Peripheral Arterial Disease in Nova Scotia: Increased Prevalence, Low Public Awareness, and Poor Edinburgh Claudication Questionnaire Sensitivity

Abstract

Background

This study had the following 3 goals: (i) to assess the prevalence of peripheral arterial disease (PAD) in a Nova Scotian population; (ii) to evaluate the validity of the Edinburgh Claudication Questionnaire (ECQ) in a Nova Scotian context; and (iii) to evaluate Nova Scotian public knowledge about PAD.

Methods

Participants were recruited from 8 sites across Nova Scotia. In 2022, they were recruited at Heartland Tour (HLT) sites—a provincial health-promotion campaign. In 2023, they were recruited in communities coinciding with HLT sites (public [PUB]). Participants completed a demographics questionnaire, ECQ, and had an ankle–brachial index (ABI) measurement. An ABI of < 0.9 was considered positive for presence of PAD.

Results

A total of 417 participants were recruited, 263 from HLT, and 154 from PUB. A total of 398 participants had ABI scores resulting in a PAD prevalence of 2.81% (249 participants) in the HLT group, and 5.37% (149 participants) in the PUB group. A total of 394 participants had both ABI and ECQ scores, with a found sensitivity of 6.67% (confidence interval 0.17%-31.95%) and specificity of 97.63% (confidence interval 95.54%-98.91%). A total of 75% of participants (311 of 417) did not have prior knowledge of PAD.

Conclusions

The PAD prevalences in both cohorts were higher than anticipated, with the PUB cohort being more than double the national average. This finding raises the following question: should specific PAD primary and/or secondary prevention strategies be targeted within the province? Our study demonstrated that a public-awareness campaign would be highly impactful, owing to a low level of awareness of PAD within both cohorts, and that the ECQ was not an effective screening tool when used on the Nova Scotian population.

Peripheral arterial disease (PAD), also known as peripheral vascular disease, is defined as a narrowing or calcification of a major peripheral artery, not including the coronary or cerebral arteries.¹ Not only does this condition jeopardize one’s limb health, it also significantly increases the risk of mortality from heart attacks and strokes.² The annual incidence of mortality from PAD has increased from 15,900 to 40,000 people between 1990 and 2013—an increase of 153.3%.³ Estimates indicate that more than 236 million people worldwide (5.56%) live with PAD, including more than 800,000 Canadians (2.1%).^4,5 However, the PAD burden in Canada may not be distributed equally among the provinces; for example, in 2016, Hong and colleagues reported a PAD prevalence of 8.1% in an Albertan population.⁶

Despite the known negative consequences of PAD, the condition remains underdiagnosed and undertreated.^1,7 However, specific risk factors for PAD, such as age, smoking, diabetes mellitus, hypertension, and hypercholesterolemia, are monitored routinely.^2,4 Widespread access to these measures begs the following question: Is a PAD screening program feasible, and would it serve to address the burden of PAD in Canada? In the current national guidelines, the only questionnaire-based PAD screening tool endorsed is the Edinburgh Claudication Questionnaire (ECQ),⁷ which was first published in 1992, reporting a sensitivity of 91.3% and a specificity of 99.3%.⁸ However, these claims recently have been critiqued in the literature.9, 10, 11 For instance, when Bell et al. tested the ECQ within a Canadian outpatient population with risk factors for PAD, they found that the ECQ had a sensitivity of 52.5% and a specificity of 87.1%.⁹

Primary prevention strategies, such as lifestyle modification, also can reduce the disease burden of PAD.¹² However, to effectively implement lifestyle-modification practices, patients need to be aware of the existence of PAD, and of its risk factors. When Lovell and colleagues assessed the knowledge of PAD in Canadians, only 35.5% of respondents had significant knowledge of the disease. Even participants identified as being “PAD aware” had poor knowledge about PAD-associated risk factors.⁵ More recently, Bridgwood et al. found that public awareness ranged between 21% and 60.5%, and noted that awareness of specific PAD risk factors remained consistently poor.¹³

Considering the rise in PAD prevalence, the potential beneficial opportunity for PAD screening, as well as a generalized lack of awareness about PAD among Canadians, this study has 3 primary objectives, designed to respond to these 3 pressing needs within Nova Scotia, Canada. First, this study aims to identify the prevalence of PAD and its risk factors in the Nova Scotian population. Second, this study aims to identify the validity of the ECQ when it is used within a Nova Scotian population. Third, this study aims to evaluate the public awareness of PAD in the Nova Scotian population.

