2014 BADIR et al Knowledge of cardiovascular disease in Turkish undergraduate nursing students

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European Journal of Cardiovascular Nursing
 http://cnu.sagepub.com/content/early/2014/06/19/1474515114540554
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DOI: 10.1177/1474515114540554
 published online 30 June 2014Eur J Cardiovasc Nurs
Aysel Badir, Kader Tekkas and Serpil Topcu
Knowledge of cardiovascular disease in Turkish undergraduate nursing students
 
 
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European Journal of Cardiovascular Nursing
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DOI: 10.1177/1474515114540554
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EUROPEAN
SOCIETY OF
CARDIOLOGY ®
Introduction
Cardiovascular disease (CVD) is the number one health 
problem worldwide, accounting for 30% of all deaths.1 
CVD is the main cause of death in Turkey and coronary 
artery disease (CAD) is the most prevalent in that cate-
gory. While a decrease in the prevalence of the disease has 
been observed in developed countries where primary and 
secondary preventive measures have been successfully 
applied toward the risk factors, a general rise has been 
reported in Turkey for both genders in the past 20 years 
and is attributed to the lifestyle changes of the population 
based on the results of the Turkish Adult Risk Factor 
Study (TARF) study representing Turkey since 1990.2
Smoking, physical inactivity, unhealthy diet, and the 
excessive use of alcohol are the primary behavioral car-
diovascular risk factors for CVD;3 CVD is preventable 
through reducing these behavioral risk factors.3,4 Even 
though Turkey has a young population compared to 
Knowledge of cardiovascular disease in 
Turkish undergraduate nursing students
Aysel Badir1, Kader Tekkas2 and Serpil Topcu1
Abstract
Background: Cardiovascular disease is the number one cause of death worldwide. However, there is not enough data 
exploring student nurses’ understanding, knowledge, and awareness of cardiovascular disease.
Aims: To investigate knowledge of cardiovascular disease and its risk factors among undergraduate nursing students, 
with an emphasis on understanding of cardiovascular disease as the primary cause of mortality and morbidity, both in 
Turkey and worldwide.
Methods: This cross-sectional survey assessed 1138 nursing students enrolled in nursing schools in Istanbul, Turkey. 
Data were collected using the Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale and questions 
from the Individual Characteristics Form about students’ gender, age, level of education, and family cardiovascular health 
history, as well as smoking and exercise habits.
Results: Respondents demonstrated a high level of knowledge about cardiovascular disease, with years of education 
(p < 0.001), gender (p < 0.001), and high school type (p < 0.05) all significantly associated with CARRF-KL scores. 
However, more than half of the students were not aware that cardiovascular disease is the primary cause of mortality and 
morbidity in Turkey and worldwide. The majority of the respondents’ body mass index (87%) and waist circumference 
values (females: 90.3%, males: 94.7%) were in the normal range and most were non-smokers (83.7%). However, more 
than half of the students did not exercise regularly and had inadequate dietary habits.
Conclusions: Although students were knowledgeable about cardiovascular disease and associated risk factors, there 
were significant gaps in their knowledge; these should be addressed through improved nursing curricula. While students 
were generally healthy, they could improve their practice of health-promoting behaviors.
Keywords
Cardiovascular disease, nursing students, knowledge, health behaviors, risk factors
Date received 27 March 2014; revised 21 May 2014; accepted 29 May 2014
1Koc University School of Nursing, Istanbul
2University of Washington School of Nursing, USA
Corresponding author:
Aysel Badir, Koc University School of Nursing, Guzelbahce Sk, No:20, 
Nisantasi 34365 Istanbul, Turkey. 
