Effects of a health education intervention on knowledge and attitudes towards chronic non‐communicable diseases among undergraduate students in Jordan

Abstract Aim To assess the effect of a health promotion course on knowledge and attitudes towards chronic non‐communicable diseases (CNCDs) among undergraduate students in a Jordanian university. Design A one‐group pre‐test–post‐test study design was used. Methods A convenience sample of 178 undergraduate students registered in a 3‐credit health promotion course was enrolled in the study and completed both pre‐ and post‐tests. This course is offered as an elective course for undergraduate students by the Faculty of Nursing at a large public university in Jordan. Twelve, one‐hour interactive sessions regarding CNCDs topics were delivered over 3 weeks as part of the health promotion course. A computer‐based questionnaire was used to evaluate students’ knowledge and attitudes towards CNCDs including diabetes, hypertension and cancer, before and after undertaking the course. Results There was a significant improvement in the overall knowledge (Cohen's d effect size (d) = 1.08) and attitudes (d = 0.62) among all the students, regardless of gender. The overall knowledge and attitudes scores were significantly higher among females in the pre‐test, but the differences in their overall scores became insignificant in the post‐test. Education on specific topics was effective in improving university students’ knowledge and attitudes about health‐promoting behaviours, thereby preventing CNCDs. It is important to incorporate health promotion education regarding CNCDs into university curricula using innovative approaches to enhance healthy behaviours in young adults.


| INTRODUC TI ON
Chronic non-communicable diseases (CNCDs) are the leading cause of morbidity and mortality globally. In 2016, CNCDs, including cardiovascular diseases (CVDs), cancers, respiratory diseases and diabetes, accounted for 71 per cent of total deaths worldwide (World Health Organization [WHO], 2018a). In Jordan, there were 36,000 total deaths in 2016 and an estimated 78 per cent of them were from CNCDs, mainly by CVDs (37%), cancer (12%) and diabetes (6%) (WHO, 2018b). The leading cause of morbidity among Jordanians aged 25 years and above include hypertension (28.6%), high cholesterol (39.5%), high triglyceride (56.5%) and diabetes (22.3%) (The Higher Health Council, 2015). These CNCDs share common, causal, behavioural risk factors including physical inactivity, unhealthy diet, smoking and alcohol (WHO, 2018b). Therefore, CNCDs and their associated complications might be preventable making these high morbidity and mortality rates unacceptable.
Primary prevention of CNCDs can be achieved by health promotion interventions that can empower people to enhance control over their own health and environments (Joh et al., 2017;Nayak et al., 2016). Health promotion education can enhance individuals' lifestyle behaviours and their knowledge and attitudes towards the adoption of healthy behaviours particularly when innovative approaches are used (Abdo et al., 2019;Belogianni & Baldwin, 2019;Nayak et al., 2016;Selvam et al., 2017). University students are vulnerable to engage in health-compromising behaviours (Almutairi et al., 2018;Joh et al., 2017), thus a distinct priority population for health promotion to enhance responsibility for their own health and minimize the risk of developing diseases later in life. Universities are key locations for cost-effective and ideal health education on CNCDs to enhance young adults lifelong behaviours, such as exercise and a healthy diet (Abdo et al., 2019;Joh et al., 2017;Nayak et al., 2016;Wang et al., 2013). Improvements in knowledge and attitudes are significant precursors of behaviour change (Belogianni & Baldwin, 2019). Research indicates that students have poor knowledge and negative attitudes regarding risk factors, preventive measures and complications of CNCDs (Abukhelaif & Alghamdi, 2017;Alsaraireh & Darawad, 2018;Kan'an, 2018;Shah et al., 2016). In Jordan, lack of awareness in terms of health promotion behaviours is a clear problem among university students (Al-Shara, 2019; Ashraah et al., 2013;Shaheen et al., 2015).
For instance, female students had relatively poor knowledge, negative attitudes and poor practice regarding breast cancer (BC) (Alsaraireh & Darawad, 2018, 2019. Evidence suggests that health education about CNCDs is effective in improving university students' knowledge, attitudes and healthy lifestyle behaviours (Abdo et al., 2019;Belogianni & Baldwin, 2019;Nayak et al., 2016;Selvam et al., 2017). In this regard, using an interactive approach can help students better engage in learning healthy lifestyles Alsaraireh & Darawad, 2019;Joh et al., 2017). The effectiveness of health education was evaluated by two Jordanian studies, revealing a positive effect on improving healthy nutritional habits (Abu-Moghli et al., 2010) and on improving knowledge, attitudes and practices on BC and breast self-examination among university students (Alsaraireh & Darawad, 2019). Yet, studies examining the effectiveness of using interactive health education on knowledge and attitudes towards health promotion and prevention of CNCDS among university students in Jordan and surrounding countries are lacking.
In summer 2016, the United Nations Population Fund (UNFPA) had a strategic goal to improve the health of young Jordanians. They collaborated with a large public university in Jordan, which regularly administers a health promotion course (HPC) to undergraduate students, to integrate CNCDs topics within its curriculum using interactive pedagogical approaches. Therefore, the purpose of this study was to assess the effect of the HPC, after integrating CNCDs topics, using a new methodology on improving the knowledge and attitudes about CNCDs among university students in Jordan. In addition to getting the baseline data, the findings from this study may encourage stakeholders in Jordan to integrate education regarding the prevention of CNCDs and adopt such interactive teaching strategies in other courses to improve the knowledge and attitudes of all young adults in Jordan.

