POPM 3240 Assignment 2
pdf
keyboard_arrow_up
School
University of Guelph *
*We aren’t endorsed by this school
Course
3240
Subject
Medicine
Date
Jan 9, 2024
Type
Pages
12
Uploaded by MagistrateOtterMaster3719
Scenario C: Human
Refugees to Canada often suffer from poor physical and mental health in
comparison to other types of immigrants to this country. This health iniquity may be
related to lack of resources, poor access to health care/medication and physical
difficulties encountered during their journey or related to the lack of infrastructure
here in Canada or some other unknown risk factor that may be related to ethnicity or
culture.
Overcrowding in refugee camps abroad can predispose people to infectious
diseases such as tuberculosis, hepatitis B, shigella and vaccine preventable
diseases. Routine infections can also be exacerbated by underlying
immunocompromising infections such as HIV/AIDS. In addition, many refugees have
a long journey from war-torn and/or gender-discriminating countries and may carry
many invisible burdens.
The Canadian government has tended to focus on infectious disease surveillance in
these mobile populations to meet the urgent needs of immigrants and protect the
health of the general public. However, there are also identified gaps in surveillance
for mental health issues, nutritional deficiencies and chronic conditions, such as
cardiovascular disease, diabetes and digestive disorders. Many diseases go
unrecognized as they rely on patients to self-report symptoms which can be
challenging if English or French is not their first language.
To help meet the needs of this refugee population, it is important from a public health
standpoint to understand the risk factors for these infections and disorders or that
predispose them to need and seek medical treatment or avoid seeking help.
Please use this scenario to help you develop a research question and proposal.
This scenario is strictly a jumping off point and therefore can be taken in a limitless
number of directions. Strong research is focused with respect to a given population,
infection/disease, risk factor and outcome measured. Be specific.
Just because Canada as a country is mentioned does not mean this needs to be
research conducted at the national level or even within Canada. Frequently we
conduct research in our own cities and provinces and extrapolate the results to the
national level.
Scenario decision:
Scenario C Human
P
- Syrian refugees (male/female) over the age of 40 living in Ontario, who have immigrated
to Canada within the last two years.
E
- limited/no English proficiency (Includes Syrian refugees with no English language
education and are unable to speak and/or understand English)
C
- Syrian refugees with sufficient English proficiency (Includes Syrian refugees who have
English language education and/or are able to communicate effectively in English)
O
- heart attacks (prevalence of cardiovascular disease among Syrian refugees)
T
- Over the next 12 months.
Research Question:
Does education in the English language decrease the rate of cardiovascular disease among
Syrian refugees over the age of 40 after immigrating to Ontario Canada compared to refugees
without this knowledge, over the next 12 months?
________________________________________________________________________
A Cross-Sectional Study Determining the Association Between Limited English
Proficiency and Prevalence of Heart Attacks Among Older Adult Syrian Refugees in
Canada
December 2
nd
, 2022
I am aware and fully understand the notions of and penalties for offences against
academic integrity as described in the current undergraduate calendar.
Background Information:
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
With the ongoing war in Syria, Canada has welcomed over 55,000 refugees to major
cities across the country (Boutmira, 2021). Unfortunately, many Syrian refugees carry the
invisible burden of non-communicable diseases (NCDs), which are responsible for 45% of
the mortality in Syria (Kuru Alici & Öztürk Çopur 2022). One common NCD is
cardiovascular disease (CVD), characterized as a group of disorders that affect the heart and
blood vessels, and are the consequence of numerous lifestyle, behavioural and genetic factors
including smoking, poor diet and physical inactivity (WHO, 2021). Heart attacks (myocardial
infarctions) are a typical indicator of CVD, caused by a severe loss of blood flow to the heart
due to blocks in the coronary arteries (Mayo Clinic, 2022).
