Of course, knowledge is the most important starting point. We are unlikely to act in a healthier way if we are not aware of the things that keep us healthy. Many of us Nepalis are, in fact, not aware of the reasons that people suffer from heart diseases. In our study in a peri-urban area of Bhaktapur district, less than one-third of the respondents were aware of the fact that smoking can lead to heart attacks, and only one percent perceived diabetes as a risk factor for heart diseases. Knowledge about all the other conventional risk factors fell in between these two. Further, 60 percent of the study participants did not know any clinical signs of a heart attack. Chest pain, which is the most prominent and important indicator of a heart attack, was mentioned by only one-fifth of them. Hence, improving the level of the knowledge regarding causes and manifestations of heart diseases is indeed an important process.

But the question is: is imparting health knowledge enough? One quarter of our study participants from Bhaktapur did not perceive themselves to be at risk of developing heart diseases and hence did not want to improve their current lifestyle. This is ironic because most of them knew about the benefits of preventive and promotive measures such as increasing their physical activity, quitting cigarettes, reducing weight and so on. This attitude of feeling immune to heart diseases, or the underestimation of one’s risk, is a major impediment toward inculcating heart-healthy behaviour. In fact, we found that this shield of attitude gets broken down, and people become more receptive to health promotive and preventive measures only when there is a blow to their own health— for example, when they start to feel symptoms of heart diseases, or when their blood reports start to worsen. Similarly, development of heart disease in a peer or a relative, especially their sudden death, can also often trigger a positive change in their attitude towards a healthier lifestyle.   

Now, this brings us to a bigger question: will a person adapt to healthier behaviours if he or she has good knowledge of the causes and consequences of heart diseases, and also has a positive attitude towards it? The answer, most of the time, unfortunately, is no. Just like having good knowledge does not always lead to a positive attitude, having such favourable attitudes also does not guarantee a heart-healthy behaviour. For example, in our Bhaktapur study, only one in 10 people who had excellent attitude towards heart-healthy behaviour actually put it into real practice such as engaging in physical activity, not smoking, eating healthy food, and so on. Similar findings have been found in other countries too.

So then, what is it that actually makes people “do” (behaviour) what they “know” (knowledge, awareness) and “think positively” (attitude) about? In fact, there are many health behaviour theories that have tried to explain this. But let us not delve into those right now. What is important to learn from these theories is the fact that it is not sufficient just to have adequate knowledge and optimum attitude in order to have healthy behaviour, because there are other factors too that affect our health behaviour.  

So, what are these other factors which determine our health behaviour? First, behaviour is affected by personal opinions such as perceived benefits (e.g. how much weight will I lose if I start to walk for half an hour every day), perceived susceptibility (e.g. I am only 35, so I can eat whatever I want) and perceived barriers (e.g. there is no healthy food available nearby where I work, so I have to eat momos everyday).  

Second, our behaviour, to a larger extent, is also influenced by those around us, both positively (e.g. somebody may decide to take up cycling to work because a co-worker is doing so) or negatively (e.g. co-workers smoking during a lunch break). Plus, our behaviour is also quite often affected by our perception of what the society thinks of us. This can again be both positive (e.g. I don’t want to drink in the party today because I want to preserve my reputation of being a good person), or negative (e.g. I want to jog but I’m very conscious of the people staring at me when I do).

Third, our health behaviour is also influenced by the factors beyond ourselves and people around us, such as the physical environment and infrastructure (e.g. dust and air pollution, or road safety are major issues for those who would want to jog) and policies (e.g. public ban on smoking or the legal restriction on driving after drinking alcohol).    

Having good knowledge and proper attitude is essential but definitely not adequate to ensure heart-healthy behaviour, because it is the ‘practice’ of heart-healthy behaviour that actually matters. It has actually been proved in many studies in Canada and the United States that increasing awareness alone does not lead to better heart-healthy behaviour.

Our focus should, therefore, be not only to increase the awareness of the people regarding risk factors and symptoms of heart diseases, but also to explore and correct the hindrances that lead to healthy behaviours.

Changing one’s behaviour is indeed a daunting task. But the good news, on the basis of evidence from other countries, is that this is possible —through personal motivation, improved built environment, availability of healthier

food options, and policies that encourage heart-healthy behaviour, to name a few.

Dr Vaidya MD PhD is Assoc. Professor of Community Medicine at Kathmandu Medical College and Research Consultant in the Department of Cardiology at Norvic International Hospital