On a global scale, cardiovascular diseases (CVDs) account for approximately 17.9 million deaths annually and are the primary cause of mortality and morbidity [1]. It is important to note that countries with lower economic status account for over 75% of these deaths [2]. There were 201,300 Saudi citizens affected by CVD in 2016. This included 51,700 people with cerebrovascular disease and 149,600 adults with ischemic heart disease. According to estimates [3,4], cardiovascular disease accounts for more than 45% of all deaths. Cardiovascular disease (CVD) continues to represent the single most important contributor to global morbidity and mortality, posing a major challenge to health systems, especially in low- and middle-income countries (LMICs).  According to the World Health Organization, an estimated 17.9 million deaths were attributed to CVD in 2019, accounting for 32% of global mortality [5].  Alarmingly, more than three quarters of these deaths occurred in LMICs, where healthcare infrastructure is inadequate to deal with the rising tide of non-communicable diseases and preventative measures are frequently underutilized. This shift in epidemiology emphasizes the urgent need to prioritize community-based approaches for both treatment and prevention [6]. Identifying modifiable risk factors and lifestyle factors that are associated with cardiovascular disease (CVD) has received more attention in recent decades. Cardiovascular diseases like ischemic heart disease, heart failure, and stroke continue to be primarily caused by hypertension, diabetes mellitus, dyslipidemia, obesity, smoking, and sedentary lifestyles [7]. However, sociodemographic, cultural, and economic contexts frequently influence population knowledge and awareness of these risk factors. While rural communities frequently suffer from structural inequalities that restrict their access to preventive health education, urban populations typically benefit from greater exposure to health information, media campaigns, and improved healthcare services [8]. The importance of knowledge, attitudes, and practices (KAP) in relation to CVD cannot be overstated. Knowledge about risk factors and early warning signs provides the foundation for behavioral change, while positive attitudes reinforce motivation to adopt healthier lifestyles. Preventive practices such as dietary modifications, regular physical activity, routine blood pressure and glucose monitoring, and avoidance of tobacco and alcohol directly reduce the likelihood of cardiovascular events. Studies. have consistently shown that inadequate knowledge and misconceptions contribute to unhealthy practices, perpetuating the cycle of preventable disease in resource limited settings [9]. In rural areas, additional challenges exist that influence KAP levels. Poverty, illiteracy, traditional dietary practices, and reliance on cultural or alternative medicine may shape perceptions of cardiovascular health. For example, awareness of hypertension as a “silent killer” is often limited, leading to 
late diagnosis only after complications develop [10].  Middle-aged adults, typically defined as individuals between 40 and 60 years of age, represent a key demographic for CVD prevention. This age group is often burdened by multiple risk factors, occupational stress, and limited opportunities for regular health check-ups. Moreover, they are at a transitional stage between the relatively low-risk younger years and the high-risk elderly period, making them a priority target for preventive interventions ]11]. Evaluating their knowledge, attitudes, and practices offers critical insights into both the current state of community cardiovascular health and opportunities for early intervention before irreversible complications arise [12]. While numerous studies have assessed cardiovascular risk awareness in urban populations, the evidence from rural communities remains comparatively scarce [13]. The available literature indicates that awareness levels are generally low, with significant misconceptions regarding causation, prevention, and treatment of CVD. For instance, surveys conducted in rural parts of South Asia and Sub-Saharan Africa have found that a substantial proportion of adults fail to recognize smoking, obesity, and lack of exercise as risk factors. Objective Therefore, the present study aims to comprehensively evaluate the knowledge, attitudes, and preventive practices regarding cardiovascular disease among middle-aged adults residing in rural settings. 

This was a cross-sectional descriptive study conducted at field practice area of Nagavalli RHTC of Sri Siddhartha Medical College, Tumkuru from January 2025 to June 2025. A total of 324 middle-aged adults (aged 40–60 years) were enrolled in the study. Non-probability consecutive sampling was employed to recruit participants who fulfilled the inclusion criteria. Adults between the ages of 40 and 60 years residing in the selected rural areas, who provided informed consent, were included in the study. Individuals with a history of diagnosed cardiovascular disease, those who were critically ill, and those unwilling to participate were excluded.

