Design

The present study was conducted on IHD patients and key informants in Lorestan province in western Iran in 2025, using a qualitative approach and conventional content analysis. Lorestan Province was chosen as the study setting because of its unique socio-cultural and environmental characteristics that can potentially affect lifestyle behaviors. Understanding these local dynamics is essential for designing context-specific interventions aimed at improving cardiovascular health in the region.

Participants

The participants of the study consisted of two groups. The first study group included IHD patients, and the second group consisted of key informants, including cardiologists, cardiology residents, and cardiology ward nurses. The inclusion criteria for patients with IHD included not following a healthy lifestyle regarding IHD, living in Lorestan province, the ability to communicate verbally, and willingness to participate in the study. The inclusion criteria for the key informants included having working experience or specific knowledge about IHD patients and the willingness to participate in the study. The exclusion criteria for both groups were failure to complete the interview and unwillingness to record the interview process.

Sampling and recruitment

Participant recruitment for this study began on January 16, 2025, and concluded on March 3, 2025. In this study, the participants were first identified and chosen through a purposive sampling method. A list of IHD patients was initially compiled by visiting Shahid Madani Hospital. The patients were subsequently contacted via phone to assess whether they had a healthy lifestyle. A healthy lifestyle was defined by the consumption of a well-balanced diet rich in fruits, vegetables, and whole grains, and a restriction on saturated fats and sugars; regular physical exercise, with a minimum of 150 minutes of moderate-intensity physical exercise per week; abstaining from tobacco use; abstaining from opioid use; limiting or abstaining from alcohol consumption; and effective stress management with the use of proper coping mechanisms. For those who did not have a healthy lifestyle, oral consent was obtained for participation in the study, and the time and place for in-person interviews were coordinated.

Data collection

Face-to-face, semi-structured interviews were conducted with the participants to collect the data (39 interviews). Initially in each interview, the interviewer explained their study field, job, and role in the research to create effective communication and build trust. The interviewer subsequently explained the study’s objectives and procedure and how the results would be reported. If the participants provided their written consent, the interview began in the presence of only the researcher and the interviewee. The interview questions were developed collectively by the research team through multiple rounds of discussion and refinement, with the support of an extensive review of the literature. Five pilot interviews were conducted to verify that the questions could capture participants’ views and experiences. The analysis of the pilot interviews was used to further refine the interview guide, which is available as Supplementary File 1. First, participants were asked demographic questions, which were followed by core questions provided in the interview guide. Additionally, based on the participants’ answers, follow-up and probing questions were posed to delve deeper into their perspectives. The key informants were interviewed after the patients were interviewed. The interviews were audio-recorded, and field notes were taken during the sessions to capture non verbal cues such as tone of voice, pronunciation, laughter, crying, and speech pauses. All of the interviews were conducted in locations chosen by the participants, thus ensuring a peaceful and private atmosphere. The interviews lasted an average of 36 minutes, with the longest interview lasting 54 minutes and the shortest one lasting 25 minutes. From the very first interview, coding and data analysis were started, and codes were frequently compared and examined. During the 27th interview with IHD patients and the 6th interview with key informants, the codes became repetitive and no new codes appeared, indicating theoretical saturation. To be assured that saturation was reached, the researchers conducted four more interviews with IHD patients and two more with key informants. Then, the researchers came to the conclusion that ultimate saturation had been reached and that more interviews would not add any new findings to the research.

Data analysis

The process of categorizing and analyzing the data were conducted using MAXQDA-2020. The analysis was performed following the Granheim and Lundman method in five steps [19]. In the initial step, after each interview, B.A. and N.N. transcribed the interviews on the same day. In the second step, J.Y.L. and B.A. carefully and repeatedly read the content of the interviews to grasp the overall meaning of the content. In the third step, J.Y.L. and B.A. systematically segmented the interview transcripts into semantic units and applied preliminary codes. In the fourth step, similar initial codes were grouped into broader categories. In the fifth step, latent patterns within the data were analyzed, resulting in the emergence of categories and subcategories. Eventually, the entire data analysis process was shared in a joint session to integrate the opinions of all the authors.

