In total, 16 participants (8 men and 8 women) were interviewed. Consent was obtained from participants to provide written information، After analyzing the data Appendix2:Code System Deta Extractions in the Maxqda, 4 main categories were formed based on the risk management cycle, which were Pre-emergency Phase, Emergency Response, and recovery phases (Table-1). At present, the priority of the World Health Organization is cardiovascular diseases with high blood pressure, diabetes and chronic respiratory diseases, which can be considered very important and urgent for global health (16).
Table 1
Challenges of providing health services for cardiovascular patients in 3 phases of emergencies management cycle
3 phases of emergencies management cycle
|
Challenges of cardiovascular patients during emergencies and disasters
|
Pre-emergency Phase
|
1. Lack of training on medication and nutrition [3،7]
2. Lack of a proper infrastructure [2]
3. Patient Identification Program [1،6]
4. Lack of manpower [4]
5. 1. Lack of training vulnerable groups [5]
6. Lack of a database of cardiovascular patients(6)
|
Emergency Response
|
1. Problems with sleep and rest patterns [8]
2. Lack of health personnel [9]
3. Lack of mental health interventions [12]
4. lack of access to medications [11]
5. Securing the camps [10]
|
Post-emergency phase
|
1. Lack of planning and management [13]
2. Patients' psychological problems [14]
4. Fatigue of the workforce [15]
5. Risk management [16]
|
Table 2
Characteristics of the experts participating in the study
No.
|
Age
|
Gender
|
Degree of education
|
Position, Organizational post
|
Work experience
|
1
|
48
|
Man
|
PhD in Nursing
|
Faculty member of the University of Medical Sciences
|
23
|
2
|
42
|
Man
|
Master of Health
|
Hospital Health Expert
|
18
|
3
|
40
|
Woman
|
PhD in Disaster Health
|
Faculty member of the University of Medical Sciences
|
21
|
4
|
46
|
Woman
|
PhD in Disaster Health
|
(Manager in the field of health) Faculty member of the University of Medical Sciences
|
25
|
5
|
38
|
Woman
|
Master of Nursing
|
ICU Nurse
|
12
|
6
|
32
|
Man
|
Epidemiologist
|
Faculty member of the University of Medical Sciences
|
15
|
7
|
34
|
Woman
|
Epidemiologist
|
Faculty member of the University of Medical Sciences
|
24
|
8
|
47
|
Woman
|
Master of Health
|
Hospital Health Expert
|
23
|
9
|
31
|
Woman
|
Master of Health
|
Hospital Health Expert
|
13
|
10
|
43
|
Man
|
Cardiologist
|
Director of the Cardiology Department of the Hospital
|
16
|
11
|
44
|
Woman
|
PhD in Disaster Health
|
Faculty member of the University of Medical Sciences
|
24
|
12
|
40
|
Man
|
PhD in Nursing
|
Faculty member of the University of Medical Sciences
|
22
|
13
|
38
|
Woman
|
Cardiologist
|
Director of the Cardiology Department of the Hospital
|
26
|
14
|
45
|
Man
|
Master of Nursing
|
Hospital Metron
|
20
|
15
|
36
|
Man
|
Bachelor of Nursing
|
ICU Nurse
|
15
|
16
|
33
|
Man
|
Epidemiologist
|
Faculty member of the University of Medical Sciences
|
12
|
1) pre-emergency Phase:
One of the main challenges in cardiovascular patients is the lack of proper nutrition during emergences’ and disasters. Evidence from epidemiological studies suggests that unhealthy lifestyles, smoking, physical inactivity, excessive alcohol consumption, poor diets, and lack of ideal weight account for approximately 80% of the risk of cardiovascular diseases.
1) lack Of Training On Medication And Nutrition
Nutrition and dietary patterns play a very important role in the prevention of cardiovascular diseases. There is ample evidence between cardiovascular health, and food intake and eating patterns. According to the results of this study, diets containing fruits and vegetables due to their high fiber, antioxidants and minerals other than sodium along with certain food groups such as legumes, nuts, fish and low-fat and fermented dairy products are suitable for the prevention of cardiovascular diseases (3).