Data Collection

Data were collected using a structured, pretested questionnaire designed to assess three main domains:

1. Knowledge regarding cardiovascular risk factors, symptoms, and prevention.
2. Attitudes toward cardiovascular health and preventive measures.
3. Practices related to diet, physical activity, smoking, alcohol use, and participation in health check-ups.

Data collection was conducted using a structured questionnaire developed specifically for this study. The questionnaire was first prepared in English and then translated into the local language to ensure cultural appropriateness and ease of comprehension. To maintain accuracy, a forward and backward translation process was carried out by bilingual experts. Before the main survey, the tool was pretested on 20 individuals from a similar rural population to assess clarity, identify ambiguities, and estimate the average time required for administration. Feedback from the pilot testing was incorporated, and necessary modifications were made before final implementation. The questionnaire consisted of four sections. The first section collected sociodemographic characteristics, including age, gender, marital status, education, occupation, and household income. The second section assessed knowledge regarding cardiovascular disease, focusing on awareness of risk factors such as hypertension, diabetes, smoking, and obesity, recognition of warning symptoms like chest pain, palpitations, and shortness of breath, and understanding of preventive measures including dietary changes, physical activity, and regular health check-ups. The third section explored attitudes toward cardiovascular health, including perceived seriousness of the disease, willingness to adopt preventive measures, and reliance on medical advice. The fourth section evaluated preventive practices such as dietary patterns, exercise frequency, smoking and alcohol use, blood pressure and glucose monitoring, and health-seeking behavior Trained data collectors administered the questionnaire through face-to-face interviews in the local language to ensure comprehension among participants with varying literacy levels.

Statistical Analysis

Data were entered and analyzed using SPSS v 21. Descriptive statistics (frequency, percentage, mean, and standard deviation) were used to summarize sociodemographic characteristics and KAP responses. Associations between knowledge, attitudes, and practices with demographic factors (such as age, gender, education, and income) were assessed using chi-square tests and independent t-tests. A p-value of <0.05 was considered statistically significant.

A total of 324 middle-aged adults participated in the study. The mean age was 49.2 ± 5.8 years. Out of the total, 176 (54.3%) were males and 148 (45.7%) were females. Most participants were married (84.9%), engaged in agriculture or labor (46.6%), and a considerable proportion had no formal education (38.6%).

Table 1. Sociodemographic Characteristics of Participants (n = 324)

Knowledge of cardiovascular disease was moderate overall. While 238 (73.5%) participants had heard of cardiovascular disease, only 186 (57.4%) correctly identified smoking as a risk factor. Awareness about hypertension (71.9%) and diabetes (65.7%) was comparatively higher, while recognition of obesity (49.4%) and sedentary lifestyle (42.0%) was lower. Chest pain (62.3%) and shortness of breath (44.8%) were the most frequently recognized warning symptoms.

Table 2. Knowledge Regarding Cardiovascular Disease (n = 324)

Attitudes toward cardiovascular disease reflected a recognition of its seriousness, but personal risk perception was low. A majority (82.1%) agreed that heart disease is a serious condition, yet only 39.8% felt they were personally at risk. Most participants (63.6%) believed lifestyle changes could help prevent heart disease, while 58.6% supported the importance of regular check-ups. However, 40.7% still believed that medication was the only effective treatment.

Table 3. Attitudes Toward Cardiovascular Health (n = 324)

Preventive practices were found to be suboptimal. Only 112 (34.6%) participants reported engaging in regular physical exercise, while 97 (29.9%) reported daily fruit and vegetable consumption. A high proportion (41.4%) were current smokers, and 61 (18.8%) reported regular alcohol use. 94 (29.0%) participants practiced routine blood pressure monitoring, and only 68 (21.0%) had their blood glucose checked regularly. Preventive health-seeking behavior was limited, with only 82 (25.3%) reporting visiting a healthcare facility for routine screening in the past year.

