VIMS Journal: December 2016

Original Article

A Study of Coronary Artery Disease (CAD) Risk Behavior and The Effect ofPlanned Health Counseling on Risk Behavior of Selected Population at Kolkata

Dr. Sonali Ganguly

Abstract :
Background And Aims :
The present study is aimed at developing plannedhealth counseling program to help individualsto identify risk factors present in them which aredetrimental to CAD that have the potential toenhance their susceptibility in CAD. Since CADis caused by multiple factors the investigatorused fishbone mode to identify the risk behaviorin two groups, educated school teachers and lowliterate slum dwellers. Two groups were selectedkeeping in mind their general education,knowledge of health and economic conditions.

Aims and Objectives :
The study aimed to find out the risk factors indeveloping the CAD risk behavior among highliterate secondary school teachers and a lowliteracy group in an urban slum community, andthe effectiveness of planned health counselingprogram. The objective of the study were to: (1)identify the CAD risk factors among secondaryschool teachers ( group I) and selected low literategroup (Group II) with a view to identify themodifiable risk factors. (2) develop and validatea planned health counseling program based onidentified risk behavior for two experimentalgroups (I A and II A). (3) find out the effectivenessin terms of changes in (i) cholesterol, (ii) bloodpressure, (iii) body weight, (iv) anxiety and (v)blood sugar of those who are diabetic vi) changesin lifestyle with regard to smoking habit andalcohol consumption in group I and group IIafter 6 months of intervention. (4) find out the effectiveness of planned health-counselingprogram in terms of increase in health knowledgeafter 6 months of intervention in bothexperimental groups. (5) compare the two studygroups on their knowledge and risk factors,before and after the intervention.


Type of Study:
The design adopted for the study was survey inphase I and a quasi experimental design withtwo non-equivalent pre-test - post-test controlgroup designs was planned in phase II.

Sample Population:
The phase I of the study included 500 highschool teachers from different zones of Kolkataand 500 selected low literate/uneducated peoplefrom a selected urban community/slum. In phaseII of the study 200 high scorers were chosenfrom each group and placed in experimental andcontrol groups, randomly.

Time Period:
It took nearly Six months (180working days) tocollect the data.

Methods:The scores were arranged according to themagnitude of the scores, and 200 high scorerswere selected in each group. Subjects wererandomly allotted to experimental and controlgroups for both school teachers and low literacygroup.

Health counseling was administered to the experimental groups I A and II A. Bothexperimental and control groups (I B AND II B)were pretested and post test was carried out on8th. 60th and 120th day. PHCP was conducted inone session for selected teachers of each school.Low literacy group was taught in small groupsof 5 to 10 PFHCP was completed in 60 days.Post tests were conducted in one session for eachschool, whereas the low literacy group was testedby door to door visit or in small groups. Feedback (or reinforced) teachings were given inquestion and discussion sessions.

Among secondary school teachers (500), majority(56%) were with in the age group of (41-50years), were as among low literacy group (500)53% were with in the age group of (41-50 years).
Out of (500) secondary school teachers majority52% were male but among low literacy group(500) 51.4% were female.
In secondary school teachers (500) 76% weremarried and in low literacy group (500) also 74%were married.
Out of secondary school teachers (500) majority(93.4%) were hindu and in low literacy group(500) also 93.4% are belonging to the hindureligion.
Among secondary school teachers (83%) werepost graduate, where as (100)% of low literacygroup had no formal degree.
Out of (500) secondary school teachers 62.2%were having the habit of ready health relatedmalerial from pamplets.
Majority 60% of secondary school teachers arewatching health related information on TV and90% low literacy group had the habit of watchinghealth related information on TV occasionally.
Among 500% secondary school teachers 44%had more than 10 years of working experience.
Findings related to the description of thesecondary school teachers and low literacygroup according to their demographiccharacteristics are described in frequencyand percentage.