Trustworthiness

Guba and Lincoln’s criteria were applied to enhance the rigor and quality of the results [20]. To enhance the credibility of the research, the researchers ensured diversity in sampling by including participants with varying economic, social, and demographic characteristics. Additionally, key informants with different areas of expertise were involved in the study. The overall understanding of the participants’ responses was summarized periodically during the interview and at the termination of the interview. The summarized understanding was then relayed to the participants, and any clarifications and corrections were made if necessary. A table of codes, subcategories, and categories with quotes was given to five participants at the end of the study to verify that the researchers had accurately reported their responses and experiences. To ensure confirmability, the data analysis and results were sent to four expert qualitative researchers. Any necessary revisions were made based on their feedback. To enhance dependability, all authors were involved in the process of data coding and analysis during multiple sessions throughout the study. They shared their opinions, and after approval was obtained from all the authors, the categories and subcategories were finalized. To increase transferability, several direct quotes from the participants’ interviews and the findings of the study were provided to several IHD patients who were eligible but did not participate in the study. They were asked if the participants’ experiences in this study accurately reflected their actual barriers to maintaining a healthy lifestyle and whether the findings resonated with their own observations or experiences.

Ethical considerations

This study was ethically approved by Lorestan University of Medical Sciences (IR.LUMS.REC.1403.414) and was conducted in accordance with the Declaration of Helsinki. The participants were informed about the purpose of the study, research ethics, methods of data collection, and recording process. They were also assured that their information would remain confidential, and that they had the right to withdraw from the study at any time. Participants were also informed that all audio recordings would be deleted following the publication of the research findings. Written informed consent to participate was obtained from all participants.

Socio-cultural barriers

A major obstacle for patients in adopting a healthier lifestyle is socio-cultural barriers. These include taboos surrounding women’s sports, misconceptions about sports, fatalism, unhealthy dietary patterns and beliefs, and patterns and beliefs regarding the use of addictive substances such as alcohol, cigarettes, and opium. Decision-making is greatly influenced by sociocultural factors, and decisions involving lifestyle and health are no exception. These decisions are formed and influenced by social norms, beliefs, and values.

Taboos surrounding women’s sports

Many women who engage in physical activities in public places feel distressed and uneasy to continue physical activities in public places, mainly because such activities are tagged with social and cultural taboos. For instance, dress codes and cultural norms often restrict women from participating in sports in public places. Older women, in particular, might also develop negative attitudes toward dressing up in sporting costumes, as they fear negative reviews or sarcasm against them from society. Husbands and fathers may discourage women from exercising outdoors by imposing traditional gender role limitations. These pressures have further reduced in their potential to enjoy physical activities and have also made them feel ashamed of doing such activities. Here is a selection of quotes:

“The place where we live is very small, and people know each other. It doesn’t have a good reputation for a woman to go out and exercise, so most women’s activities are done at home, usually in the form of housework.”

(55-year-old woman)

“Older women feel like if they go outside for a run or wear sports clothes, it’s as if they’ve committed a crime. That’s why fewer older women feel comfortable exercising outdoors.”

(34-year-old cardiology ward nurse)

Misconceptions about sports

Physical activities are limited by misconceptions, which serve as major barriers to individuals exercising and keeping fit. Older adults feel that sports are for the young; thus, they also view themselves as being excluded from participation. The problem is further compounded by safety concerns, as some individuals view physical activity as inherently risky. Additionally, walking is often stigmatized, and there is a belief that it is for poor people. Another common myth is that sports and physical activity are exclusively for men, which has discouraged women from participating. These misunderstandings have a significant role in reducing overall participation in physical activity, contributing to sedentary lifestyles and poor health outcomes in IHD patients. The following is a selection of statements:

“I’m old now. I’m afraid something might happen to me during exercise. The risks of exercising at my age outweigh the benefits.”

(80-year-old man)

“Nowadays, life is like this. You come down, get in your car, and go. The situation has gotten to the point where even a 17-year-old drives around. For someone like me, it’s embarrassing to walk on the street. The neighbors and my family will see me.”

(66-year-old man)

Fatalism

A fatalistic attitude is very much influential in hindering people’s behavior toward healthy lifestyles. Many individuals believe that life expectancy is left to the discretion of a supreme being. Some IHD patients have internalized the widespread belief that all of these efforts are pointless in engaging in a healthy lifestyle given that such behaviors have no effect on their predetermined fate. These fatalistic presumptions reduce the likelihood of people adopting healthier practices or habits, thereby fostering a culture that discourages effective health management and promotes unhealthy lifestyle choices. Below are a few highlighted quotes:

“I believe that lifespan is in God’s hands; no one’s life can be shorter or longer than what is meant to be. From the moment a person is born, it’s already determined how long they will live.”