2) Lack of a proper infrastructure
Another challenge in Pre-emergency Phase times for cardiovascular patients is the lack of proper planning and infrastructures. Hospital managers are always faced with the challenge of how to provide the highest quality level of treatment in health centers with limited resources. In the recent research, capacity planning has been mentioned as one of the most important ways to reduce costs. Most of the patient treatment process in medical centers is such that during treatment, patients need basic measures. This means that in times of disasters, we will face a shortage of equipment. This potentially puts these patients at risk (2).
3) patient Identification Program
Another challenge is lack of identification of cardiovascular patients. Health documents should be prepared for patients in which demographic characteristics, systolic and diastolic blood pressure, blood lipids, blood sugar and body mass are recorded to have better access to patients’ information to provide better services for them in the event of disasters (1).
4) lack Of Manpower
Lack of manpower is another challenge during disasters. Specialized manpower is the main source of production and provision of services in this sector and it should face a shortage of manpower under no circumstances. Therefore, standardizing the number and how to distribute nursing staff in this ward is necessary to improve the efficiency and quality of services provided to patients and to improve productivity in hospitals. Thus, standardizing the number and how to distribute nursing staff in clinical wards, especially the emergency department, is necessary to improve the efficiency and quality of services provided to patients, to make the best use of available facilities and to improve productivity in hospitals (4).
5) lack Of Training Vulnerable Groups
One of the challenges at this stage is lack of training vulnerable groups All patients have the right to receive appropriate training for maintaining and promoting health and preventing diseases. The more a person knows about his/her illness, the better he/she can deal with it. Training patients can reduce the cost of health care (18)
and increase the quality of care, and ultimately help patients achieve independence and self-sufficiency. In fact, training patients improves and promotes their health. The main purpose of training patients, like other health care processes and as a therapeutic indicator, is to help improve patients’ quality of life, promote physical and mental health and strengthen their self-confidence and ultimately improve the level of health in the society. There are many obstacles in the way of patient training during emergences’ and disasters (16).
Some factors related to the environment and management of the hospital, such as lack of a suitable location and the short duration of hospitalization, hinder the training of patients; therefore, nursing managers should analyze the situation, identify the barriers to adequate training by nurses and then make appropriate decisions. Studies conducted in the direction of managerial factors are mainly related to elements such as lack of time, manpower as well as scientific and practical competence in the effective implementation of training programs, the need to implement patient training programs in multidisciplinary, and interdisciplinary ways and coordination of health care staff in presenting these programs as well as the need to change the instrumental perspective of health care staff to a humanistic and patient-centered perspective (3).
6) lack Of A Database Of Cardiovascular Patients
One of the challenges for patients in the Pre-emergency Phase is lack of an information database from patients and their timely identification during disasters. In this regard, cardiovascular patients should be identified. Lifestyle changes in the life of these patients are usually difficult; therefore, it is emphasized that the treatment of vascular risk factors in the form of medication, along with exercise, proper diets and stress control reduces the prevalence of new vascular accidents and mortality. Cardiovascular training programs emphasize behavioral changes and ask patients to follow medication and other medical instructions to participate in their treatment. However, less attention is paid to the fact that this participation requires patients to be confident that they can make lifestyle changes and take medication for the rest of their lives (6).
The link between nutrition and coronary heart diseases has been established, and a healthier diet reduces mortality after heart attacks. Due to the effect of family on the nutritional status of members, family participation in improving eating habits seems necessary. The family-centered approach has a significant effect on improving the eating patterns of patients with heart attacks that can be very helpful in times of emergences’ and disasters (7).
2)emergency Response:
At the beginning of an emergency, pre-emergency data and rapidly available data from the fi eld are used to estimate the number of people affected, likely impact on health and health services, expected evolution of the situation, and external assistance needed (19, 20) The next step is to do rapid health assessments according to a standardised approach. These secondary assessments focus on acute events36 and do not fully address the needs of patients with CV (21, 22)
1) problems With Sleep And Rest Patterns
Sleep is one of the important biological periods in a repetitive and regular manner in human beings, which is associated with the restoration of physical and mental strength. One third of a person's life is spent in sleep and deprivation of it will endanger one's health. Changes in sleep patterns, and lack of food, healthy drinking water, proper hygiene and medication are some of the challenges evident in cardiovascular patients at the time of accidents and disasters. Disruptive environmental factors including lack of proper camps, people’s commuting, noisy environments, etc., can disrupt patients' sleep patterns (8).
