrouteprocedures.Ineachselectedhousehold,

the resident whose previous birthday was closest to the

date of the interview was invited to participate. A total

of 1624 valid interviews were obtained (response rate:

Face-to-faceinterviewswereconductedtocollectdata

onsociodemographiccharacteristics,clinicalhistory,health

literacyandspecific knowledgeonthefrequency,

preven-tion,controlandconsequencesofCVD.

A personal history of hypertension, stroke or MI was

considered present when participants recalled a medical

diagnosisoftheseconditions.

ToassesstheperceivedriskofstrokeandMI,participants

wereasked‘‘Forevery100Portuguese,howmanywill

suf-ferfrom stroke and how many will suffer fromMI during

theirlives?’’ andthe quantitativeestimates wereusedas

continuousvariablesindataanalysis.

Regarding behaviors for CVD prevention, participants

were asked to select the most important from a list of

different behaviors, namely ‘‘not smoking’’, ‘‘not

drink-ing’’,‘‘healthydiet’’,‘‘regularexercise’’,‘‘regularblood

pressure measurement’’, and ‘‘other behaviors’’, which

includedtheintakeofmultivitamins,regularweighing,

reg-ularblood testsandgeneralcheck-ups. Theproportionof

participantsidentifyingeachbehaviorasthemostimportant

waspresented.

Awarenessofthemostappropriateactioninthepresence

ofan alarmsign or symptomof apotentialcardiovascular

event was obtained through the question ‘‘In the

pres-ence of each of the following symptoms or signs (chest

painorfacialdrooping)statehowtoproceed’’.Theoptions

were‘‘callemergencynumber’’,‘‘gotoemergency

depart-ment’’, ‘‘call Saúde 24 (the national health helpline)’’,

‘‘schedulean appointment withphysician’’, ‘‘goto

phar-macy’’ and ‘‘take a ‘wait and see’ approach’’. Only the

option‘‘callemergencynumber’’wasconsideredcorrect.

To assess knowledge on the potentialconsequences of

CVD,participants wereaskedtoindicatewhethereachof

five options --- ‘‘paralysis’’, ‘‘dependence in daily

activi-ties’’,‘‘impairedspeech’’,‘‘dementia’’and‘‘epilepsy’’

---couldresult fromstroke. Similarly, participantswere also

askedtostatewhethereachoffiveoptions---‘‘angina

pec-toris’’, ‘‘heart failure’’, ‘‘impaired driving’’, ‘‘impaired

sexual activity’’ and ‘‘dependence in daily activities’’

---couldresultfromMI.Inbothquestions,thepossibleanswers

were‘‘yes’’,‘‘no’’,‘‘donotknow’’and‘‘didnotanswer’’

foreachresponsecategoryandfordataanalysisthelatter

twooptionswererecodedas‘‘no’’.

HealthliteracywasassessedusingtheNewestVitalSign

(NVS)instrument.16_{Thistoolwasdesignedtoassesshealth}

literacyskills,specificallyreadingandnumeracyskills.The

number of correct answers was usedto compute a score

rangingfrom0to6(0-1:highlikelihoodoflimitedliteracy

[HLLL], 2-3: possibility of limited literacy and 4-6:

ade-quate literacy [AL]). Participants who reported that they

were unable to read or write were classified as having

HLLL.

Statistical analyses were performed using STATA 11.1

(College Station, TX, 2009). Adjusted mean differences

in the estimated number of people affected by stroke

and MI, according to sociodemographic characteristics,

health literacy and history of CVD (hypertension, stroke

andMI),withrespective95%confidenceintervals(95%CIs),

were computed by multiple linear regression. To

esti-mate the associations between explanatory factors and

health-related knowledge variables, adjusted prevalence

ratios (PRs) and 95% CIs were computed using Poisson

regression.Allmodelswereadjustedforage,gender,

edu-cational level and health literacy. The product of design

and population weights was used for weighting in all

analyses.

ThesurveywasapprovedbytheEthicsCommitteeofthe

UniversityofPorto.

