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Abstract
Objectives To investigate the knowledge, attitude and practice (KAP) of patients with ischaemia with non-obstructive coronary arteries (INOCA) toward their condition.
Design A cross-sectional study using questionnaires to assess KAP scores among patients with INOCA.
Participants Patients with INOCA from the Xinjiang region of China were enrolled between September 2023 and February 2024.
Interventions Data were collected via structured questionnaires covering demographic information and KAP metrics.
Primary and secondary outcome measures Mean KAP scores were analysed. Correlation analyses and path analysis examined relationships among KAP components, influencing factors and indirect effects.
Results A total of 498 questionnaires were analysed (mean age of participants 54.13±10.91, 59.04% women). The mean KAP scores were 4.41±1.78 (possible range: 0–7 points), 21.29±3.40 (possible range: 6–30 points) and 26.91±6.37 (possible range: 8–40 points), respectively. Spearman correlation analysis found significant correlations between knowledge and attitude (r=0.4954, p<0.001), knowledge and practice (r=0.4589, p<0.001) and attitude and practice (r=0.5959, p<0.001). Path analysis indicated that attitude, income and drinking had direct effects on practice. Knowledge influenced practice both directly and indirectly. Indirect effects on practice were also noted for family history of INOCA, residence, marital status, coronary vascular examination and smoking.
Conclusions This study reveals suboptimal KAP levels among patients with INOCA in Xinjiang, China, highlighting an urgent need for improved patient education and disease management strategies to enhance understanding and coping with INOCA.
- CARDIOLOGY
- Coronary heart disease
- Ischaemic heart disease
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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STRENGTHS AND LIMITATIONS OF THIS STUDY
The study’s sample size of 498 patients with ischaemia with non-obstructive coronary arteries (INOCA) enhances the reliability and generalisability of the findings within the Xinjiang region.
Employing both correlation and path analysis provides a comprehensive understanding of the relationships between knowledge, attitude and practice among patients with INOCA.
The cross-sectional design introduces potential selection bias, limiting the ability to infer causality from the observed relationships among knowledge, attitude and practice scores.
The study’s findings are confined to an urban population in Xinjiang, affecting the generalisability of results to broader populations.
Introduction
Ischaemia with non-obstructive coronary arteries (INOCA) is a specific type of coronary artery disease (CAD), a chronic coronary syndrome condition that contributes to many cardiovascular outcomes, including heart failure with preserved ejection fraction and myocardial infarction.1 2 Prevalence of angiographic ischaemia with no evidence of coronary obstruction, attributed to INOCA, is estimated to be 30–70% of patients referred to coronary angiography, with a strong female predominance.2 Despite its relatively slow course, it is still related to increased morbidity/mortality, impaired quality of life and weigh on health resource utilisation.3 4 While cardiovascular diseases are one of the major global health concerns, INOCA is often under-recognised and under-diagnosed, due to the mechanisms not being completely understood and heterogenous patient populations.5 6
Different classifications and management approaches are currently tested in ongoing trials, while only about half of patients are treated appropriately.6 7 With such a background, patients’ awareness of the disease is very low, especially taking into account specific biological and sociocultural gender-related differences, as women continue to have delays in diagnosis and treatment.8 9 Understanding patients’ awareness, their attitude toward treatment options and their actual health management behaviours is essential for improving prognosis and quality of life.10
A structured survey method that investigates knowledge, attitude and practice (KAP) through a questionnaire could provide a basis for further optimisation of health education and disease management strategies for the population.11 12 Currently, relatively few studies have been conducted on perceptions, attitude and practice towards CAD and chest pain; all of them report relatively low KAP.13–15 To the best of our knowledge, no previous KAP study for INOCA was undertaken among patients with INOCA.
Therefore, this study aims to investigate the level of KAP towards INOCA in Xinjiang (China), and to provide a scientific basis for the development of more personalised and effective prevention, treatment and management strategies.
Methods
Study design and participants
This cross-sectional multicentre study enrolled patients with INOCA from the Xinjiang region (China) between September 2023 and February 2024. The hospitals included Urumqi Hospital of Traditional Chinese Medicine, Xinjiang Uygur Autonomous Region Hospital of Traditional Chinese Medicine, Xinjiang Uygur Autonomous Region Uygur Medical Hospital. The inclusion criteria were: (1) aged 20–80 years old; (2) patients who had already been diagnosed with INOCA either at our hospital or previously at other healthcare institutions; (3) signed informed consent. The exclusion criteria were: (1) coronary heart disease with coronary stenosis>50%, congenital heart disease, heart valve disease, cardiomyopathy, chronic obstructive pulmonary disease, pulmonary embolism, cerebrovascular disease, liver and kidney insufficiency; (2) anyone who did not undergo coronary angiography or Computed Tomography Angiography (CTA) or had incomplete clinical data; (3) anyone who is mentally ill or unable to cooperate with the study; (4) patients with severe infections or malignant tumours; (5) pregnant and lactating women. The diagnostic criteria for INOCA were16: (1) objective evidence of myocardial ischaemia (by exercise tolerance testing17); (2) epicardial coronary artery stenosis is less than 50% diagnosed by coronary angiography or coronary CTA; (3) myocardial ischaemia due to other cardiovascular diseases excluded).
