Climate Change As a Signiﬁcant Factor to the Aggravation of Coronary Artery Disease Among Elderly: A Basis for Emphasizing Community-based Self-care Measures

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Introduction
Communities live in an aggressive competitive relationship with nature. The persistent quest for advancement, relief, and refuge has intensified the stress on the environment.
As a result, the life-supporting environment has been forced to change more swiftly than ever. The consequences of this have brought problematic issues arising around the globe; eventually resulting in an environmental crisis and ultimately affecting the human population and life-sustaining schemes. Climate change steers the wheel toward disease migration, exacerbating present and developing health concerns; thus, putting the health status of the people at risk. Literature contends that a change in environmental temperature aggravates cardiovascular diseases, such as coronary artery disease (CAD) [1,2].
Climate change plays a crucial role in how the general population scrutinizes nature as well as the changes happening in it [3]. This change persists as time evolves and is deemed to be a major catastrophe of the new millennium [4,5]. It was further asserted that climate change covers a multitude of climatic variations as a product of extensive emission of greenhouse gases [6]. This resultant alteration is primarily relevant to human activities [1,6,7].
CAD is a complex disorder that involves a significant interaction of inherent and environmental factors. Even though there are advanced and modernized ways of treatment to manage this disease, it is still recognized as the world's leading cause of mortality among adults and the elderly [2,8]. The effects of alternating weather conditions and extremely high or low temperatures on health are well known, and cardiac effects are a major component [1]. Managing the health effects of temperature in response to climate change is a global public challenge [9]. Elderly clients both with and without cardiovascular conditions are vulnerable due to immune system deterioration.
Furthermore, the researchers posit that people, especially the elderly are not often aware of the negative impacts of climate change on their health and certain existing diseases, while they frequently go unmindful that the latter is a significant factor in the development or aggravation of CAD. There is little evidence of elderly awareness and perception of climate change; hence, they and the public remain ambivalent regarding this environmental issue and its effects on human health [4,5]. The authors also added that this can be a result of individual differences (e.g., political orientation, science, educational attainment, and social media). Increasing public awareness of the risks posed by climate change is an important predictor and catalyzes to attain adaptation.
Once the common manifestations are identified through the implementation of community-based strategies, it will safeguard the health of the public, more especially, the elderly by mitigating the negative effects of climate change. On that note, the theory of Sister Callista Roy's extended adaptation model in the community is employed by the elderly [10]. The framework explicates that human is biopsychosocial and is enforced to adapt stimuli from the external environment as a compensatory process to preserve the physiologic function of the human system. In order to achieve this, healthcare providers should utilize measures to empower adaptive and coping mechanisms through health promotion and disease prevention to enhance individual functioning.
With the foregoing explications, the researchers explored the lived experiences of the elderly on climate change, which is considered as a significant risk factor in the aggravation of coronary artery disease. Through this study, the elderly and the community would gain awareness and improve practices to manage and cope with the aggravated signs and symptoms of CAD during climate change; thus, also advancing geriatric nursing knowledge.

Research design
The research study is limited to exploring and describing the perceptions of elderly clients on the effects of extreme temperature changes in the environment as a significant factor in the aggravation of CAD. Hence, the researchers employed a descriptive phenomenological design to elicit information on the lived experiences of the elderly.

Locale of the study
This research study was conducted in the province of Cagayan situated in Northern Philippines.

Study participants
The number of samples needed in qualitative research depends on data saturation.
The researchers used purposive sampling to elicit information [11,12]. Eligibility of the participants were based on the following criteria: (1) elderly diagnosed with CAD for at least 6 months since the time data gathering was conducted; (2) elderly aging from 60-85 years old; (3) elderly who could comprehend and articulate easily in their local dialect as well as Filipino and/or English; and, (4) who manifest interest in partaking in the study.
The researchers reached data saturation with the 16 ℎ respondent; however, they continued gathering data up to the 28 ℎ participant to draw out more information to enrich the co-creation of data.

Data collection procedure
Before gathering the data, the researchers sought necessary permits and consent and each participant was given an informed consent form after explaining the purpose of the study. The researchers explored the lived experiences of the participants through faceto-face in-depth interviews along with consented audio recordings. Semi-structured open-ended guide questions were asked to obtain the necessary information. Field notes were jotted down during each interview session, the latter lasted an average of 34 min. Likewise, all of them were notified about the confidentiality of the data and their right to any time withdraw it.

Data analysis
Data were analyzed utilizing the Stevick-Colaizzi-Keen method [13,14]. The authors emphasized the importance of spending sufficient time with the participants to obtain a complete understanding of the situation being studied. Completeness of data will be attained by using different perspectives of data gathering. In this study, the researchers conducted interview sessions along with jotting down significant cues. Member checking was performed in order to validate the accuracy and completeness of data. Constant communication with participants was done to ensure that they are updated on the analysis phase of the research process. It is worth noting that the informants' verbalizations were carefully translated into the English language with the help of two English professors. Original transcripts were a combination of either Filipino and/or the participants' local dialect.