Results

Participantsinoursamplewereevenlydistributedinterms

ofgender.More than 60%were lessthan 50yearsof age,

42.5%hadlessthanfiveyearsofschoolingand45.9%

pre-sentedHLLL(Table1).Apreviousdiagnosisofhypertension

wasreportedby14.1% of participants,and 2.8% reported

priorstrokeorMI(1.8%forstrokeand1.8%forMI).

Nearly 30% of the participants did not answer or did

notknowhowtoanswerthequestionsregardingperceived

riskofstrokeandMI.Theproportionofnon-responseswas

approximatelytwo times higheramong older participants

andnearly40%loweramongthosewithAL.Subjectswitha

previousdiagnosisofstrokewerelesslikelytoestimatethe

lifetimeriskof strokein thepopulation(PR=0.41, 95%CI:

0.21-0.79).Therespondentsstatedthat,onaverage,34.2%

and35.6%ofthePortuguesepopulationwouldsufferastroke

orMI,respectively,duringtheirlifetime(Table2).Therisk

estimates provided by men were approximately8% lower

thanthoseprovided bywomen, andfor stroke those

pro-videdbyparticipants olderthan69were9.6%higherthan

theestimatesbyyoungerparticipants.

Table1 Characteristicsofstudyparticipants.

n Unweighted(%) Weighted(%) Overall 1624 - -Gender Female 998 61.4 50.3 Male 626 38.6 49.7 Age,years <30 233 14.4 27.7 30-39 224 13.8 16.6 40-49 236 14.5 19.1 50-59 283 17.4 14.4 60-69 358 22.0 12.9 70-79 290 17.9 9.3 Education,years 0-4 793 48.9 42.5 5-9 301 18.6 18.4 10-12 313 19.3 25.2 >12 216 13.3 13.9 Healthliteracy(NVS) HLLL 786 48.4 45.9 PLL 471 29.0 28.6 AL 367 22.6 25.5 Hypertension No 1330 81.9 85.9 Yes 294 18.1 14.1 Previousstroke No 1589 97.8 98.2 Yes 35 2.2 1.8 PreviousMI No 1591 98.0 98.2 Yes 33 2.0 1.8

AL:adequateliteracy;HLLL:highlikelihoodoflimitedliteracy; MI:myocardialinfarction;NVS:NewestVitalSign;PLL: possibil-ityoflimitedliteracy.

672 N.Andradeetal.

Figure1 Knowledgeonbehaviors for preventionof cardio-vasculardiseases.

a_{Percentage ofparticipantsidentifying eachbehaviorasthe}

mostimportantforpreventionofcardiovasculardisease. Otherbehaviorsincludedtheintakeofmultivitamins, regular weighing,regularbloodtests,andregulargeneralcheck-ups.

‘‘Not smoking’’ and a ‘‘healthy diet’’ were identified asthe mostimportantbehaviorsfor preventionof cardio-vascular disease by 36.8% and 32.8% of the participants, respectively,while only3.4% reported‘‘checkblood pres-sure’’(Figure1).Nosignificantdifferenceswereobserved

inresponsesconcerningpreventive behaviorsaccording to

sociodemographic characteristics, health literacy or

pre-vious diagnosis of hypertension, stroke or MI, except for

physical exercise,which was less frequently identifiedby

respondentsover69yearsold(PR=0.39,95%CI:0.17-0.89).

Lessthanhalfoftheparticipantsanswered‘‘call

emer-gencynumber’’asthemost appropriateprocedure inthe

presence of facial drooping and chest pain (48.0% and

45.1%,respectively);thiswasindependentlyassociatedwith

greaterlevelsofhealthliteracy(AL:PR=1.44;95%CI:

1.17-1.76 and AL: PR=1.45; 95% CI: 1.17-1.80, respectively, in

comparisonwithHLLL).Amongtheotherparticipants,42.2%

and 39.6% answered ‘‘go to an emergency department’’

whenfacedwithanalarmsignorsymptomofstrokeandMI,

respectively,while1.1%and0.8%wereunabletoanswer.