Methods

This is a cross-sectional study that was conducted in 2 periods, of 1 week each, in July 2022 and 2023. This study collected data at sites across Nova Scotia that aligned with scheduled programming by the annual Heartland Tour (HLT), a trans-provincial public health awareness and engagement campaign. In 2022, recruitment targeted HLT participants as a proxy for a health-conscious population, as previous research demonstrated that this population has a lower risk for adverse health outcomes.¹⁴ Consecutively, in 2023, researchers recruited participants from the same community sites, but who were in locations removed from HLT programming, such as pharmacies and shopping malls, to represent the general population. Participants were required to meet the following eligibility criteria: be aged ≥ 18 years; be a resident of Nova Scotia; and have no contraindication to ankle-brachial index (ABI) testing. Researchers added participation in the 2022 HLT programming as an additional exclusion criterion in 2023, to preclude first-phase research subjects from participating in the second phase.

Once they had provided informed consent, participants completed a questionnaire that included sex (assigned at birth), age, self-reported race, PAD risk factors and associated comorbidities, knowledge of PAD, and a complete ECQ (Fig. 1). Participants in 2023 also completed the International Physical Activity Questionnaire—short form as an assessment of their level of activity. Researchers recorded participants’ height and weight, to use to calculate body mass index (BMI). Participants’ right and left ABI scores were obtained using a Huntleigh Dopplex Ability Automatic ABI system (Huntleigh Healthcare Ltd, Wales, UK) and were calculated using the systolic blood pressure in the respective leg, divided by the highest of the upper-limb systolic blood pressures. The machine identified a positive PAD finding at < 0.9, in keeping with the per-national recommendation.⁷ Additionally, an ABI score > 1.4 is concerning for arterial calcification, a potential etiology of PAD that commonly is associated with diabetes mellitus and chronic kidney disease.^15,16 This calcification can elevate ABIs scores artificially, and additional imaging is required to diagnose PAD, which is outside the scope of this study. Considering this limitation, we recorded those who had an ABI score > 1.4 as a separate entity.

Figure 1.

Edinburgh Claudication Questionnaire (ECQ) flowchart. Question 1 is an initial screening question. If the respondent negatively answers “no,” they do not respond to any further questions. If the respondent positively answers “yes,” they fill out the remaining 5 questions. To have a positive ECQ, the respondent must give a positive answer to questions 1, 2, 3, 5, and 6. Positive responses are listed on the figure. Additionally, responses to question 4 indicate disease severity, and they do not have an impact on whether the respondent is screened in or out.

Data analysis was conducted using R, version 2023.03.0+386 (Posit Software, Boston, MA), and Excel, version 16.76 (Microsoft, Redmond, WA). Analysis was divided into 2 streams (Fig. 2). Researchers used observational descriptive analysis to assess the prevalence of PAD and of known PAD risk factors, ECQ sensitivity and specificity, as well as likelihood ratios, and the proportion of Nova Scotian communities with knowledge about PAD, within and between the health-conscious (2022) and general populations (2023). Participants without data for each corresponding analysis were excluded (Fig. 2). The ECQ test characteristics and confidence intervals were calculated using the diagnostic test calculator provided by MedCalc Software (Ostend, Belgium).

Figure 2.

Flowchart depicting the data analysis for the Heartland Tour (HLT) from the 2022 and the 2023 cohorts. ABI, ankle–brachial index; PAD, peripheral arterial disease.

