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


 Background

Cardio vascular disease (CVD), a group of disorders of heart and blood vessels. It is the leading cause of death globally including Nepal. The major factors which increase the risks are tobacco chewing/smoking, raised blood cholesterol level, high blood pressure, physical inactivity, overweight, obesity, excessive alcohol consumption, age, sex and heredity etc. Therefore, the aim of this study was to assess the level of knowledge and attitude regarding risk factors of cardio vascular disease among general people residing in Dhamboji-1,Nepalgunj, Banke; Nepal.
Methods

A descriptive cross-sectional research design was adopted for the study and entirely based on primary data collected through structured and self-administered questionnaires during the month of July 2019. Non-probability convenience sampling technique was used to select 100 general people residing in Nepalgunj, Banke. The collected data were analyzed and summarized through descriptive as well as inferential statistics using SPSS software (version 21). The descriptive analysis was performed using frequencies, percentage etc. and for the inferential part of the study, chi-square test (\({{\chi }}^{2}\)-test) was used.
Results

The results of the study revealed that among total 100 respondents; 33 (33.0%) of the respondents had poor knowledge, 35(35%) of the respondents had average knowledgee and 32(32.0%) had good level of knowledge regarding risk factors of cardio vascular disease. Likewise, the majority of respondents 68(68.0%) had unfavourable attitude, 32(32.0%) had neutral attitude and none of the respondents had favourable towards risk factors of cardio vascular disease. There was significant association between knowledge and educational status (p value = 0.010) and types of family (p value = 0.031). However, there was no statistically significant association between attitude and other demographic variables such as age, sex, family income, occupation, educational status, types of family, religion, marital status, level of education, present illness and personal habit.
Conclusion

The findings of the study conclude that, though the attitude was unfavourable but the knowledge was average towards risk factors of cardio vascular disease among general people. Thus, comprehensive interventions against all risk factors should be planned and implemented to reduce the future burden of CVD in general people of Nepal.

swiftly increased from 22-25% between 2004 and 2008. Most cardiovascular diseases share common risk factors like tobacco use, physical inactivity, unhealthy diet, harmful use of alcohol, diabetes, high blood pressure and raised lipid. Among them, behavioural risk factors unhealthy diet, physical inactivity, tobacco use and harmful use of alcohol, alone contribute 80% of coronary heart disease and cerebrovascular disease [12,13,17].
There are several risk factors contributing to hypertension, such as age, gender and ethnicity. It is common in men over 45 years and women over 55 years. Positive family history being overweight and obese is also additional risk factors. Other life style factors that contribute to hypertension are smoking, stress cell phone use and physical inactivity, consumption of alcohol, increase salt intake reduce potassium take [18]. In Nepal, hypertension was the most prevalent risk factor for CVD which ranged from 26.0-38.9%. [19]. Nepal's high prevalence of underlying behavioural risk factors, particularly tobacco and alcohol consumption and poor cardiovascular health knowledge, is a matter of concern. [20].
According to the Surgeon General's Report on smoking and health in 2014 smoking is a major cause of cardiovascular disease (CVD) and causes approximately one of every four deaths from CVD. Also, exposure to second hand smoke causes heart disease in non-smokers. More than 33,000 non-smokers die every year in the United States from coronary heart disease caused by exposure to second hand smoke. Exposure to secondhand smoke can also cause heart attacks and strokes in non-smokers [21]. Diabetes is treatable, but even when glucose levels are under control it greatly increases the risk of heart disease and stroke. That's because people with diabetes, particularly type 2 diabetes, may have the contribute to their risk for developing cardiovascular disease are high blood pressure (hypertension), abnormal cholesterol, high triglycerides, obesity, lack of physical activity, smoking [22]. STEPS survey of Nepal in 2013 detected hyper cholesterol in 23.0%, smoking in 19.0%, overweight in 21.0%, raised blood glucose in 4.0%, physical inactivity in 3.0%, and harmful use of alcohol in 2.0% [23]. A study conducted in Jhaukhel, Duwakot; Nepal, revealed that median percentage scores for knowledge, attitude and practice/behavior were 79.3, 74.3 and 48 respectively. Nearly 44% of respondents had insu cient knowledge and less than 20% had highly satisfactory knowledge. Only 14.7% had a highly satisfactory attitude and 19.5% had satisfactory attitude and 13.9% had highly satisfactory practices. The study concluded that poor knowledge, unfavorable attitude and highly adverse behavior regarding cardiovascular health [24]. A study in Lamjung district, Nepal, the results found that 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% was common risk factors of cardio vascular disease. The study concluded that the risk factors of cardiovascular disease was high in rural population of Nepal [25]. Moreover, the study in Sitapaila village development committee, Kathmandu revealed that the majority of respondents were female, one third of respondents were Brahmin and Chhettri and over a quarter of respondents (29.1%) did not attend school. Cardio vascular disease 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 there was high prevalence of cardio vascular risk factors among study respondents [26].
Cardio vascular disease is the one of the major health problem in the developed and developing countries. It is the one of the most cause of death globally. Most of the previous studies showed that the knowledge was poor and attitude was negative towards cardio vascular disease. The outcomes of studies showed that need for better awareness regarding risk factors of cardio vascular disease among general people. Cardio vascular disease has gained worldwide attention and this is noted as one of the major challenges in the public health; there is a pressing need to study the trend of attitude towards Cardio vascular disease among general people. Thus, it is necessary to recognize knowledge and attitude of general people about this issue in order to make plans for medical challenge. However, few studies have assessed the Knowledge and attitude on CVD risk factors in Nepal and none in the mid-western part of Nepal. This study, therefore, has attempted to assess the knowledge and attitude regarding risk factors of cardio vascular disease among general people residing in Dhamboji-1, Nepalgunj, Banke, Province number 5; Nepal.