Data about knowledge on the consequences of stroke

and MI are presented in Figure 2. The most

fre-quently reported consequences were ‘‘dependence in

dailyactivities’’ (90.7%), ‘‘impaired speech’’ (89.8%)and

‘‘paralysis’’(84.3%)forstroke,and‘‘heartfailure’’(86.4%),

‘‘dependenceindailyactivities’’(85.3%),‘‘impaired

driv-ing’’(81.6%)and‘‘anginapectoris’’(81.5%)forMI.

Table 3 presents the distribution of the two most

frequentlyreportedconsequencesofstrokeandMI,

accord-ing to sociodemographic characteristics, health literacy,

and clinical history of the participants. Identification of

‘‘dependenceindailyactivities’’asaconsequenceofstroke

wasmorefrequentamongthosewithadequatehealth

liter-acy (AL vs.HLLL: PR=1.08; 95%CI: 1.01-1.14) andwith a

previous diagnosisofhypertension(PR=1.05; 95%CI:

1.00-1.09), while ‘‘impaired speech’’ was more likely to be

reportedby moreeducated participants(>12 vs. <5years

education:PR=1.10;95%CI:1.00-1.21),thosewithadequate

health literacy (AL vs. HLLL: PR=1.07; 95% CI: 1.02-1.13)

andwithapreviousdiagnosisofMI(PR=1.12;95%CI:

1.06-1.18).RegardingthemainconsequencesofMI,participants

withadequate health literacy (ALvs. HLLL: PR=1.11; 95%

CI:1.04-1.19)andwithapreviousdiagnosisofMI(PR=1.18;

95%CI:1.06-1.31)morefrequentlystated‘‘heartfailure’’,

whilethosewhohadexperiencedstrokeweremorelikelyto

identify‘‘dependenceindailyactivities’’(PR=1.14;95%CI:

1.06-1.22).

Discussion

Thepresentstudyisinnovative,providingacharacterization

of key aspects of health-related knowledge on the

fre-quency,prevention,controlandconsequencesofCVDamong

the Portuguese population. Interpretation of the results

needstotake intoaccountthatgapsinspecificaspectsof

suchknowledgemaybeexpectedtohavedifferentimpacts

oneffortsforpreventionandcontrolofstrokeandMI.

Nearlyonethirdoftheparticipantswereunableto

esti-matethelifetimeriskofMIandstrokeinthepopulation.The

proportionofnon-respondentswashigh,especiallyamong

older participants,takingintoaccountthe highburden of

strokeandMIinthePortuguesepopulation,4_theattention

given in the lastdecade tothis subjectin health

promo-tioncampaignsaimedatthegeneralpopulation,17,18_andthe

increasingincidenceoftheseconditionswithage.19

Overall, the perceived risk of stroke and MI was

overestimated, with available studies on the Portuguese

population reportingincidenceratesof 207.3/100000and

82.9/100000 population, respectively,20 _{and prevalence}

estimates between 1.6 and 3.2%.21---23 _{However, it would}

probably bedifficult for thegeneral population to

distin-guishbetween thesemeasures, andinformationregarding

theriskofstrokeandMIcomesfrommethodologically

het-erogeneousstudiescarriedoutinpopulationswithdifferent

Paralysis

Dependence in daily activities

Impaired speech Dementia Epilepsy 20 40 60 80 100 Angina pectoris Heart failure Impaired driving Impaired sexual activity

Dependence in daily activities 20 40 60 80 100

Which of the following conditions may affect patients who survive a stroke (%)?a

Which of the following conditions may affect patients who survive myocardial infarction (%)?a

Figure2 Knowledgeofconsequencesofstrokeandmyocardialinfarction.

a_{Percentageofparticipantsidentifyingeachconditionasapossibleconsequenceaffectingpatientswhosurvivestrokeand} myocar-dialinfarction.

nowledge about cardiovascular disease in P ortugal 673

Table2 Perceivedriskofstrokeandmyocardialinfarction,accordingtosociodemographiccharacteristics,healthliteracyandhistoryofcardiovasculardisease. Forevery100Portuguese,howmanywillhavethisdiseaseduringtheirlives?