Table 4. Preventive Practices Related to Cardiovascular Disease (n = 324)

This study evaluated the knowledge, attitudes, and preventive practices regarding cardiovascular disease (CVD) among middle-aged adults in a rural setting. The findings reveal important gaps in awareness and behavior that may contribute to the persistent burden of CVD in underserved populations. Although most participants had heard of cardiovascular disease, knowledge of specific risk factors and warning signs was incomplete, attitudes were often shaped by limited personal risk perception, and preventive practices were generally suboptimal. The results showed that while over 70% of participants recognized hypertension and diabetes as risk factors for cardiovascular disease, fewer than half identified obesity and physical inactivity as contributors. These findings are consistent with studies from other rural populations in South Asia and Sub-Saharan Africa, which report that awareness of metabolic and lifestyle risk factors remains inadequate compared to biomedical conditions such as hypertension and diabetes [13]. Limited understanding of lifestyle-related risks may reflect gaps in health education programs, as well as cultural perceptions that normalize unhealthy dietary practices and sedentary lifestyles. Knowledge of warning symptoms was also limited, with chest pain being the most commonly identified symptom, while fewer than half recognized shortness of breath as a potential indicator of heart disease [14]. This narrow recognition of symptoms has significant clinical implications, as delayed interpretation of warning signs often results in late presentation to healthcare facilities and worse outcomes. Similar studies in rural India and Pakistan have highlighted comparable trends, suggesting that low symptom awareness is a widespread barrier to timely care-seeking in resource-constrained communities [15].

Attitudes toward cardiovascular disease reflected an acknowledgment of its seriousness, with more than 80% agreeing that it represents a major health problem. However, fewer than 40% perceived themselves as being personally at risk. This discrepancy between perceived seriousness and perceived susceptibility is a well-documented phenomenon in health behavior research [16]. According to the Health Belief Model, individuals are less likely to adopt preventive behaviors if they do not believe themselves to be vulnerable, even when they acknowledge the severity of a condition. This finding suggests that public health campaigns should focus not only on general awareness but also on improving personal risk perception through targeted community-level interventions [17].

Preventive practices in the present study were found to be poor, with fewer than one-third of participants engaging in regular physical activity or consuming fruits and vegetables daily. The prevalence of smoking was high (41.4%), particularly among men, reflecting a well-established behavioral risk factor in rural populations. Only a small proportion of participants reported routine blood pressure or glucose monitoring, and preventive healthcare-seeking behavior was low. These findings are in line with prior research showing that while knowledge and attitudes may be moderate, translation into healthy practices is hindered by multiple barriers including poverty, limited healthcare infrastructure, cultural norms, and competing daily priorities in rural life [18]. The observed gap between knowledge and practices may also reflect structural and socioeconomic factors beyond individual awareness. For example, rural communities often have limited access to affordable healthy food, recreational facilities, and healthcare providers, making it difficult to sustain preventive behaviors [19]. Additionally, misconceptions such as the belief that medication alone is sufficient for prevention, as seen in over 40% of participants, further reduce the likelihood of lifestyle modification. Addressing such beliefs requires culturally sensitive health education that emphasizes the role of diet, exercise, and screening alongside pharmacological measures [20]. The findings of this study highlight several important implications. First, there is a need for community-based educational programs tailored to rural populations that emphasize lifestyle risk factors and symptom recognition. Second, interventions should incorporate strategies to improve personal risk perception, as this is a key determinant of preventive behavior. Third, broader health system reforms are necessary to increase access to routine screening and affordable preventive care.

This study has some limitations. The cross-sectional design does not allow causal inferences to be drawn between knowledge, attitudes, and practices. Self-reported practices may be subject to recall or social desirability bias, particularly regarding sensitive behaviors such as smoking and alcohol use. The study was conducted in a specific rural setting, which may limit the generalizability of the findings to other regions. Nevertheless, the large sample size and structured methodology provide a robust overview of the existing gaps in cardiovascular health awareness and behavior.

It is concluded that middle-aged adults in rural settings possess only moderate knowledge and generally positive attitudes toward cardiovascular disease, but their preventive practices remain inadequate. While awareness of conditions such as hypertension and diabetes were relatively high, recognition of lifestyle-related factors, including obesity, physical inactivity, and unhealthy diet was poor. Preventive measures such as routine health check-ups, regular exercise, and dietary modification were not widely adopted, and a significant proportion of participants continued to engage in high-risk behaviors like smoking.

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