Cardiovascular disease (CVD), encompassing coronary artery disease, cerebrovascular disease, hypertension, and heart failure, constitutes the leading cause of death and disability globally. According to the World Health Organization (WHO), an estimated 17.9 million lives are claimed by CVDs annually, representing 32% of all global deaths. Low- and middle-income countries bear over 75% of this burden, with rural populations within these regions at particularly elevated risk due to compounded socioeconomic vulnerabilities.

In rural communities, the epidemiological transition toward non-communicable diseases (NCDs) such as CVD has accelerated significantly over the past two decades. However, this shift has not been accompanied by proportional improvements in preventive health infrastructure, public health awareness, or health-seeking behavior. Rural dwellers frequently face unique barriers including geographic isolation, poverty, low educational attainment, cultural health beliefs, and limited access to trained healthcare professionals all of which impede timely CVD prevention and management.

The Knowledge, Attitudes, and Practices (KAP) framework provides a validated, systematic approach to assessing health-related cognition, perceptions, and behaviors within a defined population. KAP studies have been extensively employed in the study of infectious diseases, reproductive health, and diabetes management; however, their application to CVD prevention in rural settings remains comparatively underexplored in the published literature.

Understanding the KAP profile of rural communities regarding CVD is critical for several reasons. First, modifiable risk factors including hypertension, dyslipidemia, tobacco use, physical inactivity, and poor dietary habits account for over 90% of CVD attributable risk, suggesting that meaningful prevention is achievable through behavioral and lifestyle modification. Second, community-level knowledge and attitudinal factors strongly predict individual preventive behavior, making them legitimate targets for health promotion strategies. Third, gender-disaggregated analyses are necessary given documented disparities in health literacy, help-seeking behavior, and risk perception between men and women in rural contexts.

This study was designed to assess the knowledge, attitudes, and practices regarding CVD prevention among adult residents of rural communities, stratified by gender. Findings from this study are expected to provide an evidence base for the formulation of gender-sensitive, culturally appropriate, community-directed cardiovascular health programs.

Statement of the Problem

Cardiovascular disease (CVD) has emerged as one of the most devastating non-communicable diseases of the twenty-first century, claiming approximately 17.9 million lives globally each year and accounting for nearly one-third of all deaths worldwide. While this epidemic affects population across all socioeconomic strata, its burden is disproportionately concentrated in low- and middle-income countries, where resource-constrained healthcare systems struggle to provide adequate preventive and curative services. Within these countries, rural communities bear a particularly heavy load of CVD-related morbidity and mortality, yet remain among the most neglected in terms of health education, early screening, and preventive care delivery.

In rural communities, CVD prevention is systematically undermined by a constellation of interrelated challenges. Geographic isolation limits access to trained healthcare professionals and diagnostic facilities, while poverty constrains individuals’ ability to afford medications, healthful foods, or preventive screenings. Low educational attainment reduces health literacy, leaving many rural residents without the foundational knowledge needed to recognize CVD risk factors, identify early warning signs, or adopt protective behaviors. Cultural beliefs and fatalistic attitudes further compound these barriers, as many rural individuals perceive CVD as an inevitable consequence of aging or divine will rather than a condition amenable to prevention through lifestyle modification. The cumulative effect of these factors is a population that is simultaneously at high risk for CVD and poorly equipped in terms of knowledge, attitudes, and practices to prevent it.

Despite the well-documented epidemiological burden of CVD in rural settings, there remains a critical shortage of empirical data on the Knowledge, Attitudes, and Practices (KAP) of rural community members specifically regarding CVD prevention. The majority of existing KAP studies have been conducted in urban or semi-urban populations, introducing a significant evidence gap that hampers the design of contextually appropriate rural health interventions. Furthermore, most available studies in rural contexts have either failed to disaggregate data by gender or have not adequately explored the determinants of knowledge and practice deficiencies. This is a particularly important omission given the well-established differences in CVD risk profiles, health-seeking behavior, and social determinants of health between men and women in rural settings differences that necessitate gender-sensitive programmatic responses.