Stroke Myocardialinfarction

Don’tknow/didnotanswer No.ofpeopleaffected Don’tknow/didnotanswer No.ofpeopleaffected

% PR(95%CI)a _{Mean ␤(95%CI)}a _{% PR(95%CI)}a _{Mean ␤(95%CI)}a

Overall 29.9 — 34.2 — 29.7 — 35.6 —

Gender

Female 29.2 [reference] 38.4 [reference] 30.4 [reference] 40.0 [reference]

Male 30.6 1.09(0.90to1.32) 29.8 _−8.26(_−11.37to_−5.15) 29.0 0.98(0.80to1.21) 31.3 _−8.13(_−11.44to_−4.83)

Age(years)

<30 20.3 [reference] 31.6 [reference] 19.3 [reference] 33.4 [reference]

30-39 19.5 0.95(0.60to1.51) 33.9 2.73(−2.78to8.24) 20.1 1.01(0.63to1.63) 36.5 3.68(−2.13to9.50) 40-49 37.4 1.67(1.11to2.52) 35.2 3.07(_−2.40to8.54) 37.8 1.73(1.14to2.63) 36.2 2.29(_−3.64to8.22) 50-59 30.6 1.33(0.89to1.99) 35.4 2.92(−2.59to8.44) 33.7 1.48(0.99to2.21) 36.9 2.52(−3.94to8.98) 60-69 34.0 1.47(0.97to2.22) 34.7 1.69(_−5.31to8.68) 32.1 1.40(0.92to2.12) 34.5 _−1.19(_−8.85to6.47) 70-79 55.5 2.27(1.49to3.46) 41.4 9.59(0.91to18.26) 51.7 2.09(1.36to3.22) 42.2 8.43(−0.60to17.46) Education(years)

<5 36.9 [reference] 35.3 [reference] 36.9 [reference] 37.0 [reference]

5-9 33.5 1.21(0.91to1.62) 34.8 1.67(−3.80to7.14) 34.1 1.19(0.90to1.58) 34.9 −2.24(−8.14to3.66)

10-12 21.5 0.91(0.63to1.32) 31.8 −1.10(−7.27to5.07) 20.9 0.86(0.59to1.25) 33.9 −3.24(−10.22to3.75)

>12 19.6 0.90(0.59to1.40) 34.3 1.61(_−5.04to8.25) 17.9 0.77(0.49to1.22) 35.6 _−1.93(_−9.33to5.48)

Healthliteracy(NVS)

HLLL 37.7 [reference] 34.6 [reference] 37.5 [reference] 34.2 [reference]

PLL 28.3 0.87(0.68to1.11) 36.3 1.83(−2.42to6.08) 26.9 0.82(0.64to1.06) 39.6 6.19(1.70to10.68)

AL 17.8 0.61(0.42to0.87) 31.5 −1.92(−6.60to2.75) 18.8 0.66(0.48to0.91) 33.6 1.34(−3.62to6.31)

Hypertension

No 27.9 [reference] 33.6 [reference] 27.6 [reference] 35.2 [reference]

Yes 42.1 1.11(0.87to1.42) 38.8 1.69(_−2.68to6.06) 42.6 1.14(0.88to1.48) 39.2 1.02(_−3.54to5.57)

Previousstroke

No 30.2 [reference] 34.1 [reference] 29.7 [reference] 35.6 [reference]

Yes 17.4 0.41(0.22to0.79) 36.3 0.95(_−6.16to8.06) 29.5 0.71(0.30to1.67) 36.0 0.82(_−8.13to9.76)

PreviousMI

No 29.8 [reference] 34.1 [reference] 29.6 [reference] 35.5 [reference]

Yes 38.2 0.83(0.39to1.77) 40.4 5.77(−5.41to16.95) 34.9 0.79(0.35to1.75) 39.9 3.80(−6.11to13.71)

AL:adequateliteracy;CI:confidenceinterval;HLLL:highlikelihoodoflimitedliteracy;MI:myocardialinfarction;NVS:NewestVitalSign;PLL:possibilityoflimitedliteracy;PR:prevalence ratio.

