Barriers and strategies for identifying and managing risk factors of cardiovascular diseases in levels of preventing , screening , and treating

© 2015 The Authors; Tabriz University of Medical Sciences This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Barriers and strategies for identifying and managing risk factors of cardiovascular diseases in levels of preventing, screening, and treating

This organization also estimates that if no effort is made to improve cardiovascular health and if the current trend continues, up until 2020, 25% of healthy living years of life will be lost due to CVD and a high volume of this number would be related to developing countries. 2In Iran CVD are also considered as the most prevalent cause of mortality. 3Studies conducted in Iran show that without considering loss resulted from Bam earthquake, 320204 people died and the first reason in terms of number, is death resulted by CVD.In the same year, the number of deaths as a consequence of CVD was 72628 for men and 62068 for women, a total of 134750 cases. 4][13] Iran also is not an exception in this case and fortunately during recent years primary cares have been properly set up and designed in our country and has had significant achievements in reducing load of diseases. 14,15esults of reviewing texts show that there have been deficiencies in field of proper identifying and managing of risk factors of CVD. 12,16Therefore, the objective of current study is to determine barriers and strategies for identifying and managing risk factors in CVD in levels of prevention, screening, and therapy using qualitative study method by beneficiaries' points of view.
During present qualitative study which was designed and conducted in Educational-Medical Cardiothoracic Subspecialty centers of Tabriz University of Medical Sciences, Iran, between June 2012 and December 2013, 60 subjects of cardiologists, nurses, patients, and their relatives were entered into the study.The reason for choosing qualitative study method is the ability of this type of study in achieving inside story of participants and extracting their experience, knowledge, and silent information. 2,17Among different approaches of qualitative studies phenomenological approach was selected to investigate experiences of people and believe in this issue that there are essences of phenomena and experiences of life which could be understood and studied. 18,19Participants of this study are cardiologists, nurses of cardiovascular wards, cardiovascular patients, and families of patients.Some of patients and doctors could not participate in the study the former due to physical problems and the later due to lack of free time.These people were selected because of their high amount of experience and knowledge.Including criteria were: having at least 1 year of work experience in health and medical system for providers, having at least bachelor degree for managers and nurses and general practitioner degree for physicians, referring to receive cardiovascular cares for patients and passing at least 6 months from diagnosis of CVD.Excluding criteria were: lack of having free time, ability, and tendency to participate in the study.
To select participants, a purposive sampling method was used.In this method, those people are selected as participants who have the highest and richest information and are able to properly share their knowledge with researchers. 17,20This was continued up to reach information saturation, which is when researchers feel that new information could not be acquired with continuing sampling. 21Finally, information saturation was gained in this study after the participation of 60 people.
To collect data, an open-ended questionnaire was used which had been designed in this field using review of texts and ideas of expert people.To identify problems of questions and proper recognition by participants, first 5 of them were completed by participants as pilot, and a questionnaire was finalized after troubleshooting.For patients and their accompaniers who had not ability or literacy to write, questionnaires were completed through an interview with them and writing down their speeches by trained questioner.To analyze data content analysis was used which is a method to identify, analyze, and report themes available inside the text and is very useful in analyzing qualitative data. 22ata encoding were done by two researchers.
Analyzing and encoding steps were as below: 1. Multiple reading of questionnaire texts-Data immersion (getting familiar with context of data-Immersed) 2. Identifying and extracting primary codes 3. Identifying themes (putting extracted primary codes in related themes) 4. Reviewing and completing identified themes 5. Naming and defining themes 6. Assuring about reliability of extracted codes and themes (agreement between two encoders by discussion and removing disputed cases).
For rigor of data peer check was used in a way that text of questionnaires and extracted codes were given to other colleagues, and their ideas were investigated and applied in results and also data immersion was also used which is a method to create rigor 23 in a way that collected and summarized texts of questionnaires were reviewed for many times by researchers to get a full familiarity and complete comprehension.
To consider ethical issues informed consent was received from participants of this study and people were free to leave the study at any point they wanted.Moreover, the objectives of the study were explained to participants at first.To conduct current study ethical approval was gained from the Regional Ethics Committee for Research located in Tabriz University of Medical Sciences.
Participants of the study include 26 patients (with mean age of 48.3 ± 12.4), 7 accompaniers of patients, 23 nurses (with work experience of 11.6 ± 4.6), and 4 cardiac specialists and subspecialists (with work experience of 14.2 ± 7.3).
Barriers and problems of proper identifying and managing risk factors of CVD in triple levels (prevention, screening, and proper treatment) from participants' points of view have been provided in table 1.
As it is seen in table 1 generally in all triple levels low information and knowledge, lack of facilities, high costs, and shortage of time are of the most important problems and barriers for proper identifying and managing risk factors of CVD.
Strategies to improve and remove barriers and problems available in proper identifying and managing risk factors of CVD in triple levels (prevention, screening, proper treatment) from participants points of view have been provided in table 2.
