Investigating Expert Views on the Dimensions of Community Participation to Control the Epidemic of Coronary Artery Diseases: A Qualitative Study

Introduction: One of the most important types of conscious and active participation of people in the management, planning and control of the epidemic of non-communicable diseases, such as coronary artery diseases, is one of the current concerns of the community due to its high prevalence. Therefore, this research was conducted with the aim of determining the views of experts on the dimensions of participation of people in controlling coronary artery diseases. Methods: This research was conducted with qualitative approach and content analysis method. 17 interviews with specialist’s experts and managers in the field of community participation in the cardiology section of the Ministry of Health and Medical Education, NGOs and charitable organizations through a targeted sampling method in 2018. Data were collected using semi-structured interviews and then analyzed by content analysis method. Results: In this study, five main themes were drawn from participant experiences that included "policy", "planning," "organizing," "coordination," and "financing". Conclusions: Countering the epidemic of non-communicable diseases and their risk factors requires extensive, effective and active interventions for all relevant organizations and ministries within and outside the health sector. Comprehensive community-based programs are an important part of the strategy for solving this global dilemma. Therefore, identifying risk factors, policy-making on how to deal with and eventually decrease their increasing trend can have a significant effect on the reduction of coronary artery disease.


Introduction
The term coronary artery disease, also known as coronary heart disease or ischemic heart disease, refers to diseases that are caused by lowering blood supply to the heart muscle [1]. Cardiovascular diseases are one of the most important causes of death in Iran and are responsible for more than a third of all deaths. Therefore, it is a serious health challenge for the country [2].
In the United States, epidemics have begun in the 1920s, in the United Kingdom since the 1930s, and in some European countries at a later date. It is now the turning point of the developing countries that are affected by the CHD (Coronary Heart Diseases) epidemic. In many advanced countries, CHD is the most important public health problem, but even in countries where CHD is declining, it is still the most common cause of death in men less than 64 years of age [3].
Researches have shown that the identification and treatment of cardiovascular diseases affect all communities of women, men and children or any ethnicity and race, and the results of these ongoing studies to change the methods of prevention and treatment planning in society is of use [4].
Risk factors associated with CHD, some of which are influenced by individual behavior, include smoking, exercise (physical activity), diet, diabetes, hypertension and high blood cholesterol. It is suggested that the adjustment of the 9 main risk factors and other modifiable factors reduce the incidence of CHD by 90% [5]. Considering the importance of preventing and reducing the cost of health in comparison with treatment, more emphasis on prevention is needed. Meanwhile, taking into account that measures to control diseases are implemented at the three levels of the individual, the system and society, and that these actions can be used to prevent disease, early diagnosis, treatment and most of the interventions to change risk behaviors such as smoking, alcohol and more are focused on the individual. Focuses on individuals can be screened, treated in a timely manner and reduce disease complications through individual or group training. Actions that can be taken at system level for change through the system can be policy, change of economic factors, insurance policies, and so on. Interventions at the community level, with the goal of preventing and controlling root causes of problems at the wider level and, for example, reducing the social gap and eliminating poverty and illiteracy and improving the environment, requires the involvement of the entire

Journal of Health Education Research & Development
community in a coordinated manner [6]. The attitude that has been raised in several countries in recent years to enhance the effectiveness of interventions is based on the participatory nature of interventions that have successfully implemented programs in identifying indigenous conditions, extracting the best possible interventions by using the views of stakeholders and implementing these interventions with the use of the people themselves [7].
Nowadays, the participation of people is a prerequisite for the success of any kind of macroeconomic, social and development agenda and approach. The goal of participation is to empower individuals to participate voluntarily. In fact, participation is a process that mobilizes local resources, utilizes diverse social groups in decision making, and engages local people in defining problems, results in the collection and learning information and implementing projects [8]. The World Health Organization has endeavored to promote the transfer of healthy knowledge and skills to people as a starting point for people to plan and manage health plans. In the 1990s, more emphasis was placed on people's participation in the planning, implementation and evaluation of health programs. Many years of experience in promoting health also advocate the need for people to participate in community health management [9].
In the process of supplying and promoting the health of citizens, which is a comprehensive process, in addition to empowering people's skills and abilities to increase and improve their health, by changing socio-environmental and economic conditions, they reduce the adverse effects of the environment on the health of the community and the individual. Certainly, participation in this process is an essential element. Having a systematic look and protectionism is essential for the participatory approach to health promotion [10].
Nowadays, the participation of communities in government programs is considered as one of the important indicators of the success rate and development process in societies and governments are trying to involve members of the society, as much as possible, in the planning and implementation of their programs, introduce them to people and ask for their help [11].
Following important advances in the control of communicable diseases, in our country, good measures have been taken to control non-communicable diseases, including coronary artery disease, since many years ago. However, despite many efforts, as in other countries, we have witnessed an extremely increase in this disease in our country. Therefore, it was necessary to make good efforts in this direction in line with our national and international commitments. For this reason, in order to fight cardiovascular diseases, this study was conducted to investigate the views of experts on the dimensions of people's participation in controlling coronary artery diseases.

Methods
The present study was done using the qualitative approach and content analysis. The main question of the research is that what are the views of experts about the extent to which people participate in control of the epidemic of coronary artery disease? Semi-structured interviews with specialists, experts and managers in the field of public participation in the cardiology section of the Ministry of Health and Medical Education, NGOs, and charity organizations who were selected purposefully were done in 2017. The interview time was an average of one hour. Before the interview, the attendees were asked for permission in person or on the phone. The objectives of the study and the interview time were determined based on the agreement. The interviews were recorded using the mobile phone and immediately after the completion of the interview, the word-by-word typing and the original interview were maintained. During the research process, from data collection to the end of the analysis and reporting of findings, such as informed consent, anonymity, confidentiality of information, right to withdraw at any time and ethical obligations were observed. All interviews were done, recorded, typed, reviewed, coded and analyzed immediately by the researcher. In this study, data collection and analysis was done with a qualitative content analysis approach. All interviews were recorded, copied and reviewed several times. In the next step, the primary codes were extracted, then the primary codes that were overlapping were grouped and sub-themes were formed. Subsequently, each of the sub themes were reviewed and adapted to the comments of the participants. In the last step, the final modification of the themes was achieved, which ultimately resulted in five main themes. An ongoing comparative analysis was carried out to validate the data and ensure their accuracy, with the analysis of each interview starting immediately after it was completed and reviewed continuously. Another action that was taken by a number of the contributors was to confirm the long-term engagement with the data and to allocate enough time to conduct interviews and analyze them.

Results
Ten participants were female and 7 were male. In terms of education, seven held PhDs, three cardiologist, and four MDs, one Master and two held bachelor. The age ranged from 25 to 53 with an average of 39 years and a work experience of 5 to 25 years, with an average of 12 years. From the analysis of the data obtained from this study, five main themes were derived from the participants' perspective, which are presented in Table 1 with the sub themes.

Number 1 theme: policy
One of the most important themes from the experiences of the participants in this study was "Policy" which included the sub-themes "formulating rules and regulations," "decisions in the field of health and public participation," "attracting people's trust", "Vision and attitude of managers", "support for popular formations". Experts emphasized on attracting the trust of the people and the support of popular organizations, and supported the change in the "vision and attitude of managers" regarding how to use community organizations and charities.
Contributor 1: In some countries, they use patients themselves, such as the Peer group and because they are suffering themselves, they are going to gather other people and then they are going to interact with each other about their illness, they teach others what they have learned, and they are very effective in self-care. Patients themselves play a very important role in the relative cure of the disease, and their lifespan is greatly increased. As self-care programs and self-cure programs are improved, their quality of life goes up. These are the socalled examples of popular participation.
Contributor 5: In order to increase social motivation and awareness of the community and to declare a plan to engage in different developmental areas based on the established policies, and for the sustained participation of the people, appropriate mechanisms must be created and strengthened.