Questionnaire introduction
The questionnaire was designed and modified with reference to the web-based KAP survey in patients with CAD after coronary artery bypass grafting surgery,12 validated Chinese version of the CAD education questionnaire,18 recent INOCA studies2 6 7 and comments by three experts in the cardiovascular field. A small test-study (30 copies) yielded Cronbach’s alpha of 0.813, suggesting acceptable reliability.19 The final questionnaire was in Chinese and contained four sections: (1) demographic information, (2) knowledge, (3) attitude and (4) practice dimensions. The knowledge dimension consisted of a total of seven questions, with 1 point for a correct answer and 0 points for an incorrect or unclear answer, with a score range of 0–7 points. The attitude dimension consisted of six questions using a 5-point Likert scale ranging from ‘Strongly Disagree’ (1 point) to ‘Strongly Agree’ (5 points) on a scale of 6–30 points. The practice dimension consisted of eight questions using a 5-point Likert scale ranging from always (5 points) to never (1 point) with scores ranging from 8 to 40 points. Questionnaires were distributed to the study participants through the Questionnaire Star web-platform.
Statistical analysis
Sample size was calculated using the formula for cross-sectional studies: α=0.05,
where 
=1.96 when α=0.05, the assumed degree of variability of p=0.5 maximises the required sample size, and δ is admissible error (which was 5% here). The calculated required sample size was 480 and included an extra 20% to allow for subjects lost during the study.
SAS V.9.4 (SAS Institute, Cary, North Carolina, USA) was used for the statistical analyses. Normally distributed data were compared with the one-way analysis of variances and described with means±SD. Paired t-test was performed for the comparisons within groups, while non-normally distributed variables were presented as median and IQR and were compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Spearman correlation analysis was used to analyse the correlation between KAP dimensions. Path analysis was used to describe the directed dependencies between variables, and to study both direct and indirect relationships between demographic characteristics and KAP dimensions.20
Results
Demographic characteristics
A total of 620 questionnaires were collected, of them 122 excluded after quality/continuity check, and 498 were analysed (mean age of participants 54.13±10.91, 59.04% women and 28.71% diagnosed with INOCA less than 1 year ago). Participants were predominantly of urban residence (60.64%), 55.62% never smoked before and 55.82% have been receiving potassium channel activators (PCA) as the main INOCA treatment. Regarding other underlying medical conditions, most prevalent were hypertension (45.58%), diabetes (31.33%) and hypercholesterinaemia (29.32%) (online supplemental table 1).
Supplemental material
Knowledge, attitude and practice dimensions
The mean KAP score was 4.41±1.78 (possible range: 0–7 points), 21.29±3.40 (possible range: 6–30 points) and 26.91±6.37 (possible range: 8–40 points), respectively (online supplemental table 1). For the knowledge dimension, the topic with the highest percentage of correctness was measures to improve the symptoms of INOCA, such as exercising (K6, answered correctly by 78.11%) or light diet (K7, answered correctly by 81.12%); the topic with the lowest percentage of correctness was the definition of INOCA (K1), with only 9.24% answered correctly, and 24.7% answered ‘unsure’. Additionally, 42.97% of participants answered ‘unsure’ on the question K2, if the main cause of INOCA is problems with the structure or function of coronary micro-vessels. In the attitude section, the question regarding the safety of PCA (A4) was the most controversial, with 21.69% remaining neutral and 4.02% disagreeing. In the practice section, 30.52% and 8.84% of participants reported rarely or never seeking information about INOCA (P1), while 15.66% and 11.04% would rarely or never participate in INOCA-related health promotion activities (P7) (online supplemental table 2).
Spearman correlation analysis
Spearman correlation analysis revealed significant medium-level correlations between knowledge and attitude, knowledge and practice, attitude and practice (all p<0.001; see table 1). Notably, these relationships remained statistically significant after adjusting for multiple comparisons using the Bootstrap method.
Correlation analysis
Path analysis
Path analysis showed that residence (β=0.48, p<0.001) and marital status (β=−0.40, p<0.001) had direct effects on knowledge. Knowledge (β=0.81, p<0.001), family history of INOCA (β=−0.53, p=0.001), coronary vascular examination (β=−0.89, p=0.002) and smoking (β=−0.57, p<0.001) had direct effects on attitude. Residence had direct (β=0.61, p=0.003) and indirect (β=0.39, p<0.001) effects on attitude. Marital status had an indirect effect on attitude (β=−0.33, p<0.001). Attitude (β=0.79, p<0.001), income (β=1.17, p<0.001) and drinking (β=−0.74, p=0.011) had direct effects on practice. Knowledge had both direct (β=0.95, p<0.001) and indirect (β=0.67, p<0.001) effects on practice. Family history of INOCA (β=−0.42, p=0.002), residence (β=1.26, p<0.001), marital status (β=−0.64, p<0.001), coronary vascular examination (β=−0.70, p=0.003) and smoking (β=−0.45, p=0.001) had indirect effects on practice (figure 1, table 2), and had good model fit (online supplemental table 3).
