Cardiovascular risk assessment of South Asians in a religious setting: a feasibility study

Feasibility of implementing a community cardiovascular health promotion program with paramedics and volunteers in a South Asian population

BACKGROUND

The South Asian population in Canada is growing and has elevated risk of cardiovascular disease and diabetes. This study sought to adapt an evidence-based community risk assessment and health promotion program for a South Asian community with a large proportion of recent immigrants. The aims were to assess the feasibility of implementing this program and also to describe the rates of cardiometabolic risk factors observed in this sample population.

METHODS

This was a feasibility study adapting and implementing the Community Paramedicine at Clinic (CP@clinic) program for a South Asian population in an urban Canadian community for 14 months. CP@clinic is a free, drop-in chronic disease prevention and health promotion program implemented by paramedics who provide health assessments, health education, referrals and reports to family doctors. All adults attending the recreation centre and temple where CP@clinic was implemented were eligible. Volunteers provided Hindi, Punjabi and Urdu translation. The primary outcome of feasibility was evaluated using quantitative process measures and a qualitative key informant interview. For the secondary outcome of cardiometabolic risk factor, data were collected through the CP@clinic program risk assessments and descriptively analyzed.

RESULTS

There were 26 CP@clinic sessions held and 71 participants, predominantly male (56.3-84.6%) and South Asian (87.3-92.3%). There was limited participation at the recreation centre (n = 19) but CP@clinic was well-attended when relocated to the local Sikh temple (n = 52). Having the volunteer translators was critical to the paramedics being able to collect the full risk factor data and there were some challenges with ensuring enough volunteers were available to staff each session; as a result, there were missing risk factor data for many participants. In the 26 participants with complete or almost complete risk factor data, 46.5% had elevated BP, 42.3% had moderate/high risk of developing diabetes, and 65.4% had an indicator of cardiometabolic disease.

CONCLUSION

Implementing CP@clinic in places of worship is a feasible approach to adapting the program for the South Asian population, however having a funded translator in addition to the volunteers would improve the program. Also, there is substantial opportunity for addressing cardiometabolic risk factors in this population using CP@clinic.

A comparison of cardiovascular risk scores in native and migrant South Asian populations

BACKGROUND

South Asians have increased cardiovascular risk burden but little data exists comparing cardiovascular (CV) risk models in migrant and native South Asians. Our retrospective cohort study in patients presenting with first acute myocardial infarction(MI) compares the predictive value of CV risk scores in native and UK migrant South Asians.

METHODS

Retrospective cohort study of 80 UK-based patients of South Asian origin admitted with first presentation MI, excluding patients with known coronary artery disease. A retrospective 10-year CV risk was calculated for each patient using four cardiovascular risk models: Framingham Risk Score(RiskFRS), World Health Organisation(RiskWHO), American College of Cardiology/American Heart Association(ACC/AHA) (RiskACC/AHA), and 3rdJoint British Societies'(RiskJBS). Our aim was to assess agreement between these risk scores and conduct comparative analysis with native South Asians.

RESULTS

RiskJBS identified the largest proportion of migrant South Asians as 'high risk' with 65% of subjects having an estimated >20% 10-year CV risk. RiskWHO provided the lowest 10-year CV risk estimates for South Asian migrants, identifying 21.25% of the migrant cohort as >20% risk of major CV event. Comparative analysis with the native South Asian cohort demonstrated RiskJBS as the risk model most likely to identify patients as 'high'(>20%) risk(55.9%; p = 0.224).

CONCLUSIONS

This study represents the first analysis of predictive cardiovascular risk scores comparing migrant and native South Asian populations. Significant variation between the CV risk scores were observed, leading to inaccuracies in patient cardiovascular risk estimation. Given the growing burden of cardiovascular disease in Asian countries and different population characteristics, we highlight the need for population specific CV disease risk models whilst providing stimulus for further large-scale prospective studies.

Empowering local communities to make lifestyle changes: is the Health Mela a potential solution?

Background

Health Melas are community-led public health events held in the North West of England that provide health information and free health checks. This descriptive observational study evaluates whether Health Melas are able to identify undiagnosed cardiovascular disease (CVD) risk factors in hard-to-reach communities and encourage individuals to make lifestyle changes.

