Assessment of knowledge and attitude regarding risk factors of cardio vascular disease among general people residing in Nepalgunj, Banke; Nepal


 Background: Cardio vascular disease (CVD) is a group of disorders of heart and blood vessels. It is the leading cause of death not only in developed but also in developing countries like Nepal. However, knowledge and attitude about risk factors of CVD have not yet studied in mid-western part of Nepal. Therefore, this study aimed to assess the level of knowledge and attitude regarding risk factors of CVD among general people residing in Nepalgunj, Banke; Nepal. Methods: A community-based cross-sectional study was conducted. The pre-tested structured and self-administered questionnaires were used to collect the data during the month of July to August 2019, and analysed using SPSS software version 21. The descriptive analysis was performed using frequencies, percentage, mean SD. Chi-square test and multinomial logistic regression (MNLR) analysis were used to identify the statistically significant factors associated with knowledge and attitude.Results: Of total 150 subjects, 23.3%, 40.7% and 36.0% of the respondents respectively had good, average and poor knowledge. Likewise, 51.3% had unfavourable, 36.0% neutral and 12.7% favourable attitude towards risk factors of CVD. MNLR analysis revealed that education, gender and profession were significant predictor variables in association with the level of CVD knowledge and attitude: illiterates were 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 compared with literates. Participants having government jobs were 12.673 times more likely (AOR = 12.673, 95% CI: 1.475–108.884, P = 0.021 < 0.05) to have good knowledge compared to those participants involving in agriculture. Males were 69.9% less likely (AOR = 0.301, 95% CI: 0.140–0.648, P = 0.002 < 0.05) to have unfavourable attitude in comparison to female over neutral attitude, and 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 more than literates. Conclusion: The findings of the study concluded that, the knowledge about CVD was adequate among general people, however the attitude was unfavourable. Thus, health awareness campaigns such as NTCP, DMP, MMMP needs to be implemented to develop knowledge and improve in attitude about risk factors of CVD.


Introduction
The Cardiovascular diseases (CVDs) are group of disorders of the heart and blood vessels and they include coronary heart disease, cerebrovascular diseases, deep vein thrombosis and pulmonary embolism and some other disorders of heart [1]. Around 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Among these three-quarters of CVD deaths take place in low and middle-income countries. According challenge and to reduce the future burden of CVD in general people of Nepal. Despite the rising prevalence of CVDs and their associated risk factors in Nepal, a few published studies have been done on the issue in different part of Nepal [32,39,40] but there are no published studies that have comprehensively assessed knowledge and attitude of CVDs and their risk factors in general people in the mid-western part of Nepal yet. This study, therefore, has attempted to assess the knowledge and attitude regarding risk factors of CVD among general people residing in Nepalgunj, Banke; Nepal.

Study Design and Area
A community based, cross sectional research design was adopted and the study was conducted in Dhamboji-1, Nepalgunj; Banke, Nepal dated in July to August 2019. Nepalgunj is a sub-metropolitan city in Banke District, which is located in the Province number 5, the mid-western part of Nepal. According to 2011 census, the total population of Banke district had 491,313. Our study area was Dhomboji-1, the heart of the city and the study population comprised of all the people residing Dhomboji-1, Nepalgunj, Banke, was 10,000 and 2100 households. A sample of 150 people was selected using non-probability convenience sampling technique. Face to Face questionnaire on paper based interviews were conducted to collect the data. Information collected during interviews included socio-demographic characteristics, knowledge and attitude of risk factors for CVD.

Inclusion Criteria
The study has included the general people having age between 20 to 60 years residing in Dhamboji-1, Nepalgunj; Banke and who were willing to participate in the study.
were available at the time of data collection Exclusion criteria General people residing Banke, who were not willing to participate in the study.

Data collection tools
The tools developed and used for data collection were pre-tested structured and self-administered questionnaire and Likert scale consisting of three parts: (i) Performa to collect socio-demographic data, (ii) structured knowledge questionnaire regarding risk factors of CVD and (iii) Likert scale to assess the attitude regarding risk factors of CVD. Further, the tool which consisted of socio-demographic data, structured knowledge questionnaire and attitude scale consisted of 11, 15 and 20 items (statements or questions) respectively. The knowledge score was classi ed into three categorized as good knowledge (>75%), average knowledge (50-75%) and poor knowledge (<50%) and also, attitude was assessed by likert scale and arbitrarily classi ed as favorable attitude (>75%), Neutral attitude (50%-75%) and unfavorable attitude (<50%).