Researchers calculated the sample size required to have a < 5% margin of error, and a 95% confidence interval, using the following formula: n = (Z² × p × (1 − p) / margin of error²), where Z = 1.96, the margin of error was 0.05, and prevalence (p) was 0.0253. The value of p is an estimation of the PAD prevalence within Nova Scotia, using the preestablished Canadian PAD prevalence (2.1%), with an added multiplier based on the known PAD risk factors that are monitored by the Canadian Chronic Disease Surveillance System (CCDSS).⁵ The average proportional difference between Canada and Nova Scotia for the known PAD risk factors was computed using the following formula: proportional difference = (absolute difference / average), for each risk factor. These differences then were averaged, yielding a proportional difference of 20.5%. The Canadian prevalence of PAD then was multiplied by this average proportional difference (0.021 ∗ 1.205) to approximate the suspected prevalence of PAD within Nova Scotia (2.53%). Using this value as p, the sample-size formula yields a minimum sample size of 38, a size that permits this study to have margins of error of 1.90% (2022) and 2.48% (2023). However, analysis of the suspected prevalence of PAD in specific regions of Nova Scotia showed that only a small number of sites in this study achieved a sample size of ≥ 38. Therefore, this study will focus exclusively on province-wide comparisons between study populations and national PAD data. Although PAD data per site are presented for completeness, we make no inferences about sites based on other sites, and we make no statistical comparisons between sites.

This study was approved by the Dalhousie Research Ethics Board (REB file# 2022-6152 and REB file #2023-6683).

Results

Demographics: sex, age, BMI, PAD risk factors, and associated conditions

A total of 417 participants were recruited, 263 from a health-conscious population (HLT; 2022), and 154 from the general population (Public [PUB]; 2023). Table 1 presents demographic characteristics of both populations. The HLT population had 55.1% female participants, and the PUB population had 56.4% female participants. The average ages were 59.8 years and 56.2 years for the HLT and PUB populations, respectively. The average BMIs were 27.0 kg/m² and 29.4 kg/m² for the HLT and PUB populations, respectively.

Table 1.

Demographic characteristics of the Heartland Tour (HLT) and Nova Scotian (PUB) sample population

	HLT	PUB
Sex
Male	117 (44.5)	65 (42.2)
Female	145 (55.1)	87 (56.4)
Age, y
Mean	59.8	56.2
18–29	12 (4.56)	22 (14.3)
30–39	14 (5.32)	11 (7.14)
40–49	6 (2.28)	13 (8.44)
50–59	72 (27.4)	33 (21.4)
60–69	117 (44.5)	29 (18.8)
70–79	36 (13.7)	34 (22.1)
≥ 80	5 (1.9)	11 (7.14)
Body mass index
Mean	27.0	29.4
Underweight	2 (0.76)	2 (1.30)
Healthy weight	90 (34.2)	36 (23.4)
Overweight	103 (39.2)	50 (32.5)
Obese	59 (22.4)	61 (39.6)
Activity level
HLT active participant
Yes	220 (83.65)	—
No	40 (15.2)	—
Public participant
Low	—	36 (23.4)
Moderate	—	57 (37)
High	—	57 (37)
Risk factors
Hypertension	52 (23)	61 (40.7)
Unmedicated	5 (2.05)	5 (3.33)
Undiagnosed	45 (18.4)	34 (22.7)
Hypercholesterolemia	60 (24.6)	54 (36)
Unmedicated	11 (4.51)	6 (4)
Diabetes mellitus	15 (6.15)	25 (16.7)
Type 1	4 (1.64)	2 (1.33)
Type 2	10 (4.1)	22 (14.7)
Unmedicated	3 (1.23)	3 (2)
Previous smoking history	69 (28.3)	22 (14.7)
Current smoking	5 (2.05)	50 (33.3)
Family history of heart disease	120 (49.2)	84 (54)
Associated conditions
Coronary artery disease	8 (3.28)	9 (6)
Myocardial infarction	6 (2.46)	12 (8)
Stroke	4 (1.64)	5 (3.33)
Transient ischemic attack	7 (2.87)	7 (4.67)
Angina	7 (2.87)	13 (8.67)

HLT, Heartland Tour; PUB, public.

Values are n (%), unless otherwise indicated.

The most notable difference between populations was the incidence of smoking, which was 10 times higher in the PUB population (33.3%), compared to that in the HLT population (2.05%). Obesity, hypertension, and type 2 diabetes mellitus were also PAD risk factors with a higher incidence in the public group (39.6%, 40.7%, and 14.7%, respectively) than in the HLT group (22.4%, 23%, and 4.1%, respectively). An interesting finding is that rates of PAD-associated conditions, such as coronary artery disease, myocardial infarctions, stroke, transient ischemic attack, and angina, were comparable between the 2 groups. The prevalences of family history of heart disease (49.2% in the HLT group vs 54% in the PUB group), unmedicated hypertension (2.05% in the HLT group vs 3.33% in the PUB group) or hypercholesterolemia (4.51% in the HLT group vs 4% in the PUB group), and potentially undiagnosed hypertension (18.4% in the HLT group vs 22.7% in the PUB group) were also comparable.

