A qualitative study on knowledge, perception, and practice related to non-communicable diseases in relation to happiness among rural and urban residents in Bhutan

Purpose Bhutan, known as a country of happiness, has experienced rapid social changes and the increasing burden of non-communicable diseases (NCDs) that can impact health and happiness. To inform future NCD prevention programs in Bhutan, this study explores knowledge, perception, and the practices of Bhutanese related to NCDs in the context of the philosophy of happiness. Methodology Research was conducted in rural and urban communities of Bhutan in 2017 among 79 inhabitants of both genders, aged ≥18. Participants were recruited through purposive sampling with the data collected by in-depth interviews, participatory observation, and anthropometric measurements. Data were analyzed by thematic analysis. Results/Discussion Across participants, health was considered as an important element of “happiness”. However, lifestyle-related NCD risk factors prevailed due to the lack of effective education programs on NCDs and thus the lack of practical knowledge for NCD prevention across society. We further found that the value of happiness “finding happiness in any situation is virtue” was universal as well as other traditional values and customs, shaping people’s health behaviors. From these observations, it is recommended that more practical NCD education/prevention programs should be urgently introduced in Bhutan that involve multiple generations, religion authorities, educational settings, and medical services. Originality This is the first comprehensive qualitative study on the NCD-related lifestyle risks among Bhutanese concerning the concept of happiness.


Introduction
Lifestyle changes may impact people's health and happiness [1][2][3][4][5][6]. Globally, the socioeconomic burden of non-communicable-diseases (NCDs) has been increasing [7][8][9][10][11]. According to a recent report by the WHO [12], the prevalence of diabetes is increasing in Bhutan in both genders, and 24.8% of the population is above the recommended weight level. Basic medical services are free and provided for all in Bhutan [13,14]. Avoiding a future increase in medical expenses and social burdens is, therefore, an issue of highest priority, while the country has to simultaneously address unmet needs of infectious diseases, malnutrition, mother and child health, and so forth [15][16][17].
To emphasize sustainable development and the happiness of the people, Bhutan sets GNH (Gross National Happiness) as the basic philosophy of the national policy based on the Constitution [11]. The GNH consists of nine indicators, including living standard, education, cultural diversity, community vitality, time use, psychological wellbeing, ecological diversity, good governance, and health [1].
According to the definition of GNH philosophy, all of the nine indicators have the same weight, and their interactions affect each other. To measure health, including the measure of NCD prevention, we must consider health aspects and link these with other indicators, including psychological wellbeing, culture, and so on. The primary NCD prevention strategies require people to modify their daily lives, such as through a healthy diet and exercise [15][16][17][18][19][20][21]. It is, therefore, essential for Bhutan to understand how health is viewed, perceived, and practiced by the people concerning "happiness" or the GNH indicators. It is unclear whether NCD prevention strategies make people happy or unhappy. We cannot ignore the possibility that they might feel happier in their shorter lives or in living with NCDs without prevention compared to having strict health controls imposed upon them.
However, there is no research on health practice aspect and no analysis about relation to "happiness". Thus, this study qualitatively explores i) the current lifestyle-related risks for NCD, ii) socio-cultural factors that affect health-seeking behaviours, iii) the concept or value of happiness, and iv) information to inform future NCD prevention programs among urban and rural residents in southern Bhutan.

Research design
This is an exploratory qualitative study that combined in-depth interviews, participatory observation of daily life, and anthropometric measurements of steps, body mass index (BMI), abdominal girth, body fat, and blood pressure [22][23][24][25].

Target population
Residents aged 18 years or older living in town (urban) and village (rural) in southern Bhutan.