The absence of reliable, gender-stratified KAP data from rural communities constitutes a fundamental barrier to evidence-based cardiovascular health programming. Without understanding what rural residents know about CVD, how they perceive their risk, and what preventive behaviors they currently practice — and without recognizing how these dimensions differ between men and women — public health authorities lack the information needed to design targeted, effective, and culturally resonant prevention strategies. This gap translates directly into missed opportunities for early intervention, continued progression of avoidable CVD events, and an escalating burden on already overstretched rural healthcare systems. The present study was therefore undertaken to address this gap by systematically assessing CVD-related KAP among rural community residents, with explicit attention to gender-based disparities, sociodemographic predictors, and actionable implications for community health programming.

Objectives

Primary Objective

To assess the level of knowledge, attitudes, and practices regarding CVD prevention among adult residents of rural communities.

Secondary Objectives

1. To compare KAP scores between male and female participants
2. To identify sociodemographic predictors of adequate KAP regarding CVD prevention
3. To identify knowledge gaps and attitudinal barriers to CVD-preventive behaviors
4. To generate evidence-based recommendations for rural cardiovascular health promotion.

Research Question

1. Is there a significant difference in CVD-related KAP scores between male and female rural community residents?
2. What sociodemographic factors (age, gender, education, income, marital status, occupation) independently predict adequate knowledge, attitudes, and practices regarding CVD prevention?
3. What are the most prevalent knowledge gaps and attitudinal barriers that hinder the adoption of CVD-preventive behaviors among rural community residents?
4. What evidence-based recommendations can be formulated to strengthen cardiovascular health promotion programs in rural community settings.

Rationale of the Study

The rationale for this study is grounded in the intersection of a growing cardiovascular disease burden, a persistent evidence gap in rural health research, and the urgent need for locally informed, gender-sensitive prevention strategies. Cardiovascular disease is not an inevitable outcome of biological aging but rather a largely preventable condition, with over 90% of CVD attributable risk arising from modifiable behavioral and lifestyle risk factors such as tobacco use, physical inactivity, unhealthy dietary habits, uncontrolled hypertension, and dyslipidemia. This biological reality makes the KAP framework especially powerful as a research tool: by identifying what a population knows, believes, and does in relation to CVD, it is possible to design precision-targeted behavioral change interventions that address specific deficits rather than relying on generic health messaging of limited efficacy.

The rural setting provides a particularly compelling context for this investigation. Rural populations in developing countries experience CVD at rates comparable to or exceeding urban populations, yet receive a fraction of the preventive health resources directed toward urban centers. The structural underdevelopment of rural health infrastructure — characterized by a shortage of qualified healthcare workers, absence of diagnostic equipment, and limited supply of essential medicines — places an even greater premium on primary prevention through behavioral and lifestyle change. In this context, health knowledge and positive attitudes function as the first line of defense against CVD, and their assessment is not merely an academic exercise but a direct prerequisite for effective public health action. Without a clear empirical profile of existing KAP levels, health authorities risk designing interventions that misalign with community realities, thereby wasting scarce resources and failing to achieve meaningful health impact.

Gender represents a critical dimension of CVD risk and prevention that has been insufficiently explored in rural health research. Men and women in rural communities differ substantially in their exposure to CVD risk factors, their patterns of health-seeking behavior, their access to and utilization of preventive health services, and their receptiveness to different modalities of health communication. Men in rural settings are disproportionately exposed to tobacco and alcohol, while women may face greater barriers to physical activity and formal healthcare utilization due to gender norms and domestic responsibilities. These differences demand gender-disaggregated data and gender-responsive intervention design — yet the majority of existing rural CVD studies treat gender as a control variable at best, rather than a primary analytical lens. By enrolling equal numbers of male and female participants (150 each) and conducting explicit gender-comparative analyses, this study addresses this methodological gap and generates the sex-stratified evidence base needed for equitable program design.

From a policy and programmatic standpoint, this study is timely and strategically significant. National and international health agendas including the WHO Global Action Plan for the Prevention and Control of Non-Communicable Diseases (2013–2030) and the United Nations Sustainable Development Goal 3.4 targeting a one-third reduction in premature NCD mortality by 2030 call explicitly for population-level data to guide targeted prevention efforts. In the absence of community-specific KAP evidence, these ambitious targets risk remaining aspirational rather than achievable in rural settings. The findings of this study are therefore positioned to contribute directly to national CVD prevention policy, to inform the design of community health worker training curricula, and to provide a replicable methodological template for KAP research in analogous rural contexts. By generating rigorous, locally grounded evidence on CVD-related knowledge, attitudes, and practices, this study constitutes a meaningful step toward bridging the rural–urban health equity divide in cardiovascular disease prevention.

