Health Care Student Attitudes toward the Prevention of Cardiovascular Disease
McFall, Marsha, Nonneman, Ruth, Rogers, Laura Q., Mukerji, Vaskar, Nursing Education Perspectives
ABSTRACT Enhancing successful counseling for cardiovascular disease prevention remains a challenge for health professionals and nursing and medical educators. To gain insight into the attitudes of health care professional students toward cardiovascular prevention strategies, this study examined the associations among prevention attitudes and health professional student demographics and health habits. Based on a self-administered survey completed by nursing and medical students from two Midwestern institutions, healthier personal lifestyle choices were independently associated with more positive attitudes toward cardiovascular prevention, but demographic factors were not. Educational experiences that encourage reflection on student lifestyles may enhance the counseling abilities of both nurses and physicians.
RESEARCH AND PRACTICE DURING THE PAST DECADE HAVE DEMONSTRATED THE SIGNIFICANT IMPACT OF LIFESTYLE BEHAVIORS ON HEALTH, ESPECIALLY REGARDING THE PRIMARY AND SECONDARY PREVENTION OF CARDIOVASCULAR DISEASE (KASHANI ET AL., 1992; McPHERSON, SWENSON, PINE, & LEIMER, 2002). The control of risk factors for cardiovascular disease reduces disease incidence and progression. Most Americans are aware of these risks, some of which include uncontrolled high blood pressure, high cholesterol levels, physical inactivity, long-term stress, obesity, smoking, diabetes, and excessive alcohol intake (Dismuke & McClary, 1990; Frisch, Kurtz, & Shamsuddin, 1999; Greenland et al., I988; Greenland & Derby, 1992; Haq et al., 2000; Kashani et al., 1993; Lynn, 2000; Reeve, Adams, & Kouzekanani, 1996; Sherman & Hershman, 1993 ; Steptoe, Doherty, Kendrick, Rink, & Hilton, 1999; Ziglio, Hagard, McMahon, Harvey, & Levin, 2000). Americans also express a need for health care professionals, including physicians and nurses in various settings, to convey information to them regarding healthy lifestyles (Greenland et al.; Greenland & Derby; Steptoe et al.). * Although physicians understand the importance of healthy lifestyle components, many feel that they are unsuccessful in altering client behaviors. Thus, their attitudes toward counseling patients are frequently pessimistic (Greenland et al.; Sherman & Hershman, 1993). Furthermore, physician attitudes and personal habits are strongly associated with patient counseling outcomes (Greenland et al.; Greenland & Derby, 1992) and have the potential to inhibit adequate health promotion counseling (Rogers et al., 2006).
Nurses have also been studied with regard to counseling patients from the perspectives of efficacy and their own personal lifestyle habits (Engler, Engler, Davidson, & Slaughter, 1992; Geirsson, Bendtaen, & Spak, 2005; Hoppe & Ogden, 1997; McPherson et al., 2002; Reeve et al., 1996; Sherman & Hershman, 1993; Steptoe et al., 1999; Wilt, Hubbard, & Thomas, 1990). Studies revealed that most nurses understood the connection between personal health and illness. But, as with physicians, they often were not optimistic about the effectiveness of their efforts toward preventive behaviors. Studies assessing the connection between counseling attitudes and smoking (Reeve et al.) or body weight (Hoppe & Ogden) demonstrated that nurses who engaged in the studied addictive behavior were less likely to address it with patients.
Researchers have reported that exposing medical students to the cardiovascular curriculum has led to changes in their attitudes toward their own counseling ability and effectiveness. However, changes have often been modest or difficult to prove statistically (Dismuke & McClary, 1990; Greenland et al., 1988; Greenland & Derby, 1992; Kashani et al., 1992; Rogers et al., 2005; Sherman & Hershman, 1993). Two studies done in the 1990s demonstrated that medical students were able to lower their own personal risks after introduction to pertinent materials and an analysis of their own health (Greenlee, Castle, & Woolley, 1992; Kashani et al., 1992), but whether this change influenced counseling attitudes or behaviors was inconclusive. Knowledge related to healthy lifestyles improves with the presentation of additional content (Dismuke & McClary, 1990; Engler et al., 1992; Frisch et al., 1999; Kashani et al., 1992), but this improvement does not consistently correlate with physicians feeling more positive about their counseling efforts.