Data collection and observation
Interviews and other observation were all performed by the PI (primary investigator, S-K.H) from June to September 2017, at the place determined by each participant, such as a private room at home or their workplace, paying careful attention to privacy protection. Semi-structured interviews (40-120 mins) were conducted according to the guides in Table 1, adjusting the order of, or omitting/adding questions considering the situation of each subject (S1 File). Due to ethnic diversity, English or local languages (Nepali, Dzongkha) were used in the interview with the cooperation of interpreters, who received prior training regarding the purpose, content, and study procedures. Participatory observation was performed taking field notes and photographs to observe daily activities of the participants (health behaviours, communication with others, food, cooking practice, and living and work environments) with special attention to the similarities with or the differences from the findings obtained in the interviews (S1 File). Furthermore, anthropometric measurements were conducted, including daily step counts for one week by pedometer, body mass index (BMI), abdominal girth, body fat, and blood pressure (S1 File).

Ethical considerations
The Research Ethical Boards approved the study protocol from the Ministry of Health of the Royal Government of Bhutan (No. 2017-027) and the Kyoto University Faculty and Graduate School of Medicine, Ethics Committee (No. R1059). Potential participants were explained with purpose, schedule, and all procedures of the study and voluntary nature of participation and were included in the study only after obtaining written informed consent.

Introduction of results
A total of 79 people participated. They were divided into four groups by the residential area (urban/rural) and age (�40/under). Participants in the urban area had higher educational and income levels and were more often self-employed or government officials, office workers, or housewives. In contrast, participants in the rural area were more often farmers. The daily step counts ranged from 4,500-5,500, the sleep hours were around seven, and body fat was 30-40% irrespective of the residential area or age. Participants having BMI �25 were higher in the urban area than the rural but exceeded 30% in all groups. Participants with high blood pressure were concentrated in the rural group aged 40 or more (41.7%) while being less than 10% in other groups, as shown in Table 3.
From the analysis, 41 codes and six themes emerged, as shown in Tables 4-9. Since common themes were found frequently, four groups were merged for final analysis.
Code validation is shown after each theme's explanation in Table. Due to the limited space, only part of the code validations is shown. Lines in "italics" are narratives from the participants with their age, residence, and participant number in the parenthesis. Lines that are not italicized are the observation from participatory observation or measurements. The questions from the interviewer are headed with "Q-." . Currently, most farmers grow money crops such as cardamom (a spice) and earn money and purchase foods such as Indian rice and daily necessities at the market. Additionally, due to changes in the natural environment, such as rivers drying up, paddies could not be maintained, and orange trees bore no fruit. Accordingly, the inhabitants had no choice but to make changes to their agricultural crops (Table 4, code No.4). Since the younger generation tends to leave the rural areas for the urban areas, this has caused the aging of agricultural workers and has increased the size of the service industry (Table 4, code No.5).

