RISK PERCEPTIONS OF CARDIOVASCULAR DISEASE AMONG SAUDI ARABIAN WOMEN IN RELATION TO HOME COOKING AND INTENTIONS TO COOK LOW FAT MEALS A dissertation submitted to the Kent State University College of Education, Health, and Human Services in partial fulfillment of the requirements for the degree of Doctor of Philosophy By Nawal Alissa May 2017 © Copyright, 2017 by Nawal Alissa All Rights Reserved ii A dissertation written by Nawal Alissa B.S., King Saud University, 1996 M.P.A., Eastern Washington University, 2001 M.Ed., Kent State University, 2017 Ph.D., Kent State University, 2017 Approved by _____________________________, Co-director, Doctoral Dissertation Committee Dianne Kerr _____________________________, Co-director, Doctoral Dissertation Committee Kele Ding _____________________________, Member, Doctoral Dissertation Committee Kimberly Schimmel Accepted by _____________________________, Director, School of Health Sciences Lynne E. Rowan _____________________________, Interim Dean, College of Education, Health and Mark A. Kretovics Human Services iii ALISSA, NAWAL, Ph.D., May 2017 HEALTH EDUCATION AND PROMOTION RISK PERCEPTIONS OF CARDIOVASCULAR DISEASE AMONG SAUDI ARABIAN WOMEN IN RELATION TO HOME COOKING AND INTENTIONS TO COOK LOW FAT MEALS (178 pp.) Co-Directors of Dissertation: Dianne Kerr, Ph.D. Kele Ding, Ph.D. The purpose of this study was to investigate the risk perceptions and cooking behaviors of Saudi Arabian women in relation to cardiovascular disease (CVD) and intentions to cook low fat meals. Participants were Saudi Arabian women (ages 22-55). Data were collected through self-administered paper-pencil surveys in the summer of 2016. This study was conducted in a primary care clinic’s waiting room in a single hospital (King Khalid University Hospital) providing services to patients mainly from the Riyadh district of Saudi Arabia. The Home Cooking and Intentions to Cook Low Fat Meals Survey instrument was used in data collection. Both descriptive and inferential statistical data analyses were conducted using SPSS version 24. The major findings of this study showed a moderate negative correlation between risk perception of CVD and fat-related cooking behavior. Significant positive correlation is seen between risk perception of CVD and intention to cook low fat meals. The participants demonstrated high fat cooking behavior. It is recommended to conduct further research to understand how perceptions are formed among Saudi Arabian women and why they do not practice healthy cooking behaviors to prevent CVD. ACKNOWLEDGMENTS For my beloved parents, who inspired me every step of the way to accomplish this study, I thank you from the bottom of my heart. A special thank you is dedicated to my husband and my children for their love, patience, and understanding throughout my academic journey. Their support was very much needed and greatly valued as I worked tirelessly on this study. I would like to express my deep appreciation to my committee members, Dr. Dianne Kerr, Dr. Kele Ding, and Dr. Kimberly Schimmel whose recommendations and advice guided me throughout this process. You all helped make this study a great success and I cannot thank you enough for making one of my lifelong dreams come true. I would also like to thank King Saud University and Kent State University for providing me with this once in a lifetime opportunity. I am excited to bring all my newfound knowledge and skills back to King Saud University and feel honored knowing that I have a second home and family at Kent State University. Also, I would be remiss if I did not take the time to thank my colleague and classmate at Kent State University, Julie Chaya. Your encouragement, support, and friendship since day one of the PhD program has always been appreciated and something I will always cherish. To the women of Saudi Arabia who participated in this research, I thank you very much for your contribution. Your valuable input allowed me to generate the necessary evidence needed to help shape a healthier future for our country. Finally, I would like to thank everyone who I have met during my doctoral experience. Your honest feedback and insightful assistance helped me to complete this study. iv TABLE OF CONTENTS Page ACKNOWLEDGMENTS ................................................................................................ iv LIST OF FIGURES…………………………………………………………………......viii LIST OF TABLES ……………………………………………………………………….ix CHAPTER I. INTRODUCTION .........................................................................................................1 Previous Work on CVD in Saudi Arabia .................................................................5 Fat Intake and Cooking Behaviors ...........................................................................6 Significance of the Study .........................................................................................8 Rationale ................................................................................................................11 Purpose of the Study ..............................................................................................14 Study Methodology ................................................................................................15 Theoretical Framework ..........................................................................................16 Health Belief Model ...................................................................................... 16 The Seven Stages of PAPM in the Application of Cardiovascular Risks of Cooking High Fat Foods ........................................................................... 17 Research Questions ................................................................................................18 Research Hypotheses .............................................................................................19 Limitations of the Study.........................................................................................19 Operational Definition of Terms ............................................................................20 Summary ................................................................................................................21 II. LITERATURE REVIEW .............................................................................................23 Cardiovascular Disease in Women ........................................................................25 CVD Risk Factors for Saudi Arabian Women .......................................................29 Dietary Fat Intake and CVD Risk ..........................................................................36 Women’s Cooking Responsibilities in the Middle East ........................................38 History of Dietary Changes in Saudi Arabia .........................................................42 The Early Stages of Dietary Changes ............................................................ 42 Reasons for the Dietary Changes ................................................................... 43 How Dietary Changes Took Place ................................................................. 44 The Importance of Nutrition in CVD Prevention ..................................................46 Nutrition Recommendations .......................................................................... 47 Low Fat Cooking Behavior ........................................................................... 51 Theoretical Basis of the Study ...............................................................................52 Health Belief Model (HBM) .......................................................................... 53 Precaution Adoption Process Model (PAPM) ............................................... 62 v Research Questions, Hypotheses, and Data Analysis Approach ...........................70 III. METHODOLOGY ......................................................................................................72 Purpose of Study ....................................................................................................72 Research Questions ................................................................................................72 Research Hypotheses .............................................................................................72 Limitations and Delimitations ................................................................................73 Study Population ....................................................................................................74 Participants .............................................................................................................74 Eligibility Criteria ..................................................................................................75 Setting ....................................................................................................................76 Instrumentation ......................................................................................................76 Pilot Study ..............................................................................................................81 Validity and Reliability .................................................................................. 82 Data Collection Process ................................................................................. 85 Example Findings .......................................................................................... 85 Data Collection Procedures