Knowledge, attitude and practices pertaining to healthy lifestyle in prevention and control of chronic diseases: a rapid review

INTRODUCTION

Non-communicable diseases (NCDs) are a group of diseases that are not infectious and are caused by genetic inheritance as well as unhealthy lifestyle like unhealthy diet, physical inactivity, stress, consumption of alcohol and tobacco.

NCDs comprise of diseases like diabetes, cardio-vascular diseases, cancers, stroke, Chronic obstructive pulmonary diseases (COPDs), Chronic kidney diseases (CKDs) and Non-alcoholic fatty liver disease (NAFLD). With the emergence of NCDs, the world is experiencing an epidemiological transition from communicable diseases to non-communicable diseases. NCDs kill 41 million people each year, equivalent to 71% of all deaths globally.¹ More than 3/4^th (77%) of all NCD deaths occur in low and middle-income countries.¹

MANAGEMENT OF NCDS

Practice of healthy lifestyle plays an important role in preventing NCDs. Once diagnosed, management consists of lifestyle modification along with regular intake of medicines. Due to the chronic nature of NCDs, adherence to treatment and healthy habits is often challenging for the patients. Intake of medicines alone does little to improve the quality of life and to restrict progression of the disease, which is why non-pharmacological interventions (healthy life-style practices) form a cornerstone in the management of NCDs. A positive patient outlook towards knowledge, attitude, and practices (KAP) pertaining to healthy lifestyle determines the progress of these diseases. While elements of KAP are interrelated and dependent on each other, they are shaped by socio economic conditions, cultural beliefs and personal habits, which implies that being informed may not necessarily lead to practice of healthy lifestyle. The objective of this review is to understand the knowledge, attitude and practices pertaining to healthy lifestyle among individuals who are at risk of developing NCDs and those living with NCDs.

A rapid review of articles available on Pubmed and Google scholar was conducted. A total of 45 published research studies focusing on knowledge, attitude and practices pertaining to healthy lifestyle, from the year 2015 to 2021 were reviewed. These studies spanned across various age groups and diverse communities from different socio-economic background and geographical areas specifically in the state of Maharashtra, India.

THEORIES OF BEHAVIOUR CHANGE

In a bid to understand knowledge, attitude and practices pertaining to healthy lifestyle, it is important to understand the process of behaviour change. There are various theories and health models that explain the process of behaviour change. The Health Belief Model (HBM) has been known to explain and predict patients’ self-care practices. The model proposes that the likelihood of an individual to follow the recommended health-related actions is influenced by perceived severity, perceived susceptibility, perceived benefits, perceived barriers and cues to action. It emphasizes that health beliefs tend to differ across age groups.² Social Cognitive Theory (SCT) rests on the tenet that personal factors, environmental influences, and behaviour continually interact. A basic premise of SCT is that people learn not only through their own experiences, but also by observing the actions of others and the results of those actions. Accordingly, the key constructs of SCT are observational learning, reinforcement, self-control, self-efficacy involving goal-setting, self-monitoring and behavioural contracting.³

Another model of health called ‘Transtheoretical model’ explains the stages of behaviour change from pre-contemplation, contemplation, preparation, action, maintenance to relapse, in that order. While studying KAP elements in a population, it is important to assess these stages along with barriers and facilitators to healthy lifestyle practices.⁴ These models of behaviour change can be used to explain why do people behave the way they behave. Studies that have used these models to interpret population behaviour have been included in this rapid review.

Knowledge

Knowledge plays a key role in shaping people’s attitude and behaviours to adopt healthy lifestyle.

As per the reviewed studies, the main sources of health-related information are mass media (Social media, internet, TV, radio) and interpersonal communication with friends, family, workplaces and social gatherings.^16,35 It is well documented that patients with better knowledge have a good adherence to treatment and healthy lifestyle practices. As per the reviewed studies, knowledge pertaining to healthy lifestyle is determined by factors such as age, education, employment status, social engagements etc.⁵ Higher education and younger age group have better knowledge about healthy lifestyle practices.^6,33 Though teenagers have decent knowledge about unhealthy eating practices, they still prefer eating junk food.⁷ People who are obese or overweight have a good knowledge about healthy lifestyle practices, indicating disagreement between knowledge and practice^5,8, but to say if these individuals gained knowledge about healthy lifestyle practices after becoming obese or prior to it, remains a grey area.

