A Qualitative Study of the Perceptions of Coronary Heart Disease Among

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PATIENT EDUCATION AND INFORMATION NEEDS

A qualitative study of the perceptions of coronary heart disease among

Hong Kong Chinese people

Choi Wan Chan, Violeta Lopez and Joanne WY Chung

Aims and objectives. The aim of this study was to investigate the perceptions of coronary heart disease among a sample of Hong

Kong Chinese people.

Background. Coronary heart disease is increasing among Chinese populations. Reducing coronary heart disease risk is highly

dependant on a persons evaluation of the risks and lifestyle behaviour. However, Chinese perceptions of coronary heart disease

and the risks have been underexplored.

Design. A qualitative study was conducted using focus group interviews.

Method. Focus group interviews were tape recorded and transcribed. The data were analysed using content analysis.

Results. The results show that the Hong Kong Chinese participants underestimated the severity of coronary heart disease.Perceptions of risk of coronary heart disease were influenced by the risk factors, symptoms, age, optimism, levels of suffering

from coronary heart disease and reliance on medical professionals. Most of the participants perceived that this is because of

inadequate understanding of coronary heart disease and lack of resources for coronary heart disease health education.

Conclusion. Societal readiness is paramount in imparting accurate coronary heart disease knowledge to mediate the perception

of coronary heart disease as a major health problem that affects the Chinese population.

Relevance to clinical practice. Understanding the Chinese participants perceptions of coronary heart disease is vital in devel-

oping illness prevention and health promotion strategies to increase their levels of knowledge of coronary heart disease risk

factors reduction.

Key words: coronary heart disease, focus groups, Hong Kong Chinese, nurses, qualitative, risk

Accepted for publication: 18 January 2010

Introduction

Heart disease as coded by the World Health Organizations

International Classification of Diseases, Ninth Revision (ICD-

9) is the second major cause of death in Hong Kong. More

than 68% of all deaths from heart disease results from

coronary heart disease (CHD) (Hospital Authority 2006).

Deaths from CHD have increased over the years between

19812005, rising from 2103 deaths in 19813719 deaths in

2003 and 4003 deaths in 2005 (Hospital Authority 2004,

2006). According to Lam et al. (2002, 2004), the causes of

CHD-related deaths in Hong Kong were because of the

economic development and concomitant westernisation. This

is further supported by Ko et al. (2007) who reported that the

increase mortality of CHD in Hong Kong was because of the

peoples increasing adoption of unhealthy lifestyle habits,

smoking, physical inactivity and unhealthy dietary habits.

Beaglehole (2001) projected that CHD will remain one of the

Authors: Choi Wan Chan, PhD, MNS, RN, Research Associate,

Research Centre for Nursing and Midwifery Practice, Australian

National University; Violeta Lopez, PhD, RN,FRCNA, Professor and

Director, Research Centre for Nursing and Midwifery, School of

Medicine, Australian National University, ACT, Australia; Joanne

WY Chung, PhD, RN Chair Professor and Head, Department of

Health andPhysical Education,The HongKong Instituteof Education,

Hong Kong, China

Correspondence: Choi Wan Chan, Research Associate, Research

Centre for Nursing and Midwifery Practice, Australian National

University, The Canberra Hospital, Building 6, Level 3, East Wing,

Yamba Drive, Garran, ACT 2605, Australia. Telephone:

(614) 2412 5223.

E-mail: [email protected]

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 11511159 1151doi: 10.1111/j.1365-2702.2010.03526.x


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leading causes of death in 2020. As such, if preventive

medicine is to make a difference to human well-being, then

CHD in Chinese populations must be urgently addressed.

Changes in health and lifestyle play an important role in

reducing CHD mortality and morbidity (Stampfer et al.

2000, Knoops et al. 2004, Yusufet al. 2004). The perception

of disease influences the way people process their health risks

and as such is fundamental in bringing about personal

judgments that guide health changes (Weinstein 1988,

Weinstein & Sandman 1992, Bandura 1997, Glanz et al.

