Health providers painted a fairly bleak picture of secondary care provision. As will become apparent, they related the current situation mainly to structural (political, social, economic and health systems) and individual behavioural risk factors, which deterred their patients from participating in lifestyle changes that could improve health outcomes from cardiovascular events. At the same time, the practitioners made concrete recommendations for actions that could be taken to overcome some of the less macro-political barriers on the system and individual patient levels, and to address problems identified within health provision itself.
Structural risk factors and barriers to healthcare
All study participants referred to stress and insecurity as the main risk factors for the notable increase of CVD in the West Bank. According to them, stress was related to (a) structural determinants, particularly to the Israeli occupation, with its political instability, lack of freedom of movement and military presence and (b) daily stressors including economic hardship, unemployment and family conflicts. A doctor said, for instance:
I don’t think it’s just one thing, sometimes you’d get the stress from, you know, directly occupation-related, and sometimes you get the stress from the social economical status which is indirectly related to the occupation.
Stress and insecurity were also related to feelings of hopelessness for the future and depression. One doctor from a private practice indicated that 20% of his patients were prescribed antidepressants while another one working for a large governmental facility noted:
Living under occupation means not much to look forward to, occupation is (a) chronic disease.
Stress was considered to be associated particularly with the separation wall and Israeli checkpoints, both of which often prevent patients from reaching appropriately specialised health facilities in time. A doctor from a governmental hospital outlined the problem for patients who need urgent medical treatment as follows:
If someone has (a) heart attack who comes to (the) hospital you hope that they present on time. The ideal of the recommended ‘door to open’ time of 90 min, or the ambulance to emergency room time of 1 h is laughable here. The patient needs a permit, basically a visa to visit [the] hospital. How could somebody with a heart attack get a visa? And if he comes, the physician needs a permit to reach the hospital. So it’s a ‘no win’ situation.
Besides these political determinants, low socioeconomic status was considered an important factor impacting on self-care and, related to this, health outcomes. On the one hand, low salaries meant that patients lacked the capacity to purchase medication and, on the other, their long working hours did not permit them to engage in physical activity. One study participant explained:
The working hours are ridiculous and then, you know, you don’t have enough time to go and do something (...) you don’t have the time to go to the gym.
Even if patients were to consider the possibility of addressing such lifestyle changes, there was a reported lack of public spaces for recreation and leisure, and the local environment was described as deficient of suitable facilities for physical activity. Someone explained:
In Bethlehem, walking here, it’s dusty, there’s lots of cars, it’s uphill [laughing]. There’re no parks for people to walk around.
Also doctors in other West Bank cities lamented a lack of recreational areas and facilities that are designed for the use of adults, adolescents and children.
Individual behavioural risk factors for CVD
Study participants referred to a number of behavioural risk factors for CVD including smoking, a sedentary lifestyle and diet and explained how they were exacerbated by the protracted political conflict and related stress. Smoking was recognised as a major issue that should be tackled to reduce the risk of cardiovascular disease:
Smoking is really a big, big problem here (…), maybe it could amount to about 70% of adult men who smoke in this part of the world.
Whilst all respondents considered a reduction in smoking important, they also highlighted that it was extremely difficult for patients to change this behaviour as they used smoking as a means to combat the stress of living within a conflict zone and as a form of enjoyment. One respondent suggested that, due to the fact that people’s circumstances are challenging, one of their escapes and possible means of enjoyment is through smoking.
Because living under occupation is the main issue here, you know, people are experiencing a hard life so cigarettes are an escape.
It was further noted that especially older patients were reluctant to quit smoking because they considered it to be a way of socialising and bringing some form of enjoyment into their occupation-affected and often insecure lives. Younger smokers, on the other hand, were believed to smoke mainly because they followed family patterns of smoking behaviour, and once started, it was a difficult behaviour to stop. In addition, several participants alluded to the worrying trend of the increasing number of women smoking shisha pipes, known as argila.
Another contributing factor to cardiovascular disease was felt to be the increasingly sedentary lifestyle of many Palestinian people. A particularly low uptake of physical exercise was noted due to the fact that it does not play an important role in people’s everyday lives. “Exercise?” one of the doctors laughed, “Zero, we don’t do it here really”. This participant suggested that exercise is not an activity that is carried out within the Palestinian society habitually and on a wide scale. Numerous respondents reflected that the sedentary lifestyle contributes to the rise in obesity. It was noted to be of particular prevalence among women patients. For instance, two doctors highlighted that one of the reasons why there were more women presenting with CVD was because their lifestyle was believed to be more sedentary than that of men, that is, they were less active because they stayed at home more. This could imply that these health providers viewed women in a stereotypical female role and that being responsible for the home and childcare are viewed as ‘sedentary’ activities. It was also suggested that there might be an increased presentation of CVD amongst women because they tend to stay at home when ill and are believed to visit hospitals more rarely. This could result in delayed hospital presentations by which time some risk factor complications may have already set in.
Furthermore, a change in dietary habits among patients was believed to lead to diabetes, obesity and high cholesterol. This was often attributed to the influence and transference over time to a Westernised diet such as high-fat fast foods and sugary drinks particularly by younger people who now opt for this in preference to traditional home-cooking. A health provider reasoned:
Now, unfortunately we’re getting slowly into this (…) Westernised lifestyle. This means obesity and all its problems such as diabetes, high cholesterol and a sedentary lifestyle. These all lead to cardiac diseases being the number one problem here.
The cultural change in the lifestyle habits of patients was identified especially by the older study respondents who, over their long years of working in cardiovascular medicine, were seeing more women smoking and noticing less healthy dietary choices. Correspondingly, many of the younger doctors also seemed to be aware that these cultural changes presented a significant problem for tackling risk factors, but felt that the patients’ lack of motivation was a key factor in encouraging lifestyle change.
