Proficiency and implementation associated with non-communicable diseases among secondary school students in Bangladesh

INTRODUCTION

Non-communicable diseases (NCDs) are a group of chronic diseases that cannot be transmitted from person to person through direct contact (Budreviciute et al., 2020). The leading causes of NCDs include hypertension, overweight or obesity, hyperglycemia, and hyperlipidemia (Alamnia et al.,2021; WHO, 2021). Besides, smoking, lack of physical activity (PA), misuse of alcohol, and an unhealthy diet increase the risk of NCD development (Budreviciute et al., 2020; Ng et al., 2020). In 2016, an estimated 40.5 out of 56.9 million deaths globally (71%) were attributed to NCDs. Specifically, 32.2 million deaths occurred due to four main types of NCDs: cardiovascular diseases (CVDs), chronic respiratory diseases (CRDs), cancers, and diabetes mellitus (DM) (NCD Countdown 2030 collaborators, 2018).

NCDs affect all regions and countries worldwide (Budreviciute et al., 2020). In recent years, the highest mortality rates from NCDs have been recorded in low-income and lower-middle-income countries (LMICs), especially in sub-Saharan Africa, Central Asia, and Eastern Europe (Martinez et al., 2020; NCD Countdown 2030 collaborators, 2018). In LMICs, urbanization and its links with the nutrition transition have appeared as the drivers of the rising burden of NCDs (Batal et al., 2018; Popkin, 2015; Popkin and Ng, 2022). As urbanization accelerates, more people switch to a Western-style diet containing large amounts of animal-based, processed, high-sugar, high-fat, and low-fiber foods, which increase the risk of chronic diseases (Billingsley et al., 2018; Goh et al.,2020; Nettleton et al., 2016; Olatona et al., 2018). Several studies in LMICs have found that urbanization is associated with a higher prevalence of type 2 DM, high blood pressure, and dyslipidemia (Bernabé-Ortiz et al., 2017; de Groot et al., 2019; Gassasse et al., 2017; Schutte et al., 2021). Evidence shows that adults and children living in urban areas are more likely to be overweight or obese than those in rural areas (Nurwanti et al., 2019). Besides, multiple studies reported that lower socioeconomic status contributes to the development of NCDs and their fatal outcomes, especially among the younger populations (Allen et al., 2017a, 2017b; Williams et al., 2018).

Bangladesh is a highly populated country, and being the LMICs where the burden of NCDs is among the most complex and critical public health challenges (Rawal et al., 2019, 2020). According to the World Health Organization, NCDs account for 67%–70% of all deaths in Bangladesh (The Daily Star, 2022; Uddin, 2022). It has been estimated that 35% of the Bangladeshi population consumes tobacco regularly (Burki, 2019). The population-based national survey in 2018 showed that 26.2% of the respondents had three or more NCD risk factors (Riaz et al., 2020). The same study revealed that urban dwellers had lower levels of PA, consumed fewer fruits and vegetables, and had a higher prevalence of obesity, hypertension, hyperglycemia, and type 2 DM than those living in the countryside (Riaz et al., 2020).

The main barriers to adequate NCDs prevention, service provision, and care-seeking include outdated and inflexible legislative frameworks, limited access to healthcare services, high healthcare expenditure, stigma and cultural disbeliefs related to NCDs, and the patients’ fear of breaching confidentiality (Dong et al., 2021; Patton et al., 2016). Although the government of Bangladesh has developed various strategies and policies to address NCDs and the risk factors, improper planning and monitoring are hindrances that hamper their implementation (Biswas et al., 2017). Besides, Bangladesh’s low-income communities experience a more significant healthcare expenditure burden (Kankeu et al., 2013; Mistry et al., 2021; Zhou et al., 2021). This is particularly important when considering the high cost of treatment for chronic NCDs. A recent study showed that households with members who had NCDs spent a 59% higher share of their income on care for these diseases than non-NCD households (Datta et al., 2018). It has been reported that NCDs have triggered most households to sell assets or borrow money from informal sources to meet the financial needs required for therapeutic interventions (Datta et al., 2018; Kabir et al., 2019; Onarheim et al., 2018). On top of that, the people in Bangladesh are also ignorant of incorporating a healthy lifestyle into their daily routine due to a lack of knowledge, infrastructure, and resources and an inability to recognize its importance (Hasan et al., 2020).