Explanation of themes and codes
The inhabitants have experienced more convenient daily lives due to better infrastructure and the popularization of motors and home appliances ( Table 4, code No.6). This has also led to improved physical access to processed goods, junk foods, alcohol, tobacco, and so forth ( Table 4, code No.7). Not only physical access has improved, but also changes in access to information due to the spread of the Internet, television, and education (  13), and increased opportunities of eating out, such as eating out during office hours (Table 5, code No.14), drinking refreshments, and eating out as a form of leisure with friends or family. We also confirmed the occurrence of people being overweight in both urban and rural areas (   �Mean±SD or n(%), Over weight = (BMI ≧25), High Blood Pressure = (systolic ≧140mmHg or Diastolic ≧90mmHg) no matter using medicine or not. https://doi.org/10.1371/journal.pone.0234257.t003 Theme III: Current situation of health education about NCDs (Table 6). Bhutan has experienced rapid social and economic changes, but an educational gap still exists across society. Medical services and education systems are improving, but NCD prevention through medical services is still inadequate ( Table 6, code No.16). NCD patients, such as those with diabetes and high blood pressure, are receiving health guidance about nutrition and exercise. However, in practice, people cannot understand this because the information is insufficient and impractical ( Theme IV: Knowledge, recognition, and preventing NCDs (Table 7). Across every educational background and economic status, we found knowledge bias and misrecognition of nutrition, exercise, and NCDs ( Only elder people can make cheese in the family. Younger generations are engaged in factory work and shop management.
Aging of agricultural workers and the increase of the service industry Rural 40≦ 6 Taxis travel between rural and urban areas several times a day. We found traffic jams from taxis and private cars in town.
More convenient daily life due to better infrastructure and popularization of motors and home appliances Both rural and urban areas focus on social acceptance and find it difficult to limit doma, alcohol, and tobacco use at home (Table 8, code No.30). They treat their families well and make them a priority. Additionally, acceptance of the natural course of events is more valued than working too hard, enduring, or managing time to accomplish a goal (Table 8, code No.31).
We found that most participants found it challenging to change their behaviours, for example, they used to follow recommendations from religious leaders, such as vegetarianism and   prostration (a gesture used in Buddhist practice) ( Table 8, code No.32). Sometimes, acceptance of the natural course disrupts discipline and changes behaviour, at the same time sometimes their social bond and their belief helps them to become more disciplined or to change their behaviour. Through the experience of sickness, many changed their religion, but regardless of creed, there exists a deep faith that the meaning of life transcends the power of human beings (  (Table 9). Happiness is important in Bhutanese traditional values. For participants, health is an important element of happiness (Table 9, code No.36), and most people mentioned that health is more important for happiness than monetary enrichment (Table 9, code No.37). The participants recognized that family, houses, food, clothes, peace, harmony, and religion are important for happiness (Table 9, code No.38) . Those participants under the age of 40 grasped that work environments and working to be independent is important for happiness (Table 9, code No.39). Participants over the age of 40 also wished for their children to earn money and contribute to society (Table 9, code No.40). However, regardless of their background, they recognized that "finding happiness in any situation is considered a virtue" (Table 9, code No.41). Moreover, valuing happiness helped them to live with diseases and be happy and accepting of their sadness or contradictions in their lives.

Summary of results
Four major gaps were identified (Fig 1) with the most significant gap being between rapid social and lifestyle changes and the situation of health education. Other gaps include the one between rising NCDs-related risk and people's perceptions, the gap between knowledge and perception and the gap between perception and practice. Rapid social changes were also found affecting people's health-seeking behaviours and the concept of happiness. Furthermore, traditional customs and values of happiness affect all situations negatively and positively. Moreover, the value of happiness helped them to live happily even with diseases and to accept their real lives.