Email: abadir@ku.edu.tr
540554 CNU0010.1177/1474515114540554European Journal of Cardiovascular NursingBadir et al.
research-article2014
Original Paper
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2 European Journal of Cardiovascular Nursing 
other European countries, the CVD morbidity rate is 
higher.5 Since 1990, there has been an annual increase of 
6.4% in CAD in the Turkish population, which is associ-
ated with lifestyle changes.2 Several screening studies 
on the prevalence of obesity in Turkey have shown that 
it is a major health problem, with increasing prevalence 
in younger age groups.2,6,7 While physical activity 
decreased (male: 2.3%, female: 6.3%) each year since 
1990, hypertension incidence increased by 21.3% 
between 2003 to 2007.8 Moreover, prevalence of diabe-
tes among individuals has increased from 7.2% to 13.7% 
in 10 years in Turkey.7,9 Besides the increasing hyperten-
sion and diabetes rates, smoking is an important concern 
in Turkey. According to the World Health Organization 
data, 33.4% of adult population was daily smokers 
(male: 50.6%; female: 16.6%).7–10
The effective management of CVD requires multidis-
ciplinary cooperation in prevention and treatment as 
well as greater patient, family, and community involve-
ment and a skilled, proactive, and diverse workforce.11,12 
There is well-documented evidence as to the effective-
ness of nurse-managed programs for CVD risk reduc-
tion, including individual, group, and community 
interventions.13–19 However, research has shown a lack 
of knowledge in nurses,20,21 nursing students,22–24 and 
both groups combined regarding CVD and associated 
risk factors.20,25,26
Wilt et al. found that most nurses agreed that counsel-
ling patients about CVD risk factors should be their 
responsibility, but only 1% reported that they were cur-
rently involved in this activity.20 Another study reported 
that, although most Chinese nursing professionals and 
students could identify common risk factors for CAD 
and had positive attitudes towards reducing the risks, 
less than 58% could correctly answer questions about 
evidence-based recommendations.26 A self-administered 
survey of nursing and medical students found that 
healthy lifestyle behaviors were independently associ-
ated with positive attitudes toward CVD prevention.23 
Similarly, Irazusta et al. evaluated and compared physi-
cal exercise habits, physical fitness, and diet in a group 
of female nursing students. Most did not exercise 
regularly.22
Despite the need for nurses to provide education to 
help reduce CVD-related morbidity and mortality in 
Turkey, no studies have been published of nursing stu-
dents’ knowledge and personal health behaviors related 
to CVD and related risk factors. This knowledge gap pre-
vents constructing a studywith a priori hypothesis. For 
this reason, our overall aim was to investigate knowledge 
CVD and associated risk factors among undergraduate 
nursing students, with an emphasis on their understand-
ing of CVD as the primary cause of mortality and mor-
bidity in Turkey and worldwide to form a base for the 
further studies.
Objectives
The objectives of this study were to (1) evaluate students’ 
knowledge of CVD and associated risk factors; (2) identify 
associations between students’ knowledge of CVD and 
individual characteristics; (3) evaluate students’ knowl-
edge of CVD as the primary cause of mortality and mor-
bidity in Turkey and worldwide; and (4) investigate 
nursing students’ personal health behaviors of exercise, 
diet, and smoking.
Methods
Design
This cross-sectional study was conducted at three public 
and three private undergraduate nursing schools in 
Istanbul, Turkey, from December 2009 to March 2010.
Participants
A total of 1814 students were invited to participate in the 
study (530 first-year, 474 second-year, 461 third-year, and 
349 fourth-year students); 1138 of the students responded, 
achieving an overall response rate of 62.73%.
Ethical concerns
This study was approved by the Koc University School of 
Nursing Institutional Research Ethics Board, which is con-
sistent with the principles outlined in the Declaration of 
Helsinki.27
Data collection
Information was gathered on students’ knowledge of CVD 
and risk factors, personal health behaviors associated with 
CVD, and knowledge of CVD as the primary cause of 
mortality and morbidity.
The data were collected using a two-stage process. 