Risk Status :
-Among secondary school teachers 80%were at moderate risk whereas in lowliteracy group 74% were at moderate risk.
- In secondary school teachers 70% weremale but in low literacy group (majority)51% were female and were at low risk ofdeveloping Cad.
- In both the groups majority of participants80% & 82 % respectively for secondaryschool teachers & low literacy group hadno family history and were not at risk fordeveloping CAD.
- Majority of participants in both groups(secondary school teachers and lowliteracy) were below or equal to idealweight (54% & 56 respectively) at werenot at body weight risk.
- In both groups half of the participants wereat risk of developing CAD due to lack ofphysical activity.
- Majority of secondary school teachers hadno risk of developing CAD due to smokingbut 44% of low literary group had the habitof smoking.
In both the groups majority of theparticipants were at risk of CAD.
- The risk status related to high bloodpressure, diabetes, salt intake very low in both the groups. Risk related to sugar intakewas high (58%) in secondary schoolteachers and alcohol consumption washigher 70% in low literacy group.
- In both the groups majority of theparticipants (64% and 96%) were of typeB personality and were at low risk ofdeveloping CAD.

It is concluded that secondary school teachersare moderately at risk of developing CAD as foras the risk factors such as age, gender, bodyweight, physical activity and personality isconcerned and low literacy group is at risk ofdeveloping CAD as for as the risk factors suchas emotional stress is concerned.

Total risk status :
Secondary school teachers and low literacy groupboth were at moderate risk status for developingCAD.

Phase – II
- Out of 400 (200 seceondary school teachers+ 200 low literacy bgroups ) maximun 48%of secondary school teachers and majority52 of low literacy group were within theage group of (4 - 50) years.
- Majority 55% of secondary school teacherswere male and maximun 48% of lowliteracy group was female.
- Majority of the secondary school teachers(81%) and low literacy group 80% weremarried.
- In both the groups majority of participants(94%) were belonging to the hindu religion.
- Majority of secondary school teachers werepost graduate but 100% of low literarygroup were either having no formal education or just discontinued it in primarylevel only.
- In both groups majority (55% and 86%respectively) secondary school teachersand low literary groups had the habit ofwatching TV occationally.
- Secondary school teachers (32%, 15%,16% and 38% respectively) had the habitof reading health related material fromdifferent sources like books, journals,magazine, pamplets but 64% of secondaryschool teachers prefer pamphets and 36%are not reading anything.
- In both the groups majority (96% and98%) respectively among secondary schoolteachers and low literacy had moderaterisk of CAD.

Effectiveness of the health counselingprogram in-terms of change in:
i) Blood cholesterol level, ii) Bloodpressure, iii) Body weight and iv) Anxietylevel.

Change in lifestyle with regard to smokinghabit and alchohol consumption in bothgroups after 6 months of intervention.

- In both the groups changes of body weightwas not that much observed in relation toinitial phase and after six months.
- In secondary school teachers after sixmonths the health related mean ofknowledge was increased from 20.60 ±3.50 to 33.85 ± 3.84.
- In all other clinical parameters also changesare visible but a high reduction wasobserved in mean score of alcoholconsumption after six months (2.70 ± 8.62)which was 13.20 ± 20.59 at hte line of preintervention.
- Among control group of secondary schoolteachers the mean pretest knowledge scorewas (15.23±2.40) and in post test after sixmonths of pretest it has become double( 31.87±3.27).
In other clinical parameters alsoimprovement was noticed to some extentthough the participants were not exposedto the intervention.
- On the other hand in both experiment andcontrol group of low literacy subjects hadimprovement in knowledge (pre 5.75 ±1.81) and 6 months 14.68 ± 1.92 & 13.87± 1.53 respectively and very littleimprovement in other clinical parameters.

The following conclusions were drawn based onthe findings from the present study.
1. The risk for developing Coronary Arterydiseases as the age advances.
2. Majority of the participants were at moderaterisk of developing CAD.
3. Majority of the participants in both groupswere at risk of CAD when factors like physicalactivity, dietary habits, salt intake, sugar intakeand emotional stress are taken intoconsideration. This suggested thatmodification of lifestyle with regard to diet,physical activity and emotional stress andoverall awareness to health promotion anddisease prevention would reduce the risk ofcoronary artery disease.
4. The mean post test knowledge of all the groupswas higher than the mean pre test knowledge.So it could be concluded that not onlyawareness program was effective, but repeatedinteraction with both the groups might helpthem togather information.