Pre-testing of tool and Reliability
Reliability of the instrument was maintained through pre testing of instrument in 10% of total sample size for arousing the understanding and accuracy of instrument. Pre-testing the instrument was done among 10% of total sample size at community of Nepalgunj and necessary modi cation of the instrument was carried out as necessary. Those participants were excluded from the study. Internal consistency and reliability of each set of items for assessment of knowledge and attitude of risk factors was evaluated using Cronbach's alpha test.
The reliability coe cients were 0.701 and 0.873 respectively for the scale of knowledge and attitude of risk factors. Thus, the scale was reliable as alpha coe cient in the range 0.70 and above [24].

Operational De nition
Knowledge: In this study, knowledge refers to the correct responses obtained from general people on risk factors of CVD which will be measured by structured knowledge questionnaire.
Attitude: It refers to the way of thinking, acting and behaving towards risk factors of CVD by respondents as measured by Likert scale.
Risk factors of CVD: It refers to particular habits, behaviors, circumstances or conditions that increase a person's risk of developing CVD.
General people: In this study, general people refers to the people of community with age (20-60) years including both male and female who lives in the community of Dhomboji-1, Nepalgunj.
When the subjects were able to read and write in the national language, they were categorized as literate and vice versa (i.e. illiterate) as de ned by the Government of Nepal.

Socio-demographic Characteristics
Socio-demographic information included age, sex, religion, family income, family type, marital status, education status, occupational status, Present Illness, Eating pattern, Personal habit. Age was collected as a continuous variable and categorized into 20-30, 30-40, 40-50, and 50-60 years. Religion was as Hinduism, Muslim, Buddhists, Christianity, Other. Family income was categorized as less than NRs.10,000, 10,000-20,000, 20,000-30000, 30000 and above. Education level was categorized into literate or illiterate. Marital status at the time of data collection was grouped into four groups as married, unmarried, widowed/Widower, Divorced/separated. Occupation was assessed and categorized as government job, business, agriculture.
Present illness assessed as hypertension, diabetic mellitus, cancer, asthma, none, eating pattern was Vegetarian, Non-vegetarian and mixed. Personal habit was assessed through smoking, tobacco, Drug, others, none.

Assessment of CVD knowledge
In the knowledge section, the questionnaire comprised 15 items (i.e. questions or statements) regarding knowledge of CVD risk factors; and each item contained four options. Each of these items (questions) was equally scored. (1 point was given for a correct answer and zero otherwise). These points were then summed across all the items. The maximum possible total knowledge score was 15. Therefore, the total score of this section ranged from 0 to 15 and the higher the score indicated the better the degree of knowledge. Then, the knowledge of CVDs was assessed by total scores of risk factors. Participants who obtained score 12 or more upto 15 (i.e.12-15) points i.e. (>75%) correct responses having "good knowledge", those with a score between 9 and 11 (i.e. 9-11) points i.e. (50-75%) were classi ed as having "average knowledge" while those with a score of 8 points and below i.e. (<50%) were classi ed as having "poor knowledge" [25]. During analysis and interpretation, participants with good and moderate knowledge were regarded as having "adequate knowledge"

Assessment of CVD Attitude
In the attitude section, it consisted 20 items and Likert scale was used to assess the level of agreement with the statements on attitude regarding risk factors of CVD among general people. All attitude statements were marked on a 5-points Likert scale such as strongly disagree, disagree, uncertain, agree and strongly agree.
Each of these questions was equally scored; response options ranged from 1 (strongly disagree) to 5 (strongly agree). The total score in this section was 20-100 points, and a higher score indicates a more positive attitude.

Statistical Analysis
The collected data were entered and analysed using IBM-Statistical Package for Social Sciences (SPSS version 21). Descriptive statistical measures such as mean, standard deviation (SD) (i.e. mean SD) for continuous variables and frequencies, percentages were computed for categorical variables. Also, frequency distribution and percentages were performed using frequency tables. Initially, bivariate analysis was performed between the dependent variables (viz. Knowledge and attitude categories) and each of the independent variables (i.e. Socio-demographic variables) to identify important candidate variables for multinomial logistic regression (MNLR) analysis. Chi-square test or Fisher's exact test wherever applicable was used to nd the association between two categorical variables; then MNLR model has been used to investigate the signi cant socio-demographic factors (predictor variables) associated with CVDs knowledge and attitude. We reported odds ratio (OR) with their corresponding 95% con dence intervals; (AOR, with 95% C.I.). As the aptness of MNLR model evaluated by Akaike Information Criterion (AIC), Bayesian Information Criterion (BIC), -2log likelihood, likelihood ratio test, goodness of t, pseudo R-square [42], for the test of model adequacy, -2log likelihood, likelihood ratio test and Pseudo R-square test were applied. For the test of model adequacy, Log likelihood ratio test, and Pseudo R-Square test were applied. Finally, if variables with P-value < 0.05 as a level of signi cance were considered statistically signi cant for a two-tailed test otherwise