2002, Pender et al. 2002). Research has shown that the

perception of CHD has an important effect on personal risk

formulation (Hunt et al. 2000, DeSalvo et al. 2005), the

prediction of preventive behaviour (Ali 2002) and changes

towards a healthy lifestyle (Hampson et al. 2000, Weinman

et al. 2000, Gump et al. 2001). However, little is known

about perceptions of CHD among Chinese populations,

which constitute about one-fifth of the worlds population

(Daily Almanac 2007a,b) and among which the mortalityand morbidity of CHD are increasing (Beaglehole 2001). It

has been highlighted that health promotion and interventions

are more effective when they are based on a clear under-

standing of the cultural and ethnic perspectives that inform

health perceptions and behaviour (Hunt et al. 2000). There-

fore, the aim of this study was to explore perceptions of CHD

in a sample of Hong Kong Chinese people.

Methods

Sampling method and sample

Convenience and snowball sampling methods were used. To

obtain a broad range of views and opinions, the sample

contained three target populations: a low-risk public (LRP)

group, a multiple risk factors (MRF) group and a myocardial

infarction (MI) group. The three target populations were

grouped according to the eight CHD risk factors identified by

Shepherd et al. (1997) including: personal history of CHD,

high blood pressure, or diabetes; family history of CHD;

smoking history; excessive alcohol consumption; high cho-

lesterol level; exercise 30 minutes/day less than once a month;

self-report of poor eating habit and attitude; and poorattitude about healthy lifestyle. The LRP participants who

had three or less CHD risk factors were recruited from the

public domains (e.g. community centres, churches, university

compounds). The MRF participants had four or more CHD

risk factors with or without a history of CHD, and the MI

participants had a medical diagnosis of MI. Participants in

the MRF and MI groups were recruited from one cardiac

rehabilitation and prevention centre in the community-based

hospital. All of the participants were aged 18 or over. These

target populations were grouped prior to the focus group

interviews. Furthermore, in view of possible regional differ-

ences in views and opinions of the study topic, the partici-

pants were recruited from three geographical areas including

Hong Kong Island, Kowloon and New Territories to max-

imise the generalisability of findings among the Hong Kong

population.

Same sex focus group interviews were conducted to

facilitate open discussions to occur as participants felt at

ease during the conversation instead of in a position of being

passive and/or dominant, if they are in a group with mixed

genders (Grbich 1999). This also addresses some cultural

norms and issues in the Hong Kong Chinese society as the

male being more dominant than women (Cheung 1997) and

that the Hong Kong Chinese women have been reported to

have higher level of self-esteem and better adjustments in the

consequences of their diseases than men (Ng et al. 2003).

The study sample consisted of different target populations,both genders and a broad age range. Morgan (1997) suggests

that the difference in attributes of the participants both

within and across groups is important in the determination of

the number of focus groups. One focus group may not reflect

either the unusual composition of that group or the dynamics

of that unique set of participants, while more than one focus

group could provide a safe ground to conclude the data and

to reflect usual and unusual data (Carey 1995, Morgan

1997). Therefore, 12 focus groups were initially planned until

data saturation is achieved.

After data saturation had been achieved, the sample

consisted of 18 single-gender focus groups (nine male and

nine female groups). Data saturation was the stage at which

no new information emerged from the focus group interview

data, and the researcher obtained repeated data from the

focus group participants (Polit & Hungler 1995).

Data collection and focus group interviews

After gaining approval from the university and hospital ethics

committees, the researcher recruited the participants by

approaching the community, cardiac rehabilitation and

prevention centres, churches and universities student com-mon room. The recruitment of participants was also

facilitated by the person in-charge of the centres. For

snowball method of recruitment, those eligible participants

who consented to participate in the study were requested to

ask other people in their universities, neighbourhood or

community centres to contact the researcher if they were

willing to participate in the study. Each eligible participant

recruited was given detailed explanation of the nature and

CW Chan et al.

1152 2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 11511159


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purpose of the study. They were also informed that partic-

ipation was on a voluntary basis and that they could

withdraw from the study at any time. They were assured

their confidentiality and privacy would be maintained. They

were also given time to ask questions regarding the study.

Those who agreed to participate were asked to sign the

consent form. Demographics and health history data includ-

ing information of CHD risk factors were collected, so that

grouping could be determined according to their levels of

CHD risk prior to focus group interviews.

The focus group interviews were mostly conducted in the

community centres and the cardiac rehabilitation and pre-

vention centres. Focus group interviews were conducted

during an eight-month period from November 2003June

2004. Each interview lasted between 6090 minutes. An

interview schedule was used to focus the discussion on the

perceptions of CHD. The interview started with questions

such as Could you tell me what you understand about

coronary heart disease? and Do you think CHD poses athreat to your health? Follow-up questions were then raised

to explore the initial answers of the participants further.