Activity level data, per the International Physical Activity Questionnaire—short form questionnaire, are available for only the PUB group. This score was used as a proxy for the following question: “Did you participate/are you participating in the physically active portions of the 2022 Heartland tour?”. In the health-conscious population, 83.65% of the respondents disclosed that they were an active participant in the HLT, as opposed to 15.4% who responded that they were not participating in an active component. In the PUB group, 23.4% had a low activity level, 37% had a moderate activity level, and 37% had a high activity level.

PAD and arterial calcification prevalence

Of 417 total participants, 249 of the HLT population, and 149 of the PUB participants had ABI results that allowed us to calculate the prevalence of PAD (Fig. 3) and arterial calcification (Fig. 4). The HLT population had a PAD prevalence of 2.81%, whereas the PUB population had a PAD prevalence of 5.37%. An examination of specific sites showed that the HLT population had the highest PAD prevalence in Annapolis Royal, New Glasgow, and Sydney, with percentages of 9.09%, 5.41%, and 4.44%, respectively. In the PUB population, Halifax had the highest prevalence of PAD at 10%, followed by Sydney and Annapolis Royal, both with 9.09%.

Figure 3.

Peripheral arterial disease prevalence in the Heartland Tour (HLT) and the general Nova Scotian (PUB) populations provincially, and community sites. Prevalence of peripheral arterial disease found across Nova Scotia in the HLT and PUB populations represented as % (affected per sample).

Figure 4.

Arterial calcification prevalence Heartland Tour (HLT) and the General Nova Scotian (PUB) populations provincially, and community sites.

Examination of the prevalence of arterial calcification showed that the HLT and the PUB populations had similar prevalences, provincewide, at 3.21% and 3.36%, respectively. In the HLT population, Yarmouth, Antigonish, and Bridgewater were sites that saw the highest prevalences of stiff arteries, at 8.7%, 8.33%, and 5.88%, respectively. In the PUB population, the greatest prevalence of arterial calcification occurred at Truro, with a prevalence of 9.52%, followed by Halifax at 5%, and Sydney at 4.55%.

ECQ

Of the 417 total participants, 394 both had their ABI calculated and completed an ECQ, which permitted an evaluation of the ECQ. Participants’ test results and test characteristics are found in Table 2. This study found a sensitivity of 6.67% (confidence interval [CI] 0.17-31.95), and a specificity of 97.63% (CI 95.54-98.91) of the ECQ. The positive predicted value was 10%, and the negative predictive value was 96.35%. The positive and negative likelihood ratios were 2.83 (CI 0.38-20.76) and 0.96 (CI 0.83-1.10), respectively.

Table 2.

Participants’ test results for Edinburgh Claudication Questionnaire (ECQ), statistical results, and confidence intervals (CIs)

ECQ test results

	PAD +	PAD –
ECQ +	1 True positive	9 False positive
ECQ –	14 False negative	370 True negative

Statistic	Value	95% CI
Sensitivity	6.67%	0.17–31.95
Specificity	97.63%	95.54–98.91
(+) likelihood ratio	2.83	0.38–20.76
(–) likelihood ratio	0.96	0.83–1.1
Positive predictive value	10%	1.48–45.1
Negative predictive value	96.35%	95.84–96.80
Odds ratio	2.96	0.35–24.99
Accuracy	94.16%	91.37–96.26

ABI < 0.9 signifies presence of peripheral arterial disease (PAD).

Researchers examined responses that yielded false negatives, to determine which question(s) inappropriately screened out participants. Half of all false negatives (50%; 7 of 14) were screened falsely by the following initial question: “Do you get pain or discomfort in either leg while walking?”. Of the remaining 7 false-negative participants, question 2 screened out 3, question 3 screened out 2, and each of questions 5 and 6 screened out 1. An interesting finding is that question 6, in the false-negative group, had only 2 positive responses from participants. The remaining responses referred primarily to either ankle or knee pain and biomechanical etiologies of pain instead of vascular etiologies.