Policy
Formulation of rules and regulations, Decisions in the field of health and community participation, attracting people's trust, managers' attitudes, support for popular organizations

Planning
Health education programs with participatory attachment (creativity, attractiveness, various training packages tailored to specific age groups, sex, work, etc.), training of care units (prevention, diagnosis, treatment and rehabilitation), participation strategies People's empowerment, goal setting, priority setting, culture (health literacy), self-care education (knowledge, skills and abilities, attitudes and beliefs, behavior change)

Organizing
Assignment of tasks, allocation of resources, agreed and pre-planned activities, strengthening of male health organizations, healthrelated social components

Co-ordination
Inter-departmental, inter-sectional and inter-institutional co-ordination, monitoring of the activities of the charities and the NGOs in the field of health

Financing
Government funding (allocation of specific budget), popular contributions (NGOs, Charities, Health Volunteers), monetary incentives, tax incentives, social responsibility of economic entities Table 1: Themes and subthemes extracted from data from interviews with experts in the field of public participation and coronary artery diseases.

Number 2 theme: planning
Contributor 4: Organizing a Healthy Heart Education Informative Campaign (HEI) is one of the important strategies for improving the health literacy of cardiovascular disease and its risk factors. The aim was to enhance the knowledge and skills of the members of the Healthy Heart Education Campaign and design a healthy heart program, audience analysis, channel analysis, and the determination of tactics and the preparation of an operational plan for implementation and ultimately evaluation of the healthy heart training program.
Contributor 9: We must take the role of people in the management of coronary artery disease, prevention and control seriously, and the first thing to do is to make them aware of these diseases, especially cardiovascular diseases and coronary artery diseases. Now this increase must either be given to the public through ourselves, such as NGOs, or the Ministry of Health and Education, or the organizations that really contribute to the creation of this force.

Number 3 theme: organizing
Contributor 8: You should consider empowering people's participation as one the priorities of the health system, and for this reason they created something called Social Assistants in the structure of the Ministry of Health and Education. This social deputy's job was to reinforce this strategy.
Contributor 10: We must organize and develop the mechanisms of cooperation and support popular and specialized organizations of the country in order to expand and deepen the spirit of cooperation and to participate voluntarily and consciously in order to advance the process of providing services to target groups.

Number 4 theme: coordination
Contributor 3: It should not be done as a single individual, and the rest of the organizations, the departments that can be effective in this case, should be affected. All of them were gathered and integrated, and let's do a serious plan to attract popular participation. Inter and intra collaboration, for example, as a public health custodian, is part of that people's health, we have to do this planning.

Contributor 16:
The Social deputy plays its role by coordinating, and each deputy must continue to play their roles. We have a thing called attracting participation in the PHC. One of the principles of PHC is, without coordination and without involvement, the rest of the goals or strategies that you have in PHC will not be achieved at all.

Number 5 theme: financing
Contributor 10: Look, people for their own health only need to trust us financially, trust is important, something that is now one of the greatest problems is that we have a trust problem, especially with regard to the government, and so on, and we have to turn it back. It takes a lot of time and effort to trust us, and when they see that we are honest, they will start moving in the right direction. There are people who can help us.
Contributor 11: One of the problems that we've had in these years in the country was the discussion on the budget. Numerous researches were carried to determine how we can attract more community participation. The main issue is that in theory the managers all agree and say that a participatory approach is necessary but when it comes to the actual implementation they only want the community to contribute to the funding side of things. It is true that there are many layers of participation, but in our country, when the managers hear about community participation, they assume that the community will handle the funding and the scheduling and the management themselves. This is one of the major issues with the implemented strategies in our country.

Discussion
The global strategic goal of the World Health Organization is to effectively control the risk factors for cardiovascular disease and reduce the burden of these diseases, which are growing rapidly, especially in developing countries. One of the most important kinds of participation is the informed and active participation of people in the management, planning and control of the epidemic of coronary artery diseases, which with regard to its high prevalence, is one of the current concerns of the community. decision in the field of health, decisions in the field of public participation, public trust, managers' attitudes, and support for popular organizations. The results of this study showed that creating a coherent policy framework, including legislation, regulation and public education is very important for the prevention and control of coronary artery disease, because in the absence of conductive environmental changes it is very difficult to change the behavior of individuals.
Health empowerment is a process in which individuals gain the ability to control more decisions and activities that affect their health. This process can be seen in the form of skills and abilities, or viewed as a policy perspective [9]. In Sweden, the parliament passed a statement in the government and declared the country's general health policy as follows. The overall goal of policy making is to create social situations that guarantee a healthy life for all people. The program also includes goals such as participation and impact on society, economic and social security, healthy and safe childhood and adolescent life, healthy work life, the environment and safe and healthy food products, effective protection against non-communicable diseases, safe sex And reproductive health, increased physical mobility, nutritional habits and healthy nutrition, reduced tobacco use, alcohol and illegal drug use. In Canada since 2002, the National Healthy Life Program has begun. The strategies of this program are to improve the health efficiency and reduce the health gap. The initial emphasis of this program is on healthy nutrition, physical mobility and its relevance to weight.
The program follows the following strategies: • Policy and policy development • Knowledge development and transfer • Community development and infrastructure • Public information society.
Although China has made good progress in developing and implementing these strategies and policies to prevent and control noncommunicable diseases, many challenges remain [12]. Lack of qualified health professionals in public health services the problem of maintaining professional persons at this level, the lack of adequate public funding for the care and management of non-communicable diseases and patients with non-communicable diseases, given the limited coverage of useful care packages. Non-communicable diseases, caused by health insurance, create a lot of economic burden. Finally, to address these challenges, develop appropriate humanitarian policies to attract more qualified health professionals at the level of primary health care; set up useful service packages to encourage communitybased health services; and increase government investment in public health interventions, with more investment in health insurance schemes [13].
"Planning" was another important topic that included sub-themes such as health education programs, the training of care units, strategies for engaging in popular contributions, setting goals, prioritizing priorities, health culture, self-care education.
In the process of participative planning, poor and deprived people, instead of being seen as objects and topics of the program, become elements of social development programs, and the exchange of information becomes the capacity where there are collaborative spaces: People should begin to plan for the benefits of the program as "recipients"; by acquiring skills and resources for demand and paying for services, they will be considered as "customers" for these services; and ultimately, by gaining experience and confidence They will be "planners and program managers" [9]. The most important strategies that countries have to play in the area of health and development are promoting poverty awareness and health issues, removing financial barriers and creating income-generating projects, especially for lowincome groups, paying attention to cross-sectorial cooperation, Promoting participation and engaging other sectors in the form of intergenerational partnerships and strengthening efforts to control and track the outbreak [14]. In China, a community-based approach to addressing non-communicable diseases (coronary artery diseases) has been considered and is recognized as one of the most effective costeffective methods. Community-based strategies include financial and administrative support for health, social mobilization, education and community health promotion, and the use of community health centers in identifying, treating and managing patients. Communitybased strategies include financial and administrative support for health, social mobilization, education and community health promotion, and the use of community health centers in identifying, treating and managing patients. With respect to the demographic, economic and social characteristics of societies, it is possible to manage programs to combat chronic diseases, especially cardiovascular diseases, by relying on resource mobilization and longterm training strategies in the community, and this need for planning Determines the precision using a community-based approach [13]. It should be acknowledged that solving problems in society is the responsibility of every health and medical system. To do this, problems must first be identified and then, with available resources and prioritization, identify the priorities for each training program. What matters in this process is the agreement of all stakeholders on the list of priorities and curriculum plans [15]. The development of a participatory process to support the delivery of lifestyle modification programs is an effective health care strategy for promoting cardiovascular health [16].
