Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine - a health professional perspective
Barriers to cardiovascular disease secondary prevention care in the West Bank, Palestine - a health professional perspective
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DOI：
10.1186/s13031-018-0165-x
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发表时间：
2018-07-16
影响因子：
3.6
通讯作者：
Kienzler, Hanna
中科院分区：
文献类型：
--
作者：
Collier, Jane;Kienzler, Hanna
背景资料：非传染性疾病（NCD）--包括心血管疾病（CVD）、癌症和糖尿病--已成为全球健康的重大负担。特别令人关切的是心血管疾病发病率，每年在全世界造成约1800万人死亡。统计数字表明，这一疾病不再是高收入国家的主要现象，而是越来越多地影响到发展中区域和受冲突影响地区的国家。在被占领的巴勒斯坦领土（oPt），这篇文章的重点，心血管疾病排名前十的非传染性疾病的杀手，约占37.6%的死亡。在初级保健环境中发现的主要风险因素与结构性决定因素（即以色列占领）和个人行为因素有关。不幸的是，没有数据可用于在该地区的二级保健设置，因此，很少有人知道患者和他们的风险因素行为变化的能力，以管理他们的cVD.To开始在知识上的差距，我们的研究提供了深入了解心血管疾病二级预防保健的总体目标，以提高管理的复杂性，如心血管疾病在受冲突影响的设置。具体而言，在西岸专门研究冠状动脉疾病的巴勒斯坦卫生专业人员中进行了研究，以了解他们对以下问题的看法：（a）社会政治，卫生系统和个人行为因素可能会阻碍患者改变其健康行为，并影响医疗保健的提供，以及（B）克服社会和个人行为改变的已识别障碍的可能解决方案-在长期conflict.Methods的背景下，二级保健提供患者的水平：这项研究是基于一个定性的方法，以提供更深入的信息，健康的信念和行为，经验和卫生专业人员的意见，就心血管疾病二级保健。总共有12个半结构化的采访中进行的医生提供治疗的心血管疾病患者在二级保健设置。访谈的重点是卫生专业人员的风险因素和感知的障碍，已知的心血管疾病患者接受二级护理的行为改变的观点。受访者还被要求提出可能采取的行动，以克服社会和个体患者层面的障碍。所有的采访都进行了数字化记录，转录和分析，使用专题analysis.Results：研究结果证实了我们先前的理论复杂的纠缠的社会政治，卫生系统和个人层面的因素与心血管疾病的经验，寻求健康和治疗。我们的假设也得到了证实，即必须了解专家的定义和治疗方法，以便掌握他们对适当和改进的预防和治疗方案的看法。特别是，研究参与者强调了政治决定因素，特别是以色列占领的有害影响，以及社会决定因素如何直接和间接地影响行为决定因素，因为获得保健设施的物质和官僚障碍、经济困难和长期压力。反过来，这些压力因素被认为对个人行为风险因素有负面影响，包括吸烟、不健康的饮食和越来越久坐的生活方式。建议的解决办法包括卫生部更有针对性的干预措施以及监测、初级预防和健康促进以及管理，以积极影响行为改变，从而解决该区域日益严重的心血管疾病负担。这项研究强调了医疗专业人员对结构和个人行为决定因素如何影响他们自己和个别患者管理心血管疾病的能力的看法。在长期冲突影响的环境中的风险因素。因此，我们建议，医疗和社会干预战略通常用于解决心血管疾病的风险，战略性地调整，以便在武装冲突的情况下是有用和有效的。具体而言，我们呼吁在制定旨在解决该地区心血管疾病的未来健康选择时，对社会政治背景和现有卫生服务以及卫生服务提供者和患者的健康信念和相关行为有深入的了解。此外，为了有效和可持续地提供保健服务，首先需要注意政治变革的解决办法。
Background: Non-communicable diseases (NCDs) - including cardiovascular disease (CVD), cancer and diabetes have become a significant global burden on health. Particularly concerning are CVD rates, causing approximately 18 million deaths worldwide every year. The statistics show that the disease is no longer a predominantly high-income country phenomenon, but affects, increasingly, countries in both developing regions and conflict-affected areas. In the occupied Palestinian territory (oPt), the focus of this article, CVD ranks top of ten NCD killers, accounting for approximately 37.6% of deaths. Key risk factors discerned in primary care settings have been related to both structural determinants (i.e. the Israeli occupation) and individual behavioural factors. Unfortunately, no data are available for secondary care settings in the region and, consequently, little is known about patients and their capacity for risk factor behaviour change to manage their CVD.To begin closing this gap in knowledge, our study provides insight into cardiovascular disease secondary prevention care with the overall aim to enhance the understanding of the complexities of managing NCDs like CVD in conflict-affected settings. Specifically, research was carried out among Palestinian health professionals who specialise in coronary artery disease in the West Bank to elicit their views on (a) how socio-political, health system and individual behavioural factors might hinder patients to change their health behaviour and impact on the provision of healthcare and (b) possible solutions for overcoming identified barriers to behaviour change on societal as well as individual-patient levels within secondary care provision in a context of protracted conflict.Methods: This study is based on a qualitative approach in order to provide more in-depth information about health beliefs and behaviours, experiences and views of health professionals with regards to CVD secondary care. In total, 12 semi-structured interviews were conducted among doctors providing treatment to patients with CVD in secondary care settings. Interviews focused on health professionals' perspectives on risk factors and perceived barriers to behaviour change among known CVD patients receiving secondary care. Interviewees were also asked to propose possible actions that could be taken to overcome the identified barriers at both societal and individual patient levels. All interviews were digitally recorded, transcribed and analysed using thematic analysis.Results: Study results confirmed our prior theory of the complex entanglement of socio-political, health system and individual-level factors with regards to CVD experience, health-seeking and treatment. Also confirmed was our assumption that it is crucial to understand experts' definitions and approaches to treatment in order to grasp their visions for appropriate and improved prevention and treatment options. In particular, study participants highlighted how political determinants, notably the detrimental impact of the Israeli occupation, and social determinants, directly and indirectly influence behavioural determinants due to physical and bureaucratic barriers to accessing health facilities, economic hardship and chronic stress. These stressors, in turn, were perceived as having a negative effect on individual behavioural risk factors including smoking, unhealthy diet and an increasingly sedentary lifestyle. Proposed solutions included more focused interventions from the Ministry of Health as well as surveillance, primary prevention and health promotion, and management to positively effect behaviour change in order to address the growing burden of CVD in the region.Conclusions: The study has highlighted medical professionals' perceptions of how structural and individual behavioural determinants influence their own and individual patient's abilities to manage cardiovascular risk factors in a setting affected by chronic conflict. Consequently, we propose that medical and social intervention strategies generally used to address CVD risk, be strategically adapted in order to be useful and effective in contexts of armed conflict. Specifically, we call for a solid understanding of the socio-political context and existing health services as well as health providers' and patients' health beliefs and related behaviours when developing future health options aimed at addressing CVD in the region. Moreover, for health provision to be effective as well as sustainable, attention needs to be given above all towards a solution for political change.