| Design, setting and sample
A one-group pre-test-post-test study was conducted in a large public university in Jordan that enrols students from all around the country. A convenience multi-disciplinary sample of undergraduate students who were enrolled in the three-credit hours HPC during the summer of 2016 was used. This elective course is offered by the university to undergraduate students from different years and all majors, except medicine and nursing majors. Otherwise, the sample included students from all other health science majors available at the university, such as pharmacy, dentistry and applied medical sciences. All students who were enrolled in the HPC and able to read and write Arabic were eligible to be included in the study.
Participation was voluntary and those who agreed to participate completed a pre-test prior to the first session of the course and a post-test after the completion of the course. The course was offered in Arabic in a classroom setting.

| Measurements
A computer-based questionnaire was used to evaluate students' health promotion knowledge and attitudes about three major CNCDs, including diabetes mellitus (DM), hypertension and cancer before and after the HPC. The researchers developed the questionnaire after reviewing relevant literature (Abukhelaif & Alghamdi, 2017;Alsaraireh & Darawad, 2018;Lorga et al., 2013;Parmar et al., 2014) and obtaining special training from the UNFPA on designing HPC material on CNCDs. The items in the questionnaire were based on the HPC content on the prevention and control of DM, hypertension and cancer.
The questionnaire consisted of three sections: demographics (8 questions), knowledge (18 questions) and attitudes (18 questions) about CNCDs. Each of the knowledge and attitudes scales consisted of three 6-item subscales on DM, hypertension and cancer. For knowledge items, a score of 1 was assigned to the correct response, while 0 was assigned to the incorrect responses, which were the "false" and "I do not know" responses, with a total knowledge score of 18. For attitudes items, responses were scored as follows (0 = disagree, 1 = not sure and 2 = agree), yielding a maximum score of 36. Higher scores indicate better knowledge and attitudes.
The questionnaire was developed in Arabic and reviewed by a panel of six assistant and associate professors in nursing who are experts in the topic to establish its content and face validity. The item content validity index (I-CVI) ranged between 0.83 and 1 and the scales content validity index (S-CVI) was >0.97 for both knowledge and attitude scales. The questionnaire was piloted for clarity, readability and feasibility on 20 students whose data were not included in the final analysis. The questionnaire was clear and easy to understand, requiring 10-15 min for completion. Internal consistency was also achieved for both knowledge and attitude scales (Cronbach's alpha: 0.78 and 0.85, respectively).

| Intervention: the HPC
The HPC is a three-credit hour elective course offered by the Faculty of Nursing at a public university in Jordan for undergraduate students from all majors, except medicine and nursing majors.
The medium of instruction for this course was Arabic. Content related to the CNCDs was integrated into the HPC to cover the definitions, modifiable and non-modifiable risk factors, signs and symptoms, complications, screening and diagnoses, treatments, preventive measures of the three CNCDs and the related healthy lifestyle modifications. Content related to the CNCDs was delivered in twelve, one-hour sessions over 3 weeks, by nursing professors who were well-trained on the content and teaching methodology. Interactive teaching methods that incorporate meaningful interactions among learners themselves and between learners and educators were used to facilitate better knowledge acquisition while facilitating a healthy learning environment (Buehl, 2017). The interactive teaching methods used are given in Table 1.

| Procedure
Following approval from the Institutional Review Board and before the course starts, the researchers sent an announcement via email to the students enrolled in the HPC requesting voluntary participation in the study. The announcement clarified the study's purpose and nature, the confidentiality and anonymity of responses, participants' right to decline participation or withdraw at any time without any penalty and that participants' pre-and post-tests scores would not be counted towards their final course grades. A written informed consent was obtained from participants during the orientation day. Three days before starting the

Orientation
The students received an orientation about the interactive teaching methods and all salient information related to the study including significance, purpose, design, procedure and pre and post-test questionnaires. course, the pre-test questionnaire was made available to the eligible participants on the e-learning platform used by the university.
At the end of the course, the participants completed the post-test using the same questionnaire and e-learning platform. All data were electronically extracted after deleting students' identifiers and stored in a password-protected computer, accessible only to the principal investigator.

