In 2021, noncommunicable diseases (NCDs), including heart disease, stroke, cancer, diabetes, and chronic lung disease, were responsible for almost 70% of deaths worldwide. Nearly three-quarters of all NCD deaths occur in low- and middle-income countries. The epidemic of NCDs poses devastating health consequences for individuals, families, and communities and threatens to overwhelm health systems [1].

According to the Ministry of Health in Cambodia, NCDs accounted for 64.0% of all deaths in Cambodia in 2018, and it is increasing by year along with double burden of infectious disease. About one in every four Cambodians (23.0%) dies prematurely, before the age of 70 years, from one of the four main NCDs: cardiovascular disease (24.0%), cancer (14.0%), chronic respiratory disease (4.0%), and diabetes (2.0%)[2]. The four main NCDs share common risk factors: tobacco use, excessive alcohol use, unhealthy diet, indoor air pollution, and physical inactivity. Currently, two million Cambodians use tobacco, with 42.5% of adult males smoking cigarettes. Over 8 in 10 do not eat enough fruit and vegetables to protect them from NCDs. Moreover, 1 in 5 Cambodian adults have high cholesterol, and 1 in 10 have high blood pressure due to a diet that is too high in saturated fats and salt [3].

Reducing the major risk factors for NCDs-tobacco use, physical inactivity, unhealthy diet, and excessive use of alcohol-is the focus of the WHO’s work to prevent deaths from NCDs [1]. It means that behavior change is well received in dealing with NCDs related to lifestyle. To prevent escalating the burden of NCDs as well as the treatment, the Ministry of Health in Cambodia identified the major interrelated causes or multiple causes for an individual and defined a number of multisectoral strategies: controlling tobacco and alcohol use, raising awareness of unhealthy food in the diet, maintaining health through physical activity, providing effective screening and treatment, and palliative care and promotion [4].

The health belief model (HBM) is one of the most effective health behavior-change models. It comprises six constructs (perceived susceptibility, severity, benefits, barriers, cues to action, and self-efficacy) explaining why an individual may or may not adopt preventive measures against the disease of interest [5]. Perceived susceptibility is the perception of the risk of acquiring an illness or disease. Perceived severity refers to a person’s feelings on the seriousness of contracting an illness or disease. Perceived benefits are the perception of the effectiveness of various actions available to reduce the threat of illness or disease. Perceived barriers refer to an individual’s feelings on the obstacles to performing a recommended health action. Perceived cues to action is the stimuli needed to trigger the decision-making process to accept a recommended health action. Lastly, self-efficacy is the level of a person’s confidence in their own ability to perform behaviors [6]. According to the HBM, individual beliefs about health and health conditions play a role in determining health-related behaviors. Therefore, the HBM is widely applied to health-related studies that examine health behaviors and health-risk behaviors in an individual.

A previous cross-sectional study found that perceived barriers and self-efficacy showed the most significant impact on NCD-related behaviors [7]. Another study found that HBM constructs were associated with participants’ exercise behavior [8]. A similar finding was reported in a study conducted in Saudi, which showed that the perception of the seriousness of obesity influenced physical activity [9].

About two decades ago, emerging global health issues may have shaped the current focus on communicable diseases, but the global burden of disease has changed to NCDs. Changing the patterns of personal health behaviors is the best way to prevent NCDs; the change can arise through education, advertisement, or advocacy activities. Society and governments also have a responsibility to create environments wherein individuals are made aware of, and can practically make, life choices that protect their health [10].

Risk perception is defined as interpretations and other subjective judgments about risks [11]. Risk perceptions are critical determinants of health with regards to making decisions such as practicing healthy behaviors [12]. NCD risk perception is important for promoting the adoption of healthy lifestyle and NCD prevention. Low level of perceived risk lead to risky behavior [13]. Despite the importance of NCD risk perception in lifestyle changes, studies related to the relationship among personal perceptions of NCDs based on the HBM are rare. One study conducted in South Africa found differences in the risk perceptions of NCDs by age groups such that young adult groups had poorer risk perceptions than middle-aged and older-aged adults, resulting in poor practices in regard to following NCD health recommendations [5]. Moreover, few studies related to the personal perceptions of NCDs have been conducted in the Asian regions.

Therefore, the purpose of this study is to (i) examine the relationships between the general characteristics of individuals and the risk perceptions of NCDs and (ii) assess the distribution of risk perceptions of NCDs according to the general characteristics of individuals. The findings of this study could inform the Cambodian government and aid in its decision-making process on public health policy and plans to prevent and manage NCDs.

We examined the Cambodians’ health behaviors and the risk perceptions of NCDs, and also examined this risk perception of NCDs according to demographics and health-related variables among Cambodians. We used the risk perception based on the HBM with six constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived cues to action, and perceived self-efficacy). Several variables were related to these constructs. In Asian regions, few studies have assessed the risk perception of NCDs. This study contributes to finding evidence for significant factors related to the risk perception of NCDs. The risk perception of NCDs has been found to be related to preventive behaviors against NCDs [7, 8]. Thus, these factors can be used to promote the risk perception of NCDs in NCD prevention.