674

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et

al.

Table3 Thetwomostfrequentlyreportedconsequencesofstrokeandmyocardialinfarction,accordingtosociodemographiccharacteristics,healthliteracyandhistoryof cardiovasculardisease.

Consequencesofstroke ConsequencesofMI

Dependenceindailyactivities Impairedspeech Heartfailure Dependenceindailyactivities

% PR(95%CI)a _{% PR(95%CI)}a _{% PR(95%CI)}a _{% PR(95%CI)}a

Gender

Women 92.1 [reference] 88.4 [reference] 86.2 [reference] 85.7 [reference]

Men 89.2 0.97(0.93to1.01) 91.2 1.03(0.98to1.08) 86.6 1.00(0.93to1.07) 85.0 0.99(0.94to1.04)

Age(years)

<30 92.3 [reference] 88.4 [reference] 87.7 [reference] 85.6 [reference]

30-39 87.1 0.94(0.87to1.02) 90.7 1.02(0.95to1.10) 87.2 0.99(0.90to1.09) 83.5 0.98(0.89to1.08) 40-49 88.5 0.98(0.89to1.08) 93.7 1.09(1.00to1.18) 89.2 1.04(0.94to1.15) 86.0 1.02(0.92to1.12) 50-59 95.0 1.07(0.99to1.15) 90.5 1.06(0.97to1.16) 90.6 1.07(0.99to1.15) 90.7 1.07(0.98to1.17) 60-69 90.9 1.05(0.95to1.16) 90.0 1.08(0.97to1.20) 86.1 1.04(0.94to1.15) 84.9 1.01(0.90to1.14) 70-79 89.3 1.04(0.93to1.16) 83.1 1.01(0.89to1.13) 69.6 0.85(0.72to1.01) 78.9 0.94(0.80to1.10) Education(years)

<5 88.4 [reference] 87.2 [reference] 82.6 [reference] 85.0 [reference]

5-9 91.7 1.05(0.96to1.16) 92.1 1.05(0.97to1.14) 89.8 1.05(0.97to1.13) 84.1 0.98(0.89to1.07)

10-12 91.8 1.05(0.94to1.17) 89.0 1.03(0.93to1.14) 88.8 1.03(0.94to1.14) 87.3 1.02(0.93to1.12)

>12 94.6 1.07(0.96to1.19) 96.8 1.10(1.00to1.21) 90.1 1.03(0.94to1.13) 85.4 0.99(0.89to1.10)

Healthliteracy(NVS)

HLLL 87.6 [reference] 87.3 [reference] 81.8 [reference] 83.9 [reference]

PLL 91.7 1.04(0.98to1.10) 88.6 1.00(0.94to1.07) 87.4 1.03(0.97to1.10) 85.4 1.00(0.93to1.08)

AL 94.8 1.08(1.01to1.14) 95.7 1.07(1.02to1.13) 93.5 1.11(1.04to1.19) 87.9 1.04(0.97to1.12)

Hypertension

No 90.2 [reference] 89.8 [reference] 86.9 [reference] 85.4 [reference]

Yes 93.4 1.05(1.00to1.09) 89.7 1.03(0.98to1.08) 83.7 1.01(0.93to1.10) 85.3 1.01(0.92to1.11)

Previousstroke

No 90.6 [reference] 89.7 [reference] 86.3 [reference] 85.1 [reference]

Yes 94.4 1.04(0.95to1.15) 95.4 1.08(0.98to1.19) 91.0 1.09(0.96to1.24) 97.0 1.14(1.06to1.22)

PreviousMI

No 90.6 [reference] 89.7 [reference] 86.3 [reference] 85.6 [reference]