Young people need to have an awareness of NCDs and their risk factors. Recent research revealed a high prevalence of smoking and alcohol consumption among high school students (Kim and Sohn, 2014; Lee et al., 2021; Lim et al., 2017). Worldwide, it has been estimated that 21% of school-going teenagers smoke tobacco (Ahammed et al., 2021; Desai et al., 2019). A significant association between cigarette smoking and alcohol use with low PA and low intake of fruits and vegetables among adolescents has been reported in 89 countries around the globe (Uddin et al., 2020). In Bangladesh, previous research revealed that more than a quarter of secondary school and university students were regular tobacco smokers (Islam et al., 2016; Kamruzzaman et al., 2022).

Moreover, schools do not prioritize PA due to a general lack of understanding of its importance. Also, since physical education does not contribute to grades, many parents prefer screen-based activities to PA for their children (Hasan et al., 2020). Suboptimal adherence of children and adolescents to health recommendations exposes them to a higher risk of developing NCDs during adulthood (Akseer et al., 2020; Hardy et al., 2017). Several studies advocated installing healthy lifestyle changes early on to reduce the NCDs burden (Afshin et al., 2017; Bruins et al., 2019; Olatona et al., 2018).

Studies in India and Sri Lanka have found insufficient knowledge about healthy lifestyles and NCDs among high school students (Bassi et al., 2021; Gamage and Jayawardana, 2017). There is limited research on this topic in Bangladesh. A recent study found that 43% of adolescents aged 13–19 had poor knowledge of NCDs (Islam et al., 2019). However, the generalizability of these results is uncertain, given the limited number of purposefully selected students from two public schools in the capital city. Besides, no local studies cover the relationship between sociodemographic factors and NCDs-related knowledge and practices among school-going children. Therefore, the objectives of this study were 1) to measure the level of knowledge about NCDs and healthy lifestyle practices and 2) to identify and appraise the independent predictors and their relationship with sociodemographic factors, in addition to the NCDs-related knowledge, practices, and healthy lifestyle practices among secondary school students in Bangladesh. The findings of this study will inform public health authorities concerning the prioritization of NCD prevention interventions in school settings in Bangladesh.

METHODS

Scoring and measurement

The response options for seven items on knowledge were coded as “yes” and “no,” where the “yes” answers were given one point. One additional question was added where the participants needed to indicate which of the nine listed diseases (high blood pressure, diabetes, cancer, obesity, Alzheimer’s disease, stroke, heart attack, osteoarthritis, and osteoporosis) can spread from one person to the other. All the disorders were NCDs, so the scoring was grouped and reversed, as shown in Table 1. The minimum and maximum possible total knowledge scores are 0 and 11, respectively, so the scores of 0 to 3, 4 to 7, and 8 to 11 were categorized as poor, moderate, and good knowledge, respectively. Sleep pattern was recorded based on sleep foundation (Suni, 2022).

Three practice-related questions on specific food consumption, namely, fruits, vegetables, and soft drinks, had Likert scale options including “every day,” “more than once a week,” “once a week,” “once a month,” and “never,” which were coded from four (every day) to zero (never). For soft drinks, the coding was reversed. Questions were also asked on how frequently the participants took junk or fast food per month and how many hours of sleep the participants got on an average school night. The answers were grouped and scored, as shown in Table 1.