The prevalence of diabetes and hypertension is 9.6% and 14.2%. Because this study only included Cambodian aged 40 years or older, prevalence of self-reported disease diagnosed is relatively high (52.5%)[16]. Regarding the health behaviors of study participants, we found that there were fewer heavy episodic drinkers and fewer smokers compared to the findings of a national study in Cambodia [2]. According to the Department of Prevention Medicine of Cambodia, 22.1% of Cambodian are smokers in 2016. Among men 71.8% are current drinkers. 48.1% of Cambodian were having five or more daily servings of fruits and vegetables. Compared these numbers, participants of this study are less smoking and having more fruits and vegetables [16]. This might be because the study sample consisted of a high proportion of women. About 50% of the respondents reported that they intake processed foods high in salt, and 12% consumed very salty food. The intake of sodium of the Cambodians (5,615.9 mg) was three times higher than the WHO recommendation (2,000.0 mg), which is attributed to the additional seasonings during daily cooking, such as fish sauce, monosodium glutamate, and prahok (a locally made fish paste) [17]. In this study, the data also show the high levels of salt consumption among Cambodians. The consumption of high sodium has contributed to about 28% of deaths caused by cardiovascular disease [2]. In addition to smoking and drinking alcohol, high levels of sodium consumption need to be managed in Cambodia.

Another interesting finding is in regard to energy drinks. Sixty-five percent of the respondents reported they drink energy drinks regularly. About 22.0% started to drink energy drinks within one year previous to the study. More than half drink energy drinks 3 to 5 times a week. In Laohasiriwong et al.[18]’s study, men, those aged 31~59, those in a household of less than 5 family members, and those earning < $300/month were more likely to consume soft drinks. In the beverage industry, they are the fastest-growing type of product [19]. A review study found that energy drinks trigger adverse events, including insomnia, stress, and depressive mood. It is recommended not to drink energy drinks frequently (no more than 5~7 energy drinks/week) and to avoid co-consumption with alcohol [19]. In Cambodia, the prevention of NCDs is focused on tobacco and alcohol use, unhealthy diet, and physical inactivity [9]. Energy drinks need to be managed because of the potential adverse events triggered by their use. Government and stakeholders can intervene on reducing the consumption of energy drinks through IEC (information, education, and communication) activities such as social media, television and radio, and additional taxation of some types of drinks.

Compared to a previous study conducted in South Africa [5], the levels of perceived susceptibility, perceived cues to action, and perceived self-efficacy were lower among respondents of this study. The perceived severity, perceived benefits, and perceived barriers were even higher or at least comparable to the previous study. Among these constructs, the perceived self-efficacy showed the lowest scores, quite lower than the previous study. The perceived self-efficacy is a significant contributing factor for health behaviors and preventive health practice [20, 21]. For example, an increase in self-efficacy scores was related to an increased chance of having had a Pap smear [20]. Self-efficacy was significantly associated with self-management of chemotherapy [21]. Based on the study finding, the lower levels of perceived self-efficacy need to be focused on when health promotion and improvement programs are implemented in Cambodia. Educational intervention, including providing basic information about epidemiology, risk factors, complications, signs and symptoms of a certain disease, importance of early detection, and recommended screening methods, is effective for enhancing self-efficacy [22]. Considering the low percentages for self-efficacy items (e.g., “I have information on how to prevent NCDs,” “I am confident about how to prevent NCDs,” and “There is a lot I can do to reduce my chances of getting an NCD-related illness”) in this study, programs should focus on self-regulatory efficacy in the healthy lifestyle behavior intervention for successful prevention of NCDs [23].

Our study found that more respondents diagnosed with a disease by a doctor reported higher levels of the perceived susceptibility of NCDs than their counterparts. When respondents had medical examination, they perceived lower barriers to NCD prevention. Regular health check-ups are an effective way to screen and early detect chronic disease [5, 24, 25]. Those respondents who had a diagnosed disease and had experienced medical examination might have more opportunities to receive health information, increasing health literacy. This might improve the perceived susceptibility of NCDs and decrease the perceived barriers. The relationship between medical examination and perceived barriers could be operating in either direction (i.e., medical examination leading to lower perceived barriers vs. lower perceived barriers leading to medical examination). Outreach health services in a community might be an effective strategy for providing medical examination, which might reduce the perceived barriers to NCD prevention. Community outreach was proposed in guidelines addressing comprehensive primary healthcare to manage NCDs in a low-income country [26]. However, in the screening and medication for NCDs, few studies reported outreach approaches in low- and middle-income countries [27]. In Cambodia, medical examination through either facility-based delivery or outreach health services can be useful in reducing the perceived barriers to NCD recommended health actions.

Our study has several limitations. This study used a cross-sectional design, which does not allow us to draw causal inferences between participants’ general characteristics and the risk perceptions of NCDs. We used non-proportional sampling, limiting the generalizability of study findings, and it is difficult to apply our study findings to other settings. A self-reported questionnaire was used to collect the data, which is subject to recall bias. Some participants might report socially desirable risk perceptions and health behaviors. There is a potential limitation related to the relatively low reliability of the HBM construct in interpreting the results. The low reliability may have been due to cultural sensitivity and the residents participating in the survey fir the first time. However, given limited studies about the personal perceptions of NCDs based on the HBM, this study provides the risk perceptions of NCDs according to the HBM in a low-income country, Cambodia, which is a strength of this study.

In this study, we examined the risk perception of NCDs based on the HBM with six constructs (perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived cues to action, and perceived self-efficacy). We found health behaviors contributing to NCDs (smoking, drinking alcohol, insufficient physical exercise, and unhealthy diet). Additionally, Cambodians drink energy drinks frequently. Among the risk perceptions, the perceived self-efficacy showed the lowest score. Respondents diagnosed with disease by a doctor reported higher perceived susceptibility of NCDs than their counterparts. Medical examination was related to lower perceived barriers to NCD recommended health actions. In Asian regions, few studies have assessed the risk perception of NCDs. Based on the present study finding, it is important to improve perceived self-efficacy in health promotion and improvement programs and to reduce perceived barriers through medical tests either by facility-based delivery or the outreach health services in Cambodia.