
==== Front
BMC Public Health
BMC Public Health
BMC Public Health
1471-2458
BioMed Central London

39294654
20030
10.1186/s12889-024-20030-w
Research
Risk factors of cardiovascular disease (CVD) in young adults: a community-based study of Iranian context
https://orcid.org/0000-0001-7011-8731
Estebsari Fatemeh 1
https://orcid.org/0000-0002-5286-2652
Barati Mohadaseh 2
https://orcid.org/0000-0003-0687-705X
Stiri Sara 2
Latifi Marzieh 3
https://orcid.org/0000-0001-9477-1778
Shahsavari Arezoo 4
https://orcid.org/0000-0002-0657-0595
Milani Arezoo Sheikh 5
https://orcid.org/0000-0001-5914-404X
RahimiKhalifehKandi Zahra Tarla1367@yahoo.com

6
1 grid.411600.2 School of Nursing and Midwifery, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
2 grid.411600.2 Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
3 https://ror.org/034m2b326 grid.411600.2 Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
4 https://ror.org/035t7rn63 grid.508728.0 0000 0004 0612 1516 Department of Medical Surgical Nursing, Aligoudarz School of Nursing, Lorestan University of Medical Sciences, Khorramabad, Iran
5 grid.411600.2 Department of Community Health Nursing, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
6 https://ror.org/056mgfb42 grid.468130.8 0000 0001 1218 604X Department of Health Education and Promotion, School of Public Health, Arak University of Medical Sciences, A’lam-Al-Hoda Street, Shahid Shiroodi Street, Arak, Markazi Province 3819693345 Iran
18 9 2024
18 9 2024
2024
24 254327 7 2024
10 9 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by-nc-nd/4.0/.
Background

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide, particularly in low- and middle-income countries. Young adults are susceptible to CVD risk factors, especially in developing countries. This study aimed to compare CVD risk factors between medical and non-medical students.

Methods

The present cross-sectional study was conducted on a sample of 302 students in Tehran, including 151 medical students and 151 non-medical students, in 2022. Data collection tools included four online questionnaires to collect demographic information, knowledge/attitudes, knowledge of risk factors, and risk factors. Data were analyzed using SPSS version 18 software at a 0.05 significance level.

Results

Data analysis revealed that the mean age of medical and non-medical students was 22.06 ± 3.53 and 21.88 ± 4.20 years, respectively. The two groups were not significantly different in gender, age, marital status, and place of residence. Knowledge of CVD was significantly different between the two groups of students (P < 0.001), but attitudes were not significantly different (P = 0.208). A significant difference in the prognosis of diabetes and dyslipidemia was observed between the two groups (P < 0.001).

Conclusions

As a large group of young adults in society, students are at risk for CVD. Poor knowledge and inappropriate attitudes regarding CVD risk factors are among the contributing factors. Therefore, it is recommended to design and implement a healthy diet, physical activity, stress management, and healthy lifestyle programs for the young group along with screening programs to prevent complications and mortality caused by CVD.

Keywords

Risk factors
Cardiovascular disease (CVD)
Young adults
Medical students
Non-medical students
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
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pmcIntroduction

Cardiovascular disease (CVD) was introduced as a global public health problem [1, 2]. CVD is also the leading cause of death and disability worldwide, particularly in low- and middle-income countries [3]. This disease annually incurs 363 billion dollars in healthcare costs and lost productivity [4]. In 2019, 17.9 million people reportedly died from CVD, which accounts for about 32% of all global human deaths that year. The most alarming part of the report is that three-quarters of these deaths (accounting for 80%) occurred in low- and middle-income countries [1, 2].

CVD is the cause of 46% of deaths in Iran [3]. The risk factors for this group of diseases are caused by unhealthy lifestyles and habits [5, 6]. Young adults, particularly in developing countries, are susceptible to CVD risk factors [7, 8].

CVD risk factors are divided into non-modifiable and modifiable categories. The former includes age, sex, family history, and race, while the latter consists of hypertension, dyslipidemia, smoking, diabetes, obesity, a sedentary lifestyle, an unhealthy diet, and stress [9, 10].

These risk factors predispose a person to various diseases, such as coronary artery disease, cardiac dysrhythmia, cerebrovascular disease, cardiomyopathy, and peripheral vascular disease [11]. Therefore, controlling modifiable risk factors (MRFs) is paramount, as they can predict about 64% of CVD incidence [12, 13]. The results of a study on German students showed that alcohol use as a risky behavior factor was observed in more than 30% [14]. Physical activity is also reported as another modifiable behavioral factor at a low level in Iranian students [5, 8, 15].

