This study assessed the level of knowledge and attitude regarding risk factors of CVD among general people residing in Nepalgunj, Banke; Nepal. This part deals according to the results obtained from the statistical analysis based on the data of the study. The results obtained from this study could help for future strategies and interventions for CVD. In the present study; of total 150 subjects, mean age was 35.73 10.83 years, ranging from 20 to 60 years.The mean scores of respondents for knowledge was 9.28±2.87 points. Overall, 35(23.3%) had good knowledge, 61(40.7%) had average knowledge and 54(36.0%) had poor knowledge regarding risk factors of CVD. These findings were in keeping with the results from various studies such as conducted in North- Eastcoast Malaysia in which mean age was of 39.9 years, mean (SD) score for knowledge 70.6 ±13.7 and more than half of the respondents 55.6% had good knowledge , another study in Malaysia, with respondents’ mean age 39.9±10.04 years, mean scores for knowledge 36.8±7.14, 55.6% had good knowledge , moderate knowledge with mean score 19.18 ± 4.46 in Turkey , mean age of participants 42.22 ±10.56 years, mean score for knowledge 31.34 5.6 , mean score for knowledge 9.060 4.805 scores ranging from 0 to 20 and majority belonged to low level knowledge category (65.20%) in India , moderate knowledge in Kuwait , good knowledge with (67%) in Pakistan , median percentage scores for knowledge 79.3%, nearly 44% of respondents had insufficient knowledge (poor), 36% had average knowledge and less than 20% had highly satisfactory knowledge (good) in Nepal , the mean scores (SD) for knowledge 60.75±4.823, maximum score 71 in Malaysia  , mean and standard deviation of the knowledge 42.98±2.46 in another study in Malaysia , median age (IQR) was 40 (33–46) years, participant’s knowledge of risk factors was low with a mean (SD) score of 1.3 (1.3) out of possible 10 in Kenya . The variations in results might be attributed to differences in study area, scale of classification and categories of enrolled subjects.
In our study, more than half of the respondents 82(54.7%) were female and 68(45.3%) of the respondents were male and majority of the respondents 80(53.3%) were married which were almost consistent results with the study in North western turkey in which nearly half of the respondents 140(46.7%) were female and majority of the respondents 210(70.0%) were married . Furthermore, the findings of this study were supported by the previous study in Nepal; median percentage scores for knowledge had 79.3, also, less than 20% of the respondents had highly satisfactory knowledge (i.e. good knowledge),36% of the respondents had average knowledge and nearly half of the respondents 44% had insufficient knowledge (i.e. poor knowledge) [ 32].
In the present study, overall, 108(72%) were literate and 42(28%) illiterate; MNLR analysis revealed that education and profession were significant predictor variables in association with the level of CVD knowledge: Education; illiterates were 80.5% less likely (AOR = 0.195, 95% CI: 0.074–0.514, P = 0.001 < 0.05) to have average knowledge and 67% less likely (AOR = 0.330, 95% CI: 0.117–0.929, P = 0.036 < 0.05) to have good knowledge about risk factors of CVD than literates relative to poor knowledge. Furthermore, occupation; participants having government jobs were 10.389 times more likely (AOR = 10.389, 95% CI: 2.015–53.560, P = 0.005 < 0.05) to have average knowledge and 12.673 times more likely (AOR = 12.673, 95% CI: 1.475–108.884, P = 0.021 < 0.05) to have good knowledge as compared to those participants involving agriculture as reference to poor knowledge (Table 5). These findings were almost comparable with the studies conducted in Kenya in which higher education was a strong predictor of CVD risk knowledge (OR = 6.72, 95 % CI: 1.98-22.84, P < 0.0001)  in Kuwait, from the multivariate logistic regression analysis, independent predictors of better level of CVD knowledge were females, age 50–59 years, high level of education, regular eating of healthy diet, and had a family history of CVD , in Buea Cameroon, from multivariable analysis; high level of education (AOR = 2.26, 95% CI:1.69–3.02, P < 0.0001), high monthly income (AOR = 1.64, 95% CI: 1.07–2.51, P = 0.023<0.05), having a family history of CVD (AOR = 1.59, 95% CI: 1.21–2.09, P = 0.001 < 0.05) and being a former smoker (AOR = 1.11,95% CI: 1.02–1.95, P = 0.043 <0.05) were significantly associated with moderate-to-good knowledge , in Pakistan factors significantly associated with knowledge included age (P = 0.023), income (P < 0.001), education level (P < 0.001), residence (p < 0.001), a family history of CHD (P < 0.001) and a past history of diabetes (P = 0.004) .This difference could be due to differences between the study populations as gender, occupation , age group , study area.
In this study, majority of the respondents 77(51.3%) had unfavourable, 54(36%) had neutral and only 19(12.7%) had favourable attitude regarding risk factors of CVD. The overall score of respondents with a mean SD of attitude 52.49 12.98 points. This finding was in line with the study done in Jhaukhel – Duwakot, Kathmandu in which median percentage scores for attitude had 74.3 and only 14.7% had a highly satisfactory attitude and 19.5% had satisfactory attitude  but lower than a study conducted in North-Eastcoast in Malaysian women, which found 55.1% , also lower than other studies in Malaysia, mean (SD) score for attitude 54.36 ± 8.711 and 57.12 ± 5.73 [33,34], higher than a study conducted in Cuddalore district, India, which found mean (SD) score ( 21.88 1.97) , lower than that reported from Lucknow city, India, mean score for attitude 11.82 ± 5.032, 37.6% score ranging from 0 to 19 . This might be due to variation in study population.