The management and treatment of NCDs is expensive and exhaustive on healthcare
resources (Kuru Alici & Öztürk Çopur, 2022). Therefore, it is imperative from a public health
perspective to understand the risk factors that predispose refugees to avoid seeking medical
attention. Previous studies have shown many risk factors including communication barriers,
financial barriers, cultural differences, lack of effective guidance, limited health facility
capacity, geographical barriers and others to prevent Syrian refugees with NCDs from
obtaining quality healthcare (Kuru Alici & Öztürk Çopur, 2022). However, language barriers
are one of the most frequently cited obstacles (Aljadeeah
et
al. 2021, Boutmira, 2021, Green,
2017, Kuru Alici & Öztürk Çopur, 2022, Torun
et al
. 2018). Accessing quality healthcare is
crucial to preventing, treating and controlling chronic diseases amongst this population, yet in
Canada the majority of Syrian refugees are found to have limited English proficiency
(Boutmira, 2021). This often leads to many chronic diseases going unrecognized as they rely
on patients to self-report symptoms which can be challenging if English is not their first
language.
The inability to communicate fluently complicates interactions with healthcare
professionals, from discussing medical history to describing characteristics and duration of
symptoms, and even in obtaining medication instructions from pharmacists (Green, 2017). It
also increases the difficulty of simply calling to schedule appointments, which can be
daunting for anyone with poor language skills in a new/foreign country. In addition, the effect
of language barriers in relation to/on accessing treatment and medicine was found to be more
pronounced among individuals over the age of 50 and who had chronic illnesses (Aljadeeah
et al
. 2021, Boutmira, 2021). With older Syrian refugees frequently lacking sufficient English
language proficiency to support themselves in Canada, many rely on family members,
neighbours, and others to help navigate the healthcare system and society (Boutmira, 2021,
Torun, 2018).
The language barrier makes it harder for older Syrian refugees with NCDs to access
healthcare for treatment, medication, and medical advice that could prevent death or disease
progression. For example, studies found that older Syrian refugees with limited native
language skills found accessing healthcare extremely challenging (Boutmira, 2021) and the
inability to access or receive appropriate care due to communication issues resulted in their
needs going unmet, leading to further deterioration of health conditions (Aljadeeah
et al
.
2021, Boutmira, 2021). As Syrian refugees continue to immigrate to Canada the number of
individuals requiring additional care for chronic diseases which could have been prevented or
controlled will only accumulate, placing a considerable strain on the healthcare system.
Currently, only qualitative studies have been conducted on the effects of language
barrier in limiting access to healthcare for older Syrian refugees, using interpretations from
interviews and surveys as evidence. No quantitative studies have been done on the effect
language barriers have on chronic disease rates to provide statistical evidence for how the
association between language barriers and inability to access healthcare impacts the outcome
of a specific disease. So far, we can only assume that improving English language proficiency
will have beneficial effects in reducing chronic disease rates among Syrian refugees, but we
have no statistical data to support this theory. With a high risk of NCDs in this vulnerable
population it is essential that chronic diseases like CVD do not go unrecognized as they put
considerable strain on our already overloaded healthcare system here in Canada. Since it
would be very difficult to study multiple NCDs at once we have chosen to focus specifically
on CVD using heart attacks as our indicator. For refugees with diagnosed or undiagnosed
CVD, eliminating the language barrier that inhibits healthcare access could mean the
difference between the occurrence of a future heart attack or preventing one.
Our study will help attempt to fill this gap in knowledge by directly measuring heart
attacks as a risk factor for CVD. The aim of our research is to determine if an association
exists between limited language abilities and CVD prevalence. The outcome of our study will
not only aid in the control of disease through prevention plans to lessen the burden on
healthcare systems, but also improve the quality of life and lifespan of Syrian refugees.
Further research will provide evidence for the most effective prevention methods to improve
this issue in Canada.
Research Question and Hypotheses:
Does education in the English language decrease the rate of cardiovascular disease
among Syrian refugees over the age of 40 after immigrating to Ontario Canada compared to
refugees without this knowledge, over the next 12 months?
