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ANALYSIS OF THE EFFECTS OF ENVIRONMENTAL FACTORS ON THE ORIGIN OF
HEART DISEASE
(ANALYTICAL ARTICLE)
Dehqonova Dilovarxon Komiljonovna
Andijan State Medical Institute
Annotation
This article was studied and written in a generalized way in a case where the influence of
environmental factors on the origin of cardiovascular diseases was used . Cardiovascular diseases
(CVDs) are the number one cause of death in the world. In most analyses of health problems,
environment plays a significant and modifiable role in causing the problem either directly or
indirectly through behavior. This study aims to understand the patients and healthcare providers’
experiences about the environmental determinants of CVD risk factors based on the Precede Model.
Key words
Disease, blood, heart, environmental factors.
Cardiovascular disease (CVDs) are the number one cause of death globally, It is predicted that by
2030, almost 23.6 million people would die from CVDs, mainly from heart disease and stroke (1). In
Iran, CVDs are the leading cause of mortality and morbidity, with high cost to health care (2). The
Inter Heart study showed that nine modifiable risk factors (abnormal lipids, smoking, hypertension,
diabetes, abdominal obesity, psychosocial factors, consumption of fruit and vegetables, regular
alcohol consumption and regular physical activity) were associated with more than 90% of the risk
of an acute myocardial infarction in this large global case-control study (3). Nonetheless CVDs
simplicity and completely are preventive (4). Interventions that have used both educational and
environmental measures have been more successful in achieving changes in health behavior than
single element interventions (5). A face-lifting environment that makes the health-promoting
behavior the easiest behavior to perform is key to a change in the behavior of the at-risk population,
as well as to a change of the environmental conditions (6). Examples of environmental conditions
include social influences (such as norms, social support, and reinforcement) and structural influences
(such as access to resources, organizational climate, and policies). Barriers to performing health
behavior are often structural; such as lack of health insurance, high-fat cafeteria foods, high cost of
healthy foods, and unsafe neighborhoods for jogging or walking (6). Environmental change usually
requires people outside the at-risk population to take action to modify the environmental conditions
(6).
To develop effective interventions, it is important to understand the behaviors of target population.
Qualitative methods are most ideal for gathering in-depth information to help develop this
understanding (7). On the other hand, qualitative methods can help the health educators to more fully
understand the health problems, behavioral and environmental causes, and determinants from the
perspective of the people involve (8). Several studies have examined environmental and social
barriers of healthy behaviors. In this studies the barriers to improve the lifestyle in regards to
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physical activity and diet included financial , stress (9) lack of social support (10) and cultural
barriers, such as lack of women- only exercise facilities (11), unsuitable built environment, unsafe
neighborhood and bad weather for doing physical activity and costs of healthy foods, unavailability
healthy foods in stores (12, 13). These studies did not use theories related to individual health
behavior in order to identify health problems, behavioral and environmental causes and their
determinants (14). The PRECEDE model that is often used in health education and health promotion
is a logical model that describes the causes of health problem (6). Based on the study by Green, the
behavioral causes can be classified to factors as predisposing, enabling and reinforcing. These factors
act as determinants for particular behavior, The most effective interventions for improving health can
be expanded for each factor (15). The predisposing factors are antecedents to behaviors that include
knowledge, attitude, belief, exiting skills, and self-efficacy. The enabling factors are antecedents to
behavioral and environmental change include the availability, accessibility, and affordability of
health care and community resources, laws and policies. The reinforcing factors are those factors
following a behavior that provide continuing reward or incentive for the persistence or repetition of
the behavior, which include social support, peer influence, significant others. The planners may see
determinants as the processes of change that must be activated or set in motion if the necessary
behavioral and environmental changes are to occur (16). A qualitative method with directed content
analysis approach was selected. The goal of a directed content analysis approach is to validate or
extend conceptually a theoretical framework or theory. Existing theory or research can help focus the
research question and it can help researchers begin by identifying key concepts or variables as initial
coding categories. This approach was employed by Hsieh and Shannon in 2005.
The data were collected through semi-structured in-depth interviews from September to March 2012.
After transcription and analysis of each interview, in case of ambiguity and for probing into
participants’ experiences, the interview was repeated to clarify different aspects of the subject, if
needed. Totally, 62 face-to-face interviews with 50 patients and 12 healthcare providers who work in
the Diabetes Units of Health Centers of Alborz University of Medical Sciences and Health Services
were conducted. Each interview lasted between 30 to 60 minutes and all the interviews were
conducted in a private room. The interview guide consisted of open-ended questions based on
subcategories of enabling and reinforcing categories of Precede Model to allow respondents fully
explain their own experiences.
The average age of participants were 46.5 ± 5.97 . The main researcher look at documents of blood
test results of patients performed by Diabetes Units’ staff, if patients had at least one biochemical
CVD risk factors such as pre-diabetes, type 2 diabetes (T2D), metabolic syndrome, hyperlipidemia
and hypertension for at least one month, and previously received advises from healthcare providers
to change lifestyle, the main researcher contacted each of the potential participants to explain the
objectives and the research questions, and if the participant agreed to take part in the research, an
interview was carried out. The patients were chosen using purposive method to consider the
maximum variation sampling based on (sex, age, level of education, occupation and the type of risk
factor) from four health centers associated with Alborz University of Medical Sciences which is
located in Karaj-Iran. The four centers were selected to obtain an understanding of patients with
various socio-economic statuses. Patients with previous heart attack, stroke, open heart surgery or
angioplasty, newly diagnosed patients (less than one month) and all type 1 diabetes patients were
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excluded from the study (n = 7). In addition, 12 healthcare providers from the Diabetic Units of four
health centers, including three general practitioners, three nurses and three dieticians were
individually interviewed. The mean age of healthcare providers was 38.4 ± 9.8 and 10 of them were
female.
This study was part of the PhD thesis of fist author, conducted in diabetes units of health centers
affiliated with Alborz University of Medical Sciences. The authors would like to thank all
participants who made this study possible. In subject‘s view point, lack of behaviors such as stress
control, diet therapy and physical activity were the main cause of the risk factors of CVD and the
environmental factor is one of the barriers for conducting these behaviors. The environmental
barriers included of structural and social environment. The structural factors are in three
subcategories of “availability and accessibility of health resources”, “new skills”, and “law and
policies” which are located in enabling category. The social factor included of three subcategories of
“social support”, “motivation to comply” and “consequences of behavior” which are located in
reinforcing category, that the most barriers to performing health behavior were often structural
(enabling factors). The environmental factors are barriers for doing health related behaviors, it
recommends in order to designing health promotion programs, policymakers not only focus on
patients' education but also consider specific facilities in related to economic, social and cultural
status. Then Identifying these determinants will help the program planners in designing of future
programs to select the most appropriate methods and applications to address these determinants in
order to decrease unhealthy behaviors in order to reducing CVD risk factors, and finally to prevent of
CVD, because the most immediate impact of an intervention is usually on a set of well-defined
determinants of behavior.
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