Heat stroke, the most severe form of heat illness, emerges as a critical public health concern globally due to the increasing incidence of heat waves. This condition, characterized by a core body temperature exceeding 40 °C, stems from an imbalance between the body’s heat production and dissipation. Such imbalances occur due to exposure to high ambient temperatures and/or intense physical activity. The resulting heat load overwhelms the body’s cooling mechanisms, potentially initiating heat stroke in environments where heat cannot be effectively dissipated (1).

Clinically, heat stroke manifests through severe central nervous system abnormalities, including altered mental status, convulsions, or coma, and may precipitate life-threatening multi-organ damage. The spectrum of heat stroke includes classic heat stroke, typically triggered by environmental heat during summer waves, and exertional heat stroke, often linked to physical exertion (2–4).

Epidemiologically, the incidence of classic heat stroke ranges from 17.6 to 26.5 cases per 100,000 during heat waves, with a mortality rate among hospitalized patients between 14 and 65%. Conversely, exertional heat stroke comprises 8.6 to 18.0% of heat-induced ailments (5).

As the most extreme heat-related illness, heat stroke can lead to dysfunction in the central nervous system, widespread organ failure, cardiovascular damage, and even death. This underscores the urgent need for enhanced public health strategies and interventions to mitigate the impact of heat waves and prevent heat stroke.

The Knowledge, Attitude, and Practice (KAP) model asserts that individual behaviors are influenced by one’s knowledge and attitudes. This framework is critical in public health for elucidating health-related behaviors, particularly through the use of KAP surveys that assess both knowledge and risk perception (6–8). Understanding public perceptions and responses to heat stroke is essential for developing effective prevention and education strategies. These strategies are designed to bridge knowledge gaps and enhance preparedness, thereby reducing the potentially severe impacts on health systems during peak heat periods. In China, public health research on urban heat waves is gaining increasing attention. For example, one study conducted in the extremely hot-humid city of Chongqing explored residents’ perceptions, physiological and psychological impacts, adaptive awareness, and broader issues such as climate justice (9). While such research provides a valuable macro-level perspective, there remains a lack of refined KAP studies that focus on the interaction pathways between knowledge, attitudes, and practices in climate-specific cities—such as Ningbo, a subtropical coastal city with dense population and prolonged humid summers.

In China, where the climate is marked by minimal regional temperature variations and prolonged periods of consistent high temperatures, this research becomes even more crucial. Some regions in China experience summer temperatures that exceed 39 °C (5). Such extreme conditions underscore the importance of tailored public health interventions to safeguard particularly vulnerable populations, who are often disproportionately affected by heat waves and may lack the resources or knowledge necessary for effective self-protection. While international studies have explored heat stroke KAP, research within China remains limited, particularly focusing on the unique context of subtropical coastal cities which are characterized by high-humidity, high-temperature summers and a dense urban population. These cities, like Ningbo, represent a critical area for public health intervention.

This study, therefore, focuses on Ningbo, a representative subtropical coastal city in China, to assess the public’s KAP regarding heat stroke. The findings aim to provide evidence for developing targeted health education strategies for Ningbo and other cities with similar climatic and socioeconomic characteristics, thereby contributing to a nuanced understanding of heat stroke preparedness in urban China.

The study revealed that the public in Ningbo City possesses adequate knowledge, maintains positive attitudes, and engages in effective practices concerning heat stroke prevention and management. Given the significant influence of knowledge and attitudes on practices, it is recommended that public health interventions focus on enhancing educational programs to further improve the community’s response to heat stroke, particularly targeting high-risk demographics identified by the study.

Our analysis confirmed the interrelationship among KAP regarding heat stroke prevention, as evidenced by significant positive correlations and SEM. Knowledge was shown to positively influence attitudes and practices, and attitudes also significantly affected practices. This interconnection suggests that enhancing public knowledge about heat stroke can be an effective strategy in improving overall community preparedness and response (13, 14).

The study also highlighted significant variations in KAP regarding heat stroke prevention among different demographic groups, with particular disparities. Notably, younger participants (aged 18–45) demonstrated slightly lower knowledge and practice scores compared to older individuals, showing that younger age was associated with lower practice engagement. This may reflect a generational difference in exposure to and prioritization of heat stroke prevention information, suggesting a need for targeted educational campaigns aimed at younger populations (15, 16).

Education level emerged as a significant predictor across all KAP dimensions, with higher education correlating with better outcomes. This finding aligns with previous research indicating that higher educational attainment enhances health literacy, which in turn promotes better health behaviors (17, 18). The multivariate analysis reinforces this, with significant odds ratios indicating that higher educational levels, including junior college, bachelor’s degree, and master’s degree or above, are strongly associated with improved practices. An unexpected finding of this study was that married individuals had lower practice scores compared with unmarried participants (OR = 0.433). Although the present study was not designed to explore the underlying causes, possible explanations include greater family and work responsibilities limiting personal preventive actions, or a “diffusion of responsibility” within households where individuals assume that other members will take preventive measures. This observation warrants further investigation in future studies, for example through qualitative interviews or targeted quantitative surveys, to clarify the social and family dynamics behind this pattern (19).