As it is seen in table 2 generally in all triple levels increasing awareness of people, reducing the costs, increasing facilities, and removing social and economic problems of people are of the most important strategies to improve and remove barriers and problems available in proper identifying and managing risk factors of CVD from participant's points of view.
By summarizing mentioned barriers from points of view of participants of the study, it is possible to divide all of them in three general groups of personal barriers, socioeconomic barriers, and health barriers.This categorization has been shown in figure 1.
Based on the results of this study, barriers and problems of proper identifying and managing risk factors of CVD in triple levels (prevention, screening, and proper treatment) were divided into three general groups of personal barriers, socio-economic barriers, and barriers related to health medical services.
In personal barriers' field, low awareness of people about CVD and its symptoms was mentioned as one of the most important barriers and problems on proper preventing, screening and treatment of these diseases.[26]   Therefore, effective planning and interfering seems necessary to increase awareness of people about CVD and proper ways of their prevention, screening, and treatment.As it was mentioned by most of the participants of this study, giving information through public media such as TV and Radio Organization and widely circulated newspapers could be of effective interferences and strategies.Besides information through public media, private information programs should be also considered in agenda.Since comprehension and knowledge level of all people is not same and maybe some of them would not be able to understand and analyze these messages and also some cardiovascular patients need informational requirements specific to themselves based on their special situations, which shows the importance of information and especial programs to increase awareness and information of specific groups.To do so it is possible to use pamphlets and educational CDs prepared in simple language proper for needs and ability level of specific groups.Furthermore, it is possible to make benefits of informed local people to train these persons.
Late referring for screening and proper treatment of CVD was also another personal barrier mentioned by participants.Review of references shows that delay in referring for treatment and screening have been observed among males and females with cardiovascular problems. 27It seems that delay in referring for screening and effective treatment is a consequence of low awareness and information.Because it seems that in the case of being aware of benefits and results of on time referring, people will try to refer on time for screening and proper treatment.As some participants of this study mentioned to wrong beliefs as one of the barriers of proper prevention, screening, and treatment, it seems that another factor of late referring is the consequence of wrong beliefs.Therefore, to remove this problem, interfering in these two issues to increase awareness and correct wrong beliefs of people could have significant results.
Almost all participants of this study mentioned to financial problems or high costs of screening and treatment of CVD, which was classified in group of socio-economic problems.Study of Moise 7 aiming at investigating treatment, costs, and consequences of cardiac ischemic diseases in Organization for Economic Co-operation and Development (OECD) countries showed that generally costs of cardiac diseases are much more higher than that of other diseases.The main reason of these costs could be due to highly complex nature of cares and treatments of these studies.In this study, some of participants mentioned to lack of proper cooperation and insurance coverage.Therefore, according to the effect of high costs on prevention, screening, and proper treatment of CVD, 28 it seems inevitable to interfere and plan in order to reduce the costs or cover them.From physicians' and some nurses' points of view shortage of time was a barrier stopping physicians and nurses, and in primary care providers of health services from proper involvement in prevention, screening, and proper treatment.Study of Ferrante et al. 29 in Argentina also showed that shortage of time of health service providers is one of the important barriers in preventing CVD.1][32] It seems that one of the reasons for shortage of time of health service providers to dedicate proper time to prevent and screen of patients is high demand for therapy services in hospitals which consumes a great deal of time of providers.The other reason for the shortage of time could be due to people's time management.In this case holding courses or workshops for effective time management could have an effective role in resolving this problem.
Shortage of health care facilities is one of the barriers related to heath care systems mentioned by participants of this study.By facilities, we mean human resources, equipped center, proper tools, and other health care facilities.4][35] Therefore dedicating more resources to this sector of health system seems a necessary issue.But considering the limitation of resources in the health sector, first it should be tried to increase efficiency and performance of available facilities using proper managerial methods.
Two interesting and important suggestions advised by patients and their accompaniers in this study were highlighting and developing the role of family physicians in prevention and screening programs of CVD and using performance indicators in hospitals.][42][43][44][45] Results of this study, like results of other qualitative studies have low generalizability to other environments and conditions. 46nother weak point of this study was the lower participation of specialist physicians in this study.
Low awareness of people, high screening, and hospital costs, lack of health care facilities, socio-economic problems of people, and delay in referring to treat and screen are of the most important barriers and problems in proper identifying and managing risk factors of CVD.Increasing awareness of people through public media, reducing the costs, supporting family physicians, and using performance indicators to evaluate and develop the quality of provided services, are also of the most important strategies suggested by participants to improve and remove available problems in proper identifying and managing risk factors of CVD.
Authors have no conflict of interest.
Finally, it is liability of researchers to extend their regards and thanks to all participants of this study and authorities of Shahid Madani Cardiothoracic Subspecialty Hospital for their kind cooperation and deducting their valuable time to researchers.