Methods

Attendees ≥18 years at three separate Health Melas in 2016–2017 were invited to participate in screening and counselling for CVD risk factors as part of a Health MOT. Information was collected about demographics, CVD risk factors, blood pressure, total cholesterol, blood sugar and attendees’ feedback. QRISK2 scoring system was used to estimate CVD risk.

Results

375 attendees completed a questionnaire. The highest proportion (36.9%) of attendees were from areas of the lowest Index of Health Deprivation and Disability quintile; 38.8% were of South Asian ethnicity. Of the attendees who were eligible for a free National Health Service Health Check, 9.1% had received one. Overall, 57.5% of all attendees had a QRISK2 score ≥10% (of whom 56.9% were not on statins), 92.2% of attendees believed the Health Mela will help them to make lifestyle changes, 98.2% said they had improved their understanding of their health, and 99.6% thought the Health Mela was useful. 73.6% of those who had received a previous Health MOT reported making lifestyle changes. There was a positive correlation between South Asian ethnicity and QRISK2 score.

Conclusion

This study suggests the Health Melas successfully involve South Asian populations and people from a lower Index of Health Deprivation and Disability. Attendees felt the events were useful, improved understanding of their health needs and encouraged them to make lifestyle changes. High rates of modifiable CVD risk factors were newly identified and a high proportion of attendees were found to be at intermediate to high risk of CVD.

Health, faith and therapeutic landscapes: Places of worship as Black, Asian and Minority Ethnic (BAME) public health settings in the United Kingdom

Within the United Kingdom, there is evidence that faith-based affiliations, ideas, actors and organisations play a role in public health (PH) that has been neither properly recognised nor integrated into mainstream health systems (November, 2014). Discourses on faith and improving health outcomes have been particularly focused on 'seldom heard' groups, including 'Black, Asian and Minority Ethnic' (BAME) communities (November, 2014; Jain, 2014; Burton et al., 2017; Muhammad, 2018). In this paper we first present findings from a qualitative scoping study carried out in the UK cities of Leeds and Bradford, between 2014 and 2015, which examined Places of Worship (PWs) as BAME PH settings. We carried out 19 semi-structured interviews with purposively selected respondents, and three focus groups. Second, we develop a theory that originates from one in the sub-discipline of 'health geography' concerned with 'therapeutic landscapes', applying it to our research findings on PWs as BAME PH settings. The paper argues for the recentring of religion and faith settings back into the therapeutic landscapes literature, reflecting evidence that faith-based affiliations, ideas, actors and organisations are relevant to the pursuit of health and wellbeing. We also contend that a therapeutic landscapes framework provides a way of making the health relevance of PWs visible to both health practitioners and to members of PWs. We argue that PWs act as therapeutic places (i.e. specific transformative sacred sites) as well as therapeutic spaces (i.e. settings that provide adjuncts to formal PH promotion services), and are often part of therapeutic networks included in 'kinship groups and networks of care provided by family, friends, therapists and other agents of support' (Smyth, 2005: 490). This approach allows us to see how influences on health behaviour are not just confined to biomedical settings, but that the 'healing process works itself out in places (or situations, locales, settings and milieus)' (Gesler, 1992: 743).

Adaptation of 2016 European Society of Cardiology/European Atherosclerosis Society guideline for lipid management to Indian patients - A consensus document

In the year 2016, European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines provided recommendations on dyslipidemia management. The recommendation from these guidelines are restricted to European subcontinent. To adapt the updated recommendations for Indian subset of dyslipidemia, a panel of experts in management of dyslipidemia provided their expert opinions. This document provides expert consensus on adapting 2016 ESC dyslipidemia guidelines recommendations in Indian setting. The document also discussed India-specific relevant literature to support the consensus opinions provided in management of dyslipidemia.

South Asians: why are they at a higher risk for cardiovascular disease?

PURPOSE OF REVIEW

We comment on the high prevalence of cardiovascular disease (CVD) in South Asians (SA). The effect of various risk factors, for example biochemical, genetic, lifestyle, socioeconomic factors and psychosocial stress on CVD risk is discussed.

