Introduction

The prevalence of cardiovascular diseases (CVDs) is increasing in Nepal, and the proportion of annual deaths caused by CVD increased from 12.2% in 1990 to 22.0% in 2021 [1]. Cardiovascular risk factors like smoking, excessive alcohol use, insufficient intake of fruits and vegetables, obesity, high blood pressure, high blood sugar and high cholesterol levels are common in adults in Nepal; 98.2% of the population exhibit at least one of these risk factors [2].

Although CVDs manifest in adulthood, exposure to risk factors begins early in life. Cardiovascular risk factors, such as coronary intimal thickening, can manifest in foetal life [3–6]. Lifestyle patterns and habits connected to diet and physical activity are established in early childhood [7,8] and often persist into adulthood, which can contribute to cardiovascular events [9]. According to the most recent data available from the Global School-Based Student Health Survey Nepal 2015, 41% of adolescents aged 13–17 years eat fruit less than once a day and 32% eat vegetables less than once per day. In addition, 50% are physically inactive, 9% are current smokers, 11% are underweight and 7% are overweight or obese [10]. A recent study in eastern Nepal showed that 21% of adolescents aged 15–19 years had pre-hypertension and 7% were hypertensive [11]. Health promotion along with prevention strategies, such as screening and lifelong personalized management of risk factors and lifestyle interventions, are likely to positively impact cardiovascular disease incidence and its effects on personal, social and economic outcomes [7,8].

For this reason, the American Heart Association (AHA) published paediatric-focused guidelines for cardiovascular health promotion that emphasize the promotion of cardiovascular health throughout the life course. The guidelines define four favorable health behaviors related to smoking, body mass index, physical activity and healthy diet status and three favorable health factors related to blood pressure, total cholesterol and fasting blood glucose levels [12].

Despite the high prevalence of CVD and its risk factors, the knowledge, attitude and practice (KAP) regarding CVD among adolescents in Nepal is poor. Around 37% of adolescents in Kathmandu [13] and 49% in Hetauda [14] have good knowledge, which suggests that the majority of adolescents have insufficient understanding. Adolescents from metropolitan cities have better knowledge than those from rural municipalities [15]. Positive attitudes regarding CVDs have been reported for only one-to-two-thirds of adolescents [13,14]. Only 34–39% of adolescents in Nepal meet the recommended levels of physical activity [16]. Even children aged 5–10 years exhibit low physical activity and prefer unhealthier food items [17].

Targeting adolescents for improving cardiovascular health awareness may be accomplished through a medium that is user friendly and easily accessible to this population. Mobile-based health education could be one way to reach this technologically inclined group. To achieve this, the KAP gaps need to be identified in the target population to inform the development of digital health education. The AHA Guide for Improving Cardiovascular Health at the Community Level encourages the use of contemporary health education methods such as electronic gaming for school-aged children [18]. Before such education is implemented, it is also important to assess the digital prerequisites (smartphone availability and internet access), as well as the acceptability and usability of any proposed education in a low-and-middle-income country (LMIC) with limited resources like Nepal. Hence, the aim of this paper was to assess adolescents’ KAP regarding cardiovascular health and their access to prerequisites for digital cardiovascular health education in Nepal.

Materials and methods

Results

Characteristics of the study participants

The characteristics of the participants are presented in Table 1. The mean age of the adolescents was 14.5 ± 1.1 years. Half of the adolescents were boys, and 60% were from private schools. The sample was distributed almost equally among the grades.

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Table 1. Characteristics of study participants.

https://doi.org/10.1371/journal.pone.0323698.t001

The anthropometric measurements of the boys and girls in public and private schools are shown in a supplementary table (S1 Table). The age-standardized z scores for BMI show that there were no significant differences neither according to sex nor school type.

Cardiovascular health knowledge, attitudes and practices

The median score for the adolescents’ knowledge of cardiovascular disease was 69.1% (63.1–74.4), the median attitude score was 77.9% (73.3–82.3), and the median practice score was 76.7% (72.2–81.1). Most of the adolescents were aware that fruits (90.1%) and vegetables (88.4%) are healthy for the heart. Fast food (sausages and burgers) was considered unhealthy by 98.3% and instant noodles by 99.1%. Although 80.9% of the adolescents identified red meat as unhealthy, only 22.5% recognized that fish is a heart-healthy food.

Less than half of the adolescents correctly identified the risk factors for CVD, including high blood pressure (47.6%), lack of exercise (41.6%), obesity (46.5%), hereditary predisposition (46.1%) and stress (50.1%). Less than one-third recognized that high blood sugar (30.5%), high blood lipids (30.5%) and sedentary lifestyle (28.5%) can lead to CVD. Only 20% of the adolescents were aware of the healthy plate concept [29], and only 4% were aware of the AHA recommendation to eat five servings of fruits and vegetables per day.