PAD knowledge

Figure 5 represents study participants’ knowledge of PAD. Overall, 25% of participants knew about the existence of PAD. In the HLT group, 25.86% of participants (68) previously had heard of PAD. In the PUB group, 24.7% of the population (38 participants) previously had heard of PAD.

Figure 5.

Participant’s knowledge of peripheral arterial disease. Differences between the Heartland Tour and the general Nova Scotian population (PUB) were minimal. The prevalence of peripheral arterial disease knowledge in the Heartland Tour group was 25.86% (68 participants), and 24.7% (38 participants) in the public group.

Discussion

PAD prevalence

Overall, results show PAD prevalences of 2.81% and 5.37% in a health-conscious population and a general population, respectively. Both prevalence rates are higher than both the national prevalence of 2.1% and our predicted provincial prevalence of 2.53%. This study found that a higher-than-national-average provincial PAD prevalence could be attributed to the higher-than-average prevalence of PAD risk factors within Nova Scotia. For example, smoking, diabetes mellitus, and hypertension are all risk factors for PAD. Health Canada reports that 11.7% of Canadians aged > 25 years are current smokers, and 23.2% of Canadians aged > 15 years are former smokers.¹⁷ According to the CCDSS, the national prevalences of diabetes mellitus and hypertension were 9.39% and 25.67%, respectively.¹⁸ The HLT participants had a lower prevalence of current smokers (2.05%), diabetes mellitus (6.15%), and hypertension (23%), but a higher prevalence of previous smoking history (28.3%). This contrasts with the PUB participants, who had a higher prevalence of current smokers (33.3%), diabetes mellites (16.7%), and hypertension (40.7%), but surprisingly, a lower prevalence of previous smoking history (14.7%), supporting the characterization of the HLT registrants as a “health-conscious population.”

This study also assessed the prevalence of known conditions associated with PAD that also are tracked by the CCDSS. According to the CCDSS, the national prevalence of myocardial infarctions is 2.31%, which is comparable to the prevalence of the HLT group (2.46%), but is almost 4 times lower than the prevalence of the PUB group (8%).¹⁸ In terms of ischemic heart disease, the CCDSS found a national prevalence of 8.48%, whereas this study found a prevalence of angina of 2.87% in the HLT group, and 8.67% in the general population.¹⁸ The CCDSS reports a national stroke prevalence of 3.09%, whereas this study showed a prevalence of 1.64% in the HLT group, and 3.33% in the general population.¹⁸

Overall, our Nova Scotian study population tended to have a prevalence of PAD risk factors and associated conditions that was higher than the national average. This finding supports our data that the PAD prevalence in Nova Scotia is higher than the national average. Moreover, in looking at strategies to reduce PAD prevalence in the province, targeting PAD risk factors would be worthwhile.

Arterial calcification

Potential arterial calcification rates were comparable in the HLT and PUB groups (3.21% and 3.36%, respectively). Although this result is not diagnostic for PAD, or associated pathologies, it is still a cause for concern. Some studies have found a correlation between an abnormally high ABI score and increased cardiovascular mortality, major adverse cardiovascular events, and all-cause mortality.19, 20, 21, 22 One theory to explain an abnormally increased ABI score comes from study of medial arterial calcification—calcification within the tunica media of the artery. Medial arterial calcification is proposed to be a subtype of PAD that differs from atherosclerosis—a common reason for anabnormally low ABI score—which occurs within the tunica intima.¹⁴ However, a point to note is that within the above-mentioned meta-analyses, a higher number of studies reported a correlation between a low ABI score and these outcomes, rather than between a high ABI score and these outcomes. Interestingly, Yang et al. found that an abnormally high ABI score was only correlated with an increase in all-cause mortality in those with coronary artery disease, which calls into question the role of comorbidities in the predictive value of a high ABI score and related outcomes.²³ Regardless, more research is necessary to specify more definitively the association between a high ABI score and negative outcomes, such as increased cardiovascular mortality, major adverse cardiovascular events, and all-cause mortality.

