Awareness and knowledge of cardiovascular disease and their associations with the lifestyles of 8-16-year-old girls: a perspective from Saudi Arabia

Abstract

Background

There has been an increased focus on children as a target for primordial prevention of cardiovascular disease (CVD). In particular, girls should receive attention to combat the burden of CVD in women, because women have higher CVD mortality and morbidity rates than men do. As health literacy is paramount, the evaluation of awareness, and knowledge of CVD and its risk factors and their associations with the lifestyles of girls forms the basis for planning cardiovascular health promotion programs aiming to improve girls’ immediate health and reduce the future burden of CVD among women.

Methods

A prospective cross-sectional study was conducted on a random sample of girls attending elementary and intermediate schools in Riyadh, Saudi Arabia. The girls completed a newly validated 24-item questionnaire that assessed their demographic data, lifestyles, and awareness and knowledge of CVD and its risk factors. Anthropometric and blood pressure measurements were obtained. Knowledge scores were calculated on the basis of correct responses and compared between subgroups via analysis of variance to determine associated factors.

Results

In total, 469 girls (mean age of 12.5 years) were included. Approximately 41.4% of them did not exercise or only exercised once a week. The dietary intake of important food groups was below or just at the minimal recommended servings for most. Overall, 44.1% were overweight/obese, and almost half were identified as hypertensive on the basis of a single resting measurement. Awareness of CVD as a dangerous disease in adults was 50.3%, whereas, cancer was identified by 61% of participants. Individual risk factors were identified by ≈ 25%, and 16.6% were not aware of any risk factors. The overall knowledge score of the participants was 2.6 (± 1.6) out of a total possible score of 8 representing 32.5% (± 20%). Knowledge levels were positively influenced by increasing school grade (P = 0.001) and family history of CVD (P < 0.001). There was no significant favorable association between improved knowledge level and lifestyle factors.

Conclusion

The awareness and knowledge of CVD among girls aged 8–16 years are poor and are largely dissociated from their lifestyle. Improved knowledge scores with increasing school grade and family history of CVD confirm a role for schools and families in improving girls’ knowledge. Our findings mirror those obtained in older women, showing that misinformation among women starts in childhood and should be targeted early in life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-19698-x.

Introduction

Cardiovascular disease (CVD), often considered a disease of men, is the greatest threat to women’s health worldwide [1]. Females experience greater CVD mortality and morbidity [2] but are largely unaware of CVD [3, 4], underestimate their risk [5] and do not engage in behaviors known to reduce this risk [4]. To improve women’s cardiovascular health, there has been increased research interest in measuring and improving their awareness of CVD [6, 7], which has been extended to teenage girls [4]. This interest should also include female children, as childhood is a critical phase for determining cardiovascular health [8] and for primordial prevention of CVD [9].

Health literacy in young people is paramount for the prevention of CVD in the future [9]. There is a general agreement that the risk of CVD increases from childhood and that children and adolescents should be a primary focus for health evaluation and promotion [10]. In this rapidly evolving pandemic of CVD risk factors among young people, health officials should monitor the awareness of CVD and the health habits of children and adolescents for optimal planning and modification of health promotion programs aimed at CVD prevention [11]. Accordingly, girls should be a main target for knowledge and health evaluation and subsequent education and health promotion.

In general, very few studies have evaluated children’s and adolescents’ awareness and knowledge of CVD and its risk factors, the factors influencing their knowledge, and the impact of their knowledge on their lifestyle [12, 13]. In particular, little is known about young girls’ awareness and how this relates to that of teenage females and adult women. This is because very few studies involving children and adolescents have focused on gender differences in knowledge [14, 15] and most studies have lacked an assessment of important CVD related knowledge aspects [13–16], which are commonly evaluated in women’s research. Hence, this study aimed to evaluate the awareness and comprehension of CVD and its associated risk factors among girls from childhood to adolescence in a sample of schoolgirls in Riyadh, Saudi Arabia. The study also aims to analyze the factors affecting their knowledge and investigate the impact of awareness on their lifestyle decisions.

Materials and methods

Study design and ethics approval

This was a prospective cross-sectional study conducted on a random sample of girls attending elementary and intermediate schools in Riyadh, the capital of Saudi Arabia. The study was approved by the institutional review board at Princess Nourah bint Abdulrahman University (IRB log number: 19–0186).