Another practice question asked with “yes” and “no” answers were whether the participants did monthly health check at least once a month or followed any specific eating habits to avoid the risk of contracting NCDs. “Yes” answers were given one point. On top of that, the participants need to explain how many hours per day they spent doing exercise/walking/running or playing outdoors (cricket/football/others), where the answers were on the Likert scale of “more than 3,” “2–3,” “1–2 hours,” “less than 30 minutes,” and “not at all.” The answer choices were scored from 4 (more than 3 hours) to 0 (not at all). The minimum and maximum possible total scores of practice are 0 and 27, respectively, so the scores of 0 to 9, 10 to 18, and 19 to 27 were categorized as poor, moderate, and good practice, respectively.

Table 1. The grouping and scoring of specific knowledge and practice items. [Click here to view]

RESULTS

Sociodemographic distribution of participants

Table 2 provides a comprehensive overview of the study participants’ characteristics. A total of 1,744 participants were analyzed, with age distribution showing that 31.9% were in the 10–13 years old category, 65.5% were in the 14–17 years old category, and only 2.5% were 18 years old. Gender distribution was nearly equal, with 48.3% being male and 51.7% female. The majority of participants (72.6%) attended schools with Bangla as the medium of instruction, while a smaller percentage attended schools with English (9.3%) or Arabic (18.1%) as the medium. In terms of residence, approximately half of the participants lived in rural areas (49.2%), while 38.6% were from urban areas and 12.2% from suburban regions. Regarding parental education, a notable proportion of fathers (34.5%) and mothers (38.5%) had either no education or completed only primary education. Household income varied, with 25.0% of students coming from households earning less than 10,000 Bangladeshi Taka (BDT) (118 USD) per month, and the remaining participants were distributed across different income ranges.

The distribution of the participants’ knowledge scores into poor and good knowledge is shown in Figure 1. In contrast, their answers to questions on NCDs-related knowledge are shown in Table 3. More than two-thirds (71.9%) of the participants did not know that NCDs cannot be spread from person to person. Almost half believed that NCDs do not increase the risk of other diseases (49.8%) and that teenagers are not susceptible to NCDs (48.7%). Most students were aware of the role of smoking as a risk factor for NCDs (77.3%) and aware of diabetes (78.0%) and high blood pressure (63.9%), and 78. Perhaps 2% agreed that junk or fast food could be an essential factor in contributing to ill health. When given some examples of NCDs, most participants were aware that those diseases could not spread from person to person, with 91.9% wrongly listing only 0 or 1 of those diseases as infectious.

The distribution of the participants’ healthy life practice scores into poor and good practice is illustrated in Figure 2, while their detailed responses are shown in Table 4. Only about one-third (32.5%) of the participants reported daily consumption of fruits, while most were eating vegetables daily (62.4%). A relatively small proportion (13.4%) reported having soft drinks daily. Notably, almost three-quarters of the participants ate junk or fast food less than seven times per month (72.4%) and slept well on an average school night (71.7%). Undergoing regular medical check-ups was reported by 15.5%, and about one-third (32.7%) of respondents were following specific healthy eating habits for NCDs prevention. Only 12.1% never exercised daily, and 27.3% never played outdoor games.

Table 2. Sociodemographic distribution of the participants (n = 1,744). [Click here to view]

Figure 1. The distribution of the knowledge scores into poor and good knowledge. [Click here to view]

The association between sociodemographic characteristics and healthy lifestyle practices among secondary school students

Female participants exhibited higher healthy lifestyle scores, with a 1.25 times greater likelihood (95% CI = 1.25, 1.51; p = 0.028), than male participants. Additionally, children studying in English medium schools had poorer scores, with a 0.77 times lower likelihood, than children in Bangla medium schools. Notably, when the household income level exceeded 40,000 takas, individuals displayed better knowledge of healthy lifestyles, with an OR of 1.39 (95% CI = 1.09, 1.99; p = 0.039), than those from households with a lower-income level of less than 20,000 BDT. These associations are summarized in Table 5.