NCD patients who do not have adequate knowledge about lifestyle modifications have a poor practice regime, but also those with knowledge may not adopt a healthy lifestyle.^8,29 Periodic screening plays an important role in preventing the complications of NCDs. It was found that 61% of the patients with diabetes did not have periodic eye examination, though these patients had good knowledge about diabetes.⁹

Overall findings from reviewed studies suggest that 70-80% of the individuals are aware about health hazards of unhealthy diet, physical inactivity, alcohol and tobacco consumption, with poor practice scores, hence merely being knowledgeable may not translate into practicing a healthy lifestyle.^5,7,8

Attitude

While evaluating attitude of people towards healthy lifestyle, the studies suggested that people have a very positive attitude towards healthy lifestyle.²⁹ They acknowledge the fact that healthy lifestyle is essential for leading a healthy life. However, this positive attitude did not translate into healthy practices. Some of the identified barriers to practicing healthy lifestyle are lack of motivation, household dynamics, social and cultural norms, workload, time pressures, environmental factors, cost etc.¹⁰

Practices

As per the studies reviewed, practice scores are influenced by socio-economic factors, demographics of the population, personal factors like lack of motivation, lack of awareness, wrong information etc.

In certain instances, people might be practicing healthy lifestyle, but due to inaccurate information it may not be adequate for example in one study it was found that majority of the women considered their activity level adequate, although they engaged in what the researchers concluded were quite low levels of activity, this shows that correct information is important in shaping people’s behaviour.¹¹

Thaler and Sunstein in their 2008 book, Nudge: Improving decisions about Health, Wealth, and Happines, contend that there exists a ‘choice architecture’ which involves all of the outside forces that may subtly guide one’s decisions in one direction or another.³⁴ A Nudge alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.

Nudges are not a compulsion, for example, putting fruits at eye level counts as a nudge but banning junk food does not, regular SMS’ to the youth about bad effects of smoking and alcohol or electronically delivered nudges for daily physical activities or treatment adherence offer low cost opportunities to increase compliance. This article reiterated the fact that we live in a ‘Post-truth’ world, where knowledge or facts play less important role in shaping people’s behaviours and opinions in comparison to their personal beliefs and emotions. The current myopic approach of public health policies is rendered rudimentary in shaping people’s behaviour.

A comprehensive analysis regarding the barriers and facilitators to practicing healthy lifestyle in conjunction with nudge theory for factoring-in sustainability, can come-in handy while designing and implementing social, behaviour change and communication strategies.

CONCLUSION

Behaviour change is imperative for preventing non-communicable diseases. Multiple factors affect individual behaviours, which are critical for formulating population level policies around behaviour change. In a given population, behaviour change is better understood with KAP elements pertaining to healthy lifestyle. Availability and accessibility to accurate information from credible sources lays the foundation for people’s attitude and practices. We saw that though individuals had the necessary information and positive attitude towards healthy lifestyle, they did not practice healthy lifestyle, this shows that being knowledgeable may or may not translate into practicing healthy life style due to myriad reasons. A lot of times it is the standpoint within the society that determines individual knowledge and behaviours as well as the perception towards healthy and unhealthy lifestyle. Epistemological analysis can help a great deal in determining and explaining existing health behaviours within a given population and thereby strategizing interventions around behaviour change. In recent years, the nudge approach to behaviour change has emerged from the behavioural sciences to challenge the traditional use of regulations in public health strategies to address modifiable individual-level behaviours related to the rise of non-communicable diseases and their treatment.

ACKNOWLEDGEMENTS

Author is grateful to Dr. Shailendra Kumar B Hegde, Senior Vice President- Public Health Innovations, PSMRI and Dr Radha Rao Valaulikar, Senior Manager, NCD-TSU, Maharashtra, for their support and guidance on this article.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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