First, the 28-item Cardiovascular Disease Risk Factors 
Knowledge Level (CARRF-KL) scale, developed by 
Arıkan et al.,28 was used to evaluate knowledge of CVD 
and risk factors, as defined by previous studies.29–35
Arıkan et al. tested the validity and reliability of the 
scale, achieving a Cronbach’s alpha of 0.77. 28 Our study 
also achieved a Cronbach’s alpha of 0.77. All items were 
true/false statements, with possible responses of ‘Yes’, 
‘No’, or ‘Do not know’. Each correct answer was awarded 
one point; six items were false, and therefore inversely 
scored. A mean score was calculated for each participant 
and the maximum total score was 28 points. A high total 
score on the CARRF-KL is positively correlated with bet-
ter knowledge of CVD risk factors.28
The data for the second stage were collected by using a 
questionnaire consisted of four open-ended questions that 
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Badir et al. 3
assessed knowledge related to the primary causes of mor-
tality and morbidity in men and women. An example of 
open-ended questions is “What is the primary cause of 
morbidity in women in Turkey and in the World?”. The 
questionnaire also included items assessing demographic 
characteristics and health behaviors which were defined as 
‘any activities undertaken to maintain, attain, or regain 
good health and prevent CVD’.36,37
Students’ nutritional patterns were evaluated based on 
dietary guidelines published by the Turkish Ministry of 
Health. These guidelines recommend two servings of pro-
tein, six servings of carbohydrates, and at least five serv-
ings of fruits and vegetables daily.38 For this study, we 
measured individual weight (kg), height (cm), and waist 
circumference (cm). We calculated body mass index 
(BMI), weighing students after they removed heavy cloth-
ing. Participants were classified as underweight (BMI ≤ 
18.5), normal weight (BMI = 18.5–24.9), or overweight 
(BMI ≥ 25.0). Waist circumference was measured on a 
horizontal plane, midway between the inferior margin of 
the ribs and the superior border of the iliac crest at the end 
of gentle expiration.37 Based on International Diabetes 
Federation and Turkish Heart Association guidelines, 
healthy waist circumference were defined as ≤80 cm for 
women and ≤ 94 cm for men.2,39
Data analysis
Data were analyzed using IBM SPSS Statistics 19.0. 
CARRF-KL total mean scores were compared using inde-
pendent sample t-tests for independent groups and one-way 
analysis of variance (ANOVA; Tukey’s HSD for further 
analysis) for independent groups. To examine the effects of 
various factors on CARRF-KL total mean scores, the fol-
lowing factors were considered as independent variables 
for multiple regression analysis: year of undergraduate edu-
cation, gender, educational background, BMI, exercise, 
waist circumference, CVD history in first degree male or 
female relatives, smoking. Significance was set at p < 0.05.
Results
Demographic characteristics
A total of 1138 students (overall mean age was 20.92±1.98 
(20.81±1.91 years female; 21.41±2.49 years male) 
responded. Of these, 91.2% (n = 1038) were female, 
52.7% (n = 600) attended a private university, 47% (n = 
538) a public university. Nearly all students had gradu-
ated from high school 92.5% (n = 1046); 7.5% (n = 85) 
had graduated from four-year vocational health schools, 
which can grant nursing diplomas in Turkey. In total, 
28% (n = 319) were first-year students, 23.6% (n = 269) 
second-year, 26.4% (n = 301) third-year, and 21.9% (n = 
249) fourth-year.
The students’ CARRF-KL scores and individual 
characteristics
The total mean CARRF-KL score was 22.47±3.38 out of a 
maximum of 28 (female = 22.63±3.31; male = 20.82±3.57). 
As shown in Table 1, 87% of students did not know that 
heart disease could be identified based on common signs 
and symptoms. About half of the students (50.4%) did not 
know what constitutes an exercise; for example, they con-
sidered slow walking and wandering as exercise. Nearly 
all students (94.2%) knew that ‘hypertension is a risk fac-
tor for heart disease’ and 87.3% knew that ‘blood pressure 
control reduces the risk of heart disease’, but only 46.4% 
knew that ‘hypertension medications should be used for a 
lifetime’. Although 93.6% knew that ‘high cholesterol is a 
risk factor for heart disease’, 35.4% did not know that 
‘there is a risk of a heart disease if good (HDL) cholesterol 
level is low’ and 35.3% did not know that ‘CAD can be 
prevented’.