Only 55.2% of the adolescents were aware of the recommended physical activity levels for their age group. Even fewer knew that physical activity increases the strength of the heart (50.8%) and helps burn fat (48.2%). Around half of the respondents (45.5%) could not identify sedentary behaviour from the given list of activities and were not mindful that they needed to engage in physical activity after every hour of sitting.

Few adolescents identified that smoking can lead to hypertension (29.9%) and diabetes (8.2%). Around half could identify tobacco use (52.5%) and alcohol consumption (58.7%) as risk factors for developing CVD. Most of the adolescents recognized that smoking is harmful (98.6%) and can cause cancer (95.7%) and lung diseases (81.5%).

Only 12.3% of adolescents ate the AHA-recommended five servings of fruits and vegetables per day. On average, they consumed 0.9 servings of fruit and 2.0 servings of vegetables daily. They were physically active for an average of 69 minutes (IQR: 36–180 mins) per day. In private schools, the adolescents scored significantly better in the categories of consumption of food with a high salt, fat or sugar content, physical activity and using smokeless tobacco (Table 2).

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Table 2. Practices for preventing cardiovascular disease among adolescents by school type.

https://doi.org/10.1371/journal.pone.0323698.t002

We found that the median knowledge scores were 73.9% (69.6–82.6) for diet, 77.7% (66.7–83.3) for physical activity and 70.9% (61.3–77.4) for alcohol/tobacco use. The median attitude scores were 75.5% (71.1–82.2) for diet, 76.6% (70–83.3) for physical activity and 80.0% (74.5–85.5) for alcohol/tobacco use. The median practice scores were 66.7% (56.7–76.7) for diet, 60.0% (60–70) for physical activity and 100% (100–100) for alcohol/tobacco use. The median scores for knowledge, attitudes and practices regarding cardiovascular health by school type and CVD risk factors are shown in Table 3.

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Table 3. Categorization of KAP on cardiovascular health among adolescents by risk factors and school type (n = 649).

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Multivariable quantile regression analysis showed that although knowledge scores did not differ by sex, adolescents in grade 9 scored 4.2pp higher than those in grade 8, and students in grade 10 scored 4.0pp higher than those in grade 8 when adjusted for sex and school type. Knowledge scores were 4.9pp higher among private school adolescents when adjusted for sex and grade. Attitude scores were 2.0pp higher among girls when adjusted for grade and school type and 1.7pp higher among adolescents in private schools when adjusted for sex and grade. Although there was no difference in practice scores according to grade, girls scored 2.2pp lower than boys when adjusted for grade and school type. Adolescents at private schools scored 2.2pp higher in practice than public school adolescents when adjusted for sex and grade (Table 4).

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Table 4. Multivariable quantile regression analysis for association of knowledge, attitude and practice percent score regarding cardiovascular health with independent variables.

https://doi.org/10.1371/journal.pone.0323698.t004

Adolescents thought that they would be motivated to eat healthier foods if they had access to better information about such food (59.0%) and if family members were eating healthy food (53.0%). However, 50.4% of adolescents said that they usually ate whatever was given to them and 34.0% of adolescents perceived that there were no barriers for eating healthy.

Adolescents mentioned that better information about the importance of physical activity (61.0%) and support from family and friends (42.5%) would motivate them to be active. They identified that a lack of leisure time (50.8%) and a lack of parks and gyms (40.1%) hindered their physical activity. The facilitators for and barriers to healthy diet and physical activity are shown in a supplementary table (S2 Table).

Availability of prerequisites for digital education

The adolescents were asked if they had access to smartphones and the internet. While 98.6% of the adolescents had access to smartphones, only half had their own. Among those with smartphones available in the family, 76% of the adolescents had access to an Android phone. Ninety-two percent had access to the internet at home. More than two-thirds of the adolescents (68.0%) reported playing mobile-based games, with 22.7% playing mobile games daily.

Although more public-school adolescents owned a smartphone, private school adolescents had more access to smartphones, either through having their own or through family members. Additionally, more private school adolescents had internet access than public school adolescents (Table 5).