Nurses also benefit from additional knowledge and feel more positive than physicians about their prevention counseling effectiveness (Geirsson et al., 2005; Steptoe et al., 1999). However, Hoppe and Ogden (1997) reaffirmed that despite increasing awareness that the belief system of health care professionals could be extremely significant, prior studies had focused on patient attitudes and not on the attitudes of caregivers.
Cardiovascular disease remains a significant cause of death in the United States. With both patients and health care professionals demonstrating greater knowledge about cardiac risk factors and a potential willingness to discuss these factors, reasons for the limited decline in morbidity have become more difficult to understand. A disparity continues to exist between educational outcomes of health promotion and effective lifestyle counseling.
The attitudes of nursing and medical students toward cardiovascular disease prevention and their relationship to personal life choices have not been thoroughly assessed. The design of both nursing and medical school curricula might benefit from such information. Therefore, the first aim of this study was to examine the associations between cardiovascular disease prevention attitudes and the demographic factors of student type (nursing/medical), age, and gender. The second aim was to examine the associations between personal health habits and cardiovascular disease prevention attitudes.
Method SAMPLE Between 2001 and 2003, the authors surveyed baccalaureate nursing students from two Midwestern universities and medical students from one Midwestern university. A 25-item questionnaire using a five-point Likert scale was given to students who volunteered to participate. The research study was approved by the local institutional review board.
The goal was to assess baseline attitudes before educational interventions might alter students' responses. The nursing students had completed basic science courses, but had minimal clinical experience. They were invited to participate prior to their cardiovascular theory and acute care setting clinical rotations. The medical students were in their third year of medical school and had basic science knowledge, which included pathology and pharmacology. They were invited to participate in the study prior to their cardiology clerkship experience; the correlation of theory to clinical situations and the application of cardiovascular protocols are implemented during this cardiology rotation.
Twenty-nine medical students and 72 nursing students (n = 101) completed the survey. The overall response rate was 83 percent. Twenty-four percent of the study participants were male. Among the nursing students, only four students were male (6 percent). Among the medical students, 20 were male (69 percent). The mean age of the sample was 23 [+ or -] 4.6 with a range of 19 to 49.
INSTRUMENT The questionnaire expanded a survey conducted by Greenland et al. (1988). The initial portion, five items, assessed attitudes toward the effectiveness of primary prevention. This portion was previously validated among first-year medical students in Greenland's study; Cronbach's alpha in the current sample was .66. The priority of cardiovascular disease prevention research (three items, Cronbach's alpha = .61) was also addressed. Six items assessed attitudes toward the usefulness of smoking cessation, treatment of hypertension, and hyperlipidemia management for primary prevention and attitudes toward the usefulness of each for treatment. Two items assessed the expected treatment and prevention benefit of weight loss in the obese patient and regular exercise. Seven items assessed personal health habits (preference for nonsmoking restaurant, recent blood pressure check, awareness of own cholesterol level, heart healthy diet, regular exercise, taking time for social activities, and awareness of family history related to heart disease). Two questions assessed gender and age.
ANALYSIS To achieve data reduction, two principal factor analyses were done (one for the eight items assessing attitudes toward risk factor interventions/one for the seven items assessing personal health habits). Factors were determined based on Eigen values > 1.0, factor loading [greater than or equal to] 4.0, inspection of Scree plots, and intuitive grouping patterns. All eight items regarding interventions loaded onto one factor (Eigen value = 4.6, Cronbach's alpha = .89 in the current sample). With regard to personal health, only four items (smoking, diet, exercise, and awareness of family history) loaded adequately onto one factor (Eigen value = 2.1, Cronbach's alpha = .67). Therefore, the mean of these four items was calculated for a "personal health" assessment. The items assessing blood pressure monitoring, individual cholesterol awareness, and time for social/recreational activities were analyzed separately.
The mean was calculated for each scale: effectiveness of primary prevention in general, five items; cardiovascular disease prevention research priority, three items; effectiveness of risk factor interventions for primary and secondary prevention, eight items; and personal health, four items. After performing descriptive analyses, Pearson correlation coefficients were calculated to explore the unadjusted associations among attitudes, personal health habits, and demographic factors. To achieve the stated study aims, partial correlations were performed adjusting for those covariates suggested by significant associations in the unadjusted analyses.
Results Means, standard deviations, and unadjusted Pearson correlation coefficients are provided in Table 1. The highest mean score for prevention attitudes was for the effectiveness of risk factor interventions, followed by primary prevention effectiveness and the priority of prevention research. Among health habits, personal blood pressure monitoring was reported most often, followed by making time for social activity, personal health, and personal awareness of cholesterol.