In examining the relationship between CARRF-KL 
mean scores and individual characteristics, we found sta-
tistically significant difference (all p < 0.001) between 
years of undergraduate education and CARRF-KL mean 
scores; first-year students’ knowledge level was signifi-
cantly lower than that of students’ knowledge level in later 
years. Logically, fourth-year students’ knowledge level 
was significantly higher than those of lower classes. 
Students who graduated from vocational health schools 
had higher mean CARRF-KL scores as compared to those 
who graduated from high schools. A t-test indicated that 
female students’ knowledge level was higher than that of 
the male students (p < 0.001, Table 2).
CVD as a primary cause of mortality and 
morbidity in Turkey and worldwide
Students answered four open-ended questions on the pri-
mary causes of mortality and morbidity in men and 
women in Turkey and worldwide. Only 16.5% of female 
and 14% of male students reported that heart disease was 
the primary cause of morbidity in women, and only 
39.7% of female and 31% of male students reported that 
heart disease was the primary cause of morbidity in men. 
Only 20.4% of female and 20% of male students reported 
that heart disease was the primary cause of mortality in 
women in Turkey and worldwide; 43.4% of female and 
36% of male students reported that heart disease was the 
primary cause of mortality in men in Turkey and world-
wide (Table 3).
Personal health behaviors associated with CVD
Waist circumference was within the normal range for 
74.5% of the students; 90.3% of the female respondents’ 
measurements were ≤80 cm, and 94.7% of the male 
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4 European Journal of CardiovascularNursing 
Table 1. The Cardiovascular Disease Risk Factors Knowledge Level (CARRF-KL) scale scores.
Correct Incorrect
 n % n %
 1. A person always realizes if she/he has a heart disease. Ta 148 13.0 990 87.0
 2. A family history of CVD increases your risk of having heart disease. T 1089 95.7 49 4.3
 3. Elderly people are at a higher risk for heart diseases. T 986 86.6 152 13.4
 4. CAD can be prevented. T 736 64.7 402 35.3
 5. Smoking is a preventable cause of death and diseases in our country. T 869 76.4 269 23.6
 6. Smoking is a risk factor for heart diseases. T 1101 96.7 37 3.3
 7. The risk of developing heart disease is reduced when smoking is stopped. T 1050 92.3 88 7.7
 8. It is beneficial to eat 2-3 portions of fruit and 2 portions of vegetable daily. T 1070 94.0 68 6.0
 9. It’s harmful to eat red meat more than 3 times a week. T 872 76.6 266 23.4
10. Eating salty leads to increase in blood pressure. T 1042 91.6 96 8.4
11. Fatty meals do not increase the cholesterol level in blood. Fb 1029 90.4 109 9.6
12. Fats that are solid at room temperature are beneficial for heart health. F 959 84.3 179 15.7
13. A low carbohydrate and low fat diet is beneficial for heart health. T 902 79.3 236 20.7
14. Overweight individuals have higher risk of heart disease. T 1097 96.4 41 3.6
15. Regular exercise reduces the risk of heart disease. T 1092 96.0 46 4.0
16. Risk can be reduced by exercising only in gym. F 944 83.0 194 17.0
17. Slow walking and wandering are also considered as exercise. F 564 49.6 574 50.4
18. Stress, sorrow, and burden increase the risk of heart disease. T 1079 94.8 59 5.2
19. Blood pressure increases under stressful conditions. T 1053 92.5 85 7.5
20. High blood pressure is a risk factor for heart disease. T 1072 94.2 66 5.8
21. Blood pressure control reduces the risk of heart disease. T 994 87.3 144 12.7
22. Hypertension medications should be used for a lifetime. T 610 53.6 528 46.4
23. High cholesterol is a risk factor for heart disease. T 1065 93.6 73 6.4
24. There is a risk of heart disease if good cholesterol (HDL) is high. F 735 64.6 403 35.4
25. There is a risk of heart disease risk if bad cholesterol (LDL) is high. T 951 83.6 187 16.4
26. Every person with high cholesterol level is given medicine. F 726 63.8 412 36.2
27. Diabetes is a risk factor for heart disease. T 796 69.9 342 30.1
28. The risk can be reduced in diabetic patients with glucose control. T 942 82.8 196 17.2
aT (True), bF (False).