The incidence of cardiovascular diseases (CVD)is on the rise in modern world. There are severalfactors contributing to its steady increase, thecommon ones are industrialization leading torapid urbanization, general improvement ineconomic status and its collective effects onpeoples lifestyle. Cardiovascular disease is nota single disease but a category of disordersaffecting the heart & blood vessels. Coronaryartery disease (CAD), cerebrovascular disease(stroke), atherosclerosis, congenital heart diseaseand hypertension are all forms of CVD. Amongmen and women & across all racial & ethnicgroups, cardiovascular disease is the world'sleading killer.

The following facts given by WHO (2012)[13]shows the extent of the disease:
- In 2008 cardiovascular disease contributedto a third of global death
- In 2008, low and middle income countriescontributed to 80% of CVD death.
- By 2030 CVD is estimated to be the leadingcause of death in developing countries.The common cardiovascular diseases thatcause the increased burden all over theworld are coronary artery disease.

Due to industrialization and changing featuresof socioeconomic scenario, the incidences ofCAD are rising in the developing countries aswell. As reported by Yavagal[5], cardiovasculardeaths in India are three to four folds higherthan in America and Europe. Among themsignificant increase was seen in men below 40years & in women below 50 years.

In view of the wide prevalence of cardiovasculardisease, it is necessary to focus our attention topreventive aspect, rather than curative aspect alone. In countries like India, It is difficult toprovide sophisticated health care facilities to alarge number of people. Hence, "Prevention isbetter than cure". The process of diseaseprevention must be aimed at not onlyunderstanding the disease mechanism and itsrisk behavior, but also identifying strategies thatdefinitively reduces the risk.

Since 1951, one of the best known largeprospective studies in USA, the Framinghamstudy [2], has played a major role in establishingthe nature of CAD risk factors and their relativeimportance. According to the study, the majorrisk factors of CAD are elevated serumcholesterol, smoking, hypertension & sedentaryhabits. Accordingly the four main possibilitiesof intervention in CAD prevention are, (1)reduction of serum cholesterol, (2) cessation ofsmoking (3) control of hypertension & promotingof physical activity [20].

The following estimated risk factors in youngmen leading to CAD shows the populationpotential to develop CAD.

Table 1 Risk factors of CAD in Men

Risk factor on Men Percentage %
Smoking 74.8
Obesity 19
Hypertension 18.8
Hypercholestrolemia 18
Diabetes Mellitus 16.4
Family history of previous MI 13.2

(Yavagal, 2009)5

hyper cholestremia (18%) diabetes mellitus andfamily history of previous MI are the least riskfactors in the development of Coronary ArteryDisease (CAD) as observed by-Yavagal.[5]

Table2. Data about CAD in Women

Risk factors in women Percentage %
Hypertension 49%
Diabetes 39%
Obesity 18%

(Yavagal, 2009)5

Yavagal [5] also observed that hypertension isidentified as the major risk factor for thedevelopment of Coronary Artery Disease (CAD)in women, i.e. (49%) of women hadhypertension, followed by diabetes (34%) andobesity (18%). Thus it is concluded that smoking,hypertension, diabetes and obesity are the majorrisk factors in the development of coronaryartery diseases (CAD).

How can these risk factors be controlled? Thiscan be achieved only through public awarenessprogramme. According to the concepts ofparticipatory care trend, the soul of health is toencourage individuals to take responsibility toimprove their own health. Individuals takingcharge of their own health will have somepositive effect on their controlling the risk factors.According to Rosenstock's Health Belief Modelthe health behavior of individual is dependenton various factors such as knowledge, felt need,demographic factors, etc [7,5,6]. The educationmust also include strategies for counseling whichwill be helpful to achieve this goal. Keepingthis in view the researcher has taken an attemptto initiate such study.

The study aimed to find out the risk factors indeveloping the CAD risk behavior among highliterate secondary school teachers and a low literacy group in an urban slum community, andthe effectiveness of planned health counselingprogram. The study further attempted to comparethe knowledge gained by both groups. Hence, apreliminary survey approach was found to beappropriate to identify the risk factors. Further,an evaluative approach using quasi experimentaldesign was considered the best and most suitableto find the effectiveness.