For our null hypothesis, we hypothesize that there is no difference in the prevalence
of heart attacks between male and female Syrian refugees over the age of 40 who have
sufficient English proficiency and those who have limited or no English proficiency, after
moving to Canada within the last two years. Next, using a two-sided approach to formulate
our alternative hypothesis, we hypothesize that the proportion of male and female Syrian
refugees over the age of 40 who have had a heart attack since moving to Canada is either
lower or higher in the group with sufficient English proficiency than in the group with limited
or no English proficiency.
Methodology:
To conduct our study, we will use a cross-sectional study design. This type of
observational study allows us to determine if the exposure (limited English proficiency) is
related to the outcome (heart attack) by randomly sampling study subjects over a single
period in time without regard for exposure or outcome status. Information for both limited
English proficiency and heart attacks will be collected at the same time. Subjects will then be
classified after selection to compare the prevalence of heart attacks in the exposed group and
unexposed group.
The advantages of this study design are they tend to be relatively fast and
inexpensive, have less potential for bias than case-control studies, and there is no loss to
follow-up as data is collected at a single point in time. Ensuring there is no loss to follow-up
is important when studying newly immigrated refugees as their living and work situations
may frequently change causing them to relocate and lose contact, thus affecting the results. A
few limitations of this study design are they are prone to all major forms of bias if not
corrected for such as selection bias, information bias, and confounding variables including
religious beliefs, socioeconomic status, and access to transportation or healthcare. As well,
there may be issues related to temporality as cross-sectional studies are only able to measure
prevalence, not incidence. Since exposure and outcome status are determined simultaneously,
it may be difficult to establish a temporal sequence as we do not know for certain whether the
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
exposure (limited English proficiency) really came before the outcome (heart attack),
potentially leading to reverse associations.
We will be studying both male and female Syrian refugees over the age of 40 living in
Ontario, who have immigrated to Canada within the last two years. To acquire our study
subjects, we will start by obtaining a list of all Syrian refugees over the age over 40 and
living in Ontario from the Canadian Immigration Office. Having samples from the target
population (Syrian refugees over the age of 40 living in Canada) reduces risk of sampling
bias. Collecting data directly from the Canadian Immigration Office helps reduce information
bias as they have an effective method for collecting essential information from every
individual at the port of entry. We will then randomly select an equal number of refugees
from each major town in Ontario. Including potential subjects from various geographical
locations will help evenly distribute any confounding variables related to socioeconomic
status and access to healthcare that may potentially introduce bias and reduce the validity of
the results. Individuals will then be randomly selected from our sampling frame using
stratified random sampling. This involves dividing the sampling frame into sub-categories
based on gender (male and female) to evenly distribute any related and hidden confounders
that may predispose individuals to avoid accessing healthcare resources.
To calculate our sample size, we used the formula for comparing two proportions with
a 95% confidence interval (Zα = 1.96) and a power of 80% (Zβ = -0.84). To date, no studies
have been done to analyze the effects of language barrier on disease status of Syrian refugees,
specifically pertaining to heart attacks. Therefore, we used values from a previous study
analyzing the effect a lack of English proficiency had on refugee resettlement to estimate our
p and q values. The first priori proportion (p1 = 0.30) estimates the prevalence of heart
attacks among Syrian refugees with limited English proficiency (Boutmira 2021). The second
priori proportion (p2 = 0.17) estimates the prevalence of heart attacks among Syrian refugees
with sufficient English proficiency (Boutmira 2021). Using the values above we calculated
the corresponding values to be q1 = 0.70, q2 = 0.83, p = 0.235 and q = 0.765. Therefore, the
minimum sample size required to conduct our study is 166 subjects per group or 332 people
total.