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Table 5. Digital prerequisites for cardiovascular health education by school type (n = 649).

https://doi.org/10.1371/journal.pone.0323698.t005

Discussion

We found that there was lower overall knowledge about cardiovascular health among adolescents in comparison to attitude and practice in a semi-urban community of Nepal. Additionally, practice regarding diet and physical activity were lower compared to smoking and alcohol intake. The lower knowledge but higher attitude and practice can be explained by the self-perception theory [30] which suggests that people develop their attitudes, emotions, and beliefs by observing their own behavior and then making inferences about what they must be feeling or thinking. This finding in our study is also supported by social cognitive theory [31] which emphasizes the role of observational learning, imitation, and modeling in behavior development suggesting that adolescents’ practice may result from imitating others despite their own low knowledge.

The low level of knowledge regarding cardiovascular health among adolescents may be attributed to a lack of regular school-based awareness campaigns or health intervention programmes [15], a lack of health literacy [32] and a low perceived relevance of CVD for adolescents, as explained by the health belief model [33]. The low knowledge of the healthy plate concept and the five servings of fruits and vegetables among the adolescents corresponds with their overall low knowledge of nutrition [34].

The overall positive attitude regarding CVDs in our study aligns with earlier studies inside and outside Nepal [13–15,34]. In one study in China, 82.1% of adolescents expressed a willingness to adopt a healthy lifestyle [35]. Cultural and societal influences and an individual’s education may influence their attitudes. Good attitude levels mean that adolescents understand the harm of CVDs and are positive about preventive strategies.

In our study, the KAP scores showed that healthy diet practices were lower than the adolescents’ knowledge of these practices. Only 12.3% of adolescents in our study ate the AHA-recommended five servings of fruits and vegetables per day. Although this is better than reports in the Nepali national data on adolescents [10], low consumption patterns in adults (3.3%) are reflected in their children [25]. Global trends show similar findings [12], with low consumption of fruits and vegetables among adolescents, especially in South and East Asia [36]. Despite knowledge about its harmful consequences, consumption of junk food and soft drinks is high among adolescents in Nepal. This could be due to easy availability [37,38], accessibility through ready-to-use packaging [38], addictive tastes [37], propaganda advertising [37], and a lack of specific policy regulations on junk food [39]. In our study, the adolescents described several barriers to healthy eating: having to eat what is offered, not wanting to give up their favorite foods and the food preferences of adult family members.

Although our study demonstrated that 62.4% of adolescents were physically active for the recommended 60 minutes or more per day, the national data from Nepal show that only 15.1% are physically active [10]. One reason for this discrepancy may be that, especially private schools in our study offered physical activity in the form of gymnastics and dancing, karate or taekwondo classes, and team sports like basketball, football and volleyball. This may explain the difference in observed physical activity between the two school types and also a higher physical activity than the national average. In addition, the different data collection tools used in the two studies may have contributed to the differences in the findings. While the national data focus on moderate-to-vigorous-intensity physical activity for 60 minutes per day, the adolescents in our study may have also included low-intensity physical activity in their answers.

Similar to Nepal, global physical activity trends are declining [40], especially since COVID-19 [41]. Evidence-based solutions recommend promoting physical activity through school support, social and digital environments, and multi-utility urban environments to urgently improve physical activity among adolescents [42]. Despite the higher physical activity reported in our study, adolescents mentioned the lack of leisure time, parks and gyms as barriers to being physically active.

In line with increasing global trends in smoking and alcohol consumption among adolescents, the national Nepalese data show that 5.0% are current smokers and 4.6% are current alcohol users [10]. Our study revealed similar data. The increasing trends in smoking stem from increased susceptibility to smoking among adolescents, mainly due to family and environmental factors [20], as well as tobacco advertising, promotion and sponsorship [43]. We found that the knowledge scores for tobacco use and alcohol consumption were lower than the corresponding practice. The lower levels of tobacco and alcohol consumption may be due to underreporting caused by social stigma and cultural norms [44,45].

In our study, the adolescents in private schools had better knowledge, attitudes and practices than those in public schools. School type can be taken as an indicator of socioeconomic status in Nepal; parents with higher socioeconomic status and better education usually enroll their children in private schools [24]. Private schools often have better resources and more qualified teachers [46,47]. In the JD-HDSS, public schools do not charge monthly tuition fees, while private schools charge between NPR 2,500 and NPR 4,500 per month (USD 18–33). Based on the government-set minimum monthly wage of NPR 17,300 (USD 127) as of July 2023 [48], private school tuition represents approximately 14–26% of a worker’s monthly income. For context, Nepal’s per capita GDP for fiscal year 2022–2023 was USD 1378 [49], or about USD 115 per month. Socioeconomic status can influence health awareness, and individuals from higher socioeconomic backgrounds often have better access to health information and resources [50]. Compared to adolescents in grade eight, those in grades nine and ten had better knowledge about CVD, likely due to higher maturity, cumulative learning over the years and increased access to information.