Participant selection and sample size calculation

A cluster random sampling technique was used to select primary and intermediate girls’ schools in Riyadh. With the assistance of the General Administration of Education in Riyadh, Ministry of Education, four out of the nine school districts of Riyadh were randomly selected for this study. The lists of primary and intermediate schools within these districts were obtained and the investigators selected participating schools by random sampling. The investigators visited the schools until the target sample size was reached.

The inclusion criteria were as follows: studies in primary or intermediate grade and parent or guardian agreed to participate by signing the study consent form. Girls whose parents/guardians did not provide consent for participation and those who were absent during the investigators’ visits to their school were excluded. Investigators visited the selected schools twice from October 2019 to March 2020. The aim of the initial visit was to distribute the informed consent forms for participation to all the girls at the specified school grades in the selected schools. The second visit was for data collection. On the second visit, the participants were requested to complete the questionnaire, and their measurements were obtained. A sample size of 400 students was planned to provide a precision level of at least 5% for the 95% confidence interval of any binary response in the questionnaire [17].

Questionnaire design and distribution

A newly developed structured Arabic questionnaire was used in this study. The questionnaire comprised 24 questions (Appendix 1). All the questions were closed-ended, except for one that assessed the exercise duration of the participants. Among all the questions, three assessed the students’ awareness and knowledge of CVD as one of the most important and serious diseases in adults and its risk factors. These questions were adapted from previous similar questionnaires involving other populations [4, 13, 15, 16]. Additionally, there were seven questions on the sociodemographic factors of the participants and 14 on the personal and family history of CVD, risk factors and lifestyle of the participants, including physical activity and dietary preferences, daily intake of fruits, vegetables, milk, and cheese, and sedentary time (time spent watching TV, using tablets, or playing video games).

The questionnaire was validated by the investigators in terms of face validity and content validity. Then, it was validated in a sample of the targeted population (n = 20) who were not included in the study before its use [18, 19]. For primary school children, the questionnaire was completed through interviews with senior medical students and interns. For intermediate school students, the participants completed the questionnaire themselves [19, 20].

Measurements

The participants’ heights and weights were measured once at study entry using a traditional stadiometer and digital scale measurement tool (Seca, Hamburg, Germany). BMI was characterized on the basis of sex- and age-specific BMI percentiles based on the growth chart criteria of the U.S. Centers for Disease Control and Prevention (CDC). An online calculator available on the CDC website that provides BMI and the corresponding BMI for age percentiles on the basis of CDC growth charts for children and teens aged 2 through 19 years was used for this purpose [21]. Obesity was defined as a BMI ≥ 95th percentile.

Blood pressure (BP) was measured using an Omron M6 Comfort (HEM7223-E) automated BP device. A single brachial BP reading was taken while the participant was resting. If the initial reading was elevated, a second reading was obtained after a few minutes, the first reading was discarded, and the second reading was recorded. The BP of the participants was classified as normal, elevated, stage 1, or stage 2 hypertension on the basis of published guidelines. The referenced online tool was used for this purpose [22]. In brief, for girls aged < 13 years, BP was classified as normal when the BP was < 90th percentile, elevated when the BP was ≥ 90th percentile to < 95th percentile or 120/80 mmHg to < 95th percentile (whichever is lower), stage 1 hypertension when the BP was ≥ 95th percentile to < 95th percentile + 12 mmHg or 130/80 to 139/89 mmHg (whichever is lower), and stage 2 hypertension when the BP was ≥ 95th percentile + 12 mmHg or ≥ 140/90 mmHg (whichever is lower). BP in girls aged ≥ 13 years was considered normal when the BP was < 120/<80 mmHg, elevated if the BP was 120/<80 to 129/<80 mmHg, stage 1 hypertension when the BP was 130/80 to 139/89 mmHg, and stage 2 hypertension when the BP was ≥ 140/90 mmHg. If the BP was > 30 mmHg above the 95th percentile in girls < 13 years of age or > 180/120 mmHg in those aged ≥ 13 years, this was considered critical [22].