Path analysis
Structural equation model of knowledge (Ksum), attitude (Asum) and practice (Psum). INOCA, ischaemia with non-obstructive coronary arteries.
Discussion
The present study found that patients with INOCA in the Xinjiang region had moderate knowledge and practice with a neutral attitude towards their condition. Knowledge gaps were identified, mostly related to the definition and causes of INOCA. Positive associations were found between knowledge and practice, potentially moderated by attitude, residence status, marital status and income.
This study included a sample of participants with a mean age of about 55 years old, being most vulnerable to the development of INOCA.2 21 Although 40.96% of respondents were men, there was no difference found in KAP scores between the two genders, partly contradicting Mehta et al,8 who noted that women are more adversely impacted by angina and receive less help with INOCA treatment. The current study did not purposely investigate the impact of INOCA on participants, but it is important to note that postmenopausal women had significantly lower practice scores. Taking into account the mean age of participants, it is possible that the study was not powered enough to search for differences between male and female participants, as well as between postmenopausal women and other participants, which is of interest for further research.
Along with the moderate knowledge and neutral attitude, some notable gaps were found in this study. The confusion of participants regarding the definition and causes of INOCA most likely mirrors the confusion of healthcare professionals, as the mechanisms of INOCA development are still not completely understood6 13; in addition, patients with lower educational backgrounds were shown to have similarly less understanding of CAD and peripheral arterial disease definitions, but the impact of such lack of knowledge on practice is not conclusive.14 In some cases, as demonstrated in the CAD study by Williamson et al,11 even after obtaining a better understanding of the disease definition/causes due to received educational intervention, participants did not demonstrate significant improvements in rehabilitation compliance. In the present study, positive associations confirmed between knowledge and practice were potentially moderated by attitude, suggesting that educational interventions should focus not only on enhancing knowledge, but on changing attitude as well.
In addition to attitude, practice scores were influenced by residence status and income, in line with previous studies undertaken in CAD,14 15 stroke22 or patients with various cardiovascular conditions.23 New finding of this study is the tight links between marital status and KAP—with former directly influencing knowledge scores, and indirectly influencing practice and attitude scores. The lowest KAP scores were demonstrated by widowed participants, and the highest—by married; comparable links were previously reported by KAP studies in COVID-1924 and diabetes.25 On the one hand, it highlights the potential efficacy of some recent KAP-based educational approaches, such as the family-centred model26 or behaviour change multi-theory model27; on the other hand, patients with INOCA living alone, including divorced and widowed, might need more attention and special education. Building on the points discussed above, this study revealed that a significant portion of participants is challenging to engage through traditional educational methods. Specifically, 39.36% of the participants reported that they rarely or never sought information about their condition, while 26.70% indicated they would rarely or never participate in health promotion activities. These findings underscore the urgent need for innovative strategies to better engage patients with INOCA and address their unique barriers to participation. The results of this study could serve as a valuable foundation for developing customised interventions that are specifically tailored to meet the needs of this population.
This study had some limitations. First, the inclusion criteria were based on the pre-existing diagnosis, and the inherited bias of cross-sectional design might have added to the selection bias. Moreover, the results and efficacy of educational interventions were not assessed. Second, although the sample size was relatively big and included participants from different study centres, the results are still limited to the urban region of Xinjiang, China; caution should be observed when generalising and comparing obtained results. And finally, the questionnaire was designed to avoid social expectation bias,28 but still researchers cannot confirm if the answers given by participants were completely true. A prospective study is needed to confirm if the educational interventions based on this study results are effective for the analysed population.
Conclusion
In conclusion, this study found that patients with INOCA in the Xinjiang region, China, exhibited moderate levels of knowledge and practice, and a neutral attitude towards their condition. Positive correlations emerged between knowledge and practice, with attitude, residential location, marital status and income potentially acting as moderating factors. This study highlights an urgent need for improved patient education and disease management strategies to enhance understanding and coping with INOCA.
Data availability statement
Data sharing not applicable as no datasets generated and/or analysed for this study.
Ethics statements
Patient consent for publication
Ethics approval
This study was approved by the Ethics Committee of Urumqi Hospital of Traditional Chinese Medicine (No. W-L-L20230710), and informed consent was obtained from study participants.
Acknowledgments
The authors sincerely thank the foundation for providing assistance.
Footnotes
Contributors YM and GS carried out the studies, participated in collecting data and drafted the manuscript. PW and GW performed the statistical analysis and participated in its design. QY and QL participated in acquisition, analysis or interpretation of data and draft the manuscript. GS is guarantor of the integrity of the entire study. All authors read and approved the final manuscript. GS takes responsibility for all aspects of the reliability and freedom from bias of the data presented and their discussed interpretation.
Funding This work was supported by the State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asia Fund (SKL-HIDCA-2021-WZ4).
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.