Perceptions and Practices of Cardiovascular Health

108 Pages·2014·10.55 MB·English

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ISBN 978-91-628-8946-3 1
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Printed by Ale Tryckteam AB, Bohus

Doctoral thesis for the degree of Doctor of Philosophy (PhD) in Medical Science

PERCEPTIONS AND PRACTICES OF
CARDIOVASCULAR HEALTH:
A population perspective from a peri-urban Nepalese community

Abhinav Vaidya
Institute of Medicine
Sahlgrenska Academy at University of Gothenburg

Göteborg, Sweden
2014
A doctoral thesis at a university in Sweden is produced either as a monograph or

as a collection of papers. In the latter case, the introductory part constitutes the
formal thesis, which summarizes the accompanying papers. These have either
been published or are manuscripts at various stages (in press, submitted, or in

manuscript).
This work is dedicated to those who are doing

their bit to preserve and promote cardiovascular health

and prevent cardiovascular diseases.

Abhinav Vaidya
Department of Internal Medicine and Clinical Nutrition, Institute of Medicine,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

[email protected]

Authors hold the rights to the published articles

ISBN 978-91-628-8946-3

Printed at Ale Tryckteam AB, Bohus, Sweden

iii iv
A doctoral thesis at a university in Sweden is produced either as a monograph or

as a collection of papers. In the latter case, the introductory part constitutes the
formal thesis, which summarizes the accompanying papers. These have either
been published or are manuscripts at various stages (in press, submitted, or in

manuscript).
This work is dedicated to those who are doing

their bit to preserve and promote cardiovascular health

and prevent cardiovascular diseases.

Abhinav Vaidya
Department of Internal Medicine and Clinical Nutrition, Institute of Medicine,
Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

[email protected]

Authors hold the rights to the published articles

ISBN 978-91-628-8946-3

Printed at Ale Tryckteam AB, Bohus, Sweden

iii iv
ABSTRACT LIST OF PAPERS
Background
Global phenomena such as urbanization and individual traits such as health literacy This Thesis is based on the following papers, which are referred to in the text by
affect people’s exposure and vulnerability to cardiovascular risk factors. Nepal, a low- their Roman numerals.
income South Asian country undergoing epidemiological transition, has limited data
and understanding of cardiovascular health issues, particularly regarding
Paper I
cardiovascular health literacy, perception and practice on the community level.
Aryal UR*, Vaidya A*, Shakya-Vaidya S, Petzold M, Krettek A. Establishing a

health demographic surveillance site in Bhaktapur district, Nepal: initial
Aims
experiences and findings. (*Equal contribution)
This Thesis investigated issues of cardiovascular health from a population perspective.
BMC Research Notes 2012;5(1):489.
Specifically, it first aimed to establish a Health Demographic Surveillance Site in a

peri-urban Nepalese setting; then, assess knowledge, attitude, and practice
Paper II
(KAP)/behavior regarding cardiovascular risk factors, manifestations, and
preventability; understand behavioral and life-style risk factors such as physical Vaidya A, Aryal UR, Krettek A. Cardiovascular health knowledge, attitude, and
activity and diet in terms of their sociodemographic correlates; and finally, explore the practice/behaviour in an urbanising community of Nepal: a population-based
perceptions of cardiovascular health and disease among those already affected. cross-sectional study from Jhaukhel-Duwakot Health Demographic Surveillance
Site.
Methods BMJ Open 2013; 3:e002976.
A health demographic surveillance site was established in Jhaukhel and Duwakot, two
peri-urban villages near Kathmandu. A mixed methods research approach was then
Paper III
used. Quantitative studies assessed cardiovascular health literacy, knowledge and
Vaidya A, Krettek A. Physical activity level and its sociodemographic
attitude in a sample population. Cardiovascular health behaviour, particularly physical
correlates in a peri-urban Nepalese population: a cross-sectional study from the
inactivity and fruit and vegetable intake, were studied. Additionally, a qualitative study
Jhaukhel-Duwakot health demographic surveillance site.
to explore perceptions and experiences of patients with cardiometabolic diseases was
International Journal of Behavioural Nutrition and Physical Activity
conducted.
2014;11:39.

Results
Forty four percent of the study population had poor knowledge of cardiovascular Paper IV
health. Moreover, only 14.7% and 13.9% of respondents with highly satisfactory Vaidya A, Oli N, Aryal UR, Karki DB, Krettek A. Disparities in fruit and
knowledge also had highly satisfactory attitude and practices, respectively. Behavioral vegetable intake by socio-demographic characteristics in peri-urban Nepalese
cardiovascular risk factors were high (low physical activity: 43.3%, inadequate fruit adults: findings from the Heart-Health Associated Research and Dissemination
and vegetable consumption: 97.9%) and varied by sociodemographic correlates. in the Community (HARDIC) Study, Bhaktapur, Nepal.
Furthermore, patients understood the importance of lifestyle modification only after Journal of Kathmandu Medical College 2013;2(1):3-11.
diagnosis.