ECQ

When using the ECQ, this study found a significantly lower sensitivity than that originally reported by Leng and Fowkes in 1992—6.67% compared to 91.3%.⁸ By contrast, this study found a similar specificity of 97.6%, compared to 99.3%.⁸ This trend of a lower sensitivity, compared to a similar specificity, is in keeping with the literature; however, the reported specificities were not quite as low as ours (6.67%), ranging from 25.8% to 52.5%.9, 10, 11^,24 This difference may be explained by the fact that these studies recruited people with either suspected or confirmed PAD, or who had high risk factors, such as acute coronary syndrome and type 2 diabetes. This population contrasts with ours, which was recruited in a more-randomized fashion, to achieve a sample representative of the Nova Scotian population. The positive likelihood ratio of 2.83, with a 20-point-wide CI, indicated considerable uncertainty in the ability to positively screen. The negative likelihood ratio (0.96) is very close to 1 and indicates that a negative test does not reduce the likelihood of having PAD significantly, an important aspect of any prospective screening test. These findings suggest that the ECQ is not appropriate for use as a general PAD screening tool.

Examination of the responses of those who were screened out inappropriately by the ECQ showed that almost half were screened out due to lack of leg pain, with the remaining false-negative participants giving responses that are not associated with classic claudication symptoms. About 50% of those with PAD do not present with classical claudication symptoms, and 40% do not have claudication symptoms at all, which may explain the high numbers of false negatives.²⁵ Additionally, the common response of “ankle” or “knee” pain in question 6 could be associated with a musculoskeletal origin, as opposed to claudication. The prevalence of PAD and common musculoskeletal conditions—such as osteoarthritis—increases with age, and thus, this could impact ECQ results. Although no current literature discusses this association, evidence indicates that comorbidities, such as type 2 diabetes mellitus, can decrease the sensitivity of the ECQ.²⁴

Although these findings suggest that the ECQ may not be an appropriate PAD screening tool, this does not mean that PAD screening should not be investigated further. Limited tools to screen for undiagnosed PAD are available in the literature; however, multiple tools use PAD symptoms to predict disease outcomes, such as the Vascular Quality of Life Questionnaire (VascuQOL), the Peripheral Artery Questionnaire (PAQ), the Peripheral Artery Disease Quality of Life Questionnaire (PADQOL), and the Claudication Symptom Instrument (CSI).26, 27, 28, 29 Other non-PAD-specific tools have been used to predict disease outcomes of PAD, such as the EuroQol 5 dimension (EQ-5D), the Medical Outcomes Study Questionnaire Short Form 36 Health Survey (SF-36), and the Walking Impairment Questionnaire (WIQ); however, considering that these tests evaluate symptoms and/or outcomes that are not PAD-specific, a high false-positive rate would be an anticipated were they to be used for undiagnosed PAD screening.^30,31 An interesting finding from Kieback et al. is that using a modified ECQ to screen for PAD, by asking only the initial question, more than doubled the sensitivity in all age cohorts, compared to that of the traditional ECQ.³² One major argument against use of questionnaire-style PAD screening tools is the inherent focus on PAD symptoms, and as previously discussed, only a minority of those with PAD present initially with claudication symptoms.²⁵ Therefore, the PAD-screening literature has moved toward recommendation of use of mechanical tools, such as the ABI, the toe-brachial index, and photoplethysmograms.^33,34 However, as mentioned by Kieback et al., machines may not be accessible in all primary-care settings; therefore, questionnaire-type PAD screening is preferable to the alternative of no screening.³²

The most-recent Canadian guidelines suggest against use of asymptomatic population-based screening for PAD; however, they do support ABI screening for those with high-risk factors for PAD, as this population benefits from early PAD diagnosis, and subsequent aggressive medical treatment.⁷ For instance, Anand et al. found that those with PAD who were treated with rivaroxaban and acetylsalicylic acid had a significantly reduced incidence of acute and chronic limb ischemia, major lower-limb amputations, and vascular interventions.³⁵ In their meta-analysis, Alahdab et al.³⁶ investigated the utility of PAD screening. They did not find evidence to support screening in high-risk populations; however, they also noted that the literature was limited on the subject, including the association between PAD screening and PAD-related morbidity and mortality.³⁶ Considering the increased prevalence of PAD, and the associated risk factors in our study population, in addition to the limited volume of PAD-screening literature available, we believe these findings merit further investigation into the use of PAD-screening tools to increase accessibility of PAD detection in collaborative and general practices across Nova Scotia.

