Facilitators and barriers in prevention of cardiovascular disease in Limpopo, South Africa: a qualitative study conducted with primary health care managers

Background In the Southern African countries, cardiovascular disease burden is increasing and the second most prevalent cause of death after infectious diseases. The sustainable primary prevention of cardiovascular disease is associated with the engagement of facilitators that support it and hindered by barriers that undermine the support of a healthy lifestyle at the community level. The purpose of the study was to investigate facilitators and barriers at the level of primary health care facilities, on prevention of cardiovascular disease in Limpopo Province of South Africa. Methods This study is an exploratory and descriptive qualitative design, where open-ended key informant interviews were conducted among 20 primary health care managers conveniently sampled in their respective health care facilities. Coding and analysis were done using the thematic analysis method with the assistance of Atlas ti qualitative software. Results Various facilitators for the prevention of CVD were identified in this study. One of such facilitators is the availability and adherence to CVD treatment guidelines in the district. Other facilitators included top-down health education programme; collaboration with schools, traditional and religious leaders; the use of modern technology; and a structured healthcare system. Barriers were also identified as poor infrastructural development; shortage of medical supplies and equipment; lack of health promotion activities; shortage of nurses and other health care personnel; and poor accessibility to primary health care services. Conclusion This study has identified barriers and facilitators that may be harnessed to improve cardiovascular disease prevention, care, and management in a rural setting in South Africa. The facilitators should be strengthened, and barriers identified redressed. Trial registration number: REC-0310111-031. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02290-1.

in the past 25 years [1]. Among non-communicable diseases (NCDs), the four top killers that together account for more than 80% of all premature NCDs deaths include CVD, cancers, respiratory diseases, and diabetes [3]. Studies estimates that the burden of CVD has doubled from 1990 to 2020 (1,2) CVD account for 82% of global mortality and 88% of mortality and morbidity from CVD low-and middle-income countries [2,4]. A study conducted by Nojila et al. [2] stated that Black South Africans are experiencing relatively high agestandardised death rates (ASDRs) from cerebrovascular disease, hypertensive heart disease, diabetes mellitus, ischaemic heart disease (IHD) and cardiomyopathy compared to Coloureds, Asians, and Whites.
The dynamics are changing, and the World Health Organization (WHO) has projected that by the year 2030, CVD will surpass communicable diseases as the leading cause of death in the African continent [4]. People in low and middle-income settings often do not have the benefit of integrated primary health care (PHC) programmes for prevention, early detection and treatment of CVD compared to those in high-income settings [4]. As a result, some people in low and middle-income countries are often detected late in the course of the disease and they die younger from CVD and other NCDs in their most productive years. For instance, in 2013, an estimated one million premature deaths were attributed to CVD in Sub-Saharan Africa, constituting 5.5% of all global CVD-related deaths and 11.3% of all deaths from different causes [5].
Furthermore, out of the 17 million global NCDs related deaths that occurred in 2015, 82% were in low and middle-income countries, including Sub-Saharan Africa, out of which 37% were caused by CVD [4]. Therefore, because of the increase in the number of CVD cases, stroke and heart failure have become common in low to middle-income in the Sub-Saharan Africa region [6]. South Africa is currently suffering from the burden of infectious diseases and NCDs that creates a significant impact in the South African health care system [2,7]. NCDs inclusive of CVD accounted for 57.4% of deaths while communicable diseases were responsible for 31.3% of deaths in 2016 [4].
A systematic review of (eligible) 28 studies identified several facilitators and barriers related to prevention of CVD including structural, organisational, professional, patient-related factors and attitudinal components [8]. Facilitators that support or barriers that hinder the implementation of interventions supporting health lifestyle in PHC facilities, have been identified [9]. Therefore, before implementing a CVD preventive programmes in PHC, it is important to identify potential facilitators and barriers that may exist among primary care health care facilities and the population [8][9][10].
The purpose of this study was to investigate facilitators and barriers at the level of primary healthcare facilities, in prevention of cardiovascular disease in Limpopo Province of South Africa.

Study design and participants
The study utilised an exploratory and descriptive qualitative design, key informant (KI) interviews were used to investigate the facilitators and barriers of CVD prevention. The study participants were 20 PHC managers selected using convenience sample from the 11 primary health care facilities. The study comprised fifteen (15) participants from one rural setting and five (5) one semiurban area. The key informants were qualified clinical nurse practitioners with vast experiences in PHC management positions. The participants encompassed two levels of management ranks, 4 local area managers, and 16 operational managers, overseeing and managing the 11 PHC facilities respectively (Table 1).

Setting and population
The study was conducted at Polokwane Municipality in Capricorn District of Limpopo Province. The population of Polokwane municipality is 797 127 [2016] with 80.36% speaking Sepedi local language [11]. Polokwane (previously called Pietersburg) is the capital town of Limpopo which is one of the nine provinces of South Africa. Limpopo ranks fifth position in South Africa in both surface area and population, covering an area of 125 754km 2 and being home to a population of 5 779 090. The district was chosen for the study due to the myriad of health challenges that it faces, including the burden of CVD [12].