The present study identified Fish bone diagramto classify risk behavior for coronary arterydiseases and Rosenstock's Health Belief modelto identify readiness in seeking preventable healthbehavior.

The independent variable deliberatelymanipulated was the teaching of PHCP onPrevention of CAD was initiated with primarilylecture and discussion session with flash cardand power point presentation. At the end of thediscussion question answer sessions were held.Duration of timings varied from 45 minutes toone hour. Feed back sessions held after 8th, and60th day were in the form of question discussion.The dependent variables of the study were riskfactors, the knowledge of risk factors andreduction of risk factors for the occurrence ofCoronary Artery Disease (CAD). The extraneousvariables, namely age, sex, income, educationand Exposure to mass media were incorporatedinto the study.

For generating the data on outcome variables,Cardiac Risk assessment Tool (r=0.93) was usedto assess the risk of individual, StructuredKnowledge Questionnaire (r=0.88) wasdeveloped to find the gain in knowledge, astandardized tool for measurement of anxiety (r=0.82) and a checklist tool for biochemicaland biomedical measurement was selected forthe study.

A planned health counseling program wasdeveloped on Prevention of CAD and wasvalidated by experts. Data collection period wasspread over two consecutive academic years intwo phases. A self-administered CAD riskassessment scale was used to collect data from30 to 35 teachers in a day from each schoolwhich took two to three days for each school.A door to door survey was made to identifyCAD risk factors of low literacy group who metthe sample criteria. Height and weight of thesamples were assessed in order to find BMI

It took nearly Six months (180working days) tocollect the data. The scores were arrangedaccording to the magnitude of the scores, and200 high scorers were selected in each group.Subjects were randomly allotted to experimentaland control groups for both school teachers andlow literacy group.

Health counseling was administered to theexperimental groups I A and II A. Bothexperimental and control groups (I B AND IIB) were pretested and post test was carried outon 8th, 60th and 120th day.

PHCP was conducted in one session for selectedteachers of each school. Low literacy group wastaught in small groups of 5 to 10 PFHCP wascompleted in 60 days. Post tests were conductedin one session for each school, whereas the lowliteracy group was tested by door to door visitor in small groups. Feed back (or reinforced)teachings were given in question and discussionsessions.

Result of the study:

Sample Characteristics
Description of sample characteristics (Secondary School Teachers )

Sl.No Sample characteristics Frequency(f) Percentage(%)
1 Age in years
21-30 3 0.6
31-40 123 24.6
41-50 278 55.6
51-60 96 19.2
2 Gender
Male 260 52
Female 240 48
3 Marital status
Single or Unmarried 76 15.2
Married 379 75.8
Divorced/ Widow/Widower 45 9
4 Religion
Christian 4 0.8
Muslim 29 5.8
Hindu 467 93.4
5 Educational status
Graduate 59 11.8
Post graduate 415 83
Other (M.Phil and PhD) 26 5.2



Sample characteristics
Table-7: Description of Sample Characteristics (Low literacy group)

Sl.No Sample characteristics Frequency(f) Percentage(%)
1 Age in years
21-30 3 0.6
31-40 106 21.2
41-50 263 52.6
51-60 128 25.6
2 Gender
Male 243 48.6
Female 257 51.4
3 Marital status
Single or Unmarried 125 25
Married 369 73.8
Divorced/ Widow/Widower 6 1.2
4 Religion
Christian 0 0
Muslim 33 6.6
Hindu 467 93.4
5 Educational status
Graduate 0 0
Post graduate 0 0
Other (Nil) 500 100


Demographic distribution of secondary school teachers and low literacy group
Gender distribution among secondary school teachers and low literacy group
Marital Status among secondary school teachers and low literacy group
Religionity among Secondary school teachers and Low literacy group
educational status among secondary school teachers and low literacy group
Habit of watching television for health-related information amongSecondary school teacher & Low literacy group
Reading habit of health-related materials among Secondary school teachers & Low literacy group

Table 11: Risk status of coronary artery disease among all Secondary school teachers andlow literacy group


Secondary School Teachers Low Literacy Group
S.No Risk Status Frequency Percentage Frequency Percentage
1 High risk 1 0.2 0 0
2 Moderate risk 491 98.2 500 100
3 Low risk 8 1.6 0 0