Table 3. Knowledge of NCDs among secondary school students (n = 1,744). [Click here to view]

Figure 2. The distribution of the healthy life scores into poor and good practices. [Click here to view]

DISCUSSION

NCDs, such as CVDs, cancers, respiratory diseases, and diabetes, cause 71% of all deaths globally and over 85% in LMICs (WHO, 2018).The mean age of the study student was 14.4 ± 1.72 years. Most of the students, 65.5%, were between 14 and 17 years old, mostly girls, and 72.6% were from Bangla medium instruction. A similar study in Nepal reported that their range was almost similar, 15.61 ± 0.99 years; nevertheless, the majority (51.1%) were male (Sitaula et al., 2022). Over 60% of our study participants were from rural and suburban areas, and most were from families with low- or middle-income backgrounds. Nonetheless, the Nepalese study found that most of the research participants were urban (Sitaula et al., 2022), and one more Malaysian study found similar respondents were principally from rural (Ithnin et al., 2020). Also, most of the students’ parents in this study did not complete education beyond the higher secondary level. One Tanzanian study reported that parents’ educational level, child sex, family earnings levels, and the number of children remain important determinant factors for children’s and adolescents’ attendance at secondary school (Pezzulo et al., 2022). Over half of the students had poor knowledge of NCDs and healthy life practices. Sri Lankan school students (17–19 years old) were found to possess poor knowledge regarding NCDs and healthy lifestyles (Gamage and Jayawardana, 2017). About one-third of students had the misconception that NCDs could be spread from one person to another. Most research respondents had an appropriate conception of the differences between NCDs and infectious diseases. NCDs became a burden for developed and developing nations (Boutayeb, 2006; Boutayeb and Boutayeb, 2005; Islam et al., 2014; Ndubuisi, 2021). The burden of infectious disease was so high that it accounted for the substantial disease load nationally and internationally (Luna and Luyckx, 2020). NCD diseases have been comparatively neglected in international health policy and planning (Luna and Luyckx, 2020). It has been reported that NCDs are socially and environmentally behave like communicable diseases (Luna and Luyckx, 2020; Marmot and Bell, 2019). Additionally, an unhealthy way of life is escalated through household members, especially among financially marginalized neighborhoods (Azul et al., 2021; Hilmers et al., 2012; Luna and Luyckx, 2020). The principally identified factors of NCDs were genetic, physiological, environmental, and behavioral factors, low PA, overweight/obesity, consuming fast food and ready eat a meal, tobacco, and alcohol (Bandoh et al., 2020; Pécout et al., 2021). Half of the secondary school students had no idea that NCDs could increase the risk of other ailments and that teenagers can develop NCDs. Earlier Bangladeshi studies reported that urban school-going teenagers had a mixed level of perception regarding NCDs risk factors; in certain aspects, it was good, and in others, it was inadequate or poor. It has been further reported that often NCDs management was not adequate or poor, such as renal diseases were neglected or did not receive any treatment that resulted in the development of hypertension (Luna and Luyckx, 2020; Luyckx et al., 2021). A similar situation