Table 2. Association between students’ individual characteristics and CARRF-KL scores.
Characteristics CARRF-KL total 
score (X ± SD)
Statistical 
test
p value
Year of undergraduate education 
First year (n = 319) 20.28 ± 3.53 F (82.41) 0.001
Second year (n = 269) 23.34 ± 2.86 
Third year (n = 301) 22.79 ± 3.08 
Fourth year (n = 249) 23.96 ± 2.57 
Educational background 
Vocational health school (n = 85) 23.68 ± 3.23 t (3.45) 0.001
High school (n = 1053) 22.37 ± 3.37 
Gender 
Female (n = 1038) 22.63 ± 3.31 t (5.18) 0.001
Male (n = 100) 20.82 ± 3.58
respondents were ≤94 cm. The majority of students had no 
first degree family history of CVD in either a first-degree 
male or female relative. A majority (63.6%) of the students 
were not aware of their blood pressure, and (0.8%) had 
diabetes mellitus type 2. 83.7% of students were non-
smokers, and 85.5% reported not taking exercise in the 
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Badir et al. 5
Table 3. The knowledge of the students that CVD is the 
primary reason for mortality and morbidity in Turkey and in 
the world.
Female 
students
Male 
students
 n % n %
Primary morbidity reason 
in women in Turkey and 
the world (n = 1018)
 
Cancer 561 54.0 46 46.0
Cardiovascular diseases 171 16.5 14 14.0
Do not know 128 12.3 22 22.0
Diabetes Mellitus 70 6.7 10 10.0
Gynecological diseases 31 3.0 0 0
Other 77 7.4 8 8.0
Primary morbidity reason 
in men in Turkey and the 
world (n = 1038)
 
Cancer 430 41.4 36 36.0
Cardiovascular diseases 412 39.7 31 31.0
Do not know 165 15.9 29 29.0
Diabetes Mellitus 14 1.3 2 2.0
Other 17 1.6 2 2.0
Primary mortality reason 
in women in Turkey and 
the world (n = 1038)
 
Cancer 512 49.3 39 39.0
Do not know 212 24.0 31 31.0
Cardiovascular diseases 233 22.4 20 20.0
Gynecological diseases 35 3.4 3 1.0
Other 46 4.4 7 7.0
Primary mortality reason 
in men in Turkey and the 
world (n = 1018)
 
Cardiovascular diseases 451 43.4 36 36.0
Cancer 337 32.5 26 26.0
Do not know 202 19.5 27 27.0
Other 48 4.6 11 11.0
Table 4. Characteristics of the students associated with CVD.
n %
BMI (n = 1129) 
<18.5 underweight 143 12.7
18.5–24.9 normal weight 841 74.5
≥25 over weight 145 12.8
Waist circumference in females 
(n = 940)
 
≤80 cm 849 90.3
≥81 cm 91 9.7
Waist circumference in males 
(n = 75)
 
≤94 cm 71 94.7
≥95 cm 4 5.3
CVD history in first-degree female 
relatives (n = 1132)
 
Yes 193 17.0
No 939 83.0
CVD history in first-degree male 
relatives (n = 1131)
 
Yes 215 19.0
No 916 81.0
Smoking (n = 1113) 
Smokers 161 14.1
Non-smokers 952 83.7
Former smokers 25 2.2
Exercise (n = 1138) 
Never 973 85.5
2–3 times per week, 40 minutes and above 
duration
165 14.5
Daily protein consumption (n = 1120) 
<2 servings 502 44.8
2 servings 437 39.0
>2 servings 181 16.2
Daily fruit/vegetables consumption 
(n = 1122)
 
<5–6 servings 1046 93.2
5–6 servings 58 5.2
>5–6 servings 18 1.6
Daily carbohydrate consumption 
(n = 1129)
 
<5–6 servings 968 85.7
5–6 servings 116 10.3
>5–6 servings 45 4.0
preceding six months (defined as exercising 2–3 times per 
week for at least 40 minutes; Table 4).