Results
The ndings have been organized and presented under the following sections: Section A:Description of socio-demographic variables of respondents Table 1 shows socio demographic characteristics of general people in which age ranged from 20 to 60 years with a mean SD age of 35.73 10.83 years. Of total 150 respondents, 61(41.7%) were belonged to age group   The results from the table 4, since, p-value (P < 0.05), there were statistically association between level of knowledge and socio-demographic variables such as age (P = 0.023), gender (P = 0.038), education (P = 0.000), occupation (P = 0.000), monthly family income (P = 0.021), marital status (P = 0.023), present illness (P = 0.011) and remaining other factors ( P-value 0.05 ) such as religion (P = 0.876), eating pattern ( P = 0.343), personal habit (P = 0.411) and family type (P = 0.279 ) were not statistically associated with level of knowledge at 5% level of signi cance. Considering all these seven statistically associated variables as candidate variables for MNLR through a stepwise selection procedure, then nal MNLR analysis came up with  (Table 5).
From table 6, since, P-value < 0.05, for selected demographic variables, there were statistically association between level of attitude and socio-demographic variables such as age (P = 0.007), gender ( P = 0.012), education (P = 0.000), occupation (P = 0.000) and family monthly income (P = 0.036) whereas remaining other variables ( as p 0.05) such as religion (P = 0.493), types of family (0.693), present illness (P = 0.429), personal habit (P = 0.433), eating pattern ( P = 0.438), marital status (P = 0.280) were not statistically associated with level of attitude at 5% level of signi cance. Therefore, these ve statistically associated variables as candidate variables for MNLR through a stepwise selection procedure, then nal MNLR analysis came up with only two signi cant predictor variables in association with attitude category namely gender and education as shown in (table 7). 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 over neutral attitude and 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).
The overall goodness of t of the estimated model is judged by deviance and Pearson's chi-square. In the Tables 5(i) and 7(i), both Pearson and Deviance residuals are statistically non-signi cant at 5% level of signi cance which suggests that the estimated model t is well to the MNLR model.

Discussions
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 ndings 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 [26], 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 [27], moderate knowledge with mean score 19.18 ± 4.46 in Turkey [28], mean age of participants 42.22 ±10.56 years, mean score for knowledge 31.34 5.6 [29], 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 [30], moderate knowledge in Kuwait [25], good knowledge with (67%) in Pakistan [31], median percentage scores for knowledge 79.3%, nearly 44% of respondents had insu cient knowledge (poor), 36% had average knowledge and less than 20% had highly satisfactory knowledge (good) in Nepal [32], the mean scores (SD) for knowledge 60.75±4.823, maximum score 71 in Malaysia [33] , mean and standard deviation of the knowledge 42.98±2.46 in another study in Malaysia [34], median age (IQR) was 40 (33)(34)(35)(36)(37)(38)(39)(40)(41)(42)(43)(44)(45)(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 [35]. The variations in results might be attributed to differences in study area, scale of classi cation 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 [36]. Furthermore, the ndings 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 insu cient knowledge (i.e. poor knowledge) [ 32].
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 nding 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 [32] but lower than a study conducted in North-Eastcoast in Malaysian women, which found 55.1% [26], 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) [29], lower than that reported from Lucknow city, India, mean score for attitude 11.82 ± 5.032, 37.6% score ranging from 0 to 19 [30]. This might be due to variation in study population.
In this study, majority of the respondents 113(75.3%) answered that the modi able risk factor of CVD: smoking, physical activity, dietary pattern, high cholesterol, 36(24.0%) answered non modi able risk factor of CVD: age, family history, sex, ethnicity and age, smoking, tobacco, stress. These ndings 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%, insu cient 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%), insu cient fruit and vegetables intake (98%), insu cient 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 [39].This difference could be due to the variations between rural and urban populations.
The nding 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 [31].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 [25]. More than half of the respondents 88(58.7%) answered lifestyle modi cation 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 [41].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 ndings 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 [31], 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 [33].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 ndings of this study may not be generalized. Despite these limitations, our study had several strengths: This is the rst known study to be conducted in mid-western part of Nepal. The present ndings would be the rst step in providing a quantitative measurement of CVD knowledge and attitude for identifying speci c 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.

Conclusion And Recommendation
Based on the above ndings and discussions of this study, it is concluded that, even though the attitude was The required data and materials are available at the hands for this study from designing structured questionnaire and face to face interview. Proper precaution has been taken to maintain privacy and con dentiality of the data. The co-author has been commissioned to collect data.       Questionnaires.docx