In the present study, more than half of the respondents 82(54.7%) were female and 68(45.3%) of were male; 48(32%) male literates and 60(40%) female literates. MNLR analysis revealed that gender and education were significant predictor variables in association with level of CVD attitude category. Gender; males were 69.9% less likely (AOR = 0.301, 95% CI: 0.140–0.648, P = 0.002 < 0.05) to have unfavourable attitude than female as reference to neutral attitude and education; illiterates were 4.158 times more likely (AOR = 4.158, 95% CI: 1.707–10.128, P = 0.002< 0.05) to have unfavourable attitude about risk factors of CVD than literates relative to neutral attitude (Table 7).
In this study, majority of the respondents 113(75.3%) answered that the modifiable risk factor of CVD: smoking, physical activity, dietary pattern, high cholesterol, 36(24.0%) answered non modifiable risk factor of CVD: age, family history, sex, ethnicity and age, smoking, tobacco, stress. These findings were almost consistent with the results [12,13] and almost comparable with previous studies conducted in Lamjung district, Nepal in which smoking 24.1%, harmful use of alcohol 10.7%, insufficient intake of fruit and vegetables 72%, low physical activity 10.1%, overweight and obesity 59.4%, hypertension 42.9%, diabetes 16.2%, dyslipidemia 56.0% were common risk factors of CVD; and in Kathmandu district, Nepal CVD risk factors included smoking (17.6%), alcohol consumption (29.4%), insufficient fruit and vegetables intake (98%), insufficient physical activity (21.0%), obesity (15.3%), hypertension (34.4%), diabetes (10.5%) and high triglyceride levels (10.8%).The study concluded that the risk factors of CVD was high in rural population of Nepal [39, 40] , almost consistent with the results of another study in rural Nepalese population, Nepal .This difference could be due to the variations between rural and urban populations.
The finding of present study, 133(88.7%) respondents had known the meaning of CVD as a group of disorder of heart and blood vessel which was supported by the study conducted in Lahore, Pakistan in which 67(60.9%) answered CVD is related to heart and blood vessels .Majority of the respondents 110(73.3%) answered dizziness, weakness, arm pain sign and symptoms of CVD which was approximately similar to the study conducted in Kuwait, the respondents 728(89.2%) answered dizziness, weakness, arm pain as sign and symptoms of CVD . More than half of the respondents 88(58.7%) answered lifestyle modification as treatment of CVD, 100(66.7%) answered avoid red meat as dietary changes for prevention of CVD. The most of the respondents 121(80.7%) answered 1 hours and 6(4.0%) answered 5 hours exercise need to prevent from CVD and 100(66.7%) answered smoking cessation as prevention of CVD which was lower than the study conducted in Italy in which most of the respondents 694(87%) answered smoking cessation as prevention of CVD in Italy .This could be due variation in awareness between study population and probably might be explained by the lack of health education about CVD in the study site.
Regarding attitude in the current study, 21(14%) participants agreed and 9(6%) strongly agreed about smoking was the major risk factor of CVD; 11(7.3%) agreed and 10(6.7%) strongly agreed about physical activity helps to reduce CVD; 25(16.7%) agreed and 10(6.7%) strongly agreed about walking 1hrs per day can prevent from CVD; 12(8%) agreed and 12(8%) strongly agreed about daily intake of enough fruits and vegetables helps to reduce the risks of CVD; 20(13.3%) agreed and 13(8.7%) strongly agreed about stress management helps to prevent from CVD; 18(12%) agreed and 12(8%) strongly agreed about tobacco chewer have the higher risks of getting CVD; 18(12%) agreed and 13(8.7%) strongly agreed about regular medical checkup can prevent from CVD ; 25(16.7%) agreed and 13(8.7%) strongly agreed about intake of red meat to increase the risk of CVD. The findings of present study were supported by the study conducted in Lahore, Pakistan with the results quarter of respondents 35(31.8%) agreed about walking 1hrs per day can prevent from CVD. 44(44.5%) agreed about daily intake of enough fruits and vegetables helps to reduce the risk of CVD, 33(30%) agreed about stress management helps to prevent from CVD , 96% participants agreed that exercise can prevent CVD, 90% agreed to prefer walking than taking any other means of transportation, 91% agreed to eat fruits and vegetables in Kuantan, Malaysia .This difference could be due to differences in the study areas and types of participants because our study was not included rural communities.
Our study had some limitations: The study was conducted to selected community of Dhomboji-1, Nepalgunj. The size of the sample was not large enough to make it a representative sample; hence the findings of this study may not be generalized. Despite these limitations, our study had several strengths: This is the first known study to be conducted in mid-western part of Nepal. The present findings would be the first step in providing a quantitative measurement of CVD knowledge and attitude for identifying specific knowledge gaps. This study could aid in the assessment of the adequacy of the present community health educational programs, and could be utilized in designing future targeted public health promotion campaigns to enhance CVD knowledge, improve in attitude and reduce the risk of CVD.