The first author served as a neutral and non-directive

moderator who guided the interviews, raised the follow-up

questions and managed the group dynamics by encouraging

quiet participants to share their views, ensuring that outspo-

ken participants did not bias the discussion and encouraging

respondents to elaborate on views that differed from the

predominant opinion. All interviews were conducted by

the first author in Chinese and were audiotaped with the

permission of the participants.

Prior to data analysis, the first author listened carefully to

each tape several times to obtain a sense of the meaning of

that data. Then, the audiotaped interviews were transcribed

verbatim into Chinese and then translated into English.

Data analysis

The focus group data were analysed using content analysis.

Content analysis is a dynamic form of analysis that assigns

verbal data categories and subcategories through the coding

of words, phrases and themes from the interview scripts

(Sandelowski 2000, Berg 2007). Data were subjected toboth manifest and latent content analysis, where the

manifest level of analysis was the coding of directly

observable descriptions and the latent level of analysis

was the coding of significant underlying meanings (Boyaat-

zis 1998, Berg 2007). Two researchers analysed the

qualitative data independently. The codes and categories

that were generated from the data were continually revised

and systematically applied in an ongoing analytical process.

The two independent researchers discussed the analysed

data to ensure that they were reliably interpreted and that

the data gave a valid representation of the phenomena

under study (Berg 2007). The audiotaped interviews and

verbatim quotes from the participants were also used as

evidence to confirm the trustworthiness of the qualitative

data.

Results

Demographic data

The total sample consisted of 100 participants (LRP = 57,

MRF = 27, MI = 21). The sample consisted of 52% men

and 48% women, age range was 1888 years old (M = 56 5;

SD 201). There were 10 LRP and four in each of the MRF

and MI focus groups. Details of the demographic back-

ground of the focus group participants are summarised in

Table 1.

Qualitative findings

Based on the descriptions of the participants perceptions of

CHD, the data were divided into three categories: (1)

perceived seriousness of CHD, (2) perceived risk of CHD

and (3) perceived opportunities to understand CHD.

Perceived seriousness of CHD

Many of the LRP, MRF and MI participants underestimated

the seriousness of CHD, as they believed it to be an invisible

disease with minimal suffering. In terms of the perceptions of

the participants regarding the impact of CHD in a societal

context, a distinct lack of the awareness of CHD was dem-

onstrated because stroke, severe acute respiratory syndrome

(SARS), hypertension and diabetes were all perceived as being

more significant diseases. For example, SARS, as an infec-

tious and incurable disease, was perceived to be more urgent

and much more serious, which influenced the perceptions of

the participants that led them to underestimate the serious-

ness of CHD as one LRP male participant said:

I think the impact of CHD when compared with SARS is that the two

are different. To me, the degree of danger of CHD is small. (LRP,

group 3, male)

Being rendered immobile and physically dependent on others

as a result of stroke was perceived to engender greater

suffering than death. A MRF male participant who had a

history of both minor stroke and CHD gave a typical

response in underestimating the severity of CHD, which he

saw as being less important than stroke as pointed out:

Patient education and information needs Qualitative study of the perceptions of CHD

2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 20, 11511159 1153


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I am afraid of the recurrence of stroke. I am really afraid of it, as I do

not know why I had a stroke. I saw stroke patients with paralysis in

the arms and legs who couldnt walk well. If I had it, then I would

suffer a lotCoronary heart disease is already there [laughed]. I am

really afraid of [stroke]. (MRF, group 3, male)

The suffering that results from hypertension and diabetes was

also commonly emphasised by participants with an over-

whelming perception that hypertension would lead to stroke,

which would eventually cause suffering. Participants with

diabetes also emphasised the serious complications arisingfrom the disease and were preoccupied by the Chinese cultural

belief that eating is a kind of fortune and joy and their

suffering is a result of dietary restrictions. When this result was

compared with other groups for similarities and differences,

their underestimation of the severity of CHD were similar.