Study Design

A descriptive cross-sectional KAP study design was employed. This design was selected for its efficiency in assessing population-level knowledge, attitudes, and behavioral practices at a single point in time, without the logistical and temporal demands of longitudinal approaches. The cross-sectional design is well-suited to the KAP framework and has been widely used in community-based health research.

Study Setting

The study was conducted in rural communities characterized by predominantly agricultural livelihoods, limited healthcare infrastructure (no tertiary hospital within 20 km), and reliance on informal healthcare providers. Community health workers identified the study sites in coordination with local health departments.

Study Population and Sampling

The target population comprised adult residents aged 18 to 65 years residing in the selected rural communities for a minimum of six consecutive months prior to data collection. A sample size of 300 participants was determined using the following formula for proportion estimation:

                                         n = Z²α/2 × p(1-p) / d²

Where Z = 1.96 (95% confidence level), p = 0.50 (expected proportion with adequate KAP, maximizing sample size), d = 0.056 (margin of error), yielding n ≈ 308; adjusted to 300 for operational feasibility. Stratified random sampling was applied to ensure equal gender representation: 150 males and 150 females. Within each stratum, participants were selected using systematic random sampling from community household lists.

Inclusion criteria: Aged 18–65 years, permanent rural resident (≥6 months), willing to provide written informed consent, no diagnosed CVD at enrollment. Exclusion criteria: Diagnosed CVD patients (to avoid response bias from prior disease experience), pregnant women (altered CVD risk perception), inability to communicate in study language.

Data Collection Instrument

A structured, self-administered questionnaire was developed and validated through expert review (three cardiologists, two public health specialists) and piloted on 30 participants not included in the main study. The questionnaire comprised 45 items across four sections:

• Section A: Sociodemographic profile (10 items) age, gender, education, occupation, income, marital status
• Section B: Knowledge domain (15 items) CVD definition, risk factors (modifiable and non-modifiable), warning signs, consequences
• Section C: Attitudes domain (15 items) perceived severity, susceptibility, benefits of preventive actions, barriers, cues to action (Health Belief Model framework)
• Section D: Practices domain (15 items) dietary habits, physical activity, smoking, alcohol use, health screening attendance, medication adherence.

Scoring

Knowledge items were scored 1 (correct) or 0 (incorrect), yielding a total score of 0–15. Similarly, attitude items were scored on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree) and practice items as 1 (adequate practice) or 0 (inadequate practice). Scores were categorized as Poor (<40%), Moderate (40–69%), and Adequate (≥70%). Internal consistency (Cronbach's alpha) was 0.81 for the knowledge domain, 0.76 for attitudes, and 0.79 for practices.

Data Collection Procedure

Trained research assistants (four nurses and two public health graduates) administered questionnaires in household settings following a structured protocol. Data collection occurred over eight weeks. Informed consent was obtained prior to participation. Questionnaires were available in the local language. Average completion time was 25–30 minutes.

Data Analysis

Data were entered into SPSS version 26.0 (IBM Corp., USA). Continuous variables were expressed as mean ± standard deviation (SD). Categorical variables were presented as frequencies and percentages. Independent samples t-tests were used to compare mean KAP scores between genders. Chi-square tests assessed associations between categorical variables. Pearson correlation coefficients examined relationships between KAP scores and continuous sociodemographic variables. Binary logistic regression identified independent predictors of adequate knowledge and practices. Statistical significance was defined as p < 0.05.

Ethical Considerations

Ethical approval was obtained from the Institutional Review Board (Ref: IRB/CVD/2026/014). All participants provided written informed consent. Anonymity and confidentiality were maintained throughout. Participation was entirely voluntary; participants could withdraw at any point without penalty. Data were stored securely with access restricted to the research team.

Sociodemographic Characteristics

A total of 300 participants were enrolled, comprising 150 males (50%) and 150 females (50%). The mean age of the overall sample was 36.4 ± 11.2 years (males: 37.1 ± 11.5; females: 35.7 ± 10.9). Table 1 presents the full sociodemographic distribution of participants.