The exposure positive group will consist of individuals with limited or no English
proficiency (cannot speak, understand or communicate effectively in English). The exposure
negative group will include refugees with sufficient English language proficiency (can speak,
understand or communicate effectively in English). Individuals will be identified using a
standardized second language comprehension test. Researchers will use a predetermined test
score to access participants and classify them into the appropriate study group. The outcome
positive group will include individuals that have had a heart attack since moving to Canada in
the last 2 years. In contrast, the outcome negative group will consist of refugees that have not
had a heart attack since moving to Canada. Individuals will be identified as outcome positive
or negative using medical records, a private survey and medical tests including an
echocardiogram (ECG) or MRI of the heart. These tests can reveal if the heart muscle has
been damaged, indicating the person has had a heart attack. The private survey should help
reduce any in-person reporting bias that may occur from embarrassment or reluctance to
disclose personal information. It will also provide knowledge of any heart attacks not
indicated on medical records, since we may not have access to past records as most refugees
are fleeing from a foreign country.
Statistical Analysis:
During the study we will be using heart attacks as a measure of heart disease among older
Syrian refugees. However, after conducting the study, we will be analyzing our results by
calculating relative risk (RR) and odds ratio (OR) for measures of association. Knowing RR
and OR for heart attacks will allow us to determine if there is a positive association present
that is worth addressing and developing prevention measures for. Otherwise, if results show
there is no association or a negative association then we know to continue searching for other
risk factors that may be contributing to refugees avoiding seeking healthcare (ie. religious
beliefs). We will also be calculating population attributable risk (PAR), and population
attributable fraction (PAF) as measures of effect. Since measurements are being collected at
one period in time, we are only studying prevalence. Therefore, we will use prevalence
measurements to determine the amount of heart attacks in the limited English proficiency
group and the entire population that are caused by the language barrier. Such data is
important for public health practice as it tells us the more crucial population to target our
prevention strategies toward.
Dissemination Strategy:
This research is important for both federal and provincial levels of government to be
aware of. Divisions of the federal government such as Canadian immigration services and the
Public Health Agency of Canada could develop prevention and education programs that
ensure all refugees receive equal access to healthcare. As well, each province has a separate
healthcare system that is also responsible for providing care and managing these programs.
Since governments typically prefer evidence-based data and statistics to guide program
development we would distribute our findings using a published paper. If our findings turnout
to be correct we would strongly suggest incorporating a survey and/or medical screening test
upon entry to Canada to determine refugees at risk so appropriate actions can be taken
immediately, as well as making English language education readily available. The healthcare
industry including hospitals, clinics, doctors, and nurses is another main audience for our
research. It is essential that the centers and professionals providing care be aware of potential
issues so they can develop effective treatment plans to minimize the burden on the healthcare
system and its resources. To disseminate our findings, we would present the data to the
hospital board of directors and staff who determine the guidelines for medical procedures. We
would highly recommend providing staff training, translated medical leaflets for patients and
employing qualified translators. Finally, it is important that the general public be aware of
these risk factors and potential outcomes as many Syrian refugees relied on friends,
neighbours, or relatives as a source of information. They can assist refugees in accessing the
education and care they need to function optimally in society. We would use bilingual video
advertising on TV, social media, and posters in public transit and newspapers to help spread
the importance of English education for the health and well-being of Syrian Refugees in
Canada. We would encourage the public to take the initiative to help any Syrian refugees in
their communities as they could potentially be providing lifesaving assistance and effective
disease control benefits the community as a whole since more resources would be available
for everyone.
Funding:
One potential source of funding for this study could be The Canadian Institutes of
Health Research (CIHR). This is a Canadian federal funding agency that collaborates with
researchers from all over the country to support new and upcoming innovations that have the
potential to improve health (CIHR, 2022). While the CIHR is open to various types of health
studies, they do have a short list of health challenges that either the government or themselves
have identified as priorities. One health challenge on this list includes inflammation and
chronic diseases (CIHR, 2022). This applies to our study as the condition being investigated
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
is cardiovascular disease, which is regarded as a chronic disease, as stated by the Public
Health Agency of Canada. Additionally, within the overview of this prioritized health
challenge, the CIHR identifies that heart diseases, such as cardiovascular disease, are
conditions which are in dire need of further investigation (CIHR, 2022).