Table-12 : Risk status of coronary artery disease among secondary school teachers and lowliteracy group in experimental and control group


Secondary School Teachers Low Literacy Group
S.No Risk Status Exp-Group(IA) Control Group(IB) Exp-Group(IIA) Control Group(IIB)
f % f % f % f %
1 High 1 1 nil nil nil nil nil nil
2 Moderate 91 91 97 97 100 100 100 100
3 Low 8 8 3 3 nil nil nil nil

Table-13: Description of clinical parameters (body weight) of experimental and control group(secondary school teachers and low literate group)


Category Body Weight Secondary School Teachers Low Literacy Group
Exp-Group(IA) Control Group(IB) Exp-Group(IIA) Control Group(IIB)
0 mths 6 mths 0 mths 6 mths 0 mths 6 mths 0 mths 6 mths
Above ideal 17 17 23 23 22 23 8 8
Below ideal 21 19 10 10 18 17 12 12
Ideal 62 64 67 67 60 60 80 80

Table 14: Distribution of selected clinical parameters, pre-test, post-test on 8th day, 2 monthsand 6 months. of experimental secondary school teachers and low literate group.
Mean and SD for secondary school teachers (Experimental group) for all variables;

Variables Pre test Post test
Mean SD 8 days 2 Months 6 Months
Mean SD Mean SD Mean SD
Knowledge 20.60 ± 3.50 25.88 ± 3.45 30.08 ± 4.16 33.85 ± 3.84
SBP 142.16 ± 9.609 135.90 ± 9.172 129.59 ± 8.762
DBP 88.64 ± 5.036 84.54 ± 5.147 79.92 ± 3.584
Cholesterol 173.44 ± 11.93 161.96 ± 12.712 149.87 ± 13.24
Sugar 131.32± 8.71 122.76 ± 8.18 113.25 ± 8.31
Anxiety 57.83 ± 5.39 54.88 ± 5.36 52.31 ± 5.40
Number of cigarette Smoking per day 4.12 ± 6.706 3.30 ± 5.43 2.59 ± 4.33
Alcohol intake 13.20 ± 20.59 5.70 ± 13.94 2.70 ± 8.62

Table-15: Mean and SD of selected clinical parameters in control group of secondary school teachers

Variables Pre test Post test
Mean SD 8 days 2 Months 6 Months
Mean SD Mean SD Mean SD
Knowledge 15.23± 2.40 24.881± 2.41 31.87±3.27
SBP 141.27 ±8.471 134.69 ±7.340 127.84 ±6.740
DBP 88.82 ±6.031 83.36 ±5.194 79.56 ± 4.446
Cholesterol 165.23 ±20.08 161.20±19.75 158.73 ±19.77
Sugar 154.43 ±8.840 141.37 ±10.144 128.68 ± 10.075
Anxiety 47.04 ±9.215 44.92 ±9.204 42.18 ±8.781
Number of cigarette Smoking per day 7.80 ±6.537 6.26 ±5.382 4.56 ±4.150
Alcohol intake 17.40 ±20.529 11.10±16.323 9 ±14.460

Table-16: Mean and SD for low literacy control group for all variables

Variables Pre test Post test
Mean SD 8 days 2 Months 6 Months
Mean SD Mean SD Mean SD
Knowledge 5.75±1.81 12.92±1.61 13.87±1.53
SBP 154.43 ±6.176 147.96 ±7.251 140.42. ±7.852
DBP 88.02 ±5.314 84.53 ±5.114 81.90 ±4.044
Cholesterol 157.04 ±6.91 148.84 ±6.43 137.04 ±11.75
Sugar 160.34 ±7.715 151.36 ±8.539 140.37 ±8.788
Anxiety 57.83 ±5.390 54.88 ±5.366 52.31 ±5.47
Number of cigarette Smoking per day 8.97± 5.811 6.90 ±4.598 4.86± 3.511
Alcohol intake 16.50± 20.516 10.50± 17.774 6.90±14.681