Moreover, significant differences were noted in practices based on gender, with females engaging more frequently in heat stroke prevention practices than males. This could be linked to a generally higher level of health-conscious behavior observed among women in various settings (20, 21). Interestingly, participants with a history of heat stroke or severe heat exhaustion displayed better knowledge and practices. This could be due to their direct experience with the condition, enhancing their perception of its seriousness and triggering more vigilant self-protective behaviors (6). Individuals with chronic diseases showed lower practice scores and also lower knowledge scores, potentially reflecting an overarching burden of disease management that may limit capacity or motivation to adopt additional preventive measures (22, 23).

Moreover, we observed substantial gaps in the public’s understanding and practical response to heat stroke, despite generally positive attitudes toward the seriousness of the condition and the need for preventive measures. Notably, there was significant uncertainty among participants about heat stroke’s occurrence during exercise in cooler environments and the effectiveness of traditional remedies. To address these deficiencies, health authorities could leverage digital and community outreach platforms to clarify misconceptions about the conditions under which heat stroke can occur (24). Furthermore, embedding heat stroke prevention education into school curricula and workplace training could ensure that younger and working-age populations are better equipped to handle heat-related risks (25, 26). Our findings suggest that public health policies in Ningbo should move beyond general awareness campaigns. For instance, given the misconception that heat stroke cannot occur in cool environments, educational materials should explicitly feature real-life scenarios such as strenuous indoor exercise or hiking on a cool but humid day. Additionally, since lower educational attainment was significantly associated with poorer heat stroke prevention practices, there is a need for community-based, visual-first health education programs. These should be disseminated through familiar platforms like community centers, local television, and social media apps such as WeChat, using infographics and video content rather than text-heavy brochures to ensure accessibility and engagement among less-educated populations (27, 28). While this study underscores the importance of strengthening health education to modify individual behavior, relying solely on personal efforts is insufficient. Structural and environmental interventions are equally critical. Individual preventive actions can only be effectively sustained within supportive environments. For example, previous research has shown that through scientifically designed community planning—such as developing cool, walkable, and cyclable transportation systems—residents’ exposure to urban heat can be substantially reduced. This represents a promising approach for building heat-resilient cities (29). Therefore, we recommend that public health departments collaborate with urban planning, transportation, and landscaping sectors to jointly promote the construction of climate-adaptive communities. In addition to educational efforts, enhancing public health infrastructure by creating heat-relief zones with adequate hydration stations and shaded areas could materially support the community, particularly in public and communal spaces (30). Tailoring interventions to high-risk groups—such as the older adults, children, and outdoor workers—by providing specific guidance and heat safety kits could further strengthen community resilience. These kits could include items such as water bottles, electrolyte packets, and educational materials on recognizing and responding to heat stroke symptoms (31, 32). Encouraging community-led health promotion, where community members educate and support each other in adopting preventive practices, can reinforce positive behaviors and foster a supportive network (33, 34).

This study has several limitations that should be considered when interpreting the results. First, our sample did not specifically target high-risk populations such as the older adults (>69 years) and children, who are physiologically more vulnerable to heat stroke. The sample also contained a high proportion of younger adults and females, which may have introduced bias and limited the generalizability of the results. Specifically, younger adults (85.87% aged 18–45) and females (62.96%) were overrepresented, which may further restrict the applicability of the findings to high-risk groups such as the older adults. Future research should employ stratified sampling methods to ensure a more balanced representation of older adults participants, males, and other vulnerable groups, and should also develop tailored questionnaires or observational tools to capture their specific knowledge and behavioral needs regarding heat stroke prevention. Second, the cross-sectional design precludes the ability to infer causality between knowledge, attitudes, and practices related to heat stroke. Third, the data were collected during winter and spring rather than in the peak summer months, which may have reduced the reported levels of awareness and preventive practices, particularly those that are season-specific, such as stocking cooling items or adjusting daily routines during hot weather. Future studies should include follow-up surveys during peak summer periods to capture these seasonal behaviors more accurately. Fourth, the sample was drawn exclusively from Ningbo City, which may limit the generalizability of the findings to other geographical areas with different climate conditions and public health infrastructures. Finally, the self-reported nature of the data may introduce response bias, as participants might overestimate their knowledge or practices concerning heat stroke prevention. In addition, while confirmatory factor analysis (CFA) for the measurement model showed acceptable fit with some indices, its RMSEA value of 0.085 was slightly above the conventional good fit threshold of 0.08, suggesting minor room for improvement in the measurement model. Furthermore, the overall Structural Equation Model (SEM) fit indices did not fully reach the recommended thresholds (CMIN/DF = 4.960 and RMSEA = 0.092 were suboptimal). Although we retained all items to preserve content validity and theoretical completeness, these limitations in model fit suggest that the interpretation of specific path coefficients should be approached with appropriate caution. Future studies should test and refine the scale with larger and more diverse samples to achieve stronger psychometric performance.

In conclusion, the study revealed that the public possesses adequate knowledge, maintains positive attitudes, and engages in appropriate practices concerning heat stroke, indicating an effective transmission of health information on this critical issue. These findings suggest the importance of continued educational interventions that enhance understanding and attitudes toward heat stroke, particularly focusing on targeted age groups and educational backgrounds to optimize preventive practices across the community.