Data collection
An open-ended key informant interview guide was used to collect the data from the participants (Additional file 1: Table S1). The guide solicited participants' views and experiences with the management and prevention of CVD in their various PHC facilities and local areas. The questions focused on the current situation and elaborated on facilitators and barriers that exist and could be utilised to improve the prevention and management of CVD. The KI guide also contained questions on the demographic characteristics of participants, prevention, care, and management. The interviews were conducted in English. After each interview, the lead investigator (MD) and an assistant researcher (NK) made notes and discussed the preliminary observations. This initial analysis helped to improve the wording of the questions in subsequent interviews as well as in noting of areas that needed to be emphasised. The interviews took place from March 2018 to April 2018 at the work premises of the participants. Participants were given unique codes; OPM (#) for operational managers and AM (#) for area managers, to conceal their identities and to be able to trace the source of each transcript for the purpose of member checking. However, only the lead investigator knew the exact participants to which the codes/transcripts belonged to ensure anonymity and confidentiality. The interviews were audio-recorded utilising a digital voice recorder.

Data analysis
All interviews were transcribed verbatim. Coding and analysis were then done using the thematic analysis approach with the assistance of the Atlas.ti qualitative software. The inductive coding process was followed in coding the data. Thus, codes were derived from original narratives and ideas expressed by the participants [13]. This was so because we were interested in identifying past experiences of the PHC managers in relation to the facilitators they faced in the prevention of CVD as well as the barriers that existed and could be explored in the prevention and management of the condition. The coding frame was developed through an iterative process of multiple discussions between the authors by paying special attention to similarities and differences. The next stage of analysis involved linkages between codes, themes, appropriate quotes, and the study objectives. Two considerations informed the interpretive analysis of codes and themes. First, the facilitators that participants faced in the prevention and management of CVD and second, the barriers existed for the prevention and management of CVD in the Capricorn District. The participants identified five facilitators and five barriers (Table 2). Appropriate excerpts for each theme were used to support our findings. Inductive thematic saturation was deemed to have been achieved when there were non-emergence of new codes or themes [14]. Data saturation was reached at participant number 19, but interviews were stopped at participant number 20 because the last participant was waiting patiently for her turn to be interviewed. Member checking was conducted by returning the results to participants to check for accuracy and resonance with their experiences.

Facilitators and barriers
Five facilitators in CVD prevention and management were identified as themes. These include: the availability of policies and guidelines for the prevention and management of cardiovascular; health education programme; collaboration with schools, traditional and religious leaders; the use of modern technology and a structured healthcare system. Five key barriers were also identified as themes that affect the prevention and management of CVD in the district. These are: poor infrastructural development; shortage of medical supplies and equipment; lack of health promotion activities; shortage of nurses and other health care personnel; and poor accessibility to primary health care services.

Facilitators of CVD prevention and management
Various prevention and management facilitators for CVD were identified in this study. One of such facilitators is the availability and adherence to CVD treatment guidelines in the district. There are numerous guidelines for the prevention and management of CVD at both national and international levels. Existent international guidelines are keen on the necessity of smoking cessation, weight optimisation and the importance of physical activity [15]. Among the reasons why CVD are persistent despite the consensus existence of treatment, guideline is the determinant of risk behaviours [15]. The present study identified that behaviour change communication in communities can be a viable opportunity to minimise CVD. Health education is a common expert lead strategy used to address modifiable risk factors for CVD at the community level. In a similar study, practitioners suggested changing direction from case treatment to health promotion by focusing on prevention through awareness creation and community empowerment campaigns to inform the populace about adverse risks factors such as smoking, obesity, and physical inactivity [16]. They also noted that, though such approaches have proved instrumental in CVD prevention, they should be tailored to suit the  situation to reduce limitations. The role of community health workers (CHWs) or volunteers becomes crucial on community empowerment through health promotion strategies to deal with modifiable risk behaviours. CHWs are effective in CVD prevention programmes at door-todoor household and community levels because they have a sense of belonging, trust, and duty to protect their communities [17]. Participants mentioned the use of modern technological gadgets in the prevention and management of CVD as a good opportunity that should be encouraged. One component of the CVD-care chain is technology, and it encompasses simple essential tools, and more complex laboratory support [18]. Although lack of equipment such as blood pressure monitoring machines and computers for data storage was a challenge, there exist an opportunity in this regard to effectively prevent and manage CVD cases. Some healthcare workers can use computers, but others still need training in the utilisation of modern technology. The deployment and usage of technology in the Capricorn district remains a big opportunity that could be explored to effectively deal with CVD cases. Despite the challenges that the healthcare system face in the light of CVD prevention and management in the district, it was somewhat functional, per participants' narratives. For instance, there is a well laid out organogram in place at the district health directorate solely for CVD management and prevention. Thus, we identified that a functional healthcare system is a workable avenue to effectively manage and prevent CVD. This is not limited to the availability of health workforce but also access to essential medicines, sustainable health financing and the role of leadership and governance [19].