happens with other NCDs, such as DM, rheumatic heart disease, and many more NCDs. If they remain neglected or not timely intervened, these NCDs sequel in developing other grave complications (Nulu, 2017). Multiple studies revealed that secondary school adolescents have a high possibility of developing NCDs because risk factors equally exist among them as the adult population (Shayo, 2019; Tandon et al., 2022; Uddin et al., 2020). In these issues, our research respondent awareness and perception were inadequate. Approximately one-quarter of students had no idea that smoking and junk or fast food are the risk factors for NCDs. One similar Saudi Arabian study revealed that more than one-third of the study population (youngsters) eat ready meals more than eleven times per week (Rahamathulla and Mohemmed, 2020). These youngsters have additional risk factors such as low PA and desk-bound life (Rahamathulla and Mohemmed, 2020). Tobacco is one of the top hazardous components for CVDs, CRDs, cancers, and diabetes. It is considered that tobacco consumption among communities is preventable and to minimize NCDs (Bhatt and Goel, 2018; Perez-Warnisher et al., 2018; Roy et al., 2017). After that, most respondents were aware of the hazard of fast food and smoking. Among the studied students, 22% and 36% had never heard about diabetes and high blood pressure, respectively. Bangladesh has 12.88 million people suffering from DM and is considered the 8th highest diabetic population (Hossain et al., 2022; Talukder and Hossain, 2020). One study reported that the pervasiveness of high blood pressure cases was 1.10%–75%. The comprehensive weighted pooled prevalence of hypertension was 20% (Chowdhury et al., 2020). One more recent Bangladeshi study reported that the rate of hypertension among Bangladeshi individuals was 27.4%. Among hypertensive Bangladeshi individuals, around 42.4% were conscious of their ailment. This study also revealed that among high blood pressure cases, only 33.8% had controlled hypertension with antihypertensive medication (Al-Kibria et al., 2021). Thereby, both DM and hypertension are quite common NCDs in Bangladesh. Nevertheless, many of our research respondents did not know these major NCDs. Around 67.5% and 37.6% of students reported not eating regular fruit and vegetables, respectively. The American Heart Association recommends a daily intake of 4–5 servings of fruits and vegetables (Dayal et al., 2017). Besides, more than half of students reported having soft drinks more than once a week. Regularly consuming sugary beverages is associated with an increased risk of NCDs and even premature death (Haque et al., 2020; Restrepo et al., 2020). Evidence suggests that soft drink advertising significantly improves children’s intake (Lichtenstein et al., 2021). A study in Australia reported that adolescents frequently consumed soft drinks because they were convenient to buy and highly available at home and on school canteen menus (Bere et al., 2008). More worryingly, 12.1% and 27.3% of students never spend time on exercise or walking or running, and playing, respectively. Low-level PA has been considered a high-risk factor and often ends with developing CVDs and DM. Nevertheless, this risk factor has been appraised as a modifiable risk issue (Bere et al., 2008; Saqib et al., 2020; Sheikholeslami et al., 2018). Thereby, a good proportion of our study respondents’ carter high-risk issues and the development of NCDs.