Discussion
This is the first study which qualitatively examined the knowledge, perception, and practices related to NCDs among Bhutanese, particularly focusing on the philosophy of happiness, which is the fundamental value of Bhutanese culture reflected in the concept of GNH. This study revealed that rapid social and lifestyle changes are underway in Bhutanese society, creating knowledge, perception, and practice gaps that may put the Bhutanese society at risk of future NCD outbreaks. Four major gaps were identified: 1) the gap between rapid lifestyle changes and the limited health education programs; 2) the gap between rising NCD-related risk and people's perceptions; 3) the gap between knowledge and perception; and 4) the gap between perception and practice. With these gaps, people are increasingly engaging in behaviours with a greater risk of NCDs, sometimes by a misunderstanding that they are having healthy behaviours or sometimes due to the lack of information on how to avoid the risks. Though many people understand the importance of reducing the intake of salt and fatty foods and the importance of exercise, irrespective of their education level, the majority did not know the number of calories of the foods they were consuming, the recommended level of daily calorie intake, and how to put such knowledge into practice.
We also found that the concept of happiness or traditional values and customs were associated with such situations in a complex manner. Traditional customs and values were found to affect the risk of NCDs through the belief that traditional foods (cheese and butter) are good for one's health, and through the "strong social cohesion and full hospitality" that makes it difficult for people to decline smoking, drinking, or sweet foods even though they know they are not good for their health. Profound faith also affects their health behaviours positively or negatively. For example, when religion authorities give Bhutanese to do prostration, they will follow regardless heavy exercise or religion authorities give them some tips when they meet some difficulty. On the other hand, it may disturb their health if they give the people misguidance.
Concerning self-reported happiness, we found "health, family, house, food, clothes, peace, harmony, religion, work environment, and work for independence" to be important for happiness. Through participatory observations, we found that there was a possibility that factors of happiness, those which residents were unaware of, such as enough sleeping time, self-affirmation, social status, good governance, and good relationships with others. However, we cannot define and measure this through our study design.
However, we have gained a deeper understanding of the concept of happiness through this study, and we found it may also have mixed impacts on health. While it may promote health by underpinning the belief that health is essential for happiness and by helping policy makers to make health issue a policy priority, the well rooted cultural value of happiness of "finding happiness in any situation is considered a virtue" among Bhutanese may make them not to take any action for the health-related situation whatever it is. However, potentially positive impacts of this value of happiness may warrant special notion. We should note that, while some NCDs are preventable, not all NCDs and disabilities cannot eventually be prevented, especially under resource limited settings like Bhutan [8,10,14,15]. Therefore, while the importance of prevention is paramount, the importance of how to live with diseases, disorders, aging, and accepting death should not be underestimated. The Bhutanese value of happiness to accept living with diseases or disorders, aging, and death may help people to live with less stress with diseases or disabilities or even help them reduce social costs associated with such situations. Accordingly, given the increasing Bhutanese life expectancy along with the number of chronic diseases [15][16][17], we should consider how to harmonize the balance between health promotion and their traditional values and customs and the value of happiness.
As suggested in the emerging four gaps identified in our study, more efforts are urgently needed to balance between health promotion and the traditional values and customs and the value of happiness. Based on these observations and respecting their harmony with society [1], four points are recommended. 1) There is a need for more practical health education: Although most people understand the importance of reducing the intake of salt and fatty foods and the importance of exercise, because of the lack of education programs, people do not know how to put such knowledges into practice [27]. It is necessary to communicate knowledge in practical forms in health education programs. 2) For health education group or community-based approach rather than individual approach should be used [28][29][30][31]: We found a strong social cohesion and a hospitality mind-set among Bhutanese. While this helps people enhance their bonding, but it can be a cause of increased snacking and stress as well as increased negative feelings from declining invitations of alcohol and tobacco. To solve this problem, group or community-based approaches rather than individual tutorials may be more effective to create new norms good for health in such as working place, or village, religious, and generational communities, and so forth. 3) Education of basic knowledge relating to nutrition and exercise in primary and junior high school curricula and the dissemination of awareness to the parents of children should be promoted: Primary and junior high school is a life period that establishes lifestyles [29]. Moreover, for a culture that values families, it is possible to encourage effective behavioural changes by disseminating awareness to parents and residential communities through children [29][30][31][32][33][34][35][36][37][38][39][40][41][42]. 4) Collaboration with the religious authorities is needed: The people's deep faith and devotion could help make difficult changes in behaviour.
Religion in Bhutanese society is closely related to the concept of happiness. "Collaboration" with religious authorities and empowering people's healthy behaviour is important. Such an approach maintains peace of mind and relieves new sources of social stress.

Limitation
This study holds several limitations. Since this is a qualitative study with a limited sample size, the findings will not be generalized unless they are combined with population-based quantitative research. However, we could get rich information for each participant, and we collected data and analysed till we could achieve theoretical saturation. Possible biases should also be considered in both interviews and analysis, however this study closely worked with a bilingual co-investigator and assistants and analyses were carefully triangulated. Moreover, using this study finding, we will continue the next phase of research to contribute to health and happiness.

Conclusion
This study revealed several important gaps in NCDs among Bhutanese society; the gap between changing society/lifestyles and health education, the gap between actual NCD risk and its perception, and the gap between perception and practice. The study also revealed that the traditional values and customs and the value of happiness had effects on the risk of NCDs. From these findings, it is recommended that community-based and more practical comprehensive health promotion programs for NCD prevention involving the community and religious leaders will have positive impacts in preventing NCDs in Bhutan.