Table 1: Sociodemographic Characteristics of Study Participants (N = 300)

Knowledge Domain Results

The mean knowledge score for the total sample was 9.2 ± 2.4 (out of 15). Only 145 participants (48.3%) achieved an adequate knowledge score (≥70%, i.e., ≥10.5/15). Females demonstrated significantly higher mean knowledge scores (10.1 ± 2.1) compared to males (8.3 ± 2.6) (t = -6.08, p = 0.003). Table 2 presents knowledge item-level responses, and Table 3 summarizes domain scores by gender.

Table 2: Knowledge Item-Level Correct Response Rates by Gender

Table 3: KAP Domain Scores by Gender

Attitudes Domain Results

The mean attitude score was 10.4 ± 2.1 out of 15. A total of 158 participants (52.7%) demonstrated moderately positive attitudes, while 97 (32.3%) showed positive attitudes (adequate), and 45 (15.0%) exhibited negative attitudes. Females scored significantly higher on attitude assessment (11.0 ± 1.8) compared to males (9.8 ± 2.3) (p = 0.012). Notably, only 128 participants (42.7%) agreed that family history constitutes a significant uncontrollable CVD risk factor. A large proportion (n = 182, 60.7%) expressed belief that CVD can be prevented through lifestyle changes, though fatalistic attitudes were observed in 22.0% of participants (n = 66), with males more likely to hold fatalistic beliefs (27.3% vs. 16.7%, p = 0.024).

Table 4: Selected Attitude Items — Response Distribution by Gender

Practices Domain Results

The mean practice score was 6.8 ± 2.3 out of 15, indicating markedly deficient preventive practices overall. Only 88 participants (29.3%) achieved an adequate practice score. Table 5 presents individual practice item rates disaggregated by gender.

Table 5: CVD-Preventive Practice Rates by Gender

Predictors of Adequate KAP Logistic Regression

Binary logistic regression identified the following independent predictors of adequate knowledge: higher educational attainment (OR = 4.21, 95% CI: 2.14–8.29, p < 0.001), female gender (OR = 2.87, 95% CI: 1.68–4.90, p < 0.001), higher income (OR = 1.93, 95% CI: 1.09–3.43, p = 0.024), and married status (OR = 1.61, 95% CI: 0.93–2.80, p = 0.088, non-significant). For adequate practices, significant predictors included adequate knowledge (OR = 3.44, 95% CI: 1.94–6.10, p < 0.001), positive attitudes (OR = 2.76, 95% CI: 1.56–4.88, p < 0.001), higher education (OR = 2.11, 95% CI: 1.21–3.68, p = 0.008), and non-smoking status (OR = 3.18, 95% CI: 1.64–6.17, p = 0.001).

Table 6: Binary Logistic Regression — Predictors of Adequate Knowledge (N = 300)

This study assessed the knowledge, attitudes, and practices (KAP) regarding cardiovascular disease (CVD) prevention among 300 rural community residents. The findings indicate that although participants possessed a moderate level of knowledge and generally positive attitudes toward CVD prevention, their preventive practices remained inadequate. The discrepancy between knowledge and actual health practices highlights a significant challenge in translating awareness into behavioral change in rural communities.

The findings showed that less than half of the participants had adequate knowledge regarding CVD and its risk factors. Although most respondents were aware that hypertension and diabetes are associated with heart disease, considerable knowledge deficiencies existed regarding hypercholesterolemia, asymptomatic presentation of CVD, and warning signs such as shortness of breath. Similar findings have been reported in previous studies conducted in rural populations of developing countries, where limited educational opportunities and restricted access to health information contributed to poor health literacy. The observed association between educational attainment and knowledge levels further supports the notion that education plays a crucial role in improving awareness and understanding of cardiovascular health.

The study also revealed significant gender differences in knowledge levels, with female participants demonstrating better knowledge compared to males. This finding may be attributed to women's greater involvement in healthcare activities, including maternal and child health programs and regular interactions with healthcare providers. Such programs often incorporate information regarding non-communicable diseases and healthy lifestyles, thereby increasing women's exposure to health-related information.