"Organizing" was another important theme, with sub-themes such as assignment of tasks, allocation of resources, agreed and pre-planned activities, strengthening of male health organizations, and socially effective components of health from the point of view of specialists. Based on the results of this research, it is possible to use the participatory capability of the concerned stakeholders, taking into account the strengths and weaknesses and the challenges identified, and provide solutions for the promotion of scientific and applied protocols.
Given the limited resources of non-communicable diseases management in developing countries, prioritizing and deciding on the type of interventions and population-based preventive strategies is important, the success of which depends on access to information based on native evidence. The common risk of these diseases is that it will not be possible to establish a "risk management system for noncommunicable diseases" [17].
Damari et al. Cited the barriers to the participation of NGOs: limited funding, inadequate communication between NGOs and the government, and the government's weak belief in the role of NGOs, were three of the main obstacles reported by the studied NGOs. The necessity of communicating with the government, according to the majority of the NGOs, and a little satisfaction with the current engagement with the government, necessitates a revision of this trust [18]. There is now a favorable view to expanding people's participation from the perspective of most policy makers, which provides a framework for more cooperation and coordination among them. The important point that has been repeatedly mentioned in this review is the lack of macro-legal and administrative infrastructure for this engagement, which is a priority to be addressed and provides the basis for popular engagement [19].
The coordination of the fourth theme was based on the views of experts with sub-themes such as inter-intra sectional coordination, monitoring of the health and well-being of charities and NGOs through the participation of the community, the actions of the Ministry of Health and education as well as interdisciplinary collaboration can be achieved through the implementation of the program, with important benefits in the management of coronary artery diseases.
The need for cooperation between the Ministry of Health and Medical Education, the Ministry of Jahad-e-Keshavarzi, the Ministry of Industry, Mining and Commerce is essential for the better implementation of the National Document on the Prevention and Control of Diseases, as well as the consideration of the principle of Prevention. It also increases the awareness of citizens in managing and reducing non-communicable diseases in the country.
In Malaysia, integration programs have a multidisciplinary perspective that address the issue of integrating and pooling organizations and potential in communities that manage and control, through national strategic interventions, some of the key challenges associated with noninvasive diseases [20].
The prevention and control methods of non-communicable diseases are very complex and the role of the health system in controlling them is very limited. A collaborative look, based on strong scientific documentation on the one hand, and efforts to integrate information and design long-term plans, on the other hand, should form the basis of non-communicable disease management and be tried through a variety of legal instruments and diverse enforcement channels. In various organizations and ministries, they adjusted their lifestyles with their direct participation [21].
Such cooperation may take the form of self-care, mutual assistance, collective action, intergenerational cooperation, or on the basis of unity for health promotion. These collaborations may take place over a limited period of time, focusing on a specific or long-term goal, in order to pursue multiple goals. In order to promote health, there is a growing need for the participation of state organs, civil society and the private sector [9].
"Financing" was another important topic extracted from interviews. This theme refers to the importance of government financial support (allocation of specific budget lines), popular contributions (NGOs, charities, health volunteers), monetary incentives, tax incentives, and social responsibility of economic entities.
Proper allocation of funds and appropriate payment methods can reduce the problems altogether and allow the system to move towards decentralization, privatization and self-regulation. Investing and optimal allocation of resources to achieve a healthy human goal leads to the development and reduction of poverty in countries [22].
There are numerous financial barriers against the improvement of the health system and the health insurance system has a long way to go. The high share of households' pocket payments will remain a serious challenge for the country unless consistent policies are pursued. These policies should take into account the past experience of the country and the success of other countries in establishing an effective system of financial support [23].
The most important source of financial revenues for NGOs are humanitarian aid and charitable organizations, and then the government, It is often believed to be "financial support of the state of the NGOs as a dedicated budget line" [18].
Considering the seriousness of the risk of Coronary Artery Disease (CAD) for national development in societies and influencing human resources in the field of health and, consequently, in the economic dimension, comprehensive programs and effective factors on promoting community participation in preventing and Early diagnosis of risk factors for coronary heart disease can be used [24].

Conclusions
Iran is among the leading countries in planning for the prevention and control of non-communicable diseases, and through interinstitutional mechanisms and in the framework of the National disease control plan, all people and authorities are working to implement these programs and reduce mortality. To reduce the effects of coronary heart disease on individuals and the community, there is a need for a comprehensive approach for all sectors that need to go together to reduce the risks of coronary artery diseases and increase interventions to prevent and control these diseases.