PAD knowledge

Only 1 in 4 participants had previous knowledge of PAD. This percentage is similar to those in previous studies, which ranged from 21.3% to 36%.^5,13,37,38 Given a 75% rate of naivete to PAD knowledge, and a found PAD prevalence rate as high as 5.37%—over double the national average—this evidence points to the need for expanded knowledge translation and public health programs about the risk factors of PAD and the impact of PAD on daily living, morbidity, and mortality.

This lack of knowledge is not a new phenomenon. Hirsch et al.³⁹ and Lovell et al.⁵ reported low rates of PAD public knowledge in 2007 and 2009, respectively.^5,39 This knowledge gap also extends to the medical community. AlHamzah et al. found, that despite encountering a similar level of exposure to PAD, and coronary artery disease, medical students identified significantly fewer PAD risk factors, clinical features, and treatments.⁴⁰ This suboptimal knowledge level can persist in physicians as well, which can have negative consequences on patient outcomes, such as underprescription of appropriate medications.^41,42 Patient education from physicians is important, as it can support patients in advocating for their own health, and in implementing risk-factor modification strategies.⁴³ Given this context, we call on primary-care providers to implement a knowledge-translation strategy, with measured output implementation, in Nova Scotia.

Limitations

This study has several limitations. First, the question in the questionnaire about knowledge of PAD was phrased as follows: “Do you know what Peripheral Arterial Disease (PAD) is?”. Participants might have answered “yes” to the binary response after being told about PAD during the consent process, which may have artificially inflated the percentage of participants indicating that they had knowledge of PAD. Second, the assumption was made that the health-conscious population was in fact more health-conscious; however, participants’ reasons for both registering for and attending the HLT could have been due to factors outside of consideration for their own health (eg, registration merchandise, free food, family get-togethers, peer pressure). Further studies, should they take a similar approach, should be sure to quantify or qualify that the health-conscious and/or healthy-living population have healthy lifestyle habits. Third, considering our relatively small sample size, our study population may be subject to selection bias. For example, while all participants were residents of Nova Scotia, no data were collected to differentiate between participants who were residents of the community sites vs those who were visiting the sites. However, we anticipate that the true prevalence of PAD in Nova Scotian is similar to that in our study, or higher, considering the increased prevalence of PAD risk factors in the province, as previously discussed. Finally, although race was not an intended outcome measure, a point that should be noted is that this study’s population contained few participants who identified as being either Indigenous or of African Nova Scotian descent. Across both arms of the study, 2 participants identified as Black (0.48%), and 6 individuals identified as Indigenous (1.43%). Another point worth noting is that the choice of “Black” on the questionnaire form is not synonymous with African Nova Scotian but implies a lack of representation of all African descendants, African Nova Scotian or otherwise. Also worthy of discussion is that having distrust from having experienced past and/or current systemic racism means that those who selected “prefer not to answer,” or “unsure,” or who left the question blank could belong to these specified demographics (n = 22; 5.27%). Further research could focus on the quantification of prevalence, and need screening relating to PAD in these specific populations, as this study contained mostly Caucasian individuals, although it did so unintentionally.

Conclusion

In response to the above-mentioned study objectives, we found the following: (i) the PAD prevalence in both the health-conscious and the general population groups of Nova Scotians was higher than the national average; (ii) when used as a PAD-screening tool with a Nova Scotian population, the ECQ offers a significantly lower level of sensitivity for PAD screening than was initially reported; and (iii) the level of knowledge of PAD within the Nova Scotian population is quite low, with only 1 in 4 participants reporting having previous knowledge of the disease. Considering the higher-than-average PAD prevalence rate, and the associated disease burden of PAD, this study highlights future areas of investigation, such as new tools for a provincial PAD-screening program, and implementation strategies that are specific for PAD–public awareness campaigns. Moreover, this study does not describe the impact of this elevated prevalence rate on the life course, health, or general well-being of Nova Scotians. These vital measures remain an important area for further study and could represent new directions for research projects like this one that coincide with the HLT.