Högskolan i Skövde

Background

In Nepal, the proportion of annual deaths from cardiovascular disease (CVD) increased from 12% in 1990 to 22% in 2021. Although CVD manifests in adulthood, exposure to risk factors begins early in life. In Nepal, a high prevalence of risk factors combined with limited knowledge about cardiovascular health warrants a life course approach. One strategy could be a digitalized health education targeted at adolescents to prevent future CVDs.

Methods

We conducted a cross-sectional survey to assess adolescents’ knowledge, attitude and practice (KAP) regarding cardiovascular health and explored possibilities for digital education. In total, 649 adolescents in grades 8–10 from two public and seven private schools in a semi-urban community of Nepal were surveyed. A self-administered questionnaire assessed KAP, digital prerequisites such as mobile phone use and internet availability at home, and gaming behaviors. Quantile regression was performed to assess the relationship among the variables.

Results

The median scores were 69.1% (Interquartile range/IQR 63.1%–74.4%) for knowledge about cardiovascular health, 77.9% (73.3%–82.3%) for attitude and 76.7% (72.2%–81.1%) for practice. Quantile regression showed that the knowledge score for grade 9 adolescents was 4.2 percentage point (pp) higher (p < 0.001) and grade 10 adolescents was 4.0pp higher (p < 0.001) than those in grade 8. Knowledge was 4.9pp higher (p < 0.001) for private than for public school adolescents. Attitude scores were 2.0pp higher (p = 0.001) for girls than for boys and 1.7pp higher (p = 0.008) for private than for public school adolescents. For practice, boys scored 2.2pp higher (p < 0.001) than girls and private school adolescents scored 2.5pp higher (p < 0.001) than public. Furthermore, 98.6% of adolescents had smartphone access, 91.5% had internet access and 68.0% played mobile games.

Conclusion

Adolescents have lower knowledge than attitude and practice regarding cardiovascular health. This combined with high digital access provides opportunities for digital health education, especially in public schools.

The burden of cardiovascular diseases (CVDs) and the risk factors in adolescents are rising in Nepal, a low-income setting. Therefore, focusing on health education related to diet and physical activity for adolescents in their formative years is urgent. A digital medium may be an efficient way to reach this technologically oriented group. We developed a digital educational game through a collaboration between researchers in health and informatics from Nepal and Sweden and piloted the game as part of the ‘Heart-Related Intervention with Digitalization Among Young Adolescents (HRIDAYA)’ study.

We found that 99% of adolescents had access to smartphones and 92% had access to the internet. The digital game was developed for android devices due to their predominance in Nepal. First, a survey was conducted among 649 adolescents to identify their digital prerequisites as well as their gaps in CVD-related knowledge, attitude, and practice. Second, the identified gaps defined the learning goals of the game, forming the foundation for an initial draft of the game concept. Third, we created a game paper prototype and tested it among 10 adolescents to explore their visual recognition and preferences. Based on the findings, we chose two levels of fidelity and tested them with 44 adolescents. We found that a higher-fidelity abstract style resulted in more positive feelings. This style was subsequently used for the final game. Fourth, the game was developed through an iterative process, which included both culturalization efforts and ensuring educational viability. Finally, the completed digital educational game ‘Happy Heart’ was played by 176 adolescents. It consisted of seven mini-games related to sugar, salt, and fat in different food items, physical activities, balanced diet, and nutrition groups. Immediate audio and video feedback kept the players motivated. Written texts in the game journal addressed knowledge gaps that could not be converted to game mechanics.

In conclusion, a digital education like Happy Heart may be helpful in increasing knowledge, attitude and practice regarding CVDs among Nepalese adolescents. The development process indicated that the digital game has the potential to reach many adolescents and that they were receptive to the game. As the game is a low-cost educational effort that can easily be scaled up, it provides a promising avenue for cardiovascular health promotion in similar low-income settings.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in Nepal. As CVD risks can develop early in life, a life course approach for non-communicable disease (NCD) prevention is needed. Due to its potentially acceptable delivery mode, digital health education could be a promising way forward to increase adolescents' CVD knowledge.