Methods
A descriptive cross sectional research design was adopted for the study dated in July 2019 to assess the knowledge and attitude regarding risk factors of cardio vascular disease among general people in Dhomboji-1, Nepalgunj; Banke; Province number 5, Nepal. The study population of the present study comprised of all the people residing Dhomboji-1, Nepalgunj, Banke, was 10,000. There were 2100 houses.
A sample of 100 people was selected from people residing Dhomboji-1, Nepalgunj, Banke by using nonprobability convenience sampling technique. Face to Face interview technique was used to collect the data. The tools developed and used for data collection were 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 cardiovascular disease and (iii) Likert scale to assess the attitude regarding risk factors of cardiovascular disease.
Further, the tool which consisted of socio-demographic data, structured Knowledge Questionnaire and attitude scale consisted of 11, 15 and 20 statements (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 measured by likert scale and arbitrarily classi ed as favorable attitude (>75%), Neutral attitude (50%-75%) and unfavorable attitude (<50%).The collected data were analyzed through descriptive as well as inferential statistics by using statistical package for social science (SPSS, version 21). The descriptive analysis was performed using frequencies, percentage in table etc. and for the inferential analysis chi-square test was used.

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.

Pre-testing of tool and Reliability
Reliability of the instrument was maintained through pre testing of instrument in 10% (10) of total sample size for arousing the understanding and accuracy of instrument. Pre-testing the instrument among 10% (10) of total sample size at community of Dhamboji-1, Nepalgunj and necessary modi cation of the instrument was carried out as necessary. Those participants were excluded from the study.

Ethical Consideration
Formal permission was taken from the Nepalgunj Sub Metropolitan city, Wada karyalaya, Dhomboji-1.
Informed consent was taken from respondents before starting questionnaire.
Con dentiality and privacy was maintained throughout the study.
The data was personalized and was used for the purpose of study only.

Results
The ndings have been organized and presented under the following sections: Section A: Description of demographic variables of respondents Table 1 depicts socio demographic characteristics that out of 100 respondents in which nearly half of the respondents 41 (41.0%) were belonged to age group (20-30) years and 15 (15.0%) of them aged between 50-60 years. Regarding sex, more than half of the respondents 56 (56.0%) were female and 44 (44.0 %) of the respondents were male. The most of the respondents 85 (85.0%) were literate and rest of the respondents 15 (15.0%) were illiterate. Likewise, 27(27.0%) respondents had possessed higher secondary education level, only 3 (3.0%) of the respondents had possessed primary level of education. Regarding religion, majority of the respondents 77(77.0%) were following Hinduism and the least of the respondents 4 (4.0%) were Buddhism. 33(33.0%) of the respondents had government jobs and least respondents 10(10.0%) were engaged in agriculture. Furthermore, majority of the respondents 69(69.0%) were married and only 1(1.0%) respondent was divorced. More than half of the respondents 59 (59.0%) did not have any present illness and the least of the respondents 2(2.0%) had cancer. Similarly, 39(39.0%) of the respondents had Rs.30, 000 and above family monthly income and 12(12.0%) of the respondents had below Rs.10,000 monthly income. Furthermore, more than half of the respondents 58(58.0%) were joint family and the least of the respondents 6(6.0%) was extended family. The majority of the respondents 70 (70.0%) ate mixed food and 11(11.0%) of the respondents were non-vegetarian. The majority of the respondents 63 (63.0%) did not have any personal habit and only 4(4.0%) of the respondents had personal habit of drug abuse and 4 (4%) were others.
Section B: Distribution of Knowledge regarding risk factors of cardio vascular disease among general people As shown in the table 2, the questionnaire contained 15 questions (statements) regarding knowledge of CVD risk factors. Each of these questions was equally scored (one point for each correct answer and zero otherwise). These points were then summed across all the questions. We categorised participants who obtained 12 or more upto 15 (i.e.12-15) correct responses having "good knowledge", those with a score between 9 and 11 (i.e. 9-11) were classi ed as having "average knowledge" while those with a score of 8 and below were classi ed as having "poor knowledge" [27] Thus, from the table 2, it reveals that among the total 100 respondents, 32 (32%) of respondents had good knowledge, 35(35.0%) of respondents had average knowledge and 33 (33.0%) had poor knowledge regarding risk factors of cardio vascular disease. The results from the table 4, since, p-value (P < 0.05) reveals that there was signi cant association between level of knowledge regarding risk factors of cardiovascular disease and educational status and types of family of respondents. Even though, there was no statistically signi cant association between level of knowledge and other demographic variables such as age, sex, family income, occupation, present illness, personal habit, religion, marital status, level of education at 5% (0.05) level of signi cance.
.Furthermore, since, p-value > 0.05, for selected demographic variables therefore, the table 5 depicts that there was no statistically signi cant association between level of attitude regarding risk factors of cardiovascular disease and socio-demographic variables such as age of respondent, sex, educational status, religion, level of education, family monthly income, types of family, occupation, present illness, personal habit, eating pattern, marital status at 5 % (0.05) level of signi cance.