Perceived risk of CHD

CHD risk factors such as eating habits, regular exercise,

family history of CHD, obesity, stress, menopause, diabetes

and high blood cholesterol were all reported in the risk for-

mulations of the participants. Participants who believed that

they were not subject to CHD risk factors perceived them-

selves to be at a low risk of developing CHD. Both male and

female participants, in the LRP, MRF and MI groups, who

were able to identify their own risk factors of developing the

disease reported fear about the perceived risk of CHD, as

demonstrated by verbatim quotes such as:

I think I have many risk factors that include work pressure, diet and

no fixed time for rest. I have them all. I have been a fat boy since I

was a child. I have thought that I would get it one day. And I smoked

a lot previously. (MRF, group 3, male)

Another LRP female participant said:

Because I am overweight and do not exercise, I know I am at risk. I

worry that I will have that problem [heart disease]. (LRP, group 1,

female)

The presence of CHD symptoms was used by some partic-

ipants to evaluate their risk of CHD. According to their

descriptions, participants who had experienced CHD symp-

toms perceived themselves to be at risk of CHD, whereas

those who believed that they did not have any symptoms of

CHD did not see themselves as being at risk of developing the

disease. This condition was exemplified by the words of one

MRF male participant, who recalled that he had underesti-

mated his own risk in the past. He had ignored his doctors

suggestion to undergo a cardiac investigation because he did

not have any chest pain and other bodily symptoms when he

said:

I did not do it [cardiac catheterisation] as I didnt think that I had a

problem. I thought that it was psychological problem. I did not have

pain here [pointing to the chest]. I did not have any problems

anywhere in the body. (MRF, group 3, male)

Age was another factor used by participants in calculating

their risk of CHD. Many of the participants who perceived

themselves to be too young to have CHD reported a low risk

of CHD. However, few of the older participants had a

different opinion of their own risk. They had a low

perception of their risk of CHD and cited that they had

Table 1 Demographic background of the

focus group participantsLow-risk public

Multiple risk

factor group

Myocardial

infarction group

10 Focus groups

(n = 57)

4 Focus groups

(n = 22)

4 Focus groups

(n = 21)

Gender n (%)

Male 28 (49) 11 (50) 13 (62)

Female 29 (51) 11 (50) 8 (38)Mean age SD (range) 496 235 (1888) 645 83 (4477) 667 84 (4578)

Education: n (%)

No formal education 9 (158) 5 (227) 4 (190)

Primary 12 (211) 8 (364) 10 (476)

Secondary 18 (316) 6 (273) 4 (190)

Postsecondary 4 (70) 0 (00) 3 (143)

Degree or above 14 (246) 3 (136) 0 (00)

Employment status: n (%)

Currently working 16 (281) 2 (91) 3 (143)

Retired 23 (404) 15 (682) 14 (667)

Homemaker 10 (175) 5 (227) 4 (190)

Student 8 (140) 0 (00) 0 (00)

CW Chan et al.



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earned enough of life as the reason for this as one MRF

female participant recounted:

There is no need to be afraid. I am now 70 years old What need is

there to be afraid of? I have earned [my life] already. (MRF, group 4,

female)

Being optimistic about the risk of CHD was identified as a

factor that led both male and female participants to negate

their own personal risk of CHD. This is typified by the

statement of a male MI participant who believed his

optimistic character negated his future risk of CHD, despite

the fact that he had a history of MI, was older and was still a

current smoker.

The level of suffering caused by CHD emerged as a factor

mediating the perception of the risk of CHD. Several

participants believed that CHD as a disease causes little

suffering, which made them less likely to view CHD as a

threatening disease and hence undermined their perception of

the risk of CHD.Some of the participants stated that they were highly

dependent on their doctors to look after their health, which

they felt reduced the risk and threat posed by CHD. An MI

participant who had depended on doctors to look after his

health in the past stated that he had overlooked the role of

diabetes and hypertension in increasing his risk of developing

CHD until he suffered a cardiac event.

An analysis of the data on risk factors and symptoms

across the three populations revealed the LRP participants

to be more likely to describe themselves as being at a low

risk of CHD, as they believed they did not have any risk

factors and had not experienced any CHD symptoms. In

contrast, the MRF and MI participants were more likely to

describe themselves as being at a high risk of CHD or of the

recurrence of CHD, as they were able to identify the risk

factors that applied to them and had experienced CHD

symptoms. In terms of age as a factor in risk perception, the

majority of the LRP participants perceived themselves as to

be less at risk of CHD because of their young age. However,

because of their perception of having earned enough of

life, the two groups of LRP participants and three groups of

MRF and MI participants who were older had a similarly

low perception of their risk of CHD. Optimism, perceptionsof the level of suffering arising from CHD and reliance on

medical professionals were also factors that affected the

perception of risk among the participants, with the LRP

participants being more likely to adopt these factors to

negate their personal risk of CHD than participants in the

MRF and MI groups.