Statistical analysis

Categorical variables are reported as numbers and percentages, and continuous variables are expressed as the means and standard deviations or medians with interquartile ranges as appropriate. A p value of ≤ 0.05 was considered to indicate statistical significance. All analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC). The knowledge levels of the participants were evaluated as scores calculated on the basis of correct responses to the knowledge-related questions. Recognition of CVD as one of the most dangerous diseases that affect adults, identification of each of the risk factors, and categorization of cardiac disease as very dangerous were each given a score of 1, for a total score of 8. Those who selected the “I do not know” option were considered to provide an incorrect response. Comparisons of knowledge scores between subgroups defined by participant characteristics were performed using analysis of variance. For classification of the knowledge level, the knowledge score was expressed as the percentage of correct answers (participants’ knowledge score/total number of correct answers (or 8) × 100) and was classified as excellent (90–100%), very good (80–89%), good (70–79%), acceptable (60–69%), or poor (< 59%) [23].

Results

Baseline characteristics

In total, 469 girls (200 from 3 elementary schools and 269 from 4 intermediate schools) were included in the study. The baseline characteristics, medical and family histories of the participants are shown in Table 1. The mean age was 12.5 years (range 8.0–16.0 years), and 91% were Saudis. Overall, 11% of the participants reported a history of chronic illness, which was mostly asthma (5%), and 3.2% had a family history of heart disease.

Table 1.

Baseline characteristics, medical and family histories of the participants

Characteristics	N = 469
Age, years
Mean ± SD	12.5 (1.8)
Range	(8.0, 16.0)
School grade, n (%)
4th	65 (13.9)
5th	52 (11.1)
6th	83 (17.7)
7th	58 (12.4)
8th	127 (27.1)
9th	84 (17.9)
Nationality, n (%)
Non-Saudi	42 (9.0)
Saudi	427 (91.0)
Number of siblings
Median, IQR	4.0 (3.0, 6.0)
Range	(0.0, 8.0)
Mother’s job, n (%)
Teacher/Employee	159 (33.9)
Doctor/Dentist/Pharmacist	10 (2.2)
Homemaker	267 (56.9)
Retired	22 (4.7)
Other	11 (2.3)
Father’s job, n (%)
Teacher/Engineer/Employee	292 (62.3)
Doctor/Dentist/Pharmacist	21 (4.5)
Unemployed	55 (11.7)
Retired	15 (3.2)
Other	86 (18.3)
Personal history of chronic illness, n (%)
No	406 (89.0)
Heart disease	3 (0.7)
Hypertension	1 (0.2)
Diabetes	3 (0.7)
Dyslipidemia	1 (0.2)
Asthma	23 (5.0)
Other	19 (4.2)
Unknown	13 (2.8)
Family history of chronic illness (parents/siblings), n (%)
No	289 (61.6)
Yes^	151 (32.2)
Heart disease	15/469 (3.2)
Hypertension	44/469 (9.4)
Diabetes	92/469 (19.6)
Dyslipidemia	6/469 (1.3)
Other	35/469 (7.4)
Unknown	29 (6.2)

^ Multiple categories can be selected by each participant

SD = Standard deviation

The lifestyle and health traits of the participants are displayed in Table 2. Approximately 41.4% of the participants did not exercise or only exercised once a week. Self-reported sedentary time (including watching TV, using tablets, and playing video games/day) was 4 h or greater in 37.5% of the participants. The dietary intake of fruits and vegetables, milk and cheese, red meat, chicken, and fish, as well as food preferences, are shown in Table 2. Approximately 85% of the participants either never consumed any product from these dietary groups or consumed only one to two portions per day. Overall, 44.1% of the participants were overweight or obese, and 39.1% and 12.3% were classified as having stage 1 hypertension and stage 2/critical hypertension, respectively, on the basis of a single resting measurement (Table 2).

Table 2.