Figure 1 .
Figure 1.Barriers and problems of proper identifying and managing risk factors of CVD (cardiovascular diseases) in triple levels from participants' points of view

Table 1 .
Barriers and problems of proper identifying and managing risk factors of CVD (cardiovascular diseases) in triple levels from participants' points of view (n = 60)

Table 2 .
Solutions to improve and remove barriers and problems available in proper identifying and managing risk factors of cardiovascular diseases in triple levels from participants points of view (n = 60) Chung M, Asher RC, Yamada D, Eagle KA.Arrhythmias after cardiac and non-cardiac surgery.Simons-Morton DG, Cutler JA.Cardiovascular disease prevention research at the national heart, lung, and blood institute.American Journal of Preventive Medicine 1998; 14(4): 317-30.Doi: 10.1016/S0749-3797(97)00057-3 3. Iranian Ministry of Health and Medical Education.A national survey on health and diseases in Iran.Tehran, Iran: Iranian Ministry of Health and Medical Education; 2000.[In Persian].4. Naghavi M. The pattern of mortality within 23 provinces of Iran in 2003.Tehran, Iran: Iranian Ministry of Health and Medical Education; 2005.[In Persian].5. Azami S, Tabrizi J, Abdollahi L, Yari Fard K, Kabiri N, Saadati M, et al.Knowledge and attitude of top managers toward accreditation; in Tabriz and Ardabil teaching hospitals.Journal of Health 2012; 3(2): 7-15.[In Persian].6. Takayanagi K, Kawai S, Aoki R. The cost of burn care and implications for efficient care.Clin Perform Qual Health Care 1999; 7(2): 70-3.7. Moïse P, Jacobzone S. OECD study of cross-national differences in the treatment, costs and outcomes of ischaemic heart disease.OECD Health Working Papers 2003; 3: 124.Doi: 10.1787/18152015 8. Sohrab N, Alireza AR, Ata M, Mahmoud S, 1.