Our study also showed that girls had better attitudes than boys with regard to CVDs. This can be explained by social role theory, which posits that societal expectations and roles assigned to genders significantly influence behaviors and attitudes [51]. Moreover, in the Nepalese context, smoking and alcohol consumption are considered acceptable for men but not for women. This could have shaped the adolescents’ attitudes, and hence, there may have been an underreporting of smoking and alcohol consumption [44]. Our study also showed that boys had better practices regarding cardiovascular health than girls. This may be due to the higher physical activity practices among boys [52].

Besides, sex, grades and school type, other factors such as parents’ education [53] and occupation [54], monthly family income [54], parental risk behaviors [55], and history of chronic illness in the family [56,57] could also affect the KAP of the adolescents.

Given the life course approach for the prevention of CVDs, and to meet the Sustainable Development Goal 3.4, immediate measures targeted at adolescents are necessary. These include integrating health education about noncommunicable diseases in school curricula, establishing school health clubs, organizing health campaigns and improving access to healthy foods and physical activity in schools, as also emphasized in the Multisectoral Action Plan for Prevention and Control of Noncommunicable Diseases II (MSAP II) [58].

Multiple school-based programs have been successfully implemented. School health and nutrition program (SHNP) [59] by the government of Nepal has provided midday meals that has not only improved the nutritional status of the children but also the school attendance. The ‘Health promoting schools initiative’ within the SNHP creates supportive environments for students to learn and grow by integrating health promotion into the school setting such as incorporating health education into the school curriculum, promoting physical activity through sports and exercise, improves nutrition standards in school meals and creates a smoke-free, substance-free environment. Other programs such as Adolescent Sexual and Reproductive Health (ASRH) Program [60]; Water, Sanitation, and Hygiene (WASH) in Schools [61] program; and Mental health awareness campaigns [62] endorsed by the government of Nepal have proved to be fruitful. However, a more focused approach in these campaigns is necessary targeting CVD and NCDs to raise awareness in this sector.

The effective implementation of any digital health programme in LMICs requires an assessment of the necessary digital infrastructure–that is, stable electricity, affordable mobile and internet services, and a good understanding of the socioeconomic context [63,64]. In our study, half of the adolescents had their own smartphones and 48% had access to smartphones through their family members. The literature on mHealth in LMICs provides evidence of the ubiquity of mobile phones and ever-increasing connectivity, even reaching remote populations [65].

Our study showed that the majority of the adolescents (76%) had access to Android-based phones. This is comparable to the data from the monthly market share of mobile operating systems in Nepal from March 2021 to March 2024, which shows an 85.6% Android predominance [66]. Future digital education efforts therefore need to account for this predominance. Furthermore, 92% of adolescents had access to the internet at home. According to the Nepal Telecommunications Authority, Nepal has reached a broadband penetration rate of 144.56% [67] with many using internet services from more than one service provider. This increasing connectivity, coupled with increasing mobile access, provides numerous opportunities for mobile-based digital health interventions in Nepal.

However, digital connectivity in terms of smartphone and internet access differed significantly between the school types. This should be taken into account when digital school-based interventions are planned.

Strengths and limitations

A strength of this study is that it not only assessed the KAP on cardiovascular health among adolescents but also evaluated the digital prerequisites for digital health education. Furthermore, our study included a comparison of public and private schools.

The study was conducted in JD-HDSS, a semi-urban to urban area outside Kathmandu. One limitation is that the results may not be generalizable to other settings. In addition, the cross-sectional nature of the study can limit the ability to draw causal inferences between the variables. We ensured that no teacher was present during data collection and assured the adolescents that the data collected would be confidential and would not affect their grades. Although these measures were taken to minimize errors and increase response rates, the self-administered nature of data collection may contribute to reporting bias. Taking school type as a socioeconomic proxy may not adequately represent the socioeconomic status of the adolescents. Although the regression model included age, school class, and school type, the possibility of residual confounding cannot be excluded due to the absence of other relevant covariates, such as socioeconomic status, parental education or occupation, or access to health information.

Conclusion

Our study showed that adolescents had lower knowledge than attitude and practice regarding cardiovascular health. Adolescents studying in private schools had better knowledge, attitude and practice, signifying the need for better health education in public schools. Increasing mobile usage and internet access in an LMIC like Nepal provides numerous opportunities for digitalized health education targeted at adolescents, especially through school-based interventions in both public and private schools.

Supporting information

Acknowledgments

We are grateful to the adolescents for their participation in the study. We acknowledge the hard work of the research assistant and the enumerators during the data collection. The support of Scribendi Inc. (Chatham, ON, Canada) for the professional language editing and proofreading of this work is acknowledged.