A number of doctors stated that, despite apparent patient awareness of the benefits of adopting healthier lifestyles, this lack of motivation was compounded by a level of complacency around family illness history relating to CVD. It was felt this near denial led to many patients not considering making lifestyle changes until after the occurrence of their own heart attack. Doctors also felt this complacency accounted for the noticeable increase in younger patients now presenting with CVD as, despite having a positive family history, young people were not addressing any required behavioural changes to reduce their own risk of CVD. This noted self-regard in the young was connected to a lack of motivation, in part due to people’s circumstances:
It’s the lack of motivation which (…) I would say under the current circumstances, (…) could not be changed. It is more difficult because when you look at the circumstances (…), the political conditions in general, there is not much hope for the younger generation .
This poor motivation for behaviour change, often driven by low mood, was believed to exist despite apparent patient awareness of the benefits of adopting healthier lifestyles.
Proposed solutions for improved secondary care provision
Respondents reflected upon what kinds of changes would be necessary and feasible to help people change their behaviour under these challenging circumstances. In particular, they highlighted the importance of developing multi-disciplinary teams in their clinics, improving communication and referral structures, increasing human and material resources, engaging more in advocacy and, importantly, policy development..
Health providers explained that they would be able to work more effectively if they could work in multi-disciplinary teams with specialists from various relevant departments. One practitioner commented that this would help him to:
Take my decision in the next step (of patient) management, this would be better for the patient. I feel there is a shortage of physiotherapists, dieticians and nurses, and this affects my work actually.
It was also suggested that working more closely with specialists from other health departments would improve the handover and continuation of patient treatment. Several doctors commented on the particular need for endocrinologists to address the increasing presentation of diabetic patients with complications, as this could affect the onset of CVD.
This lack of integrated healthcare was also connected to the importance of improving communication between and within health departments. One practitioner said for instance:
We have a defect here in our system in that not every patient is followed by the same specialist and so I guess there’s a defect in the communication between the doctors here in our department.
This poor communication was also reported between primary and secondary healthcare providers. A doctor outlined:
Actually there is no satisfaction, there is no good co-operations between the hospital and the diabetic centre for primary healthcare, it is above our ER but we don’t have any communication.
In terms of a possible solution to this problem the same doctor explained:
We should include it together, the endocrinologist in the diabetes centre (…) and with cardiologist for acute coronary syndrome to manage the risk factor from there and we manage the acute events.
Other respondents echoed the importance of working across specialisations as it was felt to be crucial for monitoring, follow-up and on-going education for lifestyle support such as smoking cessation and dietary adherence.
In order to further improve secondary healthcare for CVD, several health practitioners emphasised the importance of having enough staff on hand. Yet it is important to note that they differed in their views on whether or not there were enough medical experts available to assess and care for patients with CVD. Half of them considered there to be enough residents in their clinic while others highlighted a lack of doctors and specialists, such as those working in endocrinology, who could do more to provide support for diabetic patients. It was noticeably the younger practitioners working in the governmental hospitals who complained about a lack of specialists.
In addition to a lack of staff, respondents referred to a shortage of equipment. This, it was explained, led to many patients with known risk factors for cardiovascular disease not being supported in monitoring their condition appropriately, and not receiving adequate advice that may prevent complications or the leading to chronic disease. As a result, respondents stated that there is a higher presentation of patients to secondary care facilities once complications have set in and a rise in the presentation of younger patients with cardiovascular disease. In addition, doctors felt that patients were confused about where to go for treatment and often bypassed initial services and, instead, headed straight to secondary care. It was believed that another reason they may present initially at secondary care was due to patient concerns about the current state of primary care services. Consequently, patients preferred to attend secondary care facilities as they had more ‘trust’ in the hospital service.
Besides the faults highlighted within the primary care provision leading patients to default to secondary care services, doctors suggested other solutions to support patients to manage their CVD such as advocacy, research and health policy. In terms of advocacy, they argued that regardless of patient reluctance to behaviour change, a doctor’s most important role was education and reaching a compromise with patients about lifestyle change and treatment options. It was considered that education could be provided through the doctor-patient relationship or via social media. One study respondent stated that he carried out regular radio presentations where he focused on particular risk factors for CVD and provided advice for listeners. However, some respondents noted the relevance of the educational level of patients to be able to understand and follow advice:
The good news is our society is one of the most-educated societies in the whole Arab world (…), but at the same time there are areas in Palestine where people are much less educated and this means the compliance (...) and you talk to the family or somebody who’s well educated in the family you might (still) get problems in their understanding of the disease, and the need of follow up.
Reference was made by participants to the importance of evidence to inform priority setting. Two doctors noted a lack of published statistics to support the widely acknowledged increase in the presence of CVD risk factors:
We don’t have national statistics, at least good ones, to be sure what we are seeing.
This could be significant as potentially, without the knowledge of the number of patients presenting with risk factors, it may be difficult to consider how to plan, prioritise and fund health conditions.
Relating to an identified possible solution at policy level by participants, it was suggested that more could be done particularly within the food and tobacco industries. In relation to tobacco, one doctor commented:
It’s difficult because you need to go another ten, twenty years to be able to enforce that there is no smoking in public places.
This would imply that any potentially helpful policy changes take a long time to implement.
With regard to the food industry, mention was made of there being two types of restaurants – a costly one offering low calorie food, and a cheaper one with high calorie content. This was felt to be unfair as busy, hardworking or impoverished people would visit the cheaper restaurants and, thereby, subject themselves to a diet that was not considered to be in the least bit helpful in reducing the risk of CVD.