Assessment of the general public’s knowledge of atrial fibrillation through social media: a cross-sectional study

Atrial fibrillation (AF) is the most prevalent sustained arrhythmia. Globally, there is an estimated 46.3 million people living with AF [1]. With population ageing, the prevalence of AF will only continue to rise. For people above the age of 70 years, the prevalence of AF ranges from 4.6 to 8.2%. Particularly in Asia Pacific, the prevalence of AF has risen more than two-fold over the course of 10 years [2, 3]. The prevalence of AF in Taiwan is estimated to be 4.0% in 2040 and 5.8% in South Korea by 2060 [3]. Based on a community health screening project in Singapore, the AF prevalence of people above the age of 80 years is 5.8% [4].

Ischaemic stroke prevention is a cornerstone of AF management [5]. Notably, 70% of AF-related ischaemic stroke can be prevented by oral anticoagulant (OAC) therapy [6], yet most of AF-related ischaemic strokes happen in patients who are not on OAC therapy. High ischaemic stroke prevalence rates of 10–13% have been reported in the Far East and Southeast Asia [7]. Considering that, early detection and timely treatment of AF remains pivotal to preventing AF-related complications [8]. Late detection and subsequently delayed treatment could be attributed by the general public’s poor knowledge of AF [9]. At present, the global public awareness of AF is poor, the overall awareness of AF can be as low as 25% among the members of the public in some countries [10]. Newly diagnosed and chronic AF patients have also been reported to have poor understanding about their AF condition [11, 12].

Studies in other fields of medicine have shown poor knowledge and awareness of disease among members of the public are significant contributors to poor uptake of community screening programmes [13, 14]. Consequently, public education interventions aimed at improving the public’s AF knowledge may empower people to participate in health screening programmes and seek timely treatment for AF [15]. Nonetheless, prior to developing such public education interventions, it may be advantageous to first explore the learning needs of the public by first assessing their awareness and knowledge of AF.

To the best of our knowledge, this cross-sectional study is the first to employ digital marketing strategies on Facebook to gather responses from the public regarding their knowledge of AF. Elucidated in this study is the public’s moderately high AF knowledge scores [mean percentage score of 63.3 (SD 26.0)], which did not vary with selected demographic factors.

At present, there are several survey instruments developed to assess knowledge of AF. However, a large proportion of them were developed for patients [19]. The length of existing patient AF knowledge assessment surveys ranges from eight [20] to 58 items [21] but most of them have at least 31 items [19]. These patient AF knowledge assessment surveys may not be suitable for the general public because apart from assessing disease knowledge, they also include items examining their priorities for treatment, attitudes and behaviour towards living with AF. These items may not be relevant to one who has not been previously diagnosed with AF. Wendelboe et al. [10] developed a survey instrument to assess public awareness of AF. However, they included items to assess the participants’ awareness of other thrombotic diseases (stroke, myocardial infarction, pulmonary embolism, thrombosis, and deep vein thrombosis) and common non-thrombotic diseases (hypertension, diabetes, breast cancer, prostate cancer, and HIV/AIDS). This was done to compare the participants’ awareness of AF with that of other diseases. Considering the inclusion of these additional items and also lack of reporting of its reliability and validity, we decided not to use this instrument for this study.

We chose Abubakar et al.’s 21-item AFKAT to fulfil the aim of this study as it had relatively fewer items and assessed AF knowledge without assuming that the subject had pre-existing AF. Moreover, when administered on Australian subjects, the AFKAT had good internal consistency (Cronbach’s alpha = 0.910). When tested in our study context which comprised mostly of Singapore residents (98.4%), the AFKAT also displayed good internal consistency (Cronbach’s alpha = 0.95). In the original study, general public participants took an average of 2.5 min to complete the survey. In comparison, our study participants took a mean time of 4.0 min (SD 2.4 min) to complete the survey. The additional 1.5 min may be attributed to time spent reading the participant information sheet before attempting the survey and for leaving contact information for reimbursement purposes. Nonetheless, the time required to complete this survey was well under the recommended 10 min for online surveys [22].

When the AFKAT was administered on participants from the Australian general public, the mean percentage score was 53.4 (SD 27.7). In our study, the participants from the general public achieved a higher mean percentage score of 63.3 (SD 26.0). The sociodemographic information of the participants from the Australian general public was not disclosed in the original study [9]. As such, it was not possible to draw definitive conclusions on the difference in AF knowledge scores between the two study populations.