Another source of funding could arise from the Healthy Communities Fund (HCF), a
branch from the Canadian Ministry of Health Promotion. The HCF revolves around
improving access to priority health services for all Ontarians (PNSG, 2008). It does this by
building on current ministry-funded programs that are already functional and successful
(PNSG, 2008). This would be a great funding source for our study as the HCF aims to expand
their spectrum of health promotion initiatives that address risk factors at all levels for all
citizens (PNSG, 2008). By funding our study, they would be able to support new coming
citizens of Canada and help provide healthier lives. This would be especially beneficial for
the future Canadians who may be at risk due to limited English proficiency.
References:
Aljadeeah, S., Wirtz, V. J., & Nagel, E. (2021). Barriers to Accessing Medicines among
Syrian Asylum Seekers and Refugees in a German Federal State.
International Journal of
Environmental Research and Public Health
,
18
(2), 519.
http://dx.doi.org/10.3390/ijerph18020519
Boutmira, S. (2021). Older Syrian Refugees’ Experiences of Language Barriers in
Postmigration and resettlement Context in Canada.
International Health Trends and
Perspectives
,
1
(3), 404–417.
https://doi.org/10.32920/ihtp.v1i3.1483
Canadian Institutes of Health Research (CIHR). (2022, November 9).
Funding world-class
research
. CIHR. Retrieved November 27, 2022, from https://cihr-irsc.gc.ca/e/53207.html
Government of Canada. (2020, June 25).
Entry and exit data collection and use
. Government
of Canada, Canada Border Services Agency. Retrieved November 26, 2022, from
https://www.cbsa-asfc.gc.ca/btb-pdf/eedcu-cudes-eng.html
Green, M. (2017). Language Barriers and Health of Syrian Refugees in Germany.
American
Journal of Public Health
,
107
(4), 486.
https://doi.org/10.2105/AJPH.2016.303676
Kuru Alici, N., & Öztürk Çopur, E. (2022). Nurses’ Experiences as Care Providers for Syrian
Refugees With Noncommunicable Diseases: A Qualitative Study.
Journal of Transcultural
Nursing
.
https://doi.org/10.1177/10436596221125888
Mayo Foundation for Medical Education and Research. (2022, May 21).
Heart attack
. Mayo
Clinic. Retrieved November 26, 2022, from
https://www.mayoclinic.org/diseases-conditions/heart-attack/symptoms-causes/syc-20373106
Peel Newcomer Strategy Group (PNSG). (2008).
Funding Resources Guide - Peel
Newcomer
. FUNDING RESOURCES GUIDE FOR AGENCIES SERVING NEWCOMERS.
Retrieved November 27, 2022, from
https://peelnewcomer.org/wp-content/uploads/sites/52/2021/02/d-5-final-funding-resources-g
uide.pdf
Torun, P., Mücaz Karaaslan, M., Sandıklı, B., Acar, C., Shurtleff, E., Dhrolia, S., & Herek, B.
(2018). Health and health care access for Syrian refugees living in İstanbul.
International
Journal of Public Health
,
63
(5), 601–608.
https://doi.org/10.1007/s00038-018-1096-4
World Health Organization (WHO). (2021, June 11).
Cardiovascular diseases (CVDs)
. World
Health Organization. Retrieved November 26, 2022, from
https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)
Scientific Journals:
https://www.sciencedirect.com/science/article/pii/S0398762020301747
-
this is a link to a journal that analysed a bunch of papers regarding Syrian refugees in
Turkey and cardiovascular disease
Cardiovascular Disease among Syrian refugees: a descriptive study of patients in two
Médecins Sans Frontières clinics in northern Lebanon | Conflict and Health | Full Text
(biomedcentral.com)
Prevalence and care-seeking for chronic diseases among Syrian refugees in Jordan | BMC
Public Health | Full Text (biomedcentral.com)
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help