RECENT FINDINGS

'Prediabetes' is common in SA, but its relationship with coronary artery disease (CAD) is not significant unlike for the white population. At the same time, 'prediabetes' in SA is associated with an increased risk for cerebrovascular disease (CeVD). The differentiating factor could be the high lipids in Europeans and their relationship to CAD. Likewise, higher diastolic blood pressure in SA may explain the risk of CeVD. Small, dense, low-density lipoprotein (LDL), low high-density lipoprotein-cholesterol (HDL-C) concentration and high triglycerides may contribute to atherosclerosis. Thrombotic factors such as increased levels of plasminogen activator inhibitor, fibrinogen, lipoprotein (a) and homocysteine have been shown to be associated with increased CVD. Impaired cerebrovascular autoregulation and sympathovagal activity, increased arterial stiffness and endothelial dysfunction may increase CVD risk further. In addition, environmental and dietary factors may exaggerate the unfavourable cardiovascular profile through genetic factors.

SUMMARY

The implications of the findings suggest comprehensive screening of SA for CVD. Cultural differences should be considered while designing prevention strategies specifically targeting barriers for uptake of preventive service.

Evaluation of the point of care Afinion AS100 analyser in a community setting

Background

A ‘one stop shop’ model for multifactorial risk factor management in a culturally sensitive environment may improve cardiovascular disease and diabetes prevention. A full biochemical profile for cardiovascular disease risk assessment includes a lipid profile, glucose, glycated haemoglobin and urine albumin creatinine ratio measurements. This may require the use of more than one point of care testing instrument.

Methods

Individuals who attended a community cardiovascular disease risk screening or an audit programme of the diabetic care pathway in the community were sampled. Bland–Altman and Deming regression plots were used to assess agreement between methods for total cholesterol, high-density lipoprotein cholesterol, triglycerides, glycated haemoglobin and urine albumin creatinine ratio.

Results

There was good agreement between the Afinion AS100 analyser, Cholestech LDX and the laboratory methods for total cholesterol, high-density lipoprotein cholesterol and triglycerides ( n = 232). The Afinion AS100 agreed well with the laboratory method for glycated haemoglobin ( n = 255) and urine albumin creatinine ratio ( n = 176). There was statistically significant bias ( p = 0.03 to <0.0001) for several measurements. However, these were judged not to be clinically relevant. Specifically for the total cholesterol and high-density lipoprotein cholesterol values, we obtained good agreement (weighted kappa: 0.91 and 0.94 for the Afinion AS100 vs. Cholestech LDX and Afinion AS100 vs. laboratory method, respectively) for cardiovascular disease risk calculation using QRISK2.

Conclusions

Point of care testing can support a ‘one stop shop’ approach by providing rapid, reliable results. The Afinion AS100 analyser provides a multi-analyte platform and compares well with laboratory-based methods and another well-established point of care testing analyser.

Management of Coronary Artery Disease in South Asian Populations: Why and How to Prevent and Treat Differently

The South Asian (SA) population constitutes one of the largest ethnic groups in the world. Several studies that compared host and migrant populations around the world indicate that SAs have a higher risk of developing cardiovascular disease (CVD) than their native-born counterparts. Herein, we review the literature to address the role of the screening tools, scoring systems, and guidelines for primary, secondary, and tertiary prevention in these populations. Management based on screening for the CVD risk factors in a high-risk population such as SAs can improve health care outcomes. There are many scoring tools for calculating 10-year CVD risk; however, each scoring system has its limitations in this particular ethnicity. Further work is needed to establish a unique scoring and guidelines in SAs.

Framingham ten-year general cardiovascular disease risk: agreement between BMI-based and cholesterol-based estimates in a South Asian convenience sample