As shown in Table 4, the majority of the students 
(93.2%) did not consume the recommended daily amounts 
of fruit, vegetables, or carbohydrates, and approximately 
half (44.8%) consumed less than the recommended daily 
amount of protein. More than half of the students (58.7%) 
reported preferring unsaturated fats (e.g. vegetable oil); 
39.5% liked both saturated (e.g. margarine) and unsatu-
rated fats, and only 1.4% preferred saturated fat in 
cooking.
A multiple regression analysis was run to predict 
CARRF-KL total score from educational year, gender, edu-
cational background, BMI, exercise, waist circumference, 
CVD history in first degree male or female relatives, and 
smoking. Three variables were revealed in the multiple 
regression analysis as significantly associated with the 
CARRF-KL scale total score: gender, year of education, 
and educational background. These variables correlated 
positively with CARRF-KL scale and accounted for 20% 
of the variance in the scale (Table 5).
Discussion
In the literature, the two most common methods to meas-
ure knowledge level regarding CVD risk factors are (1) 
asking participants to indicate the correct answer of each 
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6 European Journal of Cardiovascular Nursing 
listed item and (2) asking participants to list CVD risk fac-
tors. Clearly, results from first method might indicate 
higher knowledge levels.40 The CARRF-KL is the first 
valid and reliable standardized questionnaire to measure 
individuals’ level of knowledge about CVD and its risk 
factors in Turkey.28 In the present study, we used the first 
method with the CARRF-KL scale and obtained high 
overall scores (mean = 22.47, SD = 3.38, out of a maxi-
mum of 28). Thus, the measurement style may have 
resulted in relatively higher scores for students’ knowl-
edge level than might have been obtained using a different 
method.
Although students had high overall scores, a large per-
centage of students had notably low knowledge for certain 
items on the questionnaire. First, approximately half of the 
students responded incorrectly with ‘yes’ when asked 
whether ‘slow walking is also considered to be exercise’. 
This indicates that students could not properly distinguish 
exercise from daily activity. Second, 46.4% answeredincorrectly regarding the need for lifetime usage of anti-
hypertensive medications. This suggests that the manage-
ment of hypertension ‘one of the most common risk factors 
in Turkey’ is not well understood by nursing students. This 
is consistent with the results of the Turkish PATENT 
(Prevalence, Awareness, Treatment, and Control of 
Hypertension in the Turkish Population) assessment, 
which found that only 31.1% of hypertensive patients were 
receiving pharmacological treatment.41 Third, about two-
thirds incorrectly answered items on modifiable risk fac-
tors and the preventability of CVD, indicating that their 
knowledge in these areas was low. This finding is similar 
to that of a recent study that investigated the knowledge 
and attitudes of nursing professionals and students toward 
CVD risk reduction in China, in which the participants had 
little knowledge about the preventability of CVD.26 
Modifiable risk factors are a substantial issue in the pre-
vention of CVD.
We found a statistically significant difference between 
students’ years of undergraduate education and their 
CARRF-KL mean scores, with more advanced students 
demonstrating an increased knowledge of CVD and risk 
factors. This is logical, as the medical/surgical nursing 
courses include considerable CVD-related content in the 
second year, and public health nursing courses covering 
prevention of non-communicable diseases and health pro-
motion are taught in the final year. The high CARRF-KL 
scores in students who graduated from vocational health 
schools with nursing diplomas might be explained by their 
previous knowledge and experience gained as nursing 
students.
Knowledge of CVD and related risk factors differed by 
gender. This difference could be explained by the low 
number of male students in our sample (8.8%), which 
might cause a representation gap. Although female stu-
dents had slightly higher CARRF-KL scores than male 
students, they had unhealthy diet and exercise habits as 
well.
Multiple regression analysis also demonstrated that 
variability in CARRF-KL total mean scores independently 
correlated with year of undergraduate education, educa-
tional background and gender. The link connecting 
CARRF-KL score variability with those three variables is 
indefinite in Turkish literature. This is the first study show-
ing the relationships between CARRF-KL score and nurs-
ing students’ individual characteristics. Therefore, it is 
important to investigate and clarify the link connecting 
CVD knowledge and nursing students’ characteristics in 
further research.