2) Lack Of Health Personnel
Another challenge when responding is lack of experienced manpower to provide health services. According to the WHO, a skilled and experienced workforce in the event of a disaster is someone who has the knowledge, skills and ability to meet the needs of patients. In the event of an unforeseen event, manpower is one of the most important elements in providing care and services. As much as the rational, and experienced combination of this force can have a great impact on the advancement of clinical services, it can provide optimal health services to patients in the event of accidents and disasters (9).
3) Lack Of Mental Health Interventions
Psychological problems are another challenge in patients during disasters. Excitement and extreme stress play an important role in the severity of the disease. Patients will suffer the most at this stage. Problems such as depression, and post- emergences’ stress disorders can be very effective on patients in emergencies, which by taking measures and preparing patients in this regard can be reduced to some extent (12).
4) Securing The Camps
One of the challenges during emergences’and disasters for CV patients is lack of suitable accommodation centers. The security of the camps and the appropriate space for rest provide conditions for patients to suffer less stress and mental disorders, and as a result, problems such as high blood pressure in these patients are reduced. Living in a camp can lead to poor quality of sleep, both due to lifestyle changes and lack of privacy. Poor quality of sleep in a camp may be directly related to an increase in BP, and as a result, the risk of high blood pressure due to disasters occurs. High salt intake is strongly associated with increased blood pressure. Large-scale natural disasters often lead to poor food availability. In addition, people with high blood pressure have an imbalance between salt intake and salt excretion, which leads to salt retention in the body and increases blood pressure (10).
5) lack of access to medications
Another problem at the time of emergences’and disasters for CV patients is lack of access to medications. After disasters, access to prescribed drugs may be limited or they may be inaccessible. Drug distribution methods must be planned before disasters. Medication information for cardiovascular patients helps take immediate actions to get the medicine. To get a complete list of important medications which may be needed after a disaster, several data sources are important, including data on drug sales to hospitals, clinics and nursing homes, as well as information provided by patients (11).
3)post-emergency Phase :
The post-emergency phase could also off er opportunities to improve cardiovascular patients care from baseline, including planning for management into the primary HC system ، Patients' psychological problems، Fatigue of the workforce، Risk management
1) Lack Of Planning And Management
One of the challenges at this stage for cardiovascular patients is lack of management and planning. Resource planning and emergency operation management are very important. Alarm systems are very important to inform people about weather conditions, evacuation orders and the closure of roads and medical centers. Family physicians can play an important role in responding to cardiovascular patients in disasters. Principles of care in the event of accidents and disasters must follow a set of standards for the provision of resources, and these standards are established before disasters to follow a specific principle in times of disasters (13).
2) patients' Psychological Problems
Depression, anxiety, and physical isolation are strongly associated with CVD including coronary heart diseases, strokes, and heart failure at the time of emergences’ and disasters. Unprecedented psychological stress occurs in cardiovascular patients during emergences’and disasters. A mental health crisis requires both large-scale psychological interventions and disaster management programs in terms of mental health. Adequate training of health care personnel and the optimal use of technological advances are of great importance to provide acute interventions of the mental health care (14).
3) fatigue Of The Workforce
A workforce with the knowledge, skills and ability is required to promptly respond for providing services to cardiovascular patients in disasters. This requires that all nurses and health care providers have high-quality, evidence-based, and merit-based training programs. We must use all available resources to strengthen the health care workforce. To strengthen and learn health care personnel, evidence-based training opportunities must be provided to make them prepared for disasters (15).
4) Risk Management
Risk reduction measures are a part of the preparedness strategy of risk management at the time of disasters and emergences’. Having an integrated risk assessment approach and analysis in specific situations is important for cardiovascular patients. Integrated patient assessment in accident-prone areas makes it possible to identify patients and to take appropriate actions in the event of an accident or a disaster. Also, combining the best traditional and modern approaches, fostering community interactions, and relationships, investing in preparedness and improving the use of knowledge in practice, and ensuring adequate human and financial resources are among the useful programs for patients in times of disasters (16).