(61-year-old woman)

“Everyone will die in the end, whether they follow a healthy lifestyle or not; they will live as long as God has destined for them. I prefer not to eat tasteless food during the lifetime God has given me.”

(70-year-old woman)

Unhealthy dietary patterns and beliefs

Food habits are heavily influenced by cultural beliefs and social behaviors, which also act as major barriers to healthier eating habits. At social gatherings, a substantial quantity of food is typically prepared, much of which consists of high-fat or oily dishes. Most individuals consume many local, high-fat dairy products but very few fruits and vegetables. The overconsumption of red meat makes maintaining a healthy diet more difficult. In addition, consuming less food during social gatherings is often avoided because of the fear of being perceived as impolite to the host. Fast food is now perceived as luxury food; and thus, individuals find it challenging to notice its negative health effects. There is also a common misperception of dietary fats; and therefore, the use of animal fats is still common and is believed to be a healthy option. Some patients believe that consuming red meat is good for their heart health and some are reluctant to reduce their intake of red meat or kebabs for fear of being perceived as poor. These cultural and social influences create significant challenges in the adoption of healthier eating habits. Here are a few selected quotes:

“We used to buy oil from the store, from those liquid oils. But since I’ve heard these are genetically modified, I no longer buy them, and we consume animal fat instead.”

(56-year-old man)

“Here, people care a lot about what others think of them, and this makes it difficult for them to do many things. For example, they worry that if someone doesn’t eat meat or kebab, others might think they are poor and can’t afford it. So, they continue eating these foods just to avoid judgment.”

(51-year-old cardiologist)

Patterns and beliefs regarding the use of addictive substances

Traditionalistic cultural beliefs and misunderstandings, expressed as patterns and attitudes about addictive substances, give rise to behaviors that normalize and perpetuate substance use in a wide variety of social situations, which hinders the adoption of a healthy lifestyle among patients with IHD. For example, smoking is often seen as a sign of status and prestige, whereas opium use is traditionally associated with nobility and high social standing. There is also little negative social stigma surrounding opium use; to the extent that, in some gatherings, offering opium to guests is regarded as a gesture of respect. Addictant use, especially in social gatherings, has also normalized their usage to a great level. Here is a selection of quotes:

“I think opium use here is higher than the national average because it’s somehow ingrained in the local culture. For example, it might be present at gatherings, or they might even offer it to guests as a sign of respect.”

(34-year-old cardiology ward nurse)

“Opium is a cultural issue here. People believe it’s associated with the elite, and there’s no stigma attached to using it.”

(54-year-old cardiologist)

Economic barriers

A significant challenge for patients in achieving a healthier lifestyle is economic barriers. These include the economic crisis and the high cost of maintaining a healthy lifestyle. Economic hardships shape decision-making, with financial constraints heavily influencing choices related to health and well-being, including a healthy lifestyle.

Economic crisis

The economic crisis often leads to psychological stress due to the uncontrollable price rise and inability to plan finances appropriately. Financial crises and the resulting challenges, particularly those related to children, exacerbate psychological stress. Pressing economic issues overshadow health concerns, thereby slowing down actions concerning well-being when survival and having minimum economic stability become the priority. Here are a few selected quotes:

“How can you not be stressed in these circumstances? For example, we’re farming, and suddenly everything goes wrong. Pesticide or fertilizer prices, for instance, can suddenly multiply. There are events that are hard to believe, and these things affect your mind, mood, and everything else. Our country still hasn’t been able to stabilize anything; for example, we plan based on the assumption that water costs one toman, but the next day, it’s a thousand tomans per liter. Most of my problems are economic.”

(52-year-old man)

“I’m always stressed about my kids. They’re farmers, and they work really hard, but their financial situation isn’t good.”

(55-year-old woman)

“The financial concerns are so overwhelming, and people are caught up in the daily struggles of life with the economic situation being so bad, that no one thinks about this issue. For example, no one says, ‘I’ll eat well now so that I’ll be better off in 5 years.’ No one even knows what tomorrow will bring.”