Students form a major subset of young adults in any society [3]. Previous research has documented a high prevalence of CVD risk factors in both medical [16] and non-medical [17] students. Evidence shows that knowledge of risk factors is a key element of lifestyle modification, and people who perceive themselves to be at higher risk of CVD may adopt a healthy lifestyle [18]. Therefore, measurements of the knowledge and attitude of CVD risk factors are necessary to develop and implement targeted public health interventions [19].

Previous studies conducted in different countries have presented contradictory results regarding the prevalence of CVD risk factors among medical and non-medical students [20, 21]. Also, Studies show that young adults have limited knowledge and poor attitudes about cardiovascular disease and its risk factors. They also have less healthy lifestyles [22].

The aim of this study was to investigate the risk factors for heart disease in medical and non-medical students. As the study was conducted in the culture of Iran, which is a developing country and faces challenges common to these countries, the study did not attempt to identify specific risk factors that differ between these two groups. It only looked at general differences in knowledge, attitudes and behaviors related to risk factors for heart disease, with a particular focus on lifestyle behaviors related to the disease, patients and complications of the disease during the period of study in related medical fields, compared with What is it like for non-medical students?

Materials and methods

The present descriptive-analytical cross-sectional study was conducted on non-medical (i.e., literature, engineering, law, social sciences, and economics) and medical students (i.e., medicine, nursing, midwifery, health, and pharmacology) of Shahid Beheshti University of Medical Sciences in Tehran in 2022. 264 individuals were calculated using the sample size formula used in similar studies [20] by taking into account the probability of type one error (α = 1.96), probability of type 2 error (β = 1.28), test power (0.90), and observed effect size mean difference (d = 0.40.7). Assuming a probability of dropping out of 0.15, 160 students were placed in each group. Since the questionnaires were completed online, data were analyzed with 151 medical students and 151 non-medical students (total of 302), respectively, based on recoverable data. Inclusion criteria were informed consent to participate in research and study at the university. The link to the questionnaires was sent to the representatives of students in each field of individual faculties.

Before completing the questionnaire, the research objectives were explained to the participants in several paragraphs. They were assured of the confidentiality of information used only for research purposes. The written consent form was uploaded afterward.

Upon the approval of the informed consent, the research questionnaire was displayed to the participants. The data collection tool included four demographic information, knowledge/attitude, patients’ knowledge of risk factors, and CVD risk factor questionnaires.

The demographic information questionnaire consists of 22 questions on age, gender, weight, height, waist circumference, field of study, marital status, residential status, smoking, alcohol consumption, psychoactive substance use, special drug use, economic status, source of information about CVD, history of heart problem, history of heart problem in first-degree relatives, family history of a specific disease, and history of hospitalization due to CVD. The CVD knowledge questionnaire includes 17 multiple-choice questions prepared using questionnaires that were used in previous studies [1, 19]. Correct and incorrect answers in this questionnaire were scored 1 and 0, respectively. The CVD attitude questionnaire contains eight questions designed based on the questionnaires of the two studies. This questionnaire is based on a five-point Likert scale from “completely agree” to “completely disagree”, with scores of 5 and 1, respectively. The patient’s knowledge of CVD risk factors questionnaire was designed based on the previous study [1] which contains seven questions with “Yes”, “No”, and “I Do not Know” options. The CVD risk assessment questionnaire includes 27 questions, such as the history of CVD, blood pressure, diabetes, dyslipidemia, tobacco use, alcohol use, diet, and physical activity, designed based on a questionnaire used by Amruth et al. (2015) [23].

Validation of questionnaires

The questionnaires were first translated from English to Persian and vice versa by four translators and then translated into Persian by experts. Then, content validity was evaluated in terms of content validity and face validity index using the comments of 10 experts (5 nurses, 3 health educators, and 2 social doctors). Based on the experts’ comments, content validity was determined quantitatively by calculating the Content Validity Ratio (CVR) and Content Validity Index (CVI). The questionnaires were confirmed in terms of necessity (CVR), relevance, simplicity, and clarity (CVI). The reliability of the tool was assessed using Cronbach’s alpha. For this purpose, the questionnaires were completed by 30 medical and non-medical students, followed by calculating internal correlation values for knowledge (0.85), attitude (0.76), patient’s knowledge of risk factors (0.84), and risk factor (0.92) questionnaires.