Lifestyle and health traits of the participants

Lifestyle	N = 469
Portions of fruits and vegetables consumed per day, n (%)
0	64 (13.6)
1–2	322 (68.7)
3	60 (12.8)
4	12 (2.6)
5 or more	11 (2.3)
Portions of milk and cheese consumed per day, n (%)
0	64 (13.6)
1–2	320 (68.2)
3	62 (13.2)
4	12 (2.6)
5 or more	11 (2.3)
Portions of red meat, chicken and fish consumed per day, n (%)
0	65 (13.9)
1–2	333 (71.0)
3	69 (14.7)
4	1 (0.2)
5 or more	1 (0.2)
Preferred food type, n (%)^
Fast food/French fries	231 (49.3)
Chocolate and candy/cakes and biscuits	209 (44.6)
Fruits and vegetables	187 (39.9)
Chicken/fish	135 (28.8)
Milk and cheese	71 (15.1)
Red meat	70 (14.9)
Other	41 (8.7)
Participated in sports activities – Number of days per week, n (%)
Never	106 (22.6)
Once a week	88 (18.8)
Twice a week	110 (23.5)
4–6 times a week	73 (15.6)
Daily	92 (19.6)
Number of minutes of sports practice in one of those days (among those who practiced sports)
Median, IQR	30.0 (30.0, 60.0)
Range	(5.0, 240.0)
Sedentary time (hours watching TV, using a tablet, and playing videogames/day), n (%)
< 1 h	191 (40.7)
1–3 h	102 (21.7)
4–6 h	55 (11.7)
7–9 h	80 (17.1)
> 9 h	41 (8.7)
BMI and BP
BMI (kg/m2)
Girls in 4th – 6th grade
Median, IQR	19.8 (17.0, 22.8)
Range	(10.2, 40.1)
Girls in 7th – 9th grade
Median, IQR	22.2 (19.3, 26.0)
Range	(13.0, 50.6)
BMI percentile
Median, IQR	80.0 (49.0, 93.0)
Range	(1.0, 99.0)
BMI classification, n (%)
Underweight	21 (4.5)
Normal weight	241 (51.4)
Overweight	105 (22.4)
Obese	102 (21.7)
BP, systolic / diastolic (mmHg)
Missing, n (%)	22 (4.7)
Mean (SD)	106.6 (13.7) / 78.1 (11.1)
Range	(69.0, 155.0) / (45.0, 133.0)
BP status, n (%)
Unknown	22
Normotension	184 (41.2)
Elevated BP	33 (7.4)
Stage 1 hypertension	175 (39.1)
Stage 2 hypertension	48 (10.7)
Critical	7 (1.6)

BMI = body mass index; BP = blood pressure

Participants’ awareness and knowledge of CVD and its risk factors

Figure 1 shows the participants’ responses to the questions evaluating their awareness and knowledge of CVD and associated risk factors. Cancer was considered the most dangerous disease in adults (61%), whereas CVD (heart disease) was the second choice (50.3%, Fig. 1A). Approximately 71.2% rated CVD as very dangerous, whereas 22.4% thought it was moderately dangerous. Among the remaining participants, 2.3% considered it slightly dangerous or not dangerous at all, and 4.1% were not aware of its risk to adults’ health. Regarding CVD risk factors, slightly more than one-third (37.7%) of the participants were aware that hypertension is a risk factor for CVD. Obesity, dyslipidemia, lack of exercise, and family history were recognized by 26.9%, 25.6%, 24.7%, and 14.9% of the participants, respectively. Only 9.2% thought that diabetes was a risk factor, while 16.6% were not aware of the risk factors (Fig. 1B and C).

Fig. 1.

Participants’ awareness and knowledge of cardiovascular disease and its related risk factors

Factors associated with the participants’ knowledge level

The mean ± standard deviation (SD) knowledge score of the participants was 2.6 ± 1.6, representing 32.5% ±20% of a total possible score of 8. Table 3 shows the association between the participants’ knowledge scores and their demographic characteristics and lifestyles. A significant association was detected between higher knowledge scores and increasing participant age (P < 0.001), school grade (P = 0.001), and the presence of a family history of heart disease (P < 0.001). No significant associations were detected between knowledge level and participant illness, number of siblings, or parents’ occupations. There was no significant positive association between knowledge level and lifestyle, including dietary habits and preferences, sedentary behavior and maintenance of a healthy weight.

Table 3.