(30-year-old cardiology resident)

The high cost of a healthy lifestyle

The financial repercussions of living a healthy lifestyle deter many people from engaging in healthier habits. Many opt to eat the same meals as their family members, even if these options are not healthy, owing to the high cost of preparing separate meals. Furthermore, high costs associated with gym membership, increased expenses related to access to nutritionally rich foods, and the high cost of coordinated care and lifestyle interventions for patients present serious financial obstacles. As a result, these financial barriers significantly limit the ability of IHD patients to adopt and sustain lifestyle modifications essential for managing their condition and preventing further complications. Here is a selection of statements:

“I haven’t followed the diet. I even eat fried food because I can’t cook two different meals, one for the kids and one for myself. It would be too expensive. I ate whatever the rest of the family ate.”

(55-year-old woman)

“My son goes to the gym and pays 250,000 tomans a month. If I want to go too, that would be 500,000 tomans just for the gym. Life has other expenses; it’s not all about the gym.”

(57-year-old man)

Individual barriers

Individual barriers create significant difficulties in pursuing a healthier lifestyle. These include neglecting self-care, preferring unhealthy foods, lacking access to the resources and conditions for a healthy lifestyle, having certain personality traits, having low health literacy, and having time constraints. Collectively, these factors create a complex web of challenges that hinder patients from adopting and maintaining healthier behaviors.

Neglecting self-care

The neglect of self-care is due to prioritizing others’ needs over one’s own health, such as focusing on family members’ needs rather than personal well-being. This perspective leads individuals to neglect positive habits and practices that would help them secure better health in the long term. Below are a few highlighted quotes:

“I got this illness, but thank God my kids are healthy. It’s unfair for them to have to eat tasteless food in their youth because of me.”

(55-year-old woman)

“I can’t bring myself to take away the money I could use to buy my child the things that make him happy, just so I can have the expensive oil or fish.”

(64-year-old man)

Unhealthy food preferences

Unhealthy eating preferences are often due to a liking for greasy, salty foods and sugary drinks, as well as a lack of interest in consuming healthier options, including vegetables. These choices lead patients to become more attached to food and drinks that are harmful to their health, making the transition to healthier eating habits challenging. Here is a selection of statements:

“I’d rather live 70 years eating whatever I want than live 100 years on bland food and just vegetables.”

(57-year-old man)

“Even though I was told to eat less salt, I still ate a lot of it. I don’t like low-salt food or food without animal fat.”

(70-year-old woman)

Lack of access to resources and conditions for a healthy lifestyle

Access to resources and conditions for a healthy lifestyle is often hindered by factors such as restricted physical activity due to ailments and musculoskeletal pain, living in remote areas without access to healthy food, and a lack of suitable sports facilities or opportunities for group exercise. The presence of such barriers constrains people from engaging in health-promoting behavior and makes living a healthier lifestyle difficult and less reachable. Some noteworthy quotes are as follows:

“I can’t exercise. My knee has developed wear and tear, and even my normal walking is painful.”

(80-year-old woman)

“We live in the mountains, so I can’t follow all the recommendations. For example, they say to eat low-fat dairy, but the milk and yogurt we get from our livestock are full-fat.”

(55-year-old woman)

Personality traits

Personality traits such as low industriousness, tendency toward hedonic eating, emotional sensitivity, high-stress personality, and resistance to change are important barriers to a healthier lifestyle for IHD patients. These traits can have a large influence whether an individual is able to embrace health-promoting behaviors. Tendency toward hedonic eating and low industriousness can lead to poor diet and a lack of physical activity, and emotional sensitivity and a high-stress personality can hinder effective stress management, which is a crucial component of a healthy lifestyle for patients with IHD. Resistance to change also creates difficulty in making long-term, healthy lifestyle changes. Below are some insightful quotes:

“Food is an important part of my life, and I’m not willing to take this pleasure away from myself.”

(67-year-old woman)

“I’m already at an age where I’m set in my ways. Even if I wanted to, I couldn’t change now. The way I’ve lived so far is how I’ll continue living.”