Barriers of CVD prevention and management
The current study unearthed prevailing hurdles in the prevention and management of CVD at the Capricorn district in the Limpopo Province of South Africa as well as opportunities that exist to be explored in the fight against CVD. With reference to poor infrastructural development, we identified that healthcare providers in the district operated in facilities that were particularly small, limiting their ability to have designated space(s) dedicated to CVD cases. This meant that facilities were always overcrowded, impinging on clients' privacy as individuals with various ailments gathered in same waiting rooms and sought treatment from same consulting room(s). The challenge that limited infrastructure pose to the prevention and management of CVD cases on the African continent is not peculiar to South Africa. For instance, evidence from Eastern Uganda has shown that poor healthcare infrastructure impedes the activities of health teams in combating NCDs such as hypertension by limiting the number of clients that can be received and cared for across various health facilities [17]. Lack of medical supplies and equipment were also identified to be a major barrier to the prevention and management of CVDs in the province. This ranged from the lack of basic diagnostic equipment for check-ups to essential medication for the management of CVDs across the selected health facilities [20]. Logistical challenges in healthcare provision seems to be a systemic problem in South Africa. A recent study conducted in the country identified that shortage of medication was one of the paramount barriers to the prevention and management of non-communicable diseases in the country [21]. Our findings are also buttressed by studies in Argentina and Vietnam, countries with similar socio-economic conditions as South Africa, where lack of good quality information systems was reported as a logistical setback in the management of persons with risk factors [22]. Quality health information systems are essential for the strengthening of health care provision [18]. Health information technology (HIT) targets many of the barriers to successful healthcare delivery for CVD prevention and management. Interventions such as electronic medical records system is a vital strategy in improving patient documentation, data capture, inter-provider communication, and follow-up for NCD management [18]. The huge inadequacy of computers in health facilities thus, makes good health data capture and storage an unattainable aspect of CVD care. According to Kien et al. [22], the lack of comprehensive centralized data-sharing systems in health facilities results in insufficient coordination of information between curative and preventive health systems in Vietnam. In this study, the availability of modern technology has been stated as a facilitator although capacity building in computer usage is still needed. In some facilities, electronic data capturing forces healthcare workers to use part of their already small working space for computers, and to store paper records [19].
Inadequacy of staff was identified to be another strong barrier against CVD prevention and management. The poor staffing of health care facilities across the district had a rippling effect on accessibility to primary health care services, as most facilities were compelled to open late and close early. Poor utilisation is negatively associated with rural residence and socio-economic status [16]. This deficiency meant that patients were reluctant to attend for proper diagnosis or follow-up as the workload was too great for the few health personnel. Poor access to primary health care services was largely reported by respondents as a hindrance to the prevention and management of CVD. The study indicated that health literacy in the form of health education is applicable but the behavioural change component in the form of health promotion is grossly lacking. Focusing on fighting the five major risk factors for CVD: smoking, high blood pressure, bad diet (including high saturated and transsaturated fats; as well as scanty fruit and vegetables), physical inactivity, and obesity demands health promotion behavioural change strategies [23]. Health promotion is about empowerment of the vulnerable groups and it is highly recommended for successful prevention of CVD at a community level [24].
The limitation of the study is that the findings are based only on interviews conducted with primary health care managers. The findings are based on self-report and may therefore differ from actual practice. This limitation can be alleviated by conducting further studies that involve other multidisciplinary team members that are also playing a role in CVD prevention and management.

Trustworthiness of the study Validity and reliability
Validity and reliability of the study findings was achieved by first ensuring that the study findings were credible. This was done by employing iterative questioning process during interviewing as well as frequent client probing (Additional file 1: Table 1; [25]).

Transferability, confirmability, and dependability
We ensured that our findings could be transferrable and thus could be applied to other contexts with similar characteristics based on the clear and thorough explanation of our methods (26). This also ensured that our study findings are dependable as our methods could easily be used to replicate the study should the need arise. Lastly, we ensured confirmability of our study findings by revisiting our participants with the transcripts and the initial findings for them to confirm that what we have reported was indeed what they narrated during the interview process [26]. This also ensured that the results are the experiences and ideas of the participants, rather than the characteristics and preferences of the team of researchers [27].

Conclusion
The facilitators and barriers that affect the prevention and management of CVD were identified at the Polokwane Municipality in Limpopo Province. Various stakeholders in the district should, therefore, team up to maximise the facilitators that exist in the district for CVD prevention. For instance, adequate working space should be provided progressively among all healthcare facilities dealing with CVD cases while at the same time equipping them with adequate resources and technology to be able to diagnose and manage CVD cases on time.
The study concludes with the strong recommendation