Table 4. Healthy lifestyle practices among secondary school students (n = 1,744). [Click here to view]

Table 5. OR of healthy lifestyle practice score (poor knowledge compared to good knowledge) in the socio-demographic factors among the studied participants. [Click here to view]

Figure 3. OR of good NCDs knowledge in the sociodemographic factors among the studied participants. The multinomial regression model was used to estimate the p value. ***p < 0.001, **p < 0.01, and *p < 0.05. Notes: *Reference group; #CI = Confidence Interval. [Click here to view]

We found a slightly higher percentage of girls than boys students with good knowledge of NCDs. However, the difference was not statistically significant. A recent cross-sectional survey conducted in Bangladesh showed that males had more comorbidities and risk factors for NCDs than females who were less engaged in unhealthy practices, such as smoking and consuming fast food (Biswas et al., 2019; Shah et al., 2010). Also, females had a higher rate of good practices regarding NCDs than males. However, men suffer from more NCDs than women (Syed et al., 2019).

Nonetheless, it has been reported that males enjoy better health than women (Liu et al., 2017; Oksuzyan et al., 2008). Furthermore, males have shorter life spans than females. Females have much more physiological illnesses, whereas males have deadly diseases. However, females have the more debilitating long-standing illness. Thereby, both sex has health issues, to some degree, which may be non-identical. After that particular sex can be identified as having superior and robust health. This research deduced that health deviation among both sexes depends on time, environment, and topographical area (Crimmins et al., 2019). The study found a strong association between the type of school students attended with knowledge and practices related to NCDs among secondary school students. Multiple studies revealed that knowledge, attitude, and practice regarding NCDs primarily depended on privileged communities (Aung et al., 2012; Gamage and Jayawardana, 2017; Lorga et al., 2013; Thammatacharee et al., 2012). English medium-going students demonstrated the lowest level of NCDs-related knowledge and practices. One earlier Bangladeshi study’s findings were not similar to our research findings. However, this study was conducted in rural areas (Rahman et al., 2022). Nevertheless, this finding is challenging to explain. English was adopted as the instructional language in Sri Lanka in 2001 in both secondary and tertiary education (Navaz, 2021; Wijayatunga, 2018). One Sri Lankan study revealed that secondary school students’ knowledge regarding NCDs and healthy lifestyle were substandard (Gamage and Jayawardana, 2017). This study also observed that urban students’ knowledge level was higher than rural adolescents. Our results follow a survey among selected urban school students in Bangladesh in 2019 (Desai et al., 2019). Our study depicted that students from lower-income backgrounds had poorer knowledge and practices toward NCDs than students from upper socioeconomic backgrounds. Students from wealthier families have more exposure to resources that can educate them regarding NCDs, including a higher possibility of being sent to private English medium schools (Desai et al., 2019). Besides, underprivileged communities are disproportionately affected by unhealthy lifestyles, malnutrition, and unhygienic living conditions. A recent study on NCDs and lifestyle-associated risk factors in South Africa revealed high inequality in the geographical distribution of the prevalence of stroke, hypertension, ischemic heart disease, and dyslipidemia. Specifically, the most increased adjusted risks of NCDs were observed in low-income households with limited access to healthcare facilities providing services for chronic diseases (Habib et al., 2020).

Furthermore, previous studies have identified that household income is associated with health check-up rates among different populations (Scully et al., 2017; van Ansem et al., 2014). Studies have reported that people from LMICs spend more of their budget on medical expenses than on food, hygiene, clothing, and energy (Kim et al., 2018; Onah and Govender, 2014; Shin et al., 2018). Apart from spending available monetary resources, people often have to sell their assets or borrow money to meet their healthcare needs (Akazili et al., 2017; Cunningham, 2009; Khan et al., 2017; Onah and Govender, 2014). Previous research in Bangladesh found an association between expenditure for medical care and financial distress and poverty aggravation (Msambichaka et al., 2018). Another study in Bangladesh showed that a share of medical expenses was more significant for NCD-afflicted households than households with no reported NCDs (Sloan et al., 2021). In the present study, there was a significant disparity in knowledge and practices regarding NCDs between Aboriginal and non-Aboriginal populations. This is consistent with a previous study carried out among high school students in rural Thailand, where most students from ethnic minorities displayed poor knowledge concerning NCDs and associated lifestyle risk factors (Chang et al., 2015). Thus, our study highlighted discrepancies in health-related learning between minority and nonminority students.

It was observed that the student’s knowledge of NCDs was significantly associated with their parent’s education level. Several studies revealed that adolescents whose parents had higher education (Dhungana et al., 2019; Roy et al., 2020). Additionally, highly educated parents are likely to be more conscientious and knowledgeable about choosing a healthy and unhealthy lifestyle, which could translate to developing healthy lifestyle behaviors in their children (McNiven et al., 2021). A study carried out among adolescents in Taiwan found that parents with lower levels of education were less likely to browse health information online. Subsequently, their children had less proficiency in Internet usage concerning health education and lower eHealth literacy and related skills (Alexander et al., 2003).

The participants in our sample reported several health issues frequently experienced by them. The most common health issue was body aches, such as back and limb pain. Similarly, a recent African study revealed a high prevalence (36%) of back pain among adolescents (Amarasekara et al., 2016). In addition, about a quarter of the participants reported suffering from a sleep disorder in the present study. A cross-sectional survey among 67 countries showed a strong association between difficulty in sleeping and sedentary lifestyle behavior (Golestani et al., 2021). A Hong Kong survey of children and adolescents reported that 19.1% of their participants faced sleeping difficulties, and the prevalence was higher in 16–19 years old students (Lustig, 2020).