| Data analysis
Data were analysed using SPSS 23. Descriptive statistics were used to describe students' levels of knowledge and attitudes on CNCDs for the pre-test, post-test and demographic data. The paired sample t test was used to analyse the differences in students' levels of knowledge and attitudes about CNCDs before and after the HPC. An independent sample t test was used to analyse gender differences in the level of knowledge and attitudes before and after the HPC. The significance level was set at 0.05 and the Cohen's d effect size close to d = 0.5 was classified as medium and d ≥ 0.8 as large.

| Ethics
This study was conducted after obtaining the approval of the Institutional Review Board (IRB # 184-2016) at a large public university in Jordan. A written informed consent was obtained from all participants. were from middle and southern Jordan.

| RE SULTS
The overall knowledge and attitudes scores at the baseline did not differ significantly by socio-demographic factors, except gender. Thus, males' and females' pre-and post-tests scores were compared.  (Table 3).

| Knowledge of CNCDs
The overall and subscale knowledge scores increased significantly (p < .001) in the post-test for both males and females with higher increases among males (Table 4). The overall effect size was large for males (d = 1.10) and females (d = 1.15). Comparing the scores between genders, females' knowledge scores were higher at both tests, except for the post-test knowledge of DM which was equal among both genders. However, pre-test gender differences were only significant in the total score of knowledge (p = .004), particularly regarding cancer (p = .001).

| Attitudes of students towards CNCDs
There was a significant improvement in the overall attitudes score towards CNCDs after the course with a medium effect size. There was a significant difference in students' total attitudes score before (mean 32.15, SD 3.51) and after the HPC (mean 34.28, SD 3.24); t cancer prevention significantly improved on the post-test (p < .001).
There was a significant improvement in students' scores regarding the chronicity of DM (p = .015) and the benefit of avoiding salty and fatty diets (p = .032) ( Table 5).
Males' and females' overall score towards CNCDs improved significantly (p < .001) in the post-test with higher increases among males.
The overall effect size was medium for males (d = 0.53) and females (d = 0.67) ( Table 4). Post-test scores on attitudes towards cancer significantly improved among both genders (p < .001), while the scores on DM and hypertension significantly improved (p = .017 and p < .001, respectively) only among females. Examining differences between genders, females scored higher than males on the total attitudes scale and its subscales on both tests. In the pre-test, gender differences were significant in cancer (p = .003) and total attitudes (p = .011) scores. In post-test, females scored significantly higher than males on the total scale (p = .035), DM (p = .036) and cancer subscales (p = .029).

| DISCUSSION
This study aimed to assess the effect of the HPC on knowledge and attitudes about CNCDs among undergraduate students in Jordan.
The main finding of this study showed that the HPC was effective in improving the overall knowledge and attitudes towards CNCDs among all the students, regardless of gender.

| Knowledge
Results of this study indicate that the HPC was significantly effec-  (Alsaraireh & Darawad, 2018;Asgarlou et al., 2016;Kan'an, 2018;Suleiman, 2014;Ugurlu et al., 2016). Students in this study had the lowest knowledge score on BC risk factors. Similarly, two recent Jordanian studies revealed poor knowledge of university students regarding symptoms and risk factors of BC (Alsaraireh & Darawad, 2018;Kan'an, 2018).
Knowledge scores in this study are expected among students who are young and healthy (only 5.1% of students had an existing longterm illness). Older students who have previous experience with cancer report better knowledge about cancer (Mhaidat et al., 2018).
Educating young adults about the risk factors and warning signs is important for early detection and prevention of disease occurrence later in life (Joh et al., 2017 Similarly, a Jordanian study found that the BC educational programme, using various teaching methods, was effective in improving university students' knowledge regarding BC, its warning signs and risk factors (Alsaraireh & Darawad, 2019). It was important to educate students on the risk factors and prevention of cancer, particularly BC, because it was the most common type (37.3%) of cancer among Jordanian females in 2012 and the most leading cause of cancer-related deaths among females (24.53%) (MOH, 2012).
Also, students' knowledge of DM and hypertension improved significantly after the HPC which is similar to other reports (Nayak et al., 2016;Selvam et al., 2017;Shah et al., 2016). Emphasis on the specific topics, the use of audiovisual aids and case studies, providing explicit information on normal values, risk factors and ways to manage complications in the HPC significantly improved students' knowledge. Students' baseline knowledge of diabetes and hypertension symptoms, complications and general facts was low, but improved significantly; this is comparable to previous findings (Nayak et al., 2016;Selvam et al., 2017). Similarly, Jordanian college student's knowledge of the definition, risk factors, complications (e.g. kidney, eye, nervous system and lower extremities) and prevention of DM was poor (Latifeh & Khalidisy, 2012). This highlights the need for educational programmes and awareness campaigns, lectures or brochures to address this knowledge gap (Mhaidat et al., 2018). It is essential to equip young adults with useful information for CNCDs prevention, early detection and related burden reduction to positively affect their community (Latifeh & Khalidisy, 2012 was significantly lower among males; nonetheless, this difference disappeared in the post-test. Similar findings were reported in an Indian study where baseline knowledge regarding CNCDs was lower among males, but the improvement was significant among both genders after short training (Selvam et al., 2017). This gender difference could be explained from societal and cultural perspectives that Jordanian women generally hold more caring roles for ill family members (Shaheen et al., 2015) and may seek more information regarding diseases and treatment modalities. Jordanian females were reported to be more aware of hypertension and reproductive health Jaddou et al., 2011). This gender difference regarding CNCD knowledge should be taken into consideration when providing health education to young adults.