The descriptions of the participants clearly demonstrated the

influences of CHD risk factors, CHD symptoms, age, opti-

mism, the level of suffering caused by CHD and reliance on

medical professionals in the estimation of their personal risk

and of the threat posed by CHD. Of these issues, risk factors,

symptoms and age were frequently used by most of the LRP,

MRF and MI participants in evaluating risk, although the

various groups of participants had a differentperception of the

contribution of these factors to the risk of CHD.

Perceived opportunities to understand CHD

Many of the participants felt that they lacked access to

information about CHD, which was consistently reported by

different age groups and across all of the target populations.

This was typified by one of the verbatim quote where a young

male participant in one of the LRP groups reported that it

was difficult to locate CHD information:

Those pamphlets are not so detailed and are quite simple. They are

only 12 pages and cover only some of the issues and preventive

methods. On the Internet, ah sometimes ah you cannot be sure

[whether] it is right or not and it may be not up to date. So, I feel it is

difficult to find a means of knowing exactly what CHD is. (LRP,

group 2, male)

The participants also expressed that CHD is a disease that is

difficult to understand. For example, a male MI participant

who had undergone a cardiac rehabilitation programme

emphasised that as a lay person, he had found the disease

difficult to understand as stated:

Put simply, for the general public and from a laymans perspective, it

means that my heart has a problem. I did think that. But I didnt

think that it was heart disease, because my knowledge of heartdisease was inadequate. Heart disease comes in many forms, such as

CHD, myocardial infarction, heart failure. Now I know about them,

as I have read about them. At that time though, I had no idea what

they were and what the symptoms were. (MI, group 1, male)

Other participants reported that although they had seen

posters and banners about CHD, they did not really benefit

from it because of misconception and misunderstanding

related to CHD as reported in category 1 - perceived

seriousness of CHD. They believed that CHD causes little

suffering compared with other diseases.

Discussion

To date, there has been little information about Hong Kong

Chinese perceptions of CHD. In this study, three main

categories of perceptual information about CHD have been

identified, namely, perceived seriousness of CHD, perceived

risk of CHD and perceived opportunities for better under-

standing CHD. This contributes to improve our understanding




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of how CHD is perceived by Hong Kong Chinese people.

However, it must be noted that the current findings were

obtained from a single Hong Kong Chinese sample compiled

using the convenience and snowball sampling methods, and

these limitations should be acknowledged in generalising the

results to other populations.

The Hong Kong Chinese participants in this study heavily

emphasised the concepts of physical independence and

mobility, suffering and the dichotomy of curable vs. incurable

disease in relation to the perceived severity of CHD. Stroke,

hypertension, diabetes and SARS were all regarded as more

serious health problems than CHD, which is consistent with

findings from previous studies where CHD was repeatedly

under-reported as a major health concern (Gabhainn et al.

1999, Mosca et al. 2000, Vanhecke et al. 2006). In addition,

the participants in this study likened CHD to a sudden event

with minimal suffering that leads to a peaceful and silent

death, a romantic idea about CHD that may also account for

the similar underestimation of CHD severity by all riskgroups. This indicates that public awareness about CHD

must be increased and accurate messages about CHD

imparted through public education without delay.

Risk factors, symptoms, age, optimism, level of suffering

from the disease and reliance on medical professionals were

all considered by the participants in evaluating their risk of

CHD. It is possible that the phenomenon of optimistic bias

may explain the perceptions of the participants who reported

themselves as being at a low risk of CHD. Optimistic bias or

unrealistic optimism refers to people who tend to underes-

timate their own risk of disease and is a phenomenon that has

been widely reported in the literature (Avis et al. 1989,

Marteau et al. 1995, Van Tiel et al. 1998, Green et al. 2003,

Moran et al. 2003, Vanhecke et al. 2006).