Data were analyzed using SPSS 22 software. The normality of data was first determined using the Kolmogorov–Smirnov test, which confirmed a normal distribution. Descriptive statistics were used to determine the mean, standard deviation, frequency, and percentage. The Chi-square test and t-test were calculated using analytical statistics.

Results

The data analysis results showed that the mean ages of medical and non-medical students were 22.06 ± 3.53 and 21.88 ± 4.20, respectively, with no significant difference. In addition, no significant difference was found between the two groups regarding gender, age, marriage, and residence. The findings showed significant differences in employment, service provision, source of information, history of specific medication, and coverage by health-treatment centers between medical and non-medical students (Table 1).

Table 1 Demographic information of medical and non-medical students

Demographic information	Medical students (%)	Non-medical students (%)	p	
Age	22.06 ± 3.53	21.88 ± 4.20	-	
Sex	Female	81

50.0%

	78

49.1%

	0.730	
Male	70

48.0%

	73

51.0%

	
Marital Status	Single	139

92.1%

	139

92.1%

	1.	
Married	12

7.0%

	12

7.0%

	
Educational level	Bachelor	116

50.0%

	115

49.0%

	0.064	
Master	25

46.0%

	29

53.0%

	
PhD	10

58.0%

	7

41.0%

	
Living area	Dorm	87

57.0%

	115

76.0%

	0.660	
Independently	15

9.0%

	28

18.0%

	
With family	49

32.0%

	8

5.0%

	
Employment	Employed	36

23.0%

	58

38.0%

	0.006	
Unemployed	115

76.0%

	93

61.0%

	
Being a healthcare provider	Yes	46

30.0%

	147

97.0%

	< 0.001	
No	105

69.0%

	4

2.0%

	
Information resources	Health care providers	42

27.0%

	38

25.0%

	< 0.001	
Family	9

5.0%

	22

14.0%

	
Friends	10

6.0%

	7

4.0%

	
Books	53

35.1%

	5

3.0%

	
Newspapers	4

2.0%

	10

6.0%

	
Internet	27

17.0%

	60

39.0%

	
Television	2

1.0%

	8

5.0%

	
Others	4

2.0%

	1

0.0%

	
Drug consumption	Yes	14

9.0%

	5

3.0%

	0.033	
No	137

90.0%

	146

96.0%

	
Counseling	Yes	36

23.0%

	51

33.0%

	0.057	
No	115

76.0%

	100

66.0%

	
Covered by health care centers	Yes	129

85.0%

	106

70.0%

	0.001	
No	22

14.0%

	45

29.0%

	
Going to doctor	Yes	68

45.0%

	62

41.1%

	0.486	
No	83

54.0%

	89

58.0%

	

The t-test revealed a significant difference in the CVD knowledge of the two student groups (P < 0.001). Medical and non-medical students were not significantly different in their attitudes toward CVD (P = 0.208). There was a significant difference in the knowledge of underlying CVD factors among the members of the two groups (P < 0.001) (Table 2).

Table 2 Comparison of knowledge, attitude, awareness of risk factors, and prevention of cardiovascular disease in medical and non-medical students

	Medical students
mean (SD)	Non-medical students	P-value	
Awareness	13.53 ± 1.86	11.98 ± 2.94	< 0.001	
Attitude	33.13 ± 3.29	32.61 ± 3.25	0.208	
Awareness of risk factors	13.10 ± 1.77	12.27 ± 2.15	< 0.001	

The independent t-test results indicated no significant differences in the history of heart disease, hypertension symptoms, tobacco use, alcohol use, diet, and physical activity between the two groups of medical and non-medical students. The diabetes risk factor and dyslipidemia were significantly different between the two groups (Table 3).

Table 3 Comparison of cardiovascular disease risk assessment in medical and non-medical students

	Medical students
mean (SD)	Non-medical students	P-value	
Cardiovascular disease	0.94 ± 0.22	0.94 ± 0.30	1.0	
Hypertension	121.16 ± 10.72	126.55 ± 65.22	0.318	
Diabetes	1.60 ± 0.48	1.35 ± 0.50	< 0.001	
Dyslipidemia	1.95 ± 1.23	1.437 ± 0.93	< 0.001	
Smoking	1.48 ± 0.95	1.56 ± 1.02	0.451	
Alcohol	1.03 ± 0.22	1.07 ± 0.44	0.419	
Diet	9.29 ± 1.66	9.35 ± 1.71	0.733	
Physical activity	7.35 ± 2.024	7.52 ± 1.98	0.473	

Discussion

The present study compares the underlying CVD risk factors between medical and non-medical students. The results showed that books (35.1%) and the Internet were the major sources of information among medical and non-medical students, respectively. Searching in different information sources indicates similar results in this context [6, 24]. Easy access to the Internet and the widespread use of new technologies in universities has increased the tendency to obtain information through the Internet among students. Based on the education during their studies, medical students seem to have better understood that books can be more reliable sources of information than websites.