(62-year-old man)

Low health literacy

Low health literacy results in a lack of knowledge about the importance of having a healthy lifestyle and the costs associated with not adhering to it. Misconceptions about healthy lifestyle recommendations and compliance with such practices only during periods of illness when symptoms are present, assuming that dietary rules are not needed after undergoing invasive treatments, such as stent installation or open-heart surgery, constitute part of the problem. In addition, certain beliefs contribute to the issue. To illustrate, some individuals believe that quitting opium could lead to stroke or paralysis, or that opium addiction is hereditary, similar to some diseases. There is also the misconception that alcohol consumption is beneficial due to its fat-cleansing effects and that recreational cigarette use does not harm heart health. These myths serve to prevent IHD patients from adopting and maintaining health-promoting behaviors, making a better lifestyle harder to achieve. Included here are some noteworthy quotes:

“Everyone said that at your age, if you quit opium suddenly, you’ll have a stroke or become paralyzed. I thought that if that’s the case, it’s better to keep using it.”

(69-year-old man)

“I’ve heard that it’s good for fat; it cleanses the fats. For example, when I eat fatty food like kebab, I drink alcohol with it.”

(52-year-old man)

Time constraints

Time constraints are a major barrier to a healthy lifestyle. Extended working hours tend to leave little space for physical exercise or to prepare healthy foods. Most women, with several roles to play in their personal and professional lives, find it hard to allocate time for regular exercise. Such time limitations render the pursuit of a healthy lifestyle difficult and relegate well-being to a lesser priority. Here is a selection of quotes:

“The doctor told me to eat low-salt and low-fat foods. Back when I had time, I used to cook for myself, and it was better. But now, I’m so busy that I just focus on filling my stomach. I don’t think about whether it’s healthy or not.”

(42-year-old man)

“Women have countless responsibilities at home besides working, and many of them, even though they care about their health, still don’t have time to exercise and take care of themselves.”

(44-year-old cardiology ward nurse)

Healthcare-medical barriers

Individuals with IHD face healthcare-medical barriers that make it difficult to adopt a healthy lifestyle. These include communication challenges in healthcare, management and infrastructure challenges in healthcare services, gaps in patient education and healthcare delivery, and the perceived insignificance of lifestyle recommendations by patients. These obstacles bar IHD patients from the achievement of a healthy lifestyle, as they restrict access to quality care, cause miscommunication between health care providers and patients, and give emphasis to medical interventions over lifestyle modifications.

Gaps in patient education and healthcare delivery

Gaps in patient education and healthcare delivery are major obstacles to effectively guiding IHD patients toward a healthy lifestyle. These gaps include inadequate and low-quality education provided by healthcare providers, which is often limited to medication instructions without broader health guidance, including lifestyle recommendations. There is also a tendency for physicians to delegate educational responsibilities to nurses, while many patients show greater obedience to doctors’ recommendations. Besides, there are inconsistencies between the lifestyle advice provided by doctors and that provided by nurses, which further confuses patients, hence weakening the trust of patients in lifestyle recommendations. The following is a selection of statements:

“When my illness started, I was hospitalized. The doctor didn’t tell me anything about what I should do considering my condition. But a nurse explained things to me for about two minutes when I was being discharged. She just spoke quickly and left, without giving me anything in writing. You can’t remember everything someone says in such a short time.”

(46-year-old woman)

“I haven’t seen doctors in the hospital discuss lifestyle modifications with patients. Maybe they think it’s solely our responsibility to address them. If doctors also talked about it, it would be much better because people trust their words more and tend to listen to them better.”

(36-year-old cardiology ward nurse)

Communication challenges in healthcare

Communication challenges between patients and healthcare providers significantly hinder the adoption of a healthy lifestyle among individuals with IHD, ultimately affecting their health outcomes. These include the use of highly technical jargon by health professionals, which complicates the understanding of the advice given to patients. Cultural and legal barriers may equally cause a patient to withhold true information from their healthcare providers, thus negatively impacting the guidance and support they receive for adopting a healthy lifestyle. Moreover, questions on sensitive topics such as alcohol consumption may not be asked clearly by healthcare providers, because of the fear of being misinterpreted. Unrealistic strictness coupled with a lack of professional honesty further complicates communication and delays the building of trust, which is essential for guiding patients toward a healthier lifestyle. Below are a few highlighted quotes:

“I notice in the medical community, maybe it’s just in our country, that they often exaggerate to make you comply. For example, they say, ‘Don’t eat any fat or salt at all, or something terrible will happen to you.’ Then you go to another doctor who says a little is fine, or you start eating it yourself and realize that nothing major happens. This approach makes it hard to trust doctors in the future. Even if the next doctor is telling the truth about something serious, I might not believe them.”

