Cardiovascular disease (CVD) remains the leading cause of death in women worldwide, accounting for more fatalities than all forms of cancer combined.1 Despite this burden, CVD in women is consistently underrecognized, underdiagnosed, and undertreated, partly due to persistent misconceptions that it is a predominantly male disease.2,3 This gender bias contributes to delays in care, misinterpretation of symptoms, and poorer outcomes for women.4

Health literacy – defined as the ability to access, understand, and use health information to make informed decisions – plays a critical role in managing cardiovascular risk and improving clinical outcomes.5 Limited cardiovascular health literacy has been associated with poor recognition of risk factors and symptoms, lower adherence to lifestyle recommendations and medications, and reduced engagement with preventive care.6,7

Although studies in Korea, the Gulf region and Arab populations have begun to explore cardiovascular health literacy in women,8–10 this topic remains under-investigated in many parts of Europe. In Portugal, specifically, there is a lack of data regarding women's awareness of cardiovascular disease and their ability to recognize, prevent and respond to it. Understanding the current state of cardiovascular health literacy in Portuguese women is essential to designing effective public health strategies, improving outcomes, and reducing gender-based disparities in cardiovascular care.

This study aimed to assess cardiovascular health awareness in a sample of Portuguese women. The secondary objectives were to identify predictors of low self-perceived awareness of cardiovascular disease in women, to characterize cardiovascular health literacy and to identify barriers to healthy lifestyles.

In this study assessing cardiovascular health awareness among Portuguese women, our population was mostly composed of middle-aged women, living in urban areas, with about two thirds being post-menopausal. Most women had at least a secondary level of education.

We observed an overall low level of self-perceived awareness of CVD in women. Indeed, only one in four participants correctly identified CVD as the leading cause of death among women, and just one in five acknowledged it as the most prevalent disease. This proportion is considerably lower than the 44% who recognized CVD as the leading cause of death in the American Heart Association (AHA) survey conducted in 2019, which itself represented a decline from 65% reported in 2009. In that 2019 survey, higher levels of awareness were observed in women with hypertension.11 Nonetheless, our findings showed a significant discrepancy between the high prevalence of cardiovascular risk factors and the low level of awareness of cardiovascular health in women in our study population.

We would like to highlight that, although nearly four in five participants were able to recognize symptoms of angina, fewer than a half could identify the symptoms of an acute myocardial infarction, which can contribute to delays in seeking medical attention, potentially negatively affecting prognosis. These findings underscore the need for improved education on symptom recognition, which could be addressed through awareness campaigns on acute myocardial infarction.

Although roughly two-thirds of participants achieved a high score in prevention knowledge, fewer than one-third reached a high score in risk-factor knowledge. This dissociation suggests that messages about “what to do” may be landing better than messages about “why it matters”. Future campaigns should therefore pair action-oriented prompts (recognize chest pain, call EMS) with simple, repeated cues about major risks factors using channels our cohort accesses information (television, magazines, peers).

Concerning access to information and education, we found only one in seven participants felt well informed about cardiovascular disease in women despite the large majority having encountered the topic within the past year. This finding may reinforce the perception that it could be of valuable interest to create more structured educational programs and accessible information on the topic, as the most common source of information was informal, through friends, underscoring the need for more reliable and effective communication channels.

The finding that older age, particularly above 62 years, was associated with lower cardiovascular disease awareness may be partly explained by generational differences in access to health education resources and possibly an increasing investment in public health measures, including health literacy. Our results align with previous studies, such as that by Kim et al., which reported a 1.7-fold higher likelihood of low CVD awareness among women older than 70 years, and Albaker et al., who found significantly lower health literacy among participants over 50 years of age.8,9 However, these findings contrast with the American Heart Association (AHA) 2019 survey, where awareness was higher among older women. This discrepancy may be attributed to methodological differences, as the AHA survey was conducted through an online questionnaire, which may have introduced selection bias, leading to a study population with distinct baseline characteristics.11

Raising awareness in older women could be particularly important, as older age is an independent predictor of lacking cardiovascular awareness. Awareness raising and education from healthcare professionals could be effective, as the majority reported that they felt comfortable discussing their illness with their physician.

The creation of structured educational programs, although of interest across all age groups, could be particularly impactful starting from the primary education level. The introduction of these initiatives at a young age may be helpful in cultivating interest and awareness. This is especially relevant considering that women with only primary education level showed 3.6-times higher odds of low awareness.

Economic constraints were the most frequently reported barrier to the adoption of a healthier lifestyle, whereas disinterest was seldom mentioned. This may suggest that, if these barriers are overcome, these women may be receptive to lifestyle changes. The implementation of better health policies, such as accessible and affordable exercise programs, for instance, community-based programs, could be effective and beneficial with presumed positive impact in cardiovascular outcomes.

Our study has several limitations. First, the relatively small sample size may not be representative of all Portuguese women. Additionally, there may be a selection bias, as the participants were recruited from a cardiovascular screening event and possibly represent a more conscious and health-engaged subgroup of the overall population, which may contribute to an overestimation of the level of awareness of CVD in women. Second, as the study was conducted in a single city, our findings cannot be generalized to all regions of our country, as regional variations, in particular between urban and rural areas and across different educational levels, may be significant. In addition, the questionnaire included several questions that relied on self-perceived awareness measures, which is inherently subjective and may not correctly represent the awareness and knowledge levels on CVD.

This study reveals substantial gaps in cardiovascular health literacy among Portuguese women, with a large proportion reporting limited knowledge of cardiovascular disease, its symptoms, and risk factors. Older age and lower educational attainment were independent predictors of low self-perceived awareness, while perceived barriers – financial constraints and lack of time – further hinder the adoption of healthier behaviors despite some access to information.

To our knowledge, this is the first study to specifically assess cardiovascular health literacy in women in Portugal, providing essential baseline data to guide public health policies and intervention design. Prioritizing accessible, gender-responsive education and addressing structural barriers is essential to empower women to improve risk perception, timely recognition and cardiovascular outcomes.

Not applicable. All participants provided verbal informed consent prior to completing the questionnaire. The survey was anonymous, and no identifiable personal data were collected; data were analyzed in aggregate and handled in compliance with applicable data-protection regulations (GDPR/EU). As the research involved an anonymous, minimal-risk, survey-based design with no collection of identifiable information, the study was exempt from formal ethics committee approval under our institution's policies.

This research received no specific grant from any funding agency.

The authors declare no conflicts of interest.