PURPOSE: The purpose of this study was to explore adolescents' CVD perceptions and their perceptions and preparedness for digital cardiovascular health education through mobile games.

METHODS: Twelve focus group discussions were conducted with adolescents, Grades 8-10, from two public and four private Nepalese schools. A qualitative study with a deductive thematic analysis was performed, guided by the health belief model (HBM) and the technology acceptance model (TAM).

RESULTS: The analysis resulted in 6 themes and 13 sub-themes concerning perceptions of CVD and 5 themes and 10 sub-themes on perceptions and preparedness for digital cardiovascular health education through mobile games. The adolescents viewed CVD as a serious disease with consequences. A healthy diet and physical activity were important for prevention. Benefits were the positive impacts of a heart-healthy lifestyle. Barriers were the temptation of consuming unhealthy food, lack of healthy food environments, time and motivation. The adolescents also stressed their own ability to prevent CVD. Digital cardiovascular health education through mobile games was desirable. Constraints were accessibility and technical issues, parental allowance, available time and whether the game was engrossing enough.

CONCLUSION: The adolescents perceived CVD as serious, with benefits and barriers connected to its prevention. Digital cardiovascular health education through mobile games was viewed positively but not without constraints for successful implementation.

Understanding players’ diverse visual recognition and visual preferences, especially in cross-cultural contexts, is critical for the creation of effective serious games. This study aimed to examine how varying levels of fidelity affect players' visual recognition, visual preference, and overall experience in serious gaming, using a mixed-method case study in the Bhaktapur district, Kathmandu, Nepal. Forty-four participants, aged 13 to 16 years, were enrolled in an A/B gameplay test. Fourteen students participated in in-depth interviews, thirty-six completed a questionnaire, and twenty-two provided valid telemetry data. We found that higher fidelity led to more positive affect, better recognition, stronger preference, higher familiarity, and positive emotional response from players. However, challenges were encountered regarding the identification of local food items. This highlights the key role of visual literacy, as adolescents are more influenced by familiar media than by real-life experiences in terms of visual recognition and preference. Effective visual communication in serious games should consider individual differences and the playing environment. This study contributes to serious game research by providing insights into an underrepresented demographic and demonstrating the importance of cultural context in visual communication. Findings offer practical guidance for game developers to design more inclusive and effective serious games.

Background:

Unhealthy diet and physical inactivity contribute to the growing burden of cardiovascular diseases in Nepal. Lifestyle is formed in childhood and in the Nepalese context influenced mainly by mothers, it is to date unknown how influential mothers are.

Objectives:

To assess changes in children’s diet and physical activity as perceived by their mothers after a health promotion intervention.

Methodology:

The Heart-Health Associated Research, Dissemination and Intervention in the Community is a community trial conducted in the Jhaukhel-Duwakot Health Demographic Surveillance site, in Bhaktapur district of Nepal. We conducted a health promotion intervention on diet and physical activity targeted at mothers with children aged one to nine years old in August-November 2016. Duwakot was randomized as the intervention site and Jhaukhel as the control. We conducted a follow-up study after three months to determine the outcome of the intervention. Nine trained enumerators conducted door-to-door visits to all households with eligible mothers. We calculated mean, frequency and percent changes for children’s behavior.

Results:

As responded by mothers, children in Duwakot consumed more healthy snacks after the intervention compared to Jhaukhel. Children in Duwakot increased consumption of water and milk. Children’s consumption of packet juices and soft drinks was decreased by 30% and 4% respectively. There was 21% increment in the duration of outdoor playing among the children at Duwakot during follow-up.

Conclusion:

The Heart-Health Associated Research, Dissemination and Intervention in the Community that focused on mothers showed indirect positive impact on their young children’s diet and physical activity behavior. In future, the longterm effects of such intervention should be assessed.