According to the present results, drugs are used less frequently among medical and non-medical students, although there is a significant difference between the two groups. An explanation for this result might be the greater knowledge of diseases and communication with the medical staff among medical students, who are identified earlier and take medicine in the case of disease incidence. Our results show significantly more coverage for medical students by health-treatment centers than for non-medical students. More coverage of medical students was expected since part of their internship period in Iran is spent in health treatment centers.

The results of this study reveal more knowledge of medical students compared to non-medical students about CVD and its underlying factors. This result is consistent with a study conducted in Ethiopia [25], in which more knowledge (2.6 times) about CVD risk factors was recorded among the students of the Faculty of Medicine and Health Sciences than the students of other colleges [20]. This difference in the average score might be due to differences in the field of study between the study participants. In this regard, Reiner et al. (2012) reported an increase in the knowledge level of medical students about the underlying risk factors of CVD at the end of their studies [26].

Based on the results of the present study, there is a significant difference between the knowledge of medical and non-medical students about CVD. Medical students, both those studying at high school and those studying in medical-related fields, have more information than non-medical students on topics such as diseases, factors that cause diseases, healthy lifestyles, the role of risky behaviors such as smoking, prepared foods and fast food, low physical activity, and obesity and overweight. These differences can be seen particularly in the scores on the knowledge questionnaire, which included options on the nature of heart disease, factors that cause it, healthy lifestyles and the role of high-risk behaviors.

The findings of this study showed no significant differences in the attitude toward CVD among medical and non-medical students. In this respect, the results of a systematic review study in 2020 indicated that a high knowledge level of healthcare providers did not necessarily affect their attitude toward their cardiovascular health [23]. Therefore, it is inferred that increased knowledge does not necessarily improve attitude as it is affected by different factors. In the current era, which is known as the information age, a lot of information is published every moment through different channels, especially cyberspace, and people are exposed to a large amount of information, but using this information, especially information related to health, requires a deep insight into people’s thoughts and beliefs. In developing countries, including Iran, behavioural changes depend to a large extent on people’s culture and beliefs, and the current young generation is involved in a contradiction between the beliefs they inherited from their ancestors and the huge amount of information they receive daily, and considering the fact that he does not have enough skills to integrate information and use it, therefore he faces a great challenge and obstacle under the name of cultural bias to change behavior and healthy lifestyle. For the younger generation, knowledge alone is not enough to change behavior and healthy lifestyles and requires fundamental changes in their beliefs and attitudes.

The simplicity and cost-effectiveness of screening for CVD risk factors have made it an important prevention strategy worldwide [5, 23]. Our study showed no significant difference in tobacco use among medical and non-medical students. Medical students were expected to smoke less than non-medical students and act as role models in society, but this relationship was not significant in this study. An explanation for this result may be more pressure and stress endured by medical students than non-medical students [3, 27]. In a study by Abdulrahman et al., when students were asked about the time they preferred to smoke, most of them reported smoking when they were under stress or pressure [8]. Pressure and stress in medical students cause no significant difference in smoking between the two groups, although medical students should have more knowledge about the harms of smoking.

The results showed no significant differences in the diets of medical and non-medical students. This finding is similar to those of studies Mokbel Alissa provided evidence that medical students performed poorly due to the lack of time in their daily schedule despite their more knowledge of the importance of healthy eating habits [28].

Physical activity was not significantly different between medical and non-medical students, and it was non-significantly lower in medical students, which is in line with previous studies in Iran [5] and Saudi Arabia [29]. Even if medical students are future doctors and leaders of society, they are physically at risk of CVD, like other groups of society. Therefore, it may already affect their credibility as healthcare providers. Therefore, fundamental changes are necessary in the lifestyle of students. Nevertheless, a study showed that physical activity in medical students was significantly higher than non-medical students during the COVID-19 quarantine. This discrepancy may be attributed to medical students’ high knowledge in Germany about the importance of physical activity as one of the long-term prevention methods for COVID-19 [30]. The cultural and time differences in the studied countries are the other possible reasons for this difference.