Factors affecting knowledge levels regarding cardiovascular disease

Characteristics	N	Score, mean (SD)*	P
All participants	469	2.6 (1.6)	-
Participant characteristics
Age (years)			< 0.001
8–10	78	2.1 (1.3)
11–13	224	2.5 (1.4)
14–16	167	3.0 (1.7)
School grade			0.001
4th	65	2.1 (1.3)
5th	52	2.4 (1.5)
6th	83	2.3 (1.2)
7th	58	2.7 (1.7)
8th	127	2.8 (1.7)
9th	84	3.0 (1.6)
Number of siblings			0.370
0–1	26	2.2 (1.3)
2–4	251	2.6 (1.6)
≥ 5	192	2.6 (1.5)
Having any illnesses, n (%)			0.288
No	406	2.5 (1.5)
Yes	50	2.8 (1.7)
Occupation of the parent (one or both parents)
			0.920
Doctor/Dentist/Pharmacist vs.	30	2.6 (1.8)
Other	439	2.6 (1.5)
			0.855
Teacher vs.	139	2.6 (1.6)
Other	330	2.6 (1.5)
			0.465
Homemaker/Unemployed vs.	289	2.6 (1.6)
Other	180	2.5 (1.5)
Family history of heart disease			< 0.001
No	396	2.5 (1.5)
Yes	44	3.4 (1.8)
Participants’ Lifestyle and Health Traits
Preferred food			< 0.001
Chocolate and candy/Cakes and biscuits/French fries/Fast food	328	2.7 (1.6)
Fruits and vegetables/Milk and cheese	86	2.2 (1.3)
Other	55	2.4 (1.2)
Portions of fruits and vegetables consumed per day			0.243
0	64	2.4 (1.5)
1–2	322	2.6 (1.6)
≥ 3	83	2.8 (1.5)
Portions of milk and cheese per day			0.934
0	64	2.7 (1.4)
1–2	320	2.6 (1.6)
≥ 3	85	2.6 (1.6)
Number of times participated in sports activities per week			0.061
Never	106	2.3 (1.5)
1–2 times/ week	198	2.7 (1.6)
≥ 4 times/week	165	2.7 (1.5)
Sedentary time: Hours watching TV, iPad + hours playing Sony/day			0.733
< 4 h	293	2.6 (1.5)
≥ 4 h	176	2.6 (1.7)
Participants’ BMI category			0.874
Normal weight + underweight	262	2.6 (1.6)
Overweight + obese	207	2.6 (1.5)
Participants’ BMI percentile			0.394
≤ 20th	48	2.4 (1.4)
21–40th	51	2.6 (1.4)
41–60th	57	2.5 (1.6)
61–80th	81	2.9 (1.6)
> 80th	232	2.6 (1.6)

* Out of a total score of 8 (1 for selecting heart disease in “most dangerous diseases in adults”, 1 for very dangerous in “how dangerous are heart diseases”, and 1 for each of the 6 specified “causes of heart diseases in adults”); each option is considered a T/F question

SD, standard deviation; TV, television

Discussion

The results of this study show that the awareness and knowledge of CVD and its risk factors among 8- to 16-year-old Saudi girls are inadequate and that the girls’ knowledge level is dissociated from their lifestyle, with a high prevalence of unhealthy traits, including obesity and hypertension. The majority of the participants rated cancer (61%) as the most dangerous disease in adult life, followed by CVD (50.3%), and only 71.2% considered CVD very dangerous. Knowledge about major CVD risk factors was low, and individual risk factors were, on average, identified by one-quarter of the participants. Overall, knowledge levels significantly improved with increasing age and school grade in girls and in those with a family history of CVD. Conversely, no significant favorable associations between the participants’ knowledge scores and lifestyle factors, including exercise, sedentary time, diet or maintaining a healthy BMI, were observed.

Alarmingly, an increasing prevalence of unhealthy traits was observed. Approximately 44.1% were overweight or obese, whereas 32.2% was the reported value five years ago in a sex- and age-matched population in Riyadh [24]. Moreover, the dietary intakes of fruits/vegetables, milk/cheese and important proteins for most participants were below or just at the minimal servings recommended by the American Academy of Pediatrics [25]. Moreover, almost half were identified as hypertensive, which is a higher prevalence than in a previous report from Jeddah, Saudi Arabia [26], although a single measurement was obtained from most participants, and different diagnostic cutoffs were applied in our study. In particular, there is an immediate need for the management and primary prevention of childhood obesity to combat the health hazard and socioeconomic burden of CVD from its development in childhood to its manifestation in adulthood in an effective and timely manner [27].

Awareness of CVD among women, female adolescents and female children

Our results for girls 8–16 years of age add to the available data on the awareness of CVD among women of all ages and confirm that misinformation starts in childhood and should be targeted early in life [10]. The misconception that cancer is the most life-threatening disease in adulthood followed by CVD, and the awareness levels observed in our study mirror those reported among women ≥ 25 years of age, where the awareness of CVD as the leading cause of death ranged between 44% and 56% [3, 6]. In another study that evaluated the awareness of CVD and prevention efforts among women 15 to 24 years of age, only 10.0% correctly identified CVD as the leading cause of death in women, and most participants worried little or not at all about CVD (39.2% and 38%, respectively) [4]. There have been calls to extend the American Heart Association’s “Go Red for Women” initiative, which aims to promote awareness and heart-healthy behaviors among women, to female teens [4]. The campaign should also include female children if primordial prevention of CVD in women is to be achieved.