| Attitudes
The study showed a significant improvement in students' overall attitudes regarding CNCDs and related health-promoting lifestyles after the HPC, which is consistent with previous findings (Alsaraireh & Darawad, 2019;Ouyang & Hu, 2014;Selvam et al., 2017). Such improvement demonstrates another success for the HPC. Improving attitudes at an early stage is very significant, as positive attitudes were associated with health-promoting practices that reduce disease occurrence (Dayal & Singh, 2018).
In general, students in this study demonstrated the highest improvement in their attitudes towards cancer, followed by hypertension, then DM. This might be explained by students' baseline knowledge and attitudes, where cancer scores were the lowest. A positive association between knowledge and attitudes scores was reported in previous studies (Dayal & Singh, 2018;Shen et al., 2017).
The HPC was effective in improving students' attitudes regarding risk factors and the preventive and screening measures of cancer, such as the heredity risk of cancer, the importance of healthy diets and regular exercise in cancer prevention and the importance of breast self-examination for early detection of BC. Similar positive impact of an educational programme on Jordanian students' attitudes towards BC was reported by Alsaraireh and Darawad (2019).
University students are vulnerable to engage in risky behaviours and; therefore, health education is a priority to improve their attitudes towards health-promoting behaviours and reduce their risk for developing diseases later in life (Dayal & Singh, 2018;Joh et al., 2017).
The HPC was effective in improving students' attitudes regarding different aspects of diabetes and hypertension, such as their chronic and hereditary nature. This could be explained by the improvement in students' knowledge of the aetiology of these diseases, as a positive association between knowledge and attitudes towards CVDs among young adults has been reported (Dayal & Singh, 2018). Students' attitudes towards the importance of lowsalt and low-fat diets intake to prevent hypertension also improved after the course which emphasized on healthy nutrition and consequences of poor dietary habits. Similar improvement in attitudes regarding diabetes and hypertension by educational interventions was reported (Eunice, 2017;Selvam et al., 2017

| Limitations
This study has some limitations associated with using a convenience sample and one geographical location; therefore, caution must be taken in generalizing our findings beyond the sample or to other settings. Also, using a self-report tool may introduce recall bias, limiting the generalizability of our findings. As for strengths, this study provided information on the baseline knowledge and attitudes of students in Jordan, which can be used to design interventional programmes and innovative courses to fill the gap in knowledge and enhance the attitudes towards CNCDs. Future studies that fully assess the health promotion practices of university students are recommended. Future studies could compare students' learning outcomes concerning specific teaching methodologies.

| CON CLUS ION
The findings demonstrated the effectiveness of the HPC in improving university students' knowledge and attitudes regarding CNCDs. It is important to integrate health education regarding CNCDs and other health problems into university curricula using innovative approaches to enhance healthy behaviours in young adults. Raising awareness about specific health problems among university students can increase their responsibility towards their own health by adopting healthy lifestyles to reduce their risk for developing diseases later in life. Interactive health education provides students with essential knowledge and strategies to control CNCDs and emphasizes the value of making healthy decisions to achieve a healthier lifestyle. This can empower students in promoting their health, influencing their families' health and consequently improving the quality of life of the emerging Jordanian workforce and community.

ACK N OWLED G M ENTS
The authors would like to thank Dr. Rachel Joseph for her editorial assistance and the United Nations Population Fund (UNFPA) and Royal Health Awareness Society (RHAS) in Jordan for the effective training workshops on course material and the interactive learning methods utilization for conducting the health promotion course.

CO N FLI C T O F I NTE R E S T S
The authors declare that they have no competing interests.

AUTH O R S' CO NTR I B UTI O N S
MA and RA contributed to the concept and design of the study.

DATA AVA I L A B I L I T Y S TAT E M E N T
This manuscript does not include any supporting information files for publication.