Students erroneously ranked heart disease as the third 
common cause of mortality in women and the first com-
mon cause of mortality in men. This misunderstanding is 
common among students in other studies, as well. Spillman 
reported that university students did not know that the 
leading cause of death was CVD-related illnesses.42 
Table 5. Factors associated with CARRF-KL scores.
Variable β t p 95% Confidence interval Multiple 
regression 
 Lower bound Upper bound
Year of undergraduate education 
(1/2, 3, 4) 
0.415 14.565 0.000a 2.651 3.476 R = 0.447
R2 = 0.200
Gender 0.094 3.255 0.001b 0.470 1.895 F = 31.219
p = 0.000
Durbin–
Watson = 
1.802
Educational background 0.077 2.714 0.007c 0.264 1.644
BMI −0.029 −0.878 0.380 −0.937 0.358
Exercise 0.025 0.895 0.371 −0.279 0.746
Waist circumference −0.015 −0.459 0.646 −0.889 0.552
CVD history in first-degree relatives 0.011 0.345 0.730 −0.395 0.564
Smoking −0.010 −0.305 0.760 −0.719 0.526
ap < 0.001; bp < 0.01; cp < 0.05.
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Badir et al. 7
Between 1997 and 2012, awareness of heart disease as the 
leading cause of death in women has increased considera-
bly, but is still below the targeted awareness level.37 The 
rate of death due to CVD has remained the leading cause 
of death for women,43 due to a lack of understanding of the 
risk factors and symptoms associated with CVD, as well as 
misconceptions about vulnerability. European Heart 
Health has implemented standards and requirements to 
improve women’s health, and continues to work to dimin-
ish the burden of CVD across Europe, including Turkey.44
Most of the students’ BMIs and waist circumferences 
were within the healthy range. In a prior study, nursing and 
medical students examined associations between preven-
tive attitudes and health care behaviors, and found that 
healthy lifestyle behaviors were independently associated 
with positive attitudes toward CVD prevention.23 
Therefore, we believe that the healthy BMIs and waist cir-
cumferences in our study population could be an indicator 
of better knowledge of CVD prevention, which would 
improve patient care in this area.
The majority of students reported no CVD in first gen-
eration male or female relatives. As CVD is the most prev-
alent category of disease for both genders according to the 
TARF study,2 this does not seem representative of 
the Turkish CVD profile. This may be attributable to the 
binary ‘yes’ or ‘no’ question format; students unsure of 
their family history might have answered ‘no’. We had 
expected that nursing students would be aware of their 
CVD family history; thus, we had not anticipated such a 
methodological problem. Another methodological possi-
bility may be that, since these students were young, CVD 
has not yet had adequate time to manifest in many of their 
immediate family members.
Another striking finding was that most of the students 
reported that they were non-smokers (Table 4), in contrast 
to a recent review of 31 studies that found that 27.5%–63% 
of men and 8.4%–27.8% of women in Turkey were 
smokers.45Another study 2509 university students found 
that 45.9% were smokers.46 Our finding here is very 
encouraging; since smoking is the most common CVD 
risk factor in Turkey, these non-smoking nursing students 
could be very effective positive role models.
Physical exercise combined with good nutrition can 
help to prevent CVD. According to the American Heart 
Association (AHA) and the European Heart Network 
(EHN), 47,48 to prevent CVD, adults should engage in at 
least 150 minutes of moderately intense exercise per 
week, 75 minutes of vigorous exercise per week, or a 
combination of moderate and vigorous activity. However, 
the majority of the students in our study had not exer-
cised (Table 4), in keeping with the high rates of inactiv-
ity among adolescents and adults reported by the AHA.43 
Irazusta et al. reported that only 17.4% of first-year nurs-
ing students and 19.7% of final-year nursing students 
met the recommended exercise criteria;22 another study 
conducted in Turkey reported that only 18% of under-
graduate students were sufficiently active.49 These find-
ings raise concern regarding students’ sedentary 
lifestyles, as this is a risk factor for CVD. In the present 
study, we hypothesize that a lack of exercise and recrea-
tional facilities on campuses and in student housing 
buildings might be one reason for such poor results.