According to our results, no significant difference in blood pressure symptoms was observed between medical and non-medical students, which is consistent with the study conducted in Saudi Arabia [31]. Previous research has shown that obesity, overweight, and lack of physical activity were the major factors affecting blood pressure in students [14, 30, 32]. The obesity of students in the two groups was not investigated in this study. However, the findings showed no significant difference in physical activity between the medical and non-medical students.

The results of this study showed that there was a significant difference in the knowledge of diabetes and dyslipidaemia between the medical students and the non-medical students, which is similar to a study conducted by Ajrash et al. in Bahrain [20]. In general, this study found that the risk assessment of CVD was the same in medical and non-medical students. Although medical students had more information about the risks of heart disease, their risk assessment of these diseases was like that of non-medical students. It can be said that, in this study, having more knowledge is not a reason to adopt a healthy lifestyle. As a result of a few unhealthy habits during student life, including increased consumption of convenience foods rich in saturated fats, reduced physical activity, and smoking, they may become susceptible to obesity and cardiovascular risk factors. And this was true for both groups in this study.

One of the strengths of this study is that it examines students from the most prestigious medical universities in Tehran, which admit a large number of students from across the country. This makes the sample a good representative of different Iranian cultures. A major limitation of the study was that all the findings of this paper were based on self-reported survey data. No physical measurements were taken such as blood pressure, fasting glucose, etc. It is therefore recommended that a similar study be carried out using detailed data such as biochemical and cardiac tests, paraclinical tests such as echo and anthropometric data on students.

Considering the limited knowledge of young people and their unfavorable attitudes towards cardiovascular disease and its risk factors [22], in the present study, young people with a medical background had a higher level of knowledge, attitudes and practices related to CVD risk factors and their prevalence compared to those without a medical background. Thus, the level of knowledge of medical students about CVD and its risk factors among the young population is sufficient and they have a positive attitude to avoid CVD risk factors. The reason for this may be due to the increased amount of information they receive as a result of greater exposure to diseases, patients and disease complications during their studies in related medical fields.

Conclusion

This study demonstrates that students, as a large group of young adults, are at risk of CVD. According to our findings, one of the involved factors may be their poor knowledge and unfavorable attitude toward CVD risk factors. Students are at risk of CVD, and healthy lifestyle programs are needed to address this risk. Therefore, it is suggested to design targeted interventions based on existing gaps in their knowledge. Based on this, it is recommended that health promotion school programs be implemented during the school period and that information on health and disease, healthy lifestyles, and risky behaviors, especially regarding cardiovascular diseases, be provided to students, teachers, and parents in textbooks or extracurricular forms. In university courses, units on healthy lifestyles and high-risk behaviors should also be offered to non-medical students in the form of non-core units, such as design and implementation of practical education in the fields of healthy nutrition, physical activity, stress management, and the necessary lifestyle are recommended during academic studies. Furthermore, early screening can effectively prevent CVD-related complications and mortality. so that their information on this subject is increased and the educational inequalities between these two groups in this area are reduced to some extent.

Abbreviations

CVD Cardiovascular disease

Acknowledgements

The authors would like to express their gratitude to all those who participated in this research for their sincere cooperation.

Author contributions

All authors contributed to the study’s conception and design. Material preparation was performed by [Fatemeh Estebsari], and [Zahra Rahimi Khalifeh Kandi], and data collection was performed by [Mohadaseh Barati], [Sara Stiri], [Marzieh Latifi], [Arezoo shahsavari], [Arezoo Sheikh Milani] and analysis were performed by [Fatemeh Estebsari], and [Zahra Rahimi Khalifeh Kandi]. The first draft of the manuscript was written by [Zahra Rahimi Khalifeh Kandi] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Funding

The authors did not receive support from any organization for the submitted work.

Data availability

The data underlying this article are available by request to the Arak University of Medical Sciences in Iran and the data analysis is available by contacting the corresponding author.

Declarations

Ethics approval and consent to participate

The present study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (IR.SBMU.PHARMACY.REC.1399.134). All procedures followed were by the ethical standards of the responsible committee for human experimentation and with the Helsinki Declaration of 1975, revised in 2000. Verbal informed consent was obtained from all participants to be included in the study.

Consent for publication

Not applicable any information that could reveal the identities of the study participants has been omitted or changed.

Competing interests

The authors declare no competing interests.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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