Discussions
This part deals according to the results obtained from the statistical analysis based on the data of the study. In the present study, nearly one third of the respondents 32(32.0%) had good knowledge, 35(35.0%) of the respondents had average knowledge and 33 (33.0%) had poor knowledge regarding risk factors of cardio vascular disease. This nding was in keeping with the results from a cross sectional study conducted by M Rosediani et al. in North-Eastcoast Malaysia from June to December 2010 to determine the knowledge, attitude and practice on cardio vascular disease, in which more than half of the respondents 55.6% had good knowledge [28]. Furthermore, the ndings of the study is supported by the previous cross-sectional study conducted by Vaidya A et al., in Jhaukhel -Duwakot, Kathmandu in 2011 September to November to determine the knowledge, attitude and practice/ behaviour towards cardio vascular health among residents of community of Nepal. The study revealed that 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) [ 24].
In the present study, concerning the attitude of general people regarding risk factors of cardio vascular disease, majority of the respondents 68(68.0%) had unfavourable attitude, nearly one third of the respondents 32(32.0%) had neutral attitude and none of the respondents had favourable attitude. The present study also shows that there was no statistically signi cant association between level of attitude regarding risk factors of cardiovascular disease and socio-demographic variables such as age of respondents, sex, educational status, religion, level of education, family monthly income, types of family, occupation, present illness, personal habit, eating pattern, marital status. This nding was inconsistent with another study conducted in the country.

Limitations Of The Study
The study was limited to selected community of Dhomboji-1, Nepalgunj.
The study was limited to only those respondents who were willing to participate.
The size of the sample was only 100, hence the ndings of this study may not be generalized.

Conclusion
Based on the above ndings and discussion of this study, it is concluded that, though the attitude was unfavourable but the knowledge was average towards risk factors of cardio vascular disease among general people. It indicates the health education on risk factors of cardio vascular disease should be given to general people for improving knowledge and attitude.

Recommendation
On the basis of the study, the recommendations were as follow: A similar study can be replicated on large sample to generalize the ndings.
A study can be done to nd out effectiveness of health awareness program regarding risk factors of cardio vascular disease among community people.
Further interventional study is recommended to enhance practice regarding risk factors of cardio vascular disease.
Comprehensive interventions against all risk factors should be planned and implemented to reduce the future burden of CVD in general people of Nepal. As per the guidelines of the authority, privacy and con dentiality of the respondents have been maintained. Most of the participants provided written consent and some of them provided only verbal consent as they were illiterate. Participants were voluntary. Therefore, medium of data collection was verbal since all respondents of the locality could not produce their responses in the written form as guided by the ethical committee of ward o ce. Only permission has been obtained to collect the data for research study. No institutional review has been made for the manuscript because the review facility is not available in the ward o ce.

Consent to publish
Not applicable Availability of data and materials 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.

Competing interests
The authors declare that they have no competing interests.

Funding
No funding has been received in conducting this research.

Authors' Contributions
To complete this study, RPT has contributed in designing, supervising, analysing data and writing the manuscript. SR has done in developing and pre-testing of the questionnaire, collecting data, reviewing the manuscript and interpreting the results. Both authors read and approved the nal manuscript.
as a part of a community based intervention trial in Surkhet, Mid-western region of Nepal. PLoS One.    Family monthly income Below Rs.10,000 Rs.10,000-20,000 Rs.20,000-30,000 Rs.30,000& above   Figure 1 shows that the percentage distribution according to the level of knowledge regarding risk factors of cardiovascular disease among general people