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.

Purpose: Waist-to-height ratio (WHtR) is an anthropometric index with limited data on its population distribution. The aim was to establish WHtR reference values and investigate WHtR associations with socio-demographic, lifestyle and clinical characteristics in Russian adults. 

Methods: We used data from the population-based cross-sectional Know Your Heart study (2015–2018, Arkhangelsk and Novosibirsk, N = 4495, 58.1% of women, 35–69 years, mean age 54.0). Age-adjusted WHtR reference values for the total study population and by sex were modeled as marginal 5th-95th percentiles (P5-P95) through quantile regressions. WHtR associations with cardiovascular biomarkers were assessed using linear regressions. 

Results: The conventional WHtR threshold of 0.5 for abdominal obesity was the value of P25, while P50 and P75 values were 0.54 and 0.60. In ages 35–49 years, P5-P50 values were higher in men. In the age group 60–69 years, P25-P95 values were higher in women. In both sexes, WHtR was associated with age, city of residence, not having university education and low physical activity; in women – with poor financial situation, in men – with being married, non-smoking and hazardous drinking. Among clinical parameters, C-reactive protein had the strongest positive association with WHtR in both sexes, while HDL cholesterol had the strongest negative association. Each standard deviation (SD) change in ln-transformed C-reactive protein was associated with 0.435 and 0.321 SD increase in WHtR in women and men, respectively. One SD increase in HDL cholesterol was associated with −0.334 SD change in WHtR in women and with corresponding change of −0.297 SD in men. In women, WHtR had stronger associations with age, university education, poor financial situation, blood pressure, HDL cholesterol, and ln-transformed C-reactive protein, in men – with being married, current smoking, LDL and non-HDL cholesterol, and HbA1c. 

Conclusion: Three-quarters of the study population had WHtR values exceeding the conventional threshold for abdominal obesity. Men and women differed in the WHtR associations with socio-demographic and lifestyle risk factors, biomarkers of inflammation, hypertension, dyslipidemia, and diabetes. WHtR is a useful cardiovascular risk indicator in a Russian adult population.

The anthropometric index that best predicts cardiometabolic risk remains inconclusive. This study therefore assessed the prevalence of obesity using six indices and compared their associations with obesity-related cardiometabolic disorders. We determined obesity prevalence according to body mass index, waist circumference, waist-to-hip ratio, waist-to-height ratio (WHtR), body fat percentage and fat mass index (FMI) using data from the Know Your Heart study (n = 4495, 35–69 years). The areas under the receiver operating characteristic curves (AUCs) provided predictive values of each index for detecting the presence of hypertension, hypercholesterolaemia and diabetes. Age-standardised obesity prevalence significantly varied according to anthropometric index: from 17.2% (FMI) to 75.8% (WHtR) among men and from 23.6% (FMI) to 65.0% (WHtR) among women. WHtR had the strongest association with hypertension (AUC = 0.784; p < 0.001) and with a combination of disorders (AUC = 0.779; p < 0.001) in women. In women, WHtR also had the largest AUCs for hypercholesterolaemia, in men–for hypertension, diabetes and a combination of disorders, although not all the differences from other obesity indices were significant. WHtR exhibited the closest association between hypertension and a combination of disorders in women and was non-inferior compared to other indices in men. 

Background

Sense of Coherence (SOC) relates to an individual’s overall life orientation, and stronger SOC is associated with better health, quality of life, and coping strategies. When our research group used the SOC-13 questionnaire for the first time in Nepal, we identified difficulties in response patterns. The findings necessitated further evaluation of the Nepali version of the SOC-13 questionnaire.

Objective

To qualitatively evaluate the SOC-13 questionnaire in Nepali for cross-cultural adaptation.

Method

Nineteen nurses were interviewed. We used the methodological approach of “think aloud” to obtain a deeper understanding of the interferences of the scales. Transcribed materials were analyzed using a deductive approach through qualitative content analysis. The original translated version of the SOC-13 questionnaire in Nepali was modified by replacing words that were easier to understand.

Result

Participants found the questionnaire content general and non-specific but easy to complete. The nurses experienced that the meanings and sentences in some of the items and response alternatives were difficult to understand. However, the overall comprehensiveness of most items and response alternatives was perceived as good. Nurses’ interpretation of the SOC-items in the translated version of the SOC-13 questionnaire in Nepali matched the original English version. Items that were experienced as difficult in the Nepali language were modified to increase their comprehensiveness. Modified items and response alternatives had the same content as before, but some words and meanings were substituted with easier language.