Similarly, 40% of adolescents in South China experienced sleep disorders associated with Internet use and depression (Vancampfort et al., 2019). The least common health issue experienced by the students in our study was asthma. According to the International Study of Asthma and Allergies in Childhood 2017, the prevalence of asthma among children of Bangladesh and Pakistan was 3.8% and 4.3%, respectively (Lustig, 2020), which is consistent with the present study. Some studies stressed the independent association of a sedentary lifestyle of inactivity and lack of sufficient health resources with NCDs (GBD Chronic Respiratory Disease Collaborators, 2020; Morris et al., 2018; Rosenstock et al., 1988). Alterations in the circadian rhythm and adaptation of Western lifestyles may have contributed to lifestyle diseases and health issues in children, such as frequent headaches and body pain (Freisling et al., 2020; Hootman et al., 2003).

In our study, the multinomial regression model revealed that research respondents who are obese and overweight had insufficient knowledge regarding NCDs than the normal individual. One Nigerian study reported that although obesity is low among secondary school students; nonetheless, inadequate knowledge, dismissive attitude, and fatalistic awareness were observed about hazardous issues of overweight and obesity (Oyewande et al., 2019). The model also revealed that urban secondary school students possess good knowledge than rural participants regarding NCDs. One Nepalese study reported that research respondents of secondary schools better understand NCDs in metropolitan cities than in smaller municipalities or rural areas (Sitaula et al., 2022). Similarly, one Malaysian study reported that rural adolescents had poor knowledge regarding NCDs than their urban counterparts (Ithnin et al., 2020). Our study revealed that research respondents’ parent education level of an SSC and higher had good knowledge about NCDs than functionally analphabetic. One earlier recent Bangladeshi study reported similarly (Islam et al., 2019). It has been further reported that low educational levels and disparities are associated with higher NCDs (Kim and Nam, 2017; Oshio and Kan, 2019). Our study also found that postgraduate mothers’ secondary school children possess higher knowledge levels than those of unschooled mothers. This finding also corresponds with one earlier study (Islam et al., 2019). Higher-income households were associated with better knowledge regarding NCDs among secondary school adolescents. An earlier study conducted in Bangladesh similarly reported (Islam et al., 2019).

CONCLUSION

NCDs account for more than half of the total deaths in Bangladesh. Knowledge disparity and inequalities in health practices among secondary school students from various sociodemographic backgrounds are evident from the present study’s findings. Public health programs designed to educate adolescents and their parents concerning healthy lifestyle practices should target multiple communities to address social inequalities, especially within economically disadvantaged populations and ethnic minorities living in remote areas.

The findings of this study support the idea that health literacy, including basic knowledge about NCDs and their risk factors, should be incorporated into the core curriculum of all types of schools at the earliest stages of education. Various resources, such as newspapers, billboards, and electronic media, are encouraged to disseminate knowledge among students and their parents.

DISCLOSURE

The authors declare that they do not have any financial involvement or affiliations with any organization, association, or entity directly or indirectly with the subject matter or materials presented in this article. This includes honoraria, expert testimony, employment, ownership of stocks or options, patents or grants received or pending, or royalties.

ACKNOWLEDGMENTS

The graphical abstract of this paper has been drawn utilizing the premium version of BioRender with the License number (CI258LJ8NU). Image Credit: Susmita Sinha.

AUTHORSHIP CONTRIBUTION

All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis, and interpretation, or in all these areas; they took part in drafting, revising, or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted, and have decided to be accountable for all aspects of the work.

FINANCIAL SUPPORT

There is no funding to report.

CONFLICTS OF INTEREST

The authors report no financial or any other conflicts of interest in this work.

ETHICAL APPROVAL

Ethical approval for the research was obtained from the Ethical Review Committee of the Chittagong Medical College Ethical Review Board (Reference No.: CMC/PG/2020/122; Date: 03-December-2020). The study participants were verbally explained regarding the purpose and future publication. Thereby, written informed consent was obtained before data collection.

DATA AVAILABILITY

The data is available only for research from the principal author.

PUBLISHER’S NOTE

This journal remains neutral with regard to jurisdictional claims in published institutional affiliation.

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