The goal of this analysis was to determine the agreement between body mass index-based and cholesterol-based ten-year Framingham general cardiovascular disease risk scores among a convenience sample of 773 South Asian Canadian adults attending community-based screening clinics. Scores were calculated using age, systolic blood pressure, antihypertensive use, current smoking, diabetes, and total cholesterol and high density lipoprotein (for cholesterol-based risk) or height and weight (for body mass index-based risk). Mean risk score differences (body mass index-based risk minus cholesterol-based risk) were estimated using paired t-tests. Bland-Altman plots were used to assess agreement between scores. Finally, agreement across risk categories (low [<10%], moderate [10% to <20%], high [> = 20%]) was examined using the kappa statistic. Average agreement between the two risk scores was quite good overall (mean differences of 0.6% for men and 0.5% for women), but increased to about 3% among participants 60-74 years of age. However, Bland-Altman plots revealed that the differences between the two scores and the variability of the differences increased with increasing average 10-year risk. In terms of clinical importance, the limits of agreement were reasonable for women < 60 years (95% confidence interval: -3.2% to 3.1%), but of concern for women 60-74 years (95% confidence interval: -6.0% to 12.3%), men < 60 years (95% confidence interval: -7.1% to 7.3%) and men 6-074 years (95% confidence interval: -13.8% to 18.8%). Agreement across categories was moderate for most sex and age groups examined (kappa values: 0.51 for women < 60 years, 0.50 for women 60-74 years, 0.65 for men < 60 years), except for men 60-74 years, where agreement was only fair (kappa = 0.26). In light of these disagreements, evaluation of a participant's change in cardiovascular disease risk over time will necessitate use of the same risk score (i.e., either body mass index-based or cholesterol-based) at all screening sessions.

Cardiovascular risk assessment of South Asian populations in religious and community settings: a qualitative study

BACKGROUND

Cardiovascular disease (CVD) is a leading cause of mortality, and South Asian groups experience worse outcomes than the general population in the UK. Regular screening for CVD risk factors is recommended, but we do not know the best settings in which to deliver this for ethnically diverse populations. Health promotion in religious and community settings may reduce inequalities in access to cardiovascular preventative health care.

OBJECTIVES

To use stakeholders' and attendees' experiences to explore the feasibility and potential impact of cardiovascular risk assessment targeting South Asian groups at religious and community venues and how health checks in these settings might compare with general practice assessments.

METHOD

Qualitative semi-structured interviews were used. The settings were two Hindu temples, one mosque and one Bangladeshi community centre in central and north-west London. Twenty-four participants (12 stakeholders and 12 attendees) were purposively selected for interview. Interviews were recorded and transcribed verbatim. Themes from the data were generated using thematic framework analysis.

RESULTS

All attendees reported positive experiences of the assessments. All reported making lifestyle changes after the check, particularly to diet and exercise. Barriers to lifestyle change, e.g. resistance to change from family members, were identified. Advantages of implementing assessments in religious and community settings compared with general practice included accessibility and community encouragement. Disadvantages included reduced privacy, organizational difficulties and lack of follow-up care.

CONCLUSION

Cardiovascular risk assessment in religious and community settings has the potential to trigger lifestyle change in younger participants. These venues should be considered for future health promotional activities.

Differences in the Prevalence of Obesity among Fars-Native, Turkman, and Sisstanish Ethnic Groups in Iranian Northern Adults in 2010

OBJECTIVES

The aim of this study was to evaluate the differences of obesity rate among three ethnic groups in northern adults in IR Iran in 2010.

METHODS

The present cross-sectional, analytical study was conducted on 2994 cases of the same age and sex in three ethnic proportions (Fars-native=1625, Turkman=977, and Sisstani=392). The subjects aged between 15 and 65 years old and were selected by multistage cluster sampling techniques including 150 clusters each containing 20 subjects in urban and rural areas in 11 districts in Golestan province (northern IR Iran). Obesity was defined after WHO classification by BMI (Body Mass Index) equal or over 30 kg/m(2). SPSS 16.0 software was used for statistical analysis and P value<0.05 was considered as statistically significant.

RESULTS

Mean±SD of BMI in Fars-native, Turkman, and Sisstanish ethnic groups was 26.72±5.56, 26.18±5.34, and 24.59±6.72 kg/m(2), respectively. Averagely, obesity was common in 22.8% of the subjects and was significantly higher among the females compared to males (32.3% vs13.3%) (P=0.001). Also, its prevalence was estimated as 25%, 22.6%, and 14% in Fars-native, Turkman, and Sisstanish ethnic groups, respectively. Statistical differences were significant among the three ethnic groups (P=0.001). The risk of obesity was 2.041 [95% CI, 1.502-2.722] in Fars-native and 1.781 [95% CI, 1.298-2.472] in Turkman groups compared to Sisstanish ethnic group.