Conclusion

The current revised version of SOC-13 in Nepali is valid and useful to explore individuals’ overall life orientation and their abilities to deal and cope with various life events in the Nepalese context.

Vi står inför många framtidsutmaningar kopplade till stora förändringar i vårt samhälle, vår omvärld och miljö. Dessa utmaningar är globala och för att möta dem behöver utbildning och forskning i många fall bedrivas med ett internationellt och interkulturellt perspektiv och anpassade undervisningsformer och kursinnehåll. Digitaliseringen och de erfarenheter som gjorts under COVID19-pandemin har inneburit att undervisningen och det traditionella student-, lärar- och forskarutbytet kompletterats med nya digitala former för undervisning och verktyg för internationalisering. Samtidigt som dessa former och verktyg erbjuder ökade möjligheter för mobilitet så kan man genom ett utökat arbete med internationalisering på hemmaplan nå grupper, som av olika skäl inte kan delta i mobilitet, för att dessa ska kunna erhålla internationella och interkulturella perspektiv.

För ett väl fungerande internationaliseringsarbete räcker det inte att kunskapen om internationaliseringens förutsättningar, genomförande samt eventuella hinder finns hos den enskilde läraren utan kunskapen bör finnas på olika nivåer i organisationen, och såväl i linjeledningen som hos ämnes- och programansvariga. Deltagare från Högskolan har inom ramen för Högskolornas nätverk för strategisk internationalisering (HÖNSI) under 2021-2022 medverkat i tre projekt som rör stöd kring internationalisering riktat till administrativ personal (SUCTI), lärare (SUCTIA) samt ledning. I denna presentation kommer resultaten från en förstudie om ledningsstöd att presenteras.

På Högskolan har vi också identifierat ämnes- och programansvariga som nyckelpersoner när det gäller de internationella och interkulturella inslagen i våra utbildningar. Det handlar såväl om mål för internationalisering på hemmaplan som att ge förutsättningar för deltagande i olika former av mobilitet. För detta har vi som presenterar beviljats partsgemensamma medel för en utbildningsinsats riktad mot ämnes- och programansvariga. Som en del av denna presentation vill vi presentera och diskutera ett förslag på innehåll, utformning och genomförande av denna utbildningsinsats.

Referenser:

Kirk, S. H., Newstead, C., Gann, R., & Rounsaville, C. (2018). Empowerment and Ownership in Effective Internationalisation of the Higher Education Curriculum. Higher Education: The International Journal of Higher Education Research, 76(6), 989–1005.

Stafford, S., & Taylor, J. (2016). Transnational Education as an Internationalisation Strategy: Meeting the Institutional Management Challenges. Journal of Higher Education Policy and Management, 38(6), 625–636.

SUCTIA. (2020). Systemic University Change Towards Internationalisation for Academia in European higher education institutions: an exploratory study. https://suctia.com/wpcontent/uploads/2020/11/SUCTIA-Report-1.pdf

Systemic University Change Towards Internationalisation for Academia (SUCTIA). (27februari 2023). https://suctia.com/

Background: Digital interventions are promising tools to reach adolescents for cardiovascular health promotion.

Purpose: We assessed adolescents’ knowledge, attitude and practice (KAP) regarding cardiovascular disease (CVD), explored opportunities for a digital intervention, and developed a serious game prototype.

Methods: In total, 649 adolescents grades 8-10 were surveyed in a semi-urban community of Nepal regarding KAP of CVD and digital pre-requisites. Eight focus group discussions (FGDs) separately among boys and girls (n=76) provided deeper understanding of CVD perceptions.

Findings: Median (IQR) percent scores for KAP were 70.6 (10.59), 78.5 (8.46) and 69.5 (11.59), respectively. Good KAP (median percent scores >75%) was found in 27.7%, 69% and 27.8% adolescents, respectively. Knowledge (p<0.001), attitude (p=0.025) and practice (p<0.001) was higher among adolescents in private than government schools. Girls had better attitude than boys (<0.001). Furthermore, 98% adolescents had smartphone access and 91.6% had internet access.

In preliminary FGD analyses adolescents mentioned physical, nutritional, mental, environmental and hereditary causes for CVD. Financial and work-related burdens, plus psychological and family-related issues were perceived to influence CVD severity. Junk food and physical inactivity were health barriers. Adolescents perceived serious games as beneficial and easy to use. Challenging game and attractive visuals were thought to stimulate game use.

Conclusion: With good attitude and excellent digital prerequisites, we conclude that serious games can help fill the existing gaps in knowledge and practice in Nepal. A prototype of “Happy Heart” is being pilot-tested among adolescents as a promising way for digital cardiovascular health promotion.