Yes 93.7 1.06(0.97to1.16) 97.6 1.12(1.06to1.18) 93.7 1.18(1.06to1.31) 74.3 0.89(0.60to1.31)

AL:adequateliteracy;CI:confidenceinterval;HLLL:highlikelihoodoflimitedliteracy;MI:myocardialinfarction;NVS:NewestVitalSign;PLL:possibilityoflimitedliteracy;PR:prevalence ratio.

characteristics. It is estimated that stroke will affect at

leastoneinsixmiddle-agedpeopleduringtherestoftheir

lives.24,25_{Althoughsimilarestimatesarepresentedformen}

regarding MI, the risk is lower for women, with

approxi-matelyoneinninemiddle-agedwomensufferingMIintheir

remaininglifetime.26_{DespitethehigherprevalenceofCVD}

amongmen,3_{inourstudywomenreportedahigher}

percep-tionofrisk,asobservedinpreviousstudies.27,28_Also,older

participants tendedto havehigher risk perception,which

maybe duetomore frequent provision ofinformationby

thehealthcaresystemaboutstrokeandMI,sincetheyare

atgreaterriskofdisease.19

Prevention andcontrolofthemain modifiableCVDrisk

factors, suchassmoking, alcohol consumption, unhealthy

diet,obesity,hypertension,dyslipidemia,diabetes,

psycho-logical stress and a sedentary lifestyle, are fundamental

tools to reduce the burden of stroke and CHD.29,30

Parti-cipants identified not smoking and a healthy diet as the

mainpreventivebehaviorsforCVD,althoughtheyattributed

lower importance to blood pressure control, despite the

highprevalenceofhypertensioninthecountry.22_However,

since participants were asked to select the most

impor-tant froma list of different behaviors, it is possible that

theyassumedhighbloodpressurewouldbeaconsequence

of unhealthylifestyles. Recent guidelinesonCVD

preven-tion in clinical practice suggest that cognitive-behavioral

methods are effective in helping individuals to adopt a

healthylifestyle,emphasizingtheimplementationof

nutri-tion,exercise,relaxationtraining,weightmanagementand

smokingcessationprograms.31_{Thiscallsforappropriateand}

effectivecommunicationbetweenpatientsandhealth

pro-fessionals,whichwillfacilitatetreatmentandpreventionof

CVD.

In Portugal, in the presence of signsand/or symptoms

suspiciousofstroke orMI,thecorrectprocedureistocall

theemergencynumber.32_{Althoughlessthanhalfofthe}

par-ticipants surveyed selectedthis option inthe presenceof

facialdroopingorchestpain,approximately40%indicated

thattheywouldgodirectlytotheemergencydepartment,

whichisalsoavalidprocedure.Theresultspresentedarein

agreementwithpreviousPortuguesestudies,whichrevealed

thatonlybetween22.4%and68.0%ofrespondentswouldcall

theemergencynumberwhen facedwitha possiblestroke

orMI.33---35 _{Theselowpercentagesmaybeduetotwomain}

factors:lackofawarenessoftheimportanceofcallingthe

emergencynumber,thusactivatingfast-trackprotocols,or

theinabilitytolinkthesesignsandsymptomstoeventssuch

asstrokeorMI.OnestudyconductedinPortugalshowedthat

24%of respondentsdid notrecognizethe signsand

symp-tomsofMI.33_{Nevertheless,inourpopulation,thelikelihood}

of taking appropriate action, i.e., calling the emergency

number in the presence of facial droopingor chest pain,

increasedwithhealthliteracy,whichhighlightstheneedto

improvehealth literacyand cardiovasculardisease

knowl-edgeinthePortuguesepopulation.