CONCLUSIONS

Over one out of five adults in northern IR Iran suffer from obesity and an alarming rate was shown among the women. Among the three ethnic groups, the highest and the lowest rates were seen in Fars-native and Sisstanish ethnic groups, respectively.

Influence of education in the prevalence of obesity in Iranian northern adults

BACKGROUND

The main aim of this study was to evaluate whether prevalence of obesity in educational levels is different and some related factors in Iranian northern adults.

MATERIALS AND METHODS

This was a cross-sectional descriptive study based on population and 2452 cases (1224 men and 1228 women) aged 15-65 years were chosen by cluster and stratify sampling. Subjects were randomly chosen from 125 clusters and each cluster included 20 cases. Interviewers recorded the data using a multidimensional questionnaire including socio-demographic indexes.

RESULTS

As a whole, the prevalence of obesity was seen in 24% of subjects (15.5% in male and 32.5% in female) and significantly was seen in 3.1% and 14.1% of uneducated people more than in 1-9 year schooling and in high school or college-educated people, respectively (P = 0.001). The risk of obesity was 2.294 (P = 0.001) in uneducated compared to high school or college-educated people, 1.668 (P = 0.001) in urban area compared to rural area, 2.619 (P = 0.001) in 40-65 year people compared to 15-40 year people, and 1.534 (P = 0.003) in good economic compared to poor economic groups. After adjusted for location area, gender, age, and economic stats, the risk of obesity was 2.044 (P = 0.001) in uneducated people compared to high school or college-educated subjects.

CONCLUSION

The obesity as a health problem in Iranian northern adults supported in this study and it was negatively associated with educational levels. Public health programs that aim to reduce obesity should primarily focus on the illiterate and low-educated people.

Feasibility of community-based screening for cardiovascular disease risk in an ethnic community: the South Asian Cardiovascular Health Assessment and Management Program (SA-CHAMP)

Background

South Asian Canadians experience disproportionately high rates of cardiovascular disease (CVD). The goal of this qualitative study was to determine the feasibility of implementing a sustainable, culturally adapted, community-based CVD risk factor screening program for this population.

Methods

South Asians (≥ 45 years) in Calgary, Alberta underwent opportunistic cardiovascular risk factor screening by lay trained volunteers at local religious facilities. Those with elevated blood pressure (BP) or ≥ 1 risk factor underwent point of care cholesterol testing, 10-year CVD risk calculation, counseling, and referral to family physicians and local culturally tailored chronic disease management (CDM) programs. Participants were invited for re-screening and were surveyed about health system follow-up, satisfaction with the program and suggestions for improvement. Changes in risk factors from baseline were estimated using McNemar’s test (proportions) and paired t-tests (continuous measures).

Results

Baseline assessment was completed for 238 participants (median age 64 years, 51% female). Mean TC, HDL and TC/HDL were 5.41 mmol/L, 1.12 mmol/L and 4.7, respectively. Mean systolic and diastolic blood pressures (mmHg) were 129 and 75 respectively. Blood pressure and TC/HDL ratios exceeded recommended targets in 36% and 58%, respectively, and 76% were at high risk for CVD. Ninety-nine participants (47% female) attended re-screening. 82% had accessed health care providers, 22% reported medication changes and 3.5% had attended the CDM programs. While BP remained unchanged, TC and TC/HDL decreased and HDL increased significantly (mean differences: -0.52 mmol/L, -1.04 and +0.07 mmol/L, respectively). Participants were very satisfied (80%) or satisfied (20%) with the project. Participants suggested screening sessions and CDM programs be more accessible by: delivering evening or weekends programs at more sites, providing transportation, offering multilingual programs/translation assistance, reducing screening wait times and increasing numbers of project staff.

Conclusions

SA-CHAMP demonstrated the feasibility and value of implementing a lay volunteer–led, culturally adapted, sustainable community-based CVD risk factor screening program in South Asian places of worship in Calgary, Alberta, Canada. Subsequent screening and CDM programs were refined based on the learnings from this study. Further research is needed to determine physician and patient factors associated with uptake of and adherence to risk reduction strategies.