Paper V
Conclusions
Oli N*, Vaidya A*, Subedi M, Krettek A. Experiences and perceptions about
The studies presented in this Thesis demonstrate the current inadequacy of health
cause and prevention of cardiovascular disease among people with
literacy in Nepal. In addition, gaps exist between cardiovascular health knowledge,
cardiometabolic conditions: findings of in-depth interviews from a peri-urban
attitude, and practice/behavior, even among those already affected. The coupling of
Nepalese community. (*Equal contribution)
high behavioral risk burden with low cardiovascular health literacy implies need for
Global Health Action 2014; 7:24023
multi-sector health promotional strategies in the country.

Keywords
Attitude, behavior, cardiovascular diseases, cardiovascular health, fruit and vegetable
intake, health literacy, knowledge, practice, physical activity, urbanization
v vi
ABSTRACT LIST OF PAPERS
Background
Global phenomena such as urbanization and individual traits such as health literacy This Thesis is based on the following papers, which are referred to in the text by
affect people’s exposure and vulnerability to cardiovascular risk factors. Nepal, a low- their Roman numerals.
income South Asian country undergoing epidemiological transition, has limited data
and understanding of cardiovascular health issues, particularly regarding
Paper I
cardiovascular health literacy, perception and practice on the community level.
Aryal UR*, Vaidya A*, Shakya-Vaidya S, Petzold M, Krettek A. Establishing a

health demographic surveillance site in Bhaktapur district, Nepal: initial
Aims
experiences and findings. (*Equal contribution)
This Thesis investigated issues of cardiovascular health from a population perspective.
BMC Research Notes 2012;5(1):489.
Specifically, it first aimed to establish a Health Demographic Surveillance Site in a

peri-urban Nepalese setting; then, assess knowledge, attitude, and practice
Paper II
(KAP)/behavior regarding cardiovascular risk factors, manifestations, and
preventability; understand behavioral and life-style risk factors such as physical Vaidya A, Aryal UR, Krettek A. Cardiovascular health knowledge, attitude, and
activity and diet in terms of their sociodemographic correlates; and finally, explore the practice/behaviour in an urbanising community of Nepal: a population-based
perceptions of cardiovascular health and disease among those already affected. cross-sectional study from Jhaukhel-Duwakot Health Demographic Surveillance
Site.
Methods BMJ Open 2013; 3:e002976.
A health demographic surveillance site was established in Jhaukhel and Duwakot, two
peri-urban villages near Kathmandu. A mixed methods research approach was then
Paper III
used. Quantitative studies assessed cardiovascular health literacy, knowledge and
Vaidya A, Krettek A. Physical activity level and its sociodemographic
attitude in a sample population. Cardiovascular health behaviour, particularly physical
correlates in a peri-urban Nepalese population: a cross-sectional study from the
inactivity and fruit and vegetable intake, were studied. Additionally, a qualitative study
Jhaukhel-Duwakot health demographic surveillance site.
to explore perceptions and experiences of patients with cardiometabolic diseases was
International Journal of Behavioural Nutrition and Physical Activity
conducted.
2014;11:39.

Results
Forty four percent of the study population had poor knowledge of cardiovascular Paper IV
health. Moreover, only 14.7% and 13.9% of respondents with highly satisfactory Vaidya A, Oli N, Aryal UR, Karki DB, Krettek A. Disparities in fruit and
knowledge also had highly satisfactory attitude and practices, respectively. Behavioral vegetable intake by socio-demographic characteristics in peri-urban Nepalese
cardiovascular risk factors were high (low physical activity: 43.3%, inadequate fruit adults: findings from the Heart-Health Associated Research and Dissemination
and vegetable consumption: 97.9%) and varied by sociodemographic correlates. in the Community (HARDIC) Study, Bhaktapur, Nepal.
Furthermore, patients understood the importance of lifestyle modification only after Journal of Kathmandu Medical College 2013;2(1):3-11.
diagnosis.

Paper V
Conclusions
Oli N*, Vaidya A*, Subedi M, Krettek A. Experiences and perceptions about
The studies presented in this Thesis demonstrate the current inadequacy of health
cause and prevention of cardiovascular disease among people with
literacy in Nepal. In addition, gaps exist between cardiovascular health knowledge,
cardiometabolic conditions: findings of in-depth interviews from a peri-urban
attitude, and practice/behavior, even among those already affected. The coupling of
Nepalese community. (*Equal contribution)
high behavioral risk burden with low cardiovascular health literacy implies need for
Global Health Action 2014; 7:24023
multi-sector health promotional strategies in the country.

Keywords
Attitude, behavior, cardiovascular diseases, cardiovascular health, fruit and vegetable
intake, health literacy, knowledge, practice, physical activity, urbanization
v vi
Additionally, this Thesis incorporates the following articles published during the ABBREVIATIONS
study period. They are attached as Appendix.