In this study, digital marketing strategies were employed on Facebook to recruit participants. Such web-based strategy using social media has gained interests among researchers as it is perceived to potentially reach general and specific study populations [23‐25]. In particular, the utilisation of Facebook for digital marketing can effectively target a specific demographic profile and reach a diverse audience within a vast geographic location [26]. Furthermore, it has the ability to access individuals who may not actively seek out the information and therefore remain inaccessible through the use of Google AdWords [26]. This is due to AdWords’ reliance on keyword searches initiated by the user, which limits its ability to reach individuals outside of this framework [27]. Nevertheless, the study population comprised predominantly young individuals, with 56.4% of participants aged 40 years or younger. This phenomenon of recruiting larger proportions of younger individuals was also observed in earlier studies that examined the effectiveness of digital marketing on Facebook for recruiting participants to health research-related studies [25, 28, 29].

While Facebook is used across a wide range of age groups, younger adults tend to be more engaged and active on the platform than older adults [30]. This may suggest that advertising campaigns targeting younger individuals may be more effective than those targeting older individuals, and could potentially be less expensive as a result of higher engagement rates [23]. Nonetheless, it may still be worthwhile to have reached out to a younger population in our study because the risk of AF is not only associated with age. The risk of AF is also positively associated with factors such as BMI, history of myocardial infarction or stroke and high alcohol consumption [31], and these factors are modifiable. Hence, increasing awareness of AF in younger individuals provides us the opportunity to reduce their risk of developing AF later in life. Between the age of 40 to 69 years, the risk of AF is at least 37% for every 5 kg/m² increase in BMI [31]. In consideration of that, individuals, including younger adults, who struggle with weight management are at risk of AF.

The moderately high AF knowledge scores obtained by our study participants may be attributed to their education level. Most (84.2%) of the participants’ high level of education was a Diploma. Compared with people with no or low levels of education, people with higher education levels have been shown to have better knowledge on general health, which enhances their awareness of health promotion behaviours [32]. Even though there was no statistically significant difference in the AF knowledge scores across the different age groups, there was a slight trend suggesting that older individuals had better AF knowledge scores than younger individuals [mean percentage score 60.9 (age group 21 to 30 years) versus mean percentage score 69.2 (age group 61 and above)]. Young adults in Singapore are less likely than older adults to take part in screening of chronic diseases [33, 34], hence, they may not be cognizant of heart rhythm disorders such AF. In contrast, older adults, especially aged 61 years and above, have a greater likelihood of living with at least one chronic disease and have regular medical reviews with their primary care provider [35]. During which, their primary care providers may have had the opportunity to provide education on AF.

However, as important as improving public knowledge of AF is, it is not the end goal. The focus should be on improving the uptake of preventive treatments as a measure to reduce stroke occurrence. Therefore, better AF detection rates and timely initiation of stroke-preventive treatments are essential metrics. Abubakar et al. (2019) suggested a framework based on the Capability, Opportunity, and Motivation Behaviour (COM-B) model to guide the design of interventions to improve the early detection of AF in the community [15]. The framework outlines the importance of improving people’s psychological and physical capabilities to engage in AF screening behaviour. Factors involved in improving these psychological and physical capabilities include AF knowledge, education level, cognitive function, and ability to respond to AF symptoms appropriately. Most of which is directly impacted by assessment of knowledge and health awareness campaigns [15].

Nevertheless, healthcare providers’ use of AF screening and diagnosis accompanied by accurate dispensation of treatment, advice and referral is just as important [36]. Health institutions play pivotal roles in supporting public education outreach and clinical decision support. Apart from implementing community-based AF screening for members of the general public, streamlining the community-based outreach and screening programmes to existing healthcare facilities can encourage sustainability [15]. This also ensures that people who have been newly diagnosed with AF undergo further diagnostic investigations and receive prompt treatment.

In our study, even though the participants achieved moderately good AF knowledge scores, they seemed to be less informed about measures to prevent AF (mean percentage score 53.0%). To curtail AF-related stroke burden, besides improving awareness of AF, preventive and therapeutic strategies must also be employed [37]. For instance, at the patient level, attempts to delay the development of AF by managing risk factors, encouraging healthy weight loss, increasing physical activity, and treating comorbidities should be advocated for. The term “atrial fibrillation” or “AFib” should be as easily recognised by the public as “cancer”, “heart attack” and “stroke”.

At policy and institutional levels, issues pertaining to access to health screening and subsequent care, prescribing of medications, adherence and persistence of treatment have to be addressed as well. It was shown that physicians may know that AF patients need be anticoagulated but this knowledge is not translated into practice [38]. Multifaceted, collective efforts among policymakers, health institutions, governmental organisations, professional societies, healthcare providers and patients are required to augment the use of stroke-preventive interventions among patients with AF [37].

Members of the public recruited from Facebook and via digital marketing had moderately good knowledge of AF. However, public awareness pertaining to preventing AF has potential for improvement. The utility of social media in reaching the general public was illustrated through this study.