In recent decades, substantial efforts have been made to assess, improve and track the awareness of CVD among women of adult and teenage age [4, 28, 29], with a much lesser focus on females who are early teens or children. These age groups should receive similar if not more attention to reduce the future risk of CVD among women. Furthermore, as observed in our study, young individuals are rarely devoid of CVD risk factors or have ideal cardiovascular health [30]. The escalating pro-atherogenic profile observed among the girls in this study is expected to further aggravate their risk of CVD upon reaching adulthood [30].

Prior studies on children’s and adolescents’ awareness and knowledge of CVD and its risk factors

A limited number of studies have evaluated the knowledge and awareness of CVD and its risk factors among children and adolescents worldwide [12–16], and very few reported on gender differences between young participants [14, 15]. Similar to our findings, inadequacies in knowledge have been detected despite a notably high prevalence of risk factors [13, 15, 16]. Our results are in accordance with those reported previously among 9th and 10th grade boys and girls in the rural district of West Midnapore, India, where the awareness of CVD and its risk factors was far from optimal, with a mean score of 41.1% [16]. Similarly, in a study from Delhi involving 6th-8th-grade children, only 15.3% were aware that coronary artery disease refers to blockage of the coronary artery, while 25.4% had adequate knowledge regarding CVD risk factors. A high prevalence of risk factors was similarly reported in that study, particularly in relation to exercise, dietary habits, and family history of CVD [13]. In a study in Michigan in the U.S., involving high school students (mean age of 15.6 years), only a minority (16.6%) considered CVD the greatest lifetime health risk, which was thought to be the greatest health threat for men at 42.3% compared with 14.0% for women [15].

Factors influencing participants’ knowledge levels

We found that the knowledge levels of the participants were positively influenced by increases in girls’ ages and school grades. Additionally, in comparison with our results, higher knowledge levels have been reported among secondary school students [31]. These findings highlight the importance of schools as a source of knowledge among young people. School-based educational programs significantly improve the awareness of CVD and its risk factors among children and adolescents [16] and help popularize healthy lifestyle habits.

Conversely, we found no association between the participants’ microenvironment, including parents’ occupation and number of siblings, and their CVD knowledge level, which contrasts with the observations of Notara et al., who reported that a lower number of siblings and higher parental education had a positive effect on participants’ knowledge [32]. Nonetheless, the higher knowledge scores observed in participants with a family history of CVD may still point to a family role in improving the children’s knowledge of CVD health, subject to improved awareness of the family members themselves. Data indicate that the factors affecting the home environment are complex and involve educational, financial, and other elements [33]. Further studies that explore the homes of children in detail, particularly parents’ knowledge of CVD specifically and their lifestyle habits, are warranted.

Impact of knowledge level on participants’ lifestyles

We found that the knowledge scores of the girls were not related favorably to their lifestyle. In particular, significantly higher knowledge scores were recorded among those who preferred fast and carbohydrate-rich foods. One potential explanation is that, among the risk factors for CVD, knowledge of dietary factors specifically is low [31] or that they are difficult to control. In one study, despite a high awareness of CVD risk factors, only approximately half of the participants knew what constituted healthy food, and two-thirds doubted that they could change their eating habits [34]. A lack of motivation is another potential explanation. In one study involving healthy undergraduate female students in Al-Madinah, SA, 55.8% of the participants were aware of the health consequences of excessive intake of added sugar, but only 32.6% reported making an effort to reduce their intake [35].

A high level of knowledge of CVD and its risk factors is likely not sufficient to improve health risks among young people [36], possibly because they tend to underestimate the impact of poor health behaviors. Tran et al. reported that while college students may be knowledgeable about CVD risk factors, they do not perceive themselves to be at risk of CVD, as they have not experienced the consequences of their behaviors [36]. Not foreseeing oneself to be at risk has been reported by other investigators among young individuals [4, 15], particularly women, and was cited as the first and main barrier to engaging in prevention behaviors [4]. While very limited data have suggested that women may occasionally be better informed about CVD and its risk factors than their male counterparts are [37], the myth that CVD is a disease affecting men may lead to underestimation of their risk. Furthermore, a focus on young women and schoolgirls, in particular, is warranted, as they are largely unaware of the risk CVD imposes on their health [4].