Regarding attitudes toward CVD prevention, most participants recognized that cardiovascular disease is a serious health condition and believed that lifestyle modifications can reduce the risk of developing the disease. However, a substantial proportion of respondents still held fatalistic beliefs, considering heart disease as an unavoidable consequence of fate or divine will. These beliefs may discourage individuals from adopting preventive measures and seeking timely medical care. Furthermore, less than half of the participants perceived themselves to be at risk of developing cardiovascular disease. Low perceived susceptibility has been widely recognized as an important barrier to preventive behavior, as individuals who do not consider themselves at risk are less likely to engage in healthy lifestyle practices or participate in screening programs.

Despite moderate knowledge and positive attitudes, preventive practices were notably poor among the study participants. Only a small proportion of respondents reported regular blood pressure and cholesterol screening, while healthy dietary practices, stress management, and physical activity were also found to be inadequate. The poor practice scores observed in this study may be explained by several factors, including limited healthcare facilities, financial constraints, inadequate access to screening services, and lack of community-based preventive programs in rural settings. The findings therefore demonstrate the existence of a significant knowledge-practice gap, where awareness alone is insufficient to produce meaningful behavioral change.

The study further revealed a high prevalence of smoking among male participants, which represents a major modifiable risk factor for cardiovascular disease. Cultural acceptance of tobacco use among men and inadequate smoking cessation services may contribute to this finding. In contrast, female participants demonstrated relatively healthier dietary practices, particularly regarding fruit and vegetable consumption and salt restriction. Women's traditional role in household food preparation may explain their greater adherence to healthy dietary behaviors.

The findings of this study have important implications for public health policy and practice. Community-based interventions focusing on improving health literacy, increasing risk perception, and promoting preventive behaviors are urgently needed in rural communities. Health education programs should specifically address misconceptions and fatalistic beliefs regarding cardiovascular disease and emphasize the importance of regular screening and early detection. Furthermore, gender-specific interventions may be beneficial, with particular emphasis on smoking cessation and physical activity promotion among men and increased screening participation among women.

Overall, the findings suggest that improving knowledge alone may not be sufficient to reduce the burden of cardiovascular disease in rural populations. Comprehensive strategies that combine health education, accessible screening services, and community-based behavioral interventions are essential to bridge the gap between knowledge and practice and to promote effective cardiovascular disease prevention,

This study provides a comprehensive, gender-disaggregated assessment of KAP regarding CVD prevention in rural communities. Findings indicate moderate knowledge and attitudes alongside critically inadequate preventive practices in this population. Females demonstrated superior knowledge and attitudinal scores, whereas males exhibited higher rates of tobacco use and alcohol consumption. Significant predictors of adequate KAP included educational attainment, gender, and income level.

The knowledge-practice gap identified in this study highlights the imperative for integrated, multi-level public health interventions. Strategies should encompass community-based health education using culturally appropriate media, gender-sensitive behavioral change communication, mobile CVD screening services, and fatalism-addressing health counseling. Policymakers and public health authorities must prioritize rural cardiovascular health as a critical component of non-communicable disease control strategies, with particular attention to gender equity and health literacy promotion.

These findings provide an evidence base for the development of targeted, community-directed CVD prevention programs in rural settings and call for further research, including longitudinal and intervention studies, to monitor the impact of such programs on CVD risk reduction in this underserved population.

Recommendations

Base on the study finding and discussion below mentioned recommendation were given

• It is recommended that community-based CVD health education programs may be introduced using local languages, pictorial materials, and community radio to improve awareness of cardiovascular risk factors and symptoms.
• It is also recommended that gender-sensitive interventions may be developed, with smoking cessation and alcohol reduction programs targeting men and healthy lifestyle promotion initiatives focusing on women.
• Furthermore, regular mobile CVD screening camps may be established to provide free blood pressure, blood glucose, body mass index, and lipid profile assessments.
• Community health workers may be trained in CVD risk assessment, health counseling, referral services, and behavior change communication.
• Policymakers may strengthen rural-specific non-communicable disease policies by improving healthcare access, education, and socioeconomic conditions.
• Future research may conduct longitudinal and intervention-based studies to evaluate the effectiveness of community-level CVD prevention programs.
• Further studies may incorporate clinical cardiovascular risk assessments alongside knowledge, attitude, and practice measures to provide a more comprehensive understanding of CVD prevention in rural populations.

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