As aconsequenceofdownwardtrendsin mortality,the

number of survivors from CHD and stroke is increasing,

which in turn has led to a greater number of

individ-uals suffering from sequelae.36 _{There is a wide range}

of outcomes after a CVD event, from no sequelae to a

comatose state, with considerable personal, emotional,

professional and financial costs to both individuals and

health services.37 _{Although dependence in daily}

activi-ties was frequently recognized as a major outcome of

stroke and MI, this sequela is in fact more prevalent in

stroke.38 _{This finding may be a consequence of the}

diffi-culty among the general population of differentiating MI

and stroke. Other potential consequences of stroke, such

asepilepsyand dementia,were less frequently reported,

possiblybecausetheymaybeperceived aslesssevere, or

ashaving other causes. However, previous studies reveal

that stroke almost doubles the risk of dementia after

the age of 65,39 _{and is the leading cause of seizures}

and epilepsy in the elderly.40 _{Thus, the dissemination}

of more comprehensive information regarding the global

burden of CVD is essential among the general

popula-tion.

Overall,respondentswithALweremorelikelytoanswer

thequestionsandtoprovidecorrectresponsesthanthose

with HLLL. However, a recent study reported that 49%

of Portuguese respondents have limited health literacy,41

highlighting the need to assess citizens’ health-related

knowledgewhenplanningcardiovascularpolicystrategies.

Thisstudy addresseda topicrarely investigatedin

Por-tugal --- knowledge of CVD --- based on a representative

sample of Portuguese-speakingresidents of mainland

Por-tugal.However,somelimitationsshouldbeacknowledged.

Healthliteracywasmeasuredusinganinstrumentdesigned

to assess overall health literacy skills42 _{that is not}

spe-cifictocardiovascularhealth-relatedknowledge.Thus,the

instrumentmaynotbesufficientlysensitivetoassesshealth

literacy concerning CVD specifically, given its particular

characteristics.DataontheconsequencesofstrokeandMI

wereobtained from recognition of possible consequences

in a list, which could lead to overestimation of

knowl-edgeinthisdomain.It hasbeenshown thatclosed-ended

questionsingeneralyield higherpercentages ofresponses

thanopen-endedquestions,43 _{andthelowerproportionof}

non-respondentsinthesequestionsappearstosupportthis

assumption. However, taking into account that the main

consequencesofstrokeandMIwereconsidered,significant

overestimationisunlikely.

Conclusion

EffectivepreventionandcontrolofCVDriskfactorsaswell

astherecognitionofsigns,symptoms,andwhattodowhen

facedwith alarm signs of an acute event44 _{are essential}

to reduce the burden of CVD. In the present study, the

largeproportionof non-respondentstoquestions

address-inghealth-relatedknowledge onstrokeandMI, which are

common conditions in Portugal, as well as participants’

lack of knowledge about vital aspects of these diseases,

highlighttheexistenceofimportantgapsincardiovascular

health-related knowledge. However, it was also observed

that individuals with adequate health literacy responded

more often and more appropriately than those with

lim-itedliteracy,indicatingthathealtheducationstrategiesand

practicesshouldbesensitive tothesedifferencesin order

toimprovecardiovascularhealthknowledgeamongthe

Por-tuguesepopulation.

Conflicts

of

interest

Theauthorshavenoconflictsofinteresttodeclare.

Acknowledgments

This study was funded by through the Operational

Pro-gramCompetitivenessandInternationalizationandnational

funding from the, under the project ‘Health information

ofPortuguese population: Knowledge andperceived

qual-ity and accessibility of health information sources’ (ref.

676 N.Andradeetal.

Investigac¸ãoemEpidemiologia---InstitutodeSaúdePública daUniversidade do Porto (EPIUnit)

(POCI-01-0145-FEDER-006862;ref. UID/DTP/04750/2013);the PostdocGrant (to

EA)andthePhDgrant(toARC)wereco-fundedbytheand

ProgramaOperacionalCapitalHumano(POCH/FSE).

TheEnglishversionoftheNVSwasdevelopedbyPfizer

Inc.PfizerInc.grantedauthorizationforthetranslationand

assessmentof the psychometric propertiesof NVSfor the

Portugueselanguageintheadultpopulation(aged18to64

years).

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