Studies evaluating the awareness of CVD in Saudi Arabia

To our knowledge, this is the first study to investigate the awareness and knowledge of CVD among Saudi children and adolescents and its effects on participants’ lifestyles. Few studies involving adults in Saudi Arabia exist [38–43]. A recent cross-sectional study from Riyadh reported that only 47.1% of the participants had good awareness, with men having better awareness than women in that study [38]. Limited knowledge levels were also reported in Al-Qassim Province [42, 43] and Jeddah [40, 41]. Overall, the respondents seem less likely to be aware of the role of the individual’s sex, age, family history, diabetes, and hypertension as causative factors for CVD and are better informed about the role of smoking, obesity, hyperlipidemia, unhealthy diet, and physical inactivity [38–40, 43]. There are not enough data on the predictors of knowledge level or its impact on participants’ lifestyles. In one study, following a healthy diet was an independent predictor of good CVD awareness [38].

Strengths and limitations

There was no direct question regarding smoking in the questionnaire. This is due to ethical concerns from the authors since the study included 8-year-old children who may not have been informed properly about smoking, which is both a risk factor and a bad habit. The participants, however, were given the option to enumerate any other risk factors they may know of. Nonetheless, the level of awareness of smoking, cannot be compared with the other studied risk factors. The possibility of bias from self-report questionnaires is another well-known limitation. Additionally, the study included girls with an 8-year age difference, which may have created a challenge in the questionnaire application. However from the age of 7 onward, children can be interviewed via structured questionnaires or complete self-reports, particularly if short questions, and simple terms are used [18, 19]. This age difference, has the advantage of permitting comparisons of child and teen participants’ knowledge, and adds to the continuum of data on CVD awareness among females of different ages which we were interested in studying. Although increasing age was significantly associated with better knowledge in our study, the difference in the mean knowledge score was not large, and the observed knowledge levels mirrored those of female teens and women. While the study was carried out among girls in Riyadh, the results are in accordance with those reported from other parts of the world among children in general and women, and point to the globalization of unhealthy diets and traits, and low awareness of this important disease.

Conclusions

The awareness and knowledge of CVD and its risk factors among girls aged 8–16 years is inadequate and is largely dissociated from their lifestyle, with a high prevalence of unhealthy lifestyle habits and increasing overweight/obesity and hypertension. The increased prevalence of obesity, hypertension and unhealthy lifestyle choices among those who are unaware of CVD and its risk factors is alarming and needs the attention of policy-makers, teachers, medical personnel, and the community at large. The improved knowledge scores with increasing school grade and a family history of heart disease suggests an important role for schools and families in improving knowledge of CVD. Our findings mirror those obtained in young and older women, suggesting that misinformation starts early in life and should be targeted at that stage. These observations call to extend the “Go Red” campaigns aiming to promote awareness of CVD and preventive behaviors among women, beyond young women and adolescents, to aid in the prevention of CVD in women in the future.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Author contributions

M.A. conceived and supervised the study, prepared questionnaire and wrote manuscript. R.A., S.A. contributed to writing the questionnaire. R.A., S.A., A.Alh., A.Alo., H.A., contributed to face and content validation of the questionnaire. B.A. administrative support. B.A., S.A. contributed to supervising the study. S.A., A.Alh., A.Alo., H.A. contributed to data collection. T.L. contributed to statistical analysis and writing of the statistical analysis section and revised the results. All authors reviewed and approved the manuscript.

Funding

This work was funded by Princess Nourah bint Abdulrahman University Researchers Supporting Project number (PNURSP2024R118), Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia.

Data availability

Data are available from the corresponding author upon a reasonable request, and approval of the PNU institutional review board.

Declarations

Ethics approval and consent to participate

The study was approved by the institutional review board at Princess Nourah bint Abdulrahman University (IRB log number: 19–0186). The study was performed in accordance with the Declaration of Helsinki. Written informed consents were obtained from all the legal guardians/parents of the participating children prior to data collection and after receiving approval of the study by the PNU institutional review board, the ministry of education and the participating schools.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.