With regard to the first study aim, student type, age, and gender were not associated with attitudes toward the effectiveness of primary prevention or the priority of cardiovascular prevention research (Table 1). However, risk factor interventions were felt to be more effective by medical students (r = .234, p < .05), older respondents (r = .200, p < .05), and men (r = -.222, p < .05). Because of the significant associations among student type, age, and gender, partial correlations were done to assess the associations with each of these demographic variables while adjusting for the remaining two. None of the demographic variables were found to be associated with attitudes about primary prevention effectiveness, research priority, or risk factor intervention usefulness after adjustment.
With regard to the second study aim, respondents reporting better personal health also reported more positive attitudes toward primary prevention effectiveness (r = .248, p < .05) and the effectiveness of risk factor interventions (r = .340, p < .01). Personal blood pressure monitoring, personal awareness of cholesterol, and social activity were not associated with primary prevention or risk factor intervention effectiveness. No variables related to health habits were associated with attitudes toward the priority of research.
Partial correlations adjusting for student type, age, and gender (Table 2) revealed persistent associations between better personal health and more positive attitudes toward the effectiveness of primary prevention (r = .287, p < .01) and risk factor interventions (r = .301, p < .01). Personal blood pressure monitoring was also associated with perceiving risk factor interventions as effective (r = .224, p < .05) after adjustment. Similar to the unadjusted analysis, health habits remained unassociated with attitudes about the priority of prevention research after adjustment.
Discussion Both nursing and medical students reported generally positive attitudes about cardiovascular prevention and certain healthy personal habits, with no association found between prevention attitudes and student type, gender, or age after adjustment. Although certain aspects of personal health appear related to the perception of risk factor intervention effectiveness, these same aspects were not associated with attitudes toward primary prevention in general or the priority of prevention research.
Although the finding that attitudes toward cardiovascular disease prevention were generally positive is consistent with prior studies, the current study is the first since Greenland (Greenland et al., 1988; Greenland & Derby, 1992) to assess these attitudes and among only a few that compare nurses and physicians. The presence of generally positive attitudes suggests a disconnect between knowledge about effective clinical care and actual or perceived ability to provide such care, especially with regard to lifestyle behaviors. The results suggest the need for classroom and clinical experiences that teach evidence-based strategies for enhancing healthy behaviors in patients. Such educational experiences should emphasize practical applications, rather than the need for such interventions.
The finding suggesting an association between personal lifestyle choices and prevention attitudes is also consistent with prior studies, reiterating the need for further assessment of personal health behaviors among health care students. This assessment should focus, at least in part, on nursing students, whose personal lifestyle issues have not been addressed in the literature as often as those of medical students. These issues remain largely unknown. Furthermore, objective assessment, rather than self-report, is needed to more accurately assess the potential need for intervention in both nursing and medical students to enhance their lifestyle behaviors. Once this need is clarified, prospective studies are warranted to determine if student attitudes can be improved by interventions aimed at the enhancement of personal health habits.
While a limited number of studies have included both physicians and nurses, this study is the first to include both nursing and medical students prior to being exposed to pertinent information and actual clients. The use of this type of sample offers the advantage of examining attitudes in the very formative stages. The study is also strengthened by its response rate of 83 percent and the fact that multidomain measurements were utilized. Nevertheless, several study limitations exist. The study included a small medical student sample as compared to the nursing student sample; used a cross-sectional design, making it more difficult to determine which comes first, lifestyle or attitude; and used self-reporting in reference to health habit data. Although the survey was confidential, use of self-report might have resulted in overestimating healthy behaviors, thus explaining the relatively high mean values for personal behaviors.
The need to expand both classroom and clinical experiences in the areas of lifestyle assessment and counseling seems apparent for both nurses and physicians. It is reassuring that students may not have to be convinced of the importance of prevention strategies, but education of health care professionals should provide practical skills for effectively delivering prevention interventions. Future prospective studies including both groups of students are needed. These should include objective measures of personal behaviors and assessments of health beliefs to explore possible mechanisms for meshing care provider beliefs with those of clients. Additional and expanded research is essential if we are to truly embrace the concept of cardiovascular disease prevention in the practice setting.
Cardiovascular Disease Prevention--Nursing Student Attitudes--Medical Student Attitudes--Lifestyle Behaviors--Health Promotion Counseling
Dismuke, S. E., & McClary, A. M. (1990). Evaluation of an educational program in preventive cardiology. American Journal of Preventive Medicine, 6(2), 99-105.
Engler, M. M., Engler, M. B., Davidson, D. M., & Slaughter, R. E. (1992). Cardiovascular disease prevention: Knowledge and attitudes of graduate nursing students. Journal of Advanced Nursing, 17(10), 1220-1225.
Frisch, A. S., Kurtz, M., & Shamsuddin, K. (1999). Knowledge, attitudes and preventive efforts of Malaysian medical students regarding exposure to environmental tobacco and cigarette smoking. Journal of Adolescence, 22(5), 627-634.
Geirsson, M., Bendtsen, P., & Spak, F. (2005). Attitudes of Swedish general practitioners and nurses to working with lifestyle change, with special reference to alcohol consumption. Alcohol and Alcoholism, 40(5), 388-393.
Greenland, P., Castle, C. H., Cohen, J. D., Davidson, D. M., Krakoff, L. R., Nowacek, G.A., et al. (1988). Attitudes toward prevention of cardiovascular diseases among first-year students at eight American medical schools, 1983-1985. Preventive Medicine, 17(6), 700-711.
Greenland, P., & Derby, C.A. (1992). Medical students' improved attitudes toward prevention of cardiovascular diseases from entry to graduation. Preventive Cardiology Academic Cooperative Research Group of the National Heart, Lung, and Blood Institute. American Journal of Preventive Medicine, 8(1), 53-57.
Greenlee, R, Castle, C. H., & Woolley, F. R. (1992). Successful modification of medical students' cardiovascular risk factors. American Journal of Preventive Medicine, 8(1), 43-52.
Haq, C., Rothenberg, D., Gjerde, C., Bobula, J., Wilson, C., Bickley, L., et al. (2000). New world views: Preparing physicians in training for global health work. Family Medicine, 32(8), 566-572.
Hoppe, R., & Ogden, J. (1997). Practice nurses' beliefs about obesity and weight related interventions in primary care. International Journal of Obesity and Related Metabolic Disorders, 21(2), 141-146.
Kashani, I.A., Kaplan, R. M., Criqui, M. H., Nader, P. R., Rupp, J., Sallis, J. F., et al. (1992). Cardiovascular risk factor assessment of medical students as an educational tool. American Journal of Preventive Medicine, 8(6), 384-388.
Kashani, I.A., Kaplan, R. M., Rupp, J.W., Langer, R. D., McCann,T. J., Sallis, J. F., et al. (1993). Effects of a preventive cardiology curriculum on behavioral cardiovascular risk factors and knowledge of medical students. Patient Education and Counseling, 21(1-2), 15-27.
Lynn, M. M. (2000). Primary and secondary prevention of coronary heart disease. Evidence offers multiple strategies. Advance for Nurse Practitioners, 8(6), 37-43.
McPherson, C. P., Swenson, K. K., Pine, D.A., & Leimer, L. (2002). A nurse-based pilot program to reduce cardiovascular risk factors in a primary care setting. American Journal of Managed Care, 8(6), 543-555.
Reeve, K., Adams, J., & Kouzekanani, K. (I 996).The nurse as exemplar: Smoking status as a predictor of attitude toward smoking and smoking cessation. Cancer Practice, 4(1), 31-33.
Rogers, L. Q., Gutin, B., Humphries, M. C., Lemmon, C. R., Waller, J. L., Baranowski, T., et al. (2005). A physician fitness program: Enhancing the physician as an "exercise" role model for patients. Teaching and Learning in Medicine, 17(1), 27-35.
Rogers, L. Q., Gutin, B., Humphries, M. C., Lemmon, C. R., Waller, J. L., Baranowski, T., et al. (2006). Evaluation of internal medicine residents as exercise role models and associations with self-reported counseling behavior, confidence, and perceived success. Teaching and Learning in Medicine, 18(3), 215-221.
Sherman, S. E., & Hershman, W. Y. (1993). Exercise counseling: How do general internists do? Journal of General Internal Medicine, 8(5), 243-248.
Steptoe, A., Doherty, S., Kendrick, T., Rink, E., & Hilton, S. (1999). Attitudes to cardiovascular health promotion among GPs and practice nurses. Family Practice, 16(2), 158-163.
Wilt, S., Hubbard, A., &Thomas, A. (1990). Knowledge, attitudes, treatment practices, and health behaviors of nurses regarding blood cholesterol and cardiovascular disease. Preventive Medicine, 19(4), 466-475.
Zigliol, E., Hagard, S., McMahon, L., Harvey, S., & Levin, L. (2000). Principles, methodology and practices of investment for health. Promotion and Education, 7(2), 4-15.
Marsha McFall, MS, RN, is an assistant professor at St. John's College Department of Nursing, Springfield, Illinois. Ruth Nonneman, MS, RN, CNP, retired, was a nurse practitioner with the Southern Illinois University School of Medicine, Division of Cardiology, Springfield. Laura Q. Rogers, MD, MPH, is an associate professor, Southern Illinois University School of Medicine, Springfield. Vaskar Mukerji, MD, is an intervention cardiologist, Springfield Clinic, Springfield. Contact Dr. Rogers at email@example.com.
Table 1. Unadjusted Correlations Among Demographic Factors, Personal Health, and Cardiovascular Disease Prevention Attitudes 1 2 3 4 1. Student type (1 = nursing, .369 *** -.674 *** -.027 2 = medical) 2. Age -.235 * .018 3. Gender (I = male, 2 = .032 female) 4. Effectiveness of primary prevention (M = 4.2, SD = .53) 5. Cardiovascular disease prevention research priority (M = 3.6, SD = .54) 6. Effectiveness of risk factor interventions (M = 4.5, SD =.45) 7. Personal health (M = 3.8, SD = .68) 8. Personal blood pressure monitoring (M = 4.5, SD =.70) 9. Personal awareness of cholesterol (M = 3.6, SD = 1. 15) 10. Social Activity (M = 4.1, SD = .84) 5 6 7 1. Student type (1 = nursing, .131 .234 * .332 ** 2 = medical) 2. Age .061 .200 * .028 3. Gender (I = male, 2 = .094 -.222 * -.245 * female) 4. Effectiveness of primary .364 ** .444 ** .248 * prevention (M = 4.2, SD = .53) 5. Cardiovascular disease .168 .113 prevention research priority (M = 3.6, SD = .54) 6. Effectiveness of risk .340 ** factor interventions (M = 4.5, SD =.45) 7. Personal health (M = 3.8, SD = .68) 8. Personal blood pressure monitoring (M = 4.5, SD =.70) 9. Personal awareness of cholesterol (M = 3.6, SD = 1. 15) 10. Social Activity (M = 4.1, SD = .84) 8 9 10 1. Student type (1 = nursing, -.137 .171 .173 2 = medical) 2. Age .063 .074 -.282 ** 3. Gender (I = male, 2 = .029 .061 .088 female) 4. Effectiveness of primary .014 .086 .083 prevention (M = 4.2, SD = .53) 5. Cardiovascular disease .034 .014 .062 prevention research priority (M = 3.6, SD = .54) 6. Effectiveness of risk .185 .021 .057 factor interventions (M = 4.5, SD =.45) 7. Personal health (M = 3.8, .144 .122 .107 SD = .68) 8. Personal blood pressure .344 ** .383 ** monitoring (M = 4.5, SD =.70) 9. Personal awareness of .065 cholesterol (M = 3.6, SD = 1. 15) 10. Social Activity (M = 4.1, SD = .84) * p<.05 / ** p<.01 / *** p<.001 Table 2. Partial Correlations Between Personal Health Habits and Cardiovascular Disease Prevention Attitudes Adjusted for Age, Gender, and Student Type EFFECTIVENESS PREVENTION EFFECTIVENESS OF PRIMARY RESEARCH OF RISK FACTOR PREVENTION PRIORITY INTERVENTIONS Personal Health .287 ** .168 .301 ** Personal Blood Pressure Monitoring .005 -.053 .224 * Personal Cholesterol Awareness .077 -.007 .040 Social Activities .076 .038 .135 * p<.05 / ** p<.01…
Questia, a part of Gale, Cengage Learning. www.questia.com
Publication information: Article title: Health Care Student Attitudes toward the Prevention of Cardiovascular Disease. Contributors: McFall, Marsha - Author, Nonneman, Ruth - Author, Rogers, Laura Q. - Author, Mukerji, Vaskar - Author. Journal title: Nursing Education Perspectives. Volume: 30. Issue: 5 Publication date: September-October 2009. Page number: 285+. © 2009 National League for Nursing, Inc. COPYRIGHT 2009 Gale Group.
This material is protected by copyright and, with the exception of fair use, may not be further copied, distributed or transmitted in any form or by any means.