Results
Twenty-eight participants participated. Upon in-depth analysis, the researchers yielded warming. In addition to that some also mentioned and included the perceived causes and factors that contribute to climate change. DOI    measures to adapt to it. In return, these interventions will prevent the worsening of pre-existing medical conditions and future occurrences of disease such as in the case of coronary artery disease (CAD). On the latter note, creating awareness will greatly aid elderly clients to be cognizant with the impacts of climate change on health, specifically the cardiovascular system. Hence, conscientious planning, organization, and application of adaptive measures will be employed as a turning point to improve and strengthen the prevention of CAD aggravation.

Discussion
Climate change is undeniably the biggest environmental problem that the world faces today. It is believed to be the root cause of various catastrophic phenomena that were documented. It affects the public and posits negative impressions on health in numerous ways. It is presumed to worsen and beget devastating, enormous, and dreadful consequences in the future unless efforts are made to control its effects [16][17][18].
Salience is vital in addressing the adverse effects of climate change [19]. The result of this research study shows that most of the participants positively claimed that they have previous knowledge on climate change. This evidence is consistent with previous research that there is an increasing level of public awareness when it comes to observing and perceiving either vast or little changes in the weather condition [1,6,20]. This is predominantly due to the widespread use of electronic media such as television, radio, the internet, and other telecommunication devices.
In this research study, participants identified several contributory factors of climate change like burning of plastic material and pollution [5,18,21]. Climate change has a strong correlation with the declining state of wellness among individuals. It imposes significant threats and aggravates predefined health issues [1,18]. The incidence of cardiovascular diseases such as CAD has largely escalated due to varying weather conditions. The rising number of environmental-related issues affects every individual.
Similar to the result of this research study, the most vulnerable population includes the elderly with or without pre-existing cardiovascular medical conditions [4,22]. Literature illustrated several reasons for this: (1) weakened physiologic ability to maintain thermoregulation; and (2) decreased capacity to adapt to the situation and the environment [6,9,20]. Anent this, the study has considered the age of the participants as a significant variable that greatly affects their vulnerability. Also, participants who were exposed to heavy workloads often experience more pronounced effects compared to those with minimal activity. Increased activity imposes greater demand on the heart; thus, limiting its capability to function normally or cope with demands [1]. Lastly, all the participants were living in the urban area, thereby predisposing them to acquire climate changerelated problems such as CAD [1,4,23].
Generally, the results show that the participants have been experiencing a series of manifestations associated with the cardiovascular system, specifically those who were diagnosed with CAD experienced worst conditions when exposed to alternating weather conditions. It was recorded that higher incidence of CAD occurs during extreme environmental temperature conditions [23,24]. Participants claimed that during warm weather conditions, they often experience fainting, shortness of breath, severe palpi-level, and marked peripheral vasoconstriction [6]. This is also supported by a study [25] that the signs and symptoms are triggered during extreme low temperatures. However, results also revealed that few of them did not recognize any significant effect during cold climates.
The necessity is to address the impacts of climate change on the health of the elderly to prevent a more complex adverse effect in the future. Understanding the complexities of climate change would make the public more resilient [21]. The participants enumerated several practical self-care measures to adapt to or mitigate the consequences of the changing climate. During the upsurge of temperature, they mentioned the following: (i) accomplish tasks before the temperature gets too high; (ii) stay indoors; (iii) alternate rest and activity period; (iv) drink plenty of water as tolerated; (v) wearing light and loose clothes, (vi) taking cold shower or bath two or more times per day; (vii) avoid too much alcohol; (viii) recognize effects to CAD; and, (ix) staying in a cool environment. All these are consistent with existing knowledge on people and not only on elderly who have CAD [2,18,21].Whereas, during cold exposure, the participants suggested the following adaptive strategies as they find them efficient and effective: (i) drink plenty of water; (ii) refrain from going outside the house when the breeze is cold; (iii) take a warm shower; iv) oil application; and (v) wear thick clothes. Effective management on the effects of climate change through the utilization of adaptive coping strategies greatly helps the public to be resilient, especially those at risk and/or with existing cardiovascular medical conditions.
Dealing with the vast and complex health effects of climate change is incredibly challenging. This study is an eye-opener not only for the nursing profession but more especially for the elderly and those living with elderly people.

Study limitations
Within the lens of phenomenological research design and utilizing Roy's extended adaptation model, this research study is focused on describing the lived experiences of the elderly diagnosed with CAD, specifically, on the effects of climate change on their condition. This was only conducted in one Northern province of the Philippines; hence, the context and perception on the effects of climate change on their existing CAD might be culturally or medically different from other provinces and countries.

Conclusion
This research study concludes that elderly clients have an awareness of climate change brought about by global warming and that it aggravates physiologic manifestations of CAD. This further concludes that elderly people residing in urban areas who are exposed to sudden changes involving extreme environmental temperatures are at risk of an aggravated CAD condition. Significantly, employment of simple community-based and practical self-care measures and practices as an adaptation to climate change helps the elderly prevent and control the manifestations of CAD.
Climate change because of environmental and atmospheric changes possess a great impact on the health of every individual; hence, it is recommended that the community, together with the nursing profession and other health sectors to continuously collaborate and strengthen their commitment toward educating and raising awareness, especially of and for the elderly. Public health organizations should implement adaptation strategies to minimize the health effects of prolonged hot and cold environmental exposure.
The following community-based recommendations manage manifestations of CAD: