The Health Promoting Schools (HPS) approach introduced in the late 1980s, embeds health into the school mission, and encourages the adoption of healthy decisions and behaviors in school settings (1). HPS are educational institutions that prioritize the health of students, faculty, staff, and the wider community, and strive for safer and healthier school environments.

One key feature of HPS approach is flexibility, allowing schools to focus on the most pressing topics in their community, while ensuring a timely and cost-effective implementation of global objectives (2). For example, at the height of the COVID-19 pandemic, schools played an important role in educating students and their families, about hygiene, social distancing, and the identification of alarm symptoms requiring medical care (3). Similarly, HPS programs and schemes related to body mass index, physical activity, and nutritional habits, were impactful in changing habits (4). The effectiveness of health promotion approaches in schools highly depends on the close collaboration between medical professionals and other stakeholders who issue HPS curricula, and education professionals who deliver the message, to ensure understanding of the material and objectives (5). The presence of qualified teachers, supportive school administration, sustainable funding, and long-term planning contribute to the success rates of HPS approaches (6, 7).

HPS seem paramount for addressing the United Nation’s Sustainable Development Goals mainly SDGs 3 and 4 related to good health and wellbeing and quality education respectively, as well as the goals of the World Health Organization (WHO) global action plan for non-communicable diseases (NCDs) prevention, 2013–2020 (8).

NCDs are evolving into a growing burden worldwide. In Lebanon, cardiovascular diseases (CVDs) account for 47% of all deaths (9). This is attributed to a worsening cardiovascular profile in the population with high risk factors like obesity (41.5%), alcohol (18.96%), and smoking (43.1%) (10). The Lebanese National Non-Communicable Disease Prevention and Control Plan 2016–2020 (NCD-PCP) was established by the Ministry of Public Health (11), and was based on a multisectoral approach to health promotion and community-based primary prevention of NCDs. Nonetheless, the program lacked an assessment of baseline knowledge, beliefs, and attitudes of the general population concerning NCDs, notably CVDs, and first aid care of cardiovascular emergencies. It also failed to involve school-based initiatives to increase students’ awareness of CVDs, although school-based health promotion has been shown to significantly impact long-term health outcomes and risk-behaviors (12).

Studies have also documented a gap in knowledge of CVDs, heart attacks and their symptoms, and a need for emergency medical care in the adult population in Lebanon and the wider Middle East (13–19). This lack of recognition of heart attack signs and symptoms by the general population is concerning, as it causes delays in seeking medical attention and treatment, leading to poorer prognosis and increased mortality. This delay has been attributed to a lack of recognition of the signs and symptoms of heart attack and hesitancy to perform cardiopulmonary resuscitation (CPR), which has been shown to increase chances of survival by 2–3 folds (20). This hesitancy has been linked to lack of training and lack of prior experience in performing CPR (21).

Several educational campaigns were initiated globally to increase knowledge of signs and symptoms of heart attack and reduce the delay in hospital arrival. A face-to-face session and counseling on common symptoms of heart attack and appropriate response to such an event increased knowledge in adults who were diagnosed with coronary artery disease (CAD) in the previous 6 months (22), and was maintained after 12 months. The use of a personal resuscitation manikin with video education enhanced basic life support (BLS) performance of hospital staff with limited or no direct patient contact, for up to six months in Norway (23). Moreover, students have demonstrated a stronger capacity to learn, receive, and retain new information related to CPR compared to older individuals (24–26). Students aged 15 to 16 years, who took CPR instruction were not only able to initiate BLS in times of need, but also created an information cascade by sharing their knowledge with their families (27).

Accordingly, the main objectives of this research are to (1) assess baseline knowledge, beliefs, and attitudes of high school students regarding heart attack signs and symptoms, (2) assess baseline knowledge of CPR among high school students, (3) implement an educational intervention based on a self-developed video, and (4) assess the change in baseline knowledge, beliefs and attitudes after the educational session.

CVDs are the leading cause of mortality in Lebanon, accounting for around half of all annual fatalities (9). Despite national efforts to address CVDs, they remain prominent notably due to worsening cardiovascular profile of the population, and difficulties in establishing and sustaining related health-promoting and preventative practices. Thus, it seems necessary to educate the public, and particularly students, about early recognition of heart attacks and performance of bystander CPR until emergency services arrive. By focusing on high school students, our study recognizes the essential role that teenagers play in sharing health information with their families and communities, possibly increasing the intervention’s impact. One effective approach for early action on disease risk factors is to create a supportive school environment and promote positive health behaviors through HPS. However, a study involving 50 Lebanese schools showed that, although the majority had health-related initiatives, less than half conducted a program evaluation or set a plan for improvement of their health promotion strategy (33).

Our results on HL add to existing literature that shows that a majority of Lebanese adolescents (73.2%) have moderate level of HL (34). In fact, higher HL appears to be a predictor of positive attitude towards heart attack among Lebanese students. Hence, the development of HPS and the implementation of HL related to CVDs may reduce heart attack risk factors and promote early recognition and call for help. Moreover, moderate to high levels of HL in Lebanese adolescents was shown to significantly lower their odds of adopting risky health behaviors like smoking, consuming alcohol, adopting a sedentary lifestyle, and being overweight (34). Similarly, exposure to sexuality education in schools increased the likelihood of Lebanese adolescents adopting protective behavior on their first sexual encounter; this is particularly noteworthy, as schoolteachers were reported to be the main source of information on sexual and reproductive health (35).

Our study showed that Lebanese high school students had poor knowledge of heart attack signs and symptoms. Additionally, participants identified the typical symptoms of a heart attack (like chest pain) more readily than atypical symptoms. This was consistent with previous studies from Lebanon and Saudi Arabia (17, 19). Other studies in Jordan, Kuwait, and Saudi Arabia showed that difficulty breathing was the most known symptom (18, 36, 37). In our study, abdominal pain was the least identified symptom. In contrast, headache was the least identified symptom in Italy (3.5%) (38), and pain or discomfort in the arm or shoulder was least identified in South Korea (53.8%) (39). Nevertheless, a systematic review suggests that a typical characterization of heart attack is impossible, especially among patients with comorbidities (40). Thus, given the high incidence of atypical presentations of acute heart attack, it is necessary to educate students about all possible prodromal symptoms, and not only the common clinical picture of chest pain and dyspnea.

Our study demonstrated poor baseline knowledge of CPR. A similar level of knowledge was found in students in Northern Ireland, where only 4.3% achieved a knowledge score of more than 70% (41). One of the main reasons for the observed lack in CPR knowledge was inadequate or absent training, which in turn was linked to lack of time or interest, lack of needed infrastructure, and not knowing the timing and location of available CPR training sessions (42, 43). Nevertheless, despite their inadequate knowledge, students had positive attitudes towards learning CPR (44, 45). Those findings show that a positive attitude towards learning and performing CPR along with the perception of self-efficacy are essential determinants of people’s willingness to perform bystander BLS prior to arrival of professional help (46, 47). Ensuring this readiness fulfills the 5th and 6th standards of the WHO Global Standards and Indicators for HPS (48), whereby the school expands its health-promoting resources to include teaching and non-teaching staff as well as parents (standard 5), and initiates new partnerships to contribute to the quality, sustainability, and impact of health promotion initiatives (standard 6). However, knowledge alone is not enough. It is important to instil the understanding that CPR, even if done poorly, is better than no CPR.

The students who always required assistance in reading medical instructions had less confidence in recognizing a heart attack incidence and adopted a rather negative attitude. Reading and understanding basic health information constitutes functional HL. It has been reported that around 66% of the Lebanese population have insufficient functional HL, associated with low education, low socioeconomic status, and being a widow (49). Another local study associated higher HL levels and sufficient numeracy skills to healthy behaviors like exercise, healthy diet, regular glucose monitoring, and comprehension of information related to diabetes (50). Given that a vast majority of Lebanese adolescents spend extended periods online, exceeding two hours daily (34), it is essential to promote their skills to assess the accuracy and reliability of information, and provide trustworthy sources for health education (51).

Our findings were consistent with existing literature showing that prior knowledge of heart attacks, from reading information about heart attack symptoms in the media or being taught about ACS symptoms by a healthcare professional, predicted better belief in one’s ability to respond to a heart attack occurring in front of them (52). Additionally, consistent with the literature, requiring assistance in understanding medical instructions was predictive of worse belief toward heart attack.

Our study showed that a brief educational video based on the AHA guidelines and tailored to high school students can improve their knowledge, attitudes, and beliefs towards heart attack as well as CPR knowledge. Video-based interventions have been shown to be effective in improving knowledge about heart attack among adult patients aged 40 to 60 years in the United States (53), patients’ with history of heart attack in Australia (22), hospital employees in Norway (23), college students in Japan (54), family members of hospitalized heart attack patients in the United States and China (55, 56), and school students aged 7 to 12 years in Portugal (25). However, there was no difference in overall mortality, total revascularizations, or hospitalizations between participants who got education, through video-based intervention or through healthcare professionals, as part of cardiac rehabilitation, and people in control groups (57).

Our video was balanced in terms of cognitive load, visual representations, and student engagement. The script was presented in Arabic to avoid language barrier. In addition, our intervention was delivered in small groups of 15–30 participants to ensure adequate information acquisition. This was developed in response to prior research that showed that large classes were a reason for failure of HPS initiatives (6, 7, 58). In larger classes, instructors struggle to offer attention to each student, there is less interaction between instructors and students, and teachers and school personnel struggle to monitor the health and well-being of each student. School administrators welcomed our project and instructors expressed a strong interest in learning more about heart attacks and CPR. Our initiative is worth scaling up because it provides a cost-effective means to increase Lebanese students’ health-related knowledge and their personal agency. This is particularly important in view of the surge of symptoms of anxiety and mental strain among Lebanese adolescents and young adults following the corona pandemic, and other major stressors like the political instability, the economic collapse, and the Beirut port explosion (34, 59, 60).

This study showed that high school students in Lebanon had insufficient baseline knowledge of heart attack symptoms and CPR. An intervention, based on an educational video, proved to be efficient, time-saving, and practical. This can be used as part of a health promoting schools program aimed at raising awareness of heart attack and first responder preparedness. The intervention may be extended to teachers and other school personnel.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The study involving humans were approved by the Lebanese American University’s Institutional Review Board. The study were conducted in accordance with the local legislation and institutional requirements. Written informed consent for participation in this study was provided by the participants’ legal guardians/next of kin.

MoA: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft, Writing – review & editing. EB: Conceptualization, Investigation, Methodology, Writing – original draft. KT: Conceptualization, Data curation, Investigation, Methodology, Writing – original draft. OA: Conceptualization, Investigation, Methodology, Writing – original draft. MNA: Formal analysis, Validation, Writing – original draft, Data curation. CB: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.