1. Vaidya A. Tackling cardiovascular health and disease in Nepal:
CVD cardiovascular disease
epidemiology, strategies and implementation.
BMJ Heart Asia 2011;3:87-91.
GPAQ Global Physical Activity Questionnaire

2. Vaidya A*, Shakya S*, Krettek A. Obesity Prevalence in Nepal: Public HARDIC Heart-Health Associated Research and Dissemination In the
Health Challenges in a Low-Income Nation during an Alarming Worldwide
Community
Trend.
(*Equal contribution) HDSS health-demographic surveillance site
Int. J. Environ. Res. Public Health 2010;7:2726-2744.
KMC Kathmandu Medical College
3. Vaidya A, Krettek A. Is health promotion the starting point of primary
LPA low physical activity
cardiovascular care in low- and middle-income countries like Nepal?
Health Promot. Pract. 2012;13:3 412-415. LMIC low- and middle- income country

MDG Millennium Development Goal
NCD non-communicable disease
NMC Nepal Medical College
RF/RHD rheumatic fever/rheumatic heart disease
TPA total physical activity
VDC village development committee
WHO World Health Organization

vii viii
Additionally, this Thesis incorporates the following articles published during the ABBREVIATIONS
study period. They are attached as Appendix.

1. Vaidya A. Tackling cardiovascular health and disease in Nepal:
CVD cardiovascular disease
epidemiology, strategies and implementation.
BMJ Heart Asia 2011;3:87-91.
GPAQ Global Physical Activity Questionnaire

2. Vaidya A*, Shakya S*, Krettek A. Obesity Prevalence in Nepal: Public HARDIC Heart-Health Associated Research and Dissemination In the
Health Challenges in a Low-Income Nation during an Alarming Worldwide
Community
Trend.
(*Equal contribution) HDSS health-demographic surveillance site
Int. J. Environ. Res. Public Health 2010;7:2726-2744.
KMC Kathmandu Medical College
3. Vaidya A, Krettek A. Is health promotion the starting point of primary
LPA low physical activity
cardiovascular care in low- and middle-income countries like Nepal?
Health Promot. Pract. 2012;13:3 412-415. LMIC low- and middle- income country

MDG Millennium Development Goal
NCD non-communicable disease
NMC Nepal Medical College
RF/RHD rheumatic fever/rheumatic heart disease
TPA total physical activity
VDC village development committee
WHO World Health Organization

vii viii
PRELUDE circumstance required me to first establish a health demographic surveillance
site in the study area. At the time, it felt like an unnecessary deviation, but the

establishment of a surveillance site turned out to be a blessing in disguise
I have been interested in the epidemiological and preventive aspects of
because it would provide us with detailed otherwise unavailable social and
cardiovascular disease since I graduated in medicine in 2000. Apart from the
health-related information about the population of the study site.
clinical work I did as a doctor, I had pursued cardiovascular research in various
However, the major blow was yet to come. During the penultimate year of
capacities since the beginning of my career. During 2002–2003, I participated as
my planned PhD defense, the Nordic Council of Ministers decided unexpectedly
a research officer in the multicentric INTERHEART study. During my MD
to close the Nordic School of Public Health NHV by the end of 2014. Weeks of
training, I was principal investigator of the first and only community-based
despair and desperation followed. Attempts to acquire academic asylum at the
prevalence study of coronary heart disease in Nepal. To pursue further training
University of Gothenburg became a long administrative struggle that was
in cardiovascular epidemiology and prevention, I went to England in August
gallantly spearheaded by my supervisor, Alexandra. Finally, an auspicious
2008 to attend a 10-day teaching seminar that was organized by The
morning in August 2013 brought the good news that the University of
International Society of Cardiovascular Disease Epidemiology and Prevention.
Gothenburg had officially confirmed my acceptance into its PhD program. The
Thirty participants from different Asian, African, European, and South
storm was over. It was time for some science again!
American countries had gathered at Oxford. Among them was Alexandra
Speaking of science, the most fulfilling part of my PhD has been the
Krettek, who would become my future supervisor. During one of those 10 days,
opportunity to work on cardiovascular health in the community. Indeed, my area
I was chatting with Alexandra about Nepal and what both of us were doing. I
of work not only fulfills my personal interest, but also answers an urgent need in
discovered that her institute, the Nordic School of Public Health NHV, had
Nepal. I am happy that I have been able to contribute something toward that
shown some interest in Nepal in the past but somehow the collaboration process
effort. However, much work remains, and this is just the beginning of my
had remained incomplete. On the other hand, I was seeking an opportunity to
journey.
pursue cardiovascular health issues. Soon our discussion turned out to be

productive for both of us. On the last evening of the seminar, Alexandra and I

bade each other goodbye and said we would stay in touch about our common
interest. Six months later, I was a PhD student at the Nordic School of Public
Health NHV.
That was the beginning of my journey into the PhD world, a journey that
began with mixed feelings of enthusiasm, confusion, and uncertainty. A detour
quickly appeared in the form of a major change in the research plan. Instead of
plunging directly into my area of work in cardiovascular health, financial
ix x