2.1 Therapeutic Lifestyle Change Intervention
The shift in global attention towards lifestyle-related diseases, spurred by socioeconomic development and the discovery of oil and gas, has introduced new health challenges worldwide (Conceição-Vertamatti et al., 2019; Ifeanyi, 2020; Tajamal et al., 2020). Health institutions across the globe have been making concerted efforts to promote their citizens' health (Denburg et al., 2016; Marrero et al., 2001; Scisney-Matlock et al., 2009). Meanwhile, the spread of the COVID-19 pandemic has created an imminent public health threat by exacerbating non-communicable diseases (NCDs) such as cardiovascular disorders, hypertension, cholesterol issues, and diabetes (Chang et al., 2021; Denburg et al., 2016; Ferdinan Augusty, 2014). These conditions pose a higher risk of patients suffering from stroke, kidney failure, and coronary heart disease (CHD) (Cane, Connor, & Michie, 2012; Hall, Do Carmo, Da Silva, Wang, & Hall, 2015; Sun, 2015), and premature death (Palmer et al., 2018; Sumarni & Putri, 2020).
Studies in Oman have revealed that lifestyle changes, dietary habits, and ageing, often linked to obesity, underlie the spread of these diseases (Matlock et al., 2009; Vertamatti et al., 2019). This is corroborated by local data showing high obesity (20.5%) and diabetes (11.6%) rates in the population (Anwar et al., 2018). Furthermore, unhealthy behaviours seem to be deeply entrenched in the Omani population's lifestyle (Al-Noumani et al., 2017; Al-Zakwani & Al-Hashmi, 2018). It is, therefore, crucial to make significant lifestyle changes to tackle NCDs. A decrease in fat and salty food consumption, along with increased physical activity, can significantly contribute to better Therapeutic Lifestyle Change (TLC) intervention and reduce the number of NCD patients in Oman. This will also mitigate the severe impact of communicable diseases like COVID-19 on public health (Chang et al., 2021; Leung et al., 2016; Naci et al., 2019; M. Palmer et al., 2018). The socioeconomic status, educational level, and health-related beliefs of patients and their families can greatly influence their willingness to change their lifestyle, particularly during a widespread pandemic like COVID-19 (Allen et al., 2017; Niessen et al., 2018; Posai et al., 2021).
2.2 Healthcare System & Therapeutic Lifestyle Change Intervention
The growing burden of communicable diseases like COVID-19 on NCDs presents a formidable challenge for individuals, families, and healthcare systems globally (Chang et al., 2021; Posai et al., 2021; Upadhyay, 2015). In Oman, the spread of chronic diseases is particularly alarming, demanding a systematic approach to curb this public health issue (Hall et al., 2015; Laar et al., 2019). The healthcare system's role involves multiple facets, from providing detection and treatment services to managing patients' healthcare records electronically for efficient follow-ups (Hills et al., 2018; Muka et al., 2015). However, a lack of supportive resources such as gyms or open areas for exercise may hamper the implementation of healthier lifestyles (Grill et al., 2016; Hills et al., 2018; Laar et al., 2019). Therefore, strategies compatible with patients' lifestyles, routines, and environments are needed to promote their willingness to follow TLC (Grill et al., 2016).
2.3 Health Behaviours & Therapeutic Lifestyle Change Intervention
Individuals' actions and norms greatly influence their health behaviours (Fennis, Andreassen, & Lervik-olsen, 2015; Long et al., 2016). The international health objective is to reduce the burden of communicable and non-communicable diseases and maintain a healthy public through behavioural change strategies, especially amid the COVID-19 crisis (Chung et al., 2009; Di Ciaula et al., 2021; Mustapha et al., 2014; Posai et al., 2021). Established habits and behaviours, such as dietary habits and physical exercise, strongly link to public health (Kane et al., 2017).
2.4 Health Behaviours & Healthcare System
Healthcare personnel play a pivotal role in providing affordable, high-quality care for chronic conditions and fostering therapeutic changes (Ashar Malik, 2014; Hills et al., 2018). As the spread of NCDs and the prevalence of COVID-19 continue to rise, the healthcare system must be fortified to cope with these challenges (Kim, Ahn, & No, 2012; Azarpazhooh et al., 2020; Abdel Fattah et al., 2021; Alalawi, 2018; Van Minh et al., 2014). Effective healthcare system management involves designing strategies for sector coordination, policy monitoring, and evaluation, adopting cost-effective treatment and medication plans, and advancing the use of technology (Ashar Malik, 2014; Muka et al., 2015; Rehr et al., 2018).
Moreover, the healthcare system plays a dynamic role in monitoring mortality and morbidity rates (Chukwuma, 2017; Gotch & Sargent, 1985; Mayosi et al., 2015), which provides healthcare personnel and policymakers with vital information to handle different situations and issues (Chukwuma, 2017; Mayosi et al., 2015). Thus, a better-managed healthcare system can influence individuals' decisions and behaviours towards NCDs, leading to healthier lifestyle changes (Dean & Söderlund, 2015; Hills et al., 2018; Laar et al., 2019). Despite social determinants determining individuals’ health behaviour, healthcare systems also directly shape people’s behaviour (Dean & Söderlund, 2015; Hills et al., 2018; Laar et al., 2019). Continuous patient-care personnel interaction facilitates patients’ awareness regarding their health condition and enhances their health habits (Al-Noumani et al., 2017; Ferdinand et al., 2014; Scisney-Matlock et al., 2009). An integrated collaboration among the healthcare system, society and individuals may present a comprehensive healthcare approach to controlling non-communicable disease spread (Al-Noumani et al., 2017; Ferdinand et al., 2014; Riet et al., 2015). Furthermore, it is necessary to understand the interrelations between health behaviours and the healthcare system, to develop effective strategies for dealing with NCDs, particularly in the context of the current global health crisis brought about by the COVID-19 pandemic.
2.5 Socioeconomic Status & Therapeutic Lifestyle Change Intervention
Socioeconomic status (SES) is a multifaceted measure that involves the economic and social position of an individual or family concerning others (Chetty et al., 2018; Gkiouleka et al., 2018). Various studies have suggested that SES has a significant influence on health outcomes, including mortality and morbidity rates (Huisman et al., 2013; Kondo et al., 2018). Higher SES is generally associated with better health status, and this correlation persists across different countries, cultures, and health systems (Mackenbach et al., 2015; Marmot et al., 2008).
Research has suggested that low socioeconomic status is linked to unhealthy lifestyle behaviours, such as poor diet, lack of physical activity, smoking, and excessive alcohol consumption (Pampel et al., 2010; Stringhini et al., 2010). These behaviours can lead to an increased risk of non-communicable diseases, including cardiovascular disease, diabetes, and cancer (Cutler et al., 2011; Spring et al., 2012). Therefore, improving these behaviours through Therapeutic Lifestyle Changes (TLCs) is a crucial component of efforts to reduce health disparities related to socioeconomic status (Artinian et al., 2010; Rosenstock et al., 1988).
However, changing lifestyle behaviours is a complex process that is influenced by a multitude of factors, including individual motivation, social support, and access to resources (Ferdinand et al., 2014; Resnicow et al., 1997). Interventions to promote TLCs must therefore consider these factors and provide tailored, culturally sensitive support to individuals (Ferdinand et al., 2014; Resnicow et al., 1997). They should also aim to address the social determinants of health, including poverty, education, and social exclusion, which can hinder individuals' ability to adopt and maintain healthy lifestyle behaviours (Allen et al., 2017; Niessen et al., 2018).
In conclusion, an integrated and multidimensional approach, incorporating individual, societal and systemic factors, is essential in promoting TLCs and tackling the global burden of NCDs. NCDs Management & Healthcare System
2.6 Socioeconomic Status & Healthcare System
Socioeconomic status (SES) plays a pivotal role in the accessibility and quality of healthcare services. It is an undeniable fact that healthcare is a social determinant that is deeply influenced by SES (Kondo et al., 2018; Mackenbach et al., 2015). Lower SES is frequently associated with reduced access to healthcare services, decreased quality of care, and inferior health outcomes (Braveman et al., 2010; Adler & Newman, 2002).
The impact of SES on the healthcare system is multilayered. At the system level, healthcare resources are often unevenly distributed, with lower-resourced areas often having fewer healthcare facilities, less staffing, and limited access to advanced medical technologies (Gaskin et al., 2009; Starfield et al., 2005). Moreover, the type and quality of healthcare that individuals receive often depend on their insurance coverage, which is typically influenced by their employment status, income level, and educational attainment (Sommers et al., 2012; Buchmueller et al., 2005).
At the individual level, patients with lower SES may lack the necessary health literacy to navigate the healthcare system effectively, understand medical advice, and adhere to treatment plans (Kutner et al., 2006; Berkman et al., 2011). Furthermore, individuals with low SES may face additional barriers such as transportation difficulties, limited clinic hours, or inability to take time off work for medical appointments (Syed et al., 2013; Arcury et al., 2005).
Improving health outcomes for individuals with low SES requires multifaceted interventions that not only target individual behaviours but also address systemic barriers within the healthcare system (Fattah and Al Halbusi, 2022). This can include interventions to improve the distribution of healthcare resources, increase the affordability and accessibility of health services, and improve health literacy among disadvantaged groups (Berkman et al., 2011; Marmot et al., 2008).
2.7 Interactions Among Variables
The intricate interplay among therapeutic lifestyle changes, the healthcare system, and socioeconomic status shape health outcomes at both individual and population levels. The socioeconomic status of an individual or community may dictate the extent to which they can adopt healthier lifestyle practices and influences their interaction with the healthcare system. The healthcare system, in turn, affects the accessibility, quality, and effectiveness of health interventions, which then impact the health behaviours of the individuals it serves.
Furthermore, these interactions occur within a broader context characterized by cultural norms, societal structures, and policy environments, which further influence the adoption and maintenance of healthy behaviours, access to and use of healthcare services, and overall health outcomes (Braveman et al., 2011; Frohlich & Potvin, 2008; Fattah et al., 2022).
Understanding these interactions is vital in designing effective health interventions, policies, and systems that cater to diverse populations with varying SES and health behaviours. A comprehensive and inclusive approach is required, addressing not just the biological determinants of health, but also the social, economic, and systemic factors that underlie health disparities (Marmot et al., 2008; Raphael, 2006). Only through such a holistic approach can we aspire to achieve the goal of health for all.
2.8 Conceptual framework
The model depicted in Figure 1 is derived from a comprehensive review of relevant literature. This model has been designed with a specific focus on the management of non-communicable diseases (NCDs) within Oman's population. The model identifies several key factors that can influence NCD management, particularly therapeutic lifestyle change interventions, healthcare system characteristics, and health behaviours of individuals.
2.9 Research Hypothesis
H1a: There is a significant relationship between therapeutic lifestyle change intervention and non-communicable disease management in Oman.
H1b: There is a significant relationship between therapeutic lifestyle change intervention and health behaviours.
H1c: Health behaviours mediate the relationship between therapeutic lifestyle change intervention and non-communicable disease management.
H2a: There is a significant relationship between the healthcare system and non-communicable disease management in Oman.
H2b: There is a significant relationship between the health care system and health behaviours.
H2c: Health behaviours mediate the relationship between the healthcare system and non-communicable disease management.
H3: There is a significant relationship between health behaviours and non-communicable disease management in Oman.