The perceived CHD risk attributed to the various risk

factors among the present sample of participants was quite

consistent with the results of a previous study (Perkins-Porras

et al. 2006), in that a high percentage (72%) of participants

with a positive family history of CHD attributed heart disease

to heredity, a high percentage (85%) of obese participants

attributed CHD to being overweight and almost half (49%)

of the sedentary participants attributed it to a lack of exercise.

Reliance on medical professionals as a factor in determin-ing the evaluation of the risk of CHD among the participants

may be because of the cohort effect, in that the sample of

participants who were older had greater faith in medical

judgments of illness and were of a generation that tends to

view doctors as a source of authority. However, defence

mechanism may also be a factor, in that by depending on a

doctor to look after their health, they in effect freed

themselves from being preoccupied with any risk or threat

of disease and thus placed themselves outside of the param-

eters of increased risk of CHD.

The finding that CHD is difficult to comprehend is

consistent with previous studies, where both layman and

patients with CHD reported having difficulty in articulating

the processes that contribute to CHD, which consequently

resulted in misconceptions about the disease (Wiles &

Kinmonth 2001, Karner et al. 2003, Angus et al. 2005).

The lack of accessible information about CHD knowledge

and how to prevent CHD found in this study concur with the

result of the study of Farooqi et al. (2000) in the South Asians

living in the UK and the result of Steenkiste et al. (2004)

among the Dutch people. In both of these studies, the

participants reported that information about the prevention

of cardiac disease was insufficient. There are plausible

explanations for our findings. First, the understanding of

CHD among lay people and patients and their need for

information about CHD have been underexplored. This

would lead to incongruence between the CHD informationand health messages that are delivered by healthcare profes-

sionals and the information that is expected by lay people and

patients. This is a phenomenon that has been consistently

highlighted in the literature (Wiles & Kinmonth 2001, Angus

et al. 2005, Allmark & Tod 2006) and indicates a pressing

need for health professionals to explore the understanding of

CHD among lay people and patients and their informational

needs and to provide information that can be easily under-

stood, interpreted and used.

The second possible explanation is that there are few

effective public health education programmes and campaigns

devoted to CHD as a result of increased attention being paid

to other recent health problems in Hong Kong, such as

SARS and avian influenza. This may have contributed to a

decrease in awareness of CHD among the public and the

disengagement of the public from a socially facilitating

environment where they can acquire opportunities to secure

better knowledge and information about CHD. To prevent

CHD, it is important to promote a facilitating environment

where people can share common social concerns, discuss

issues such as health, illness and healthy behaviour in

relation to CHD and gain informational support to promote

CHD health and prevent the disease. Adequate and effectivepublic campaigns are urgently needed to create an environ-

ment where people can understand and increase their

awareness of CHD and its prevention.

Conclusion

The present qualitative study adds knowledge to the

literature by demonstrating that the severity of CHD is

CW Chan et al.



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underestimated by the Hong Kong Chinese population, that

the population has an unrealistic optimism about the disease

and that there is an inadequate understanding of CHD, all of

which have created a lack of societal readiness to engage in

coronary health promotion and disease prevention. Thus, the

study highlighted that societal readiness to impart accurate

CHD information among Chinese populations is vital in

coronary healthcare for containing CHD, achieving well-

being and decreasing the health costs of heart disease,

especially as Chinese people constitute such a large portion

of the worlds population.

This study reports findings on the perceptions of CHD

from a single sample and used the convenience and snowball

sampling methods to recruit participants, which limits the

generalisability of the results. More research among Chinese

populations is therefore suggested, as this is a largely

underexplored area.

Relevance to clinical practice

Understanding the Hong Kong Chinese participants percep-

tions of CHD is vital in developing illness prevention and

health promotion strategies to increase their levels of knowl-

edge of CHD risk factors reduction.

Acknowledgements

We acknowledge with gratitude the men and women who

participated in this study. Their willingness to be interviewed

provided us with useful information. Special thanks to

Dr Fielding, Prof Thompson, Dr Yu and Prof Twinn for

their preliminary advice. We are also grateful to the anon-

ymous reviewers for their very helpful comments of this

manuscript.

Contributions

Study design: CWC; data collection: CWC; data analysis:

CWC, VL, JC and manuscript preparation: CWC, VL, JC.

Conflict of interest

There are no conflicts of interest.

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A Qualitative Study of the Perceptions of Coronary Heart Disease Among