Table-17: Mean and SD for low literacy (experimental group) for all variables

Variables Pre test Post test
Mean SD 8 days 2 Months 6 Months
Mean SD Mean SD Mean SD
Knowledge 5.75 ±1.81 7.68±1.76 12.63 ±2.10 14.68 ±1.92
SBP 141.05 ±8.299 134.21 ± 7.084 127.58±6.521
DBP 88.74 ±6.108 83.46±5.233 79.66±4.431
Cholesterol 160.64 ± 20.7 156.38 ±19.83 152.90 ±19.0
Sugar 157.02±8.979 148.38± 10.597 127.76±9.428
Anxiety 47.47 ± 9.942 45.09±9.806 43.08 ± 9.555
Number of cigarette Smoking per day 5.27 ± 7.118 4.20 ±5.803 3.13 ±4.382
Alcohol intake 16.50±23.884 9.60 ±16.992 5.70 ±12.57

The findings of the study were discussed withreference to the objectives and hypothesis andwith the findings of the studies. The issuesemerged from the findings of the analyzed data.

The conceptual framework consists of certainpredisposing factors in the development of CAD.They are divided into modifiable and nonmodifiablerisk factors. These risk factors areunknown or little known to the normal individual.While doing risk assessment, the samples willgain knowledge regarding their risk status andthis will motivate them to attend the awarenessprogramme and further change their lifestyle toprevent the occurrence their CAD. In this studyit is showed that majority of the participants inboth the groups belonged to moderate risk ofdeveloping CAD and only 4% of secondaryschool teachers had high risk. Juliet (2000) andMathai (1998) also observed that majority ofparticipants fell in moderate risk category (Juliet85.33%, Mathai-59.5%). This findings supportthe Rosenstock's health behavior model. Theknowledge of the risk status motivates theparticipants to take preventive health behavior.This made them to listen to the planned healthcounseling program on CAD.

Initially many of the participants did not havesufficient knowledge on risk factors of CAD andBhaswati (2008) found that the knowledge ondiet to prevent cardiac diseases was poor amongthe school teachers. Praveena (2002) also foundthat college teachers had low level of knowledgeon planned teaching program on prevention ofCoronary Heart Disease.

The mean post-test knowledge scores obtainedwere significantly higher than the mean pre-testscores. This indicated that the awareness programhad improved the knowledge of the participantson various aspects of CAD and its Prevention.Thus it could be suggested that the effectiveawareness program could increase the knowledgeof individuals.

A study conducted by John (2000) to evaluatethe effectiveness of a planned patient counselingprogram on prevention of recurrence of renalcalculi in terms of gain in knowledge , changein dietary practices and selected biochemicalcomponents in serum and urine of patients withrenal calculi. The findings showed that theplanned counseling program was effective inimproving the participants knowledge andbrought about the changes in dietary practicesand reduction in blood sugar levels in diabeticclients. Studies conducted by Manju (2007),Manashi (2005), Pritha (2003) had observedsignificantly higher knowledge in the post-testfollowing the administration of a teachingprogram. Thus the finding of the present studywas similar to others' findings. This confirmedthat the awareness program had an impact inimproving the knowledge of the participants.

Effectiveness of health counseling programmein terms of changes (i) cholesterol level, (ii)blood pressure, (iii) body weight and (iv)anxiety level (v) blood sugar level of thosewho are diabetic (vi) changes in lifestyle withregard to smoking habit and alcoholconsumption in (group I and group II) after6 months of intervention.

It was assumed that the numbers of factorsinfluences the lifestyle of an individual,knowledge on preventive health behavior wasvery much necessary for a healthy lifestyle. Thepresent study revealed that there was less but significant changes were observed in cholesterollevel, (ii) blood pressure, (iii) body weight and(iv) anxiety level (v) blood sugar level of thosewho are diabetic (vi) changes in lifestyle withregard to smoking habit and alcohol consumption.

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  3. Stuart. G. W., Sundeen. S. T., Principals and Practice of Psychiatry Nursing. C.V. Mosby & Co, 1995, Page269 - 271.

  4. Stone, S. C. (1991). Comprehensive family andcommunity health nursing. (3rd edn). St. Louis:Mosby year book.

  5. Polit; D.F. Hungler; Nursing Research Principles andmethods; 6th ed. Lippincott: Philadelphia; 2006.


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