(61-year-old man)

“If a patient’s alcohol use is noted in their medical history during admission, then yes, we definitely talk to them about alcohol. Otherwise, no, because many patients don’t like it. They feel like we’re judging them based on their appearance and assuming they’re alcoholics.”

(34-year-old cardiology ward nurse)

Management and infrastructure challenges in healthcare services

Various challenges regarding the management and infrastructure of health services negatively impact quality care, including lifestyle recommendations. Low consultation fees at clinics and short doctor visits further reduce the time for doctors to explain preventive measures and provide lifestyle guidance. A lack of referral systems makes patients seek specialists, even for minor health issues, which could have been treated by a general physician. This overwhelms specialists with the high volume of cases, thereby compromising the quality of care they can provide and further limiting the resources available to offer comprehensive lifestyle recommendations, which in turn makes it difficult for patients to adopt healthier habits. In addition, the failure to supervise physicians properly also undermines the effectiveness of the provided care since it results in the absence of quality of care minimum standards, thereby leaving it to personal preference. Here is a selection of quotes:

“No one here has time for this kind of talk (lifestyle recommendations). Everywhere in the world, for example, a doctor might see 4 or 5 patients and spend 20 minutes with each. How many patients do we see in a day? Sometimes I see 45 or 50. I even remember a day when it reached 70. All of this is because the consultation fee is so low that you have to see so many patients to make it worthwhile. So, you’re forced to spend less time, and the first thing to be cut out is these things.”

(45-year-old cardiologist)

“There’s hardly any oversight. No one checks to ensure that, by law, you’re spending at least 15 minutes with each patient or providing the necessary recommendations.”

(45-year-old cardiologist)

The perceived insignificance of lifestyle recommendations by patients

The perceived insignificance of lifestyle advice by patients is also one of the major impediments to proper health care with regards to providing lifestyle recommendations. Most patients prefer medical interventions over advice on lifestyle changes, and they request procedures rather than preventive measures. In addition, physicians’ nonpharmacological advice is mostly underestimated by patients. Patients also prefer shorter visits that exclude lifestyle counseling instead of having to wait longer in the office for a more comprehensive consultation. This attitude results in fewer lifestyle recommendations being implemented in their daily lives, at the expense of their long-term health status. Here are a few selected quotes:

“Patients don’t value it if a doctor takes the time to explain what to eat, what to avoid, or what actions to take. They believe the doctor’s role is to perform a procedure or, as they put it, ‘put them under some kind of machine’.”

(54-year-old cardiologist)

“If you sit in your office and spend 15 minutes with each patient to thoroughly explain and guide them, you’ll have patients outside the door shouting in frustration. It seems that neither we as doctors nor the patients visiting us have been taught to dedicate proper time for this process.”

(45-year-old cardiologist)

Strengths and limitations

This study has multiple advantages that can increase the validity and reliability of the findings. Semi-structured in-depth interviews allowed in-depth contextual data collection, including complex barriers that patients with IHD face during lifestyle change. Triangulation of views was made possible by including both patients and key informants like cardiologists, residents, and nurses to have a broader understanding of the experience of these patients. Focusing on Lorestan Province, which has its own socio-cultural and economic conditions, helped to identify the local problems. To ensure methodological rigor, we used strategies like purposeful sampling for demographic variety, member checking, external expert review, and collaborative coding in line with Guba and Lincoln’s criteria. In addition, this study’s clear focus on and detailed capture of healthcare system-based barriers, an area that has received minimal attention in the majority of previous studies, is one of its most notable strengths.

Although the study has notable strengths, certain limitations must be considered. The qualitative and regional focus limits the generalizability of findings to other populations and settings. To address this, we provided rich context, detailed demographics, and direct quotes from participants to increase transferability. In addition, participants were purposefully selected, so there is potential for selection bias, particularly toward those who are more willing or able to share their experiences. We minimized this risk by ensuring variation in age, gender, socioeconomic status, and health literacy and including patients and healthcare providers from diverse backgrounds. Moreover, as data was self reported, the findings may be subject to social desirability or recall bias. In order to counteract this, we used neutral, nonjudgmental language during our private interviews and employed probing techniques to elicit candid, thorough answers. Family members’ and community leaders’ opinions, whose opinions could affect patient behaviors, were not included in the study. However, we partially compensated for this by including healthcare providers who observe patients’ family and community interactions.