Two servings of protein, at least five servings of fruit 
and vegetables, and six servings of carbohydrate daily for 
ideal health are recommended by the AHA,47 EHN,48 and 
Ministry of Health in Turkey the General Directorate of 
Primary Health Care.38 However, most of the students did 
not consume these quantities of fruit, vegetables, or carbo-
hydrates, and approximately half of the students consumed 
less than the recommended daily number of servings of 
protein. This was similar to Irazusta et al., who found that 
students’ nutrient intake was poor (very low in carbohy-
drates and very high in fat).22 We hypothesize that this 
poor nutrition might be associated with living in student 
housings, financial problems, greater consumption of 
snack foods, and fat diets. In addition, students’ unhealthy 
eating practices might be learned from food marketing and 
media (television advertisementsand social media). 
Therefore, there is a need for major change in media to 
include positive messages promoting good nutrition and 
physical activity. While the students’ BMIs and waist cir-
cumferences were within the healthy range overall, their 
poor dietary habits and inactivity raise concerns that these 
indicators might worsen in the future, increasing their 
CVD risk.
Conclusion
Nurses, one of the largest groups of health care providers, 
have the potential to identify risk groups, promote healthy 
lifestyles, prevent complications, and improve treatment 
compliance through education and counselling in health 
care settings. Nursing education should provide the knowl-
edge, skills, and resources to allow them to function as 
leaders in CVD prevention.50
Our study revealed that students had high overall 
knowledge but notable knowledge gaps in the areas of 
modifiable risk factors, disease prevention, exercise, and 
the common signs and symptoms of CVD. Moreover, their 
personal health characteristics and habits were mixed: they 
generally had healthy BMIs and waist circumferences and 
did not smoke, but most did not exercise regularly and 
reported poor eating habits. It seems that, despite their 
knowledge of the possible negative consequences of 
unhealthy individual behaviors, they do not practice what 
they know.
Despite some tentative hypotheses, the underlying 
causes for the unhealthy lifestyle behaviors of these stu-
dents remains unclear; further research is needed to deter-
mine the reasons behind their sedentary lifestyles and poor 
 at TEXAS SOUTHERN UNIVERSITY on October 28, 2014cnu.sagepub.comDownloaded from 
http://cnu.sagepub.com/
8 European Journal of Cardiovascular Nursing 
eating habits. There is a need for a greater emphasis on the 
benefits of regular physical exercise and adequate nutri-
tion in nursing curricula to encourage students to adopt 
healthier behaviors and become positive role models, pro-
viding more effective preventive counselling about exer-
cise and nutrition for their future patients. For this reason, 
we suggest incorporating evidence-based health promo-
tion courses into the nursing curricula throughout the 
undergraduate education.
Limitations
There were potential limitations to this study. First, the 
only possible responses on the questionnaires were ‘yes’ 
and ‘no’, limiting the data collected. Second, this sample 
used students from Istanbul, Turkey; more geographically 
diverse data are needed to enable nation- or worldwide 
generalizations of Turkish nursing students’ CVD knowl-
edge and health behaviors. Finally, there were considera-
bly fewer male than female students, which is normal in 
nursing programs.
Implications for Practice
•• Since nurses are expected to act as leaders to 
reduce CVD morbidity and mortality, nursing 
students should be well prepared to identify 
their individual cardiovascular risks as well as 
adhere to the recommended healthy lifestyle 
behaviors.
•• Based on the results of this study evidence-
based health promotion courses might be 
added into the nursing curricula throughout the 
undergraduate education.
Acknowledgements
We wish to thank all of the nursing school directorships that gave 
their permission and support for gathering data, as well as the 
nursing students who participated in the survey.
Conflict of interest
The authors declare that there are no conflicts of interest.
Funding
This research received no specific grant from any funding agency 
in the public, commercial, or not-for-profit sectors.
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