Physical Measurements

5.4.2.2 Height ... 125 5.4.2.3 Waist and Hip Circumferences... 125 5.4.2.4 Blood Pressure... 126 5.4.3 The Semi-Structured Interview ... 127 5.4.4 Validity and Reliability of the Instruments... 130 5.5 Pilot Project ... 132 5.6 Main Study... 136 5.6.1 Duration... 136 5.6.2 Research Procedure ... 136 5.7 Description of Variables ... 138 5.7.1 Age……… …….138 5.7.2 Religion………... 138 5.7.3 Income……… ... 139 5.7.4 Level of Education ... 139 5.7.5 Birth Place /Length of Residency in Australia ... 139 5.7.6 Physical Activity... 139 5.7.7 Salt Intake... 140 5.7.8 Fat Intake... 140 5.7.9 Obesity 141 5.7.10Tobacco Smoking... 141 5.7.11Cholesterol... 141 5.7.12Blood Pressure... 141 5.7.13Alcohol Intake ... 142 5.8 Data Analysis... 142 5.8.1 Significance Levels... 142 5.8.2 Abbreviations ... 143 5.9 Description of Data Analyses ... 143 5.9.1 Statistical Analyses I: Descriptive ... 143 5.9.2 Statistical Analyses II: Inferential ... 143

5.10 Summary...145 CHAPTER FIVE

RESEARCH METHOD

5.1 Introduction

Coronary heart disease remains a leading cause of death in Australia despite its decline in the past 25 years (Al-Roomi, Dobson, Hall, Heller, and Magnus, 1989, Bennett and Magnus, 1994). The decline has been attributed mainly to the improvements in medical management and to the lower prevalence of behaviours associated with the development of heart disease, such as smoking (Cardiovascular Health In Australia, 1994). It is evident in the literature (Young, 1992; Donovan, d’Espaingnet, Merton and Van Ommeren, 1992) that the mortality rate from coronary heart disease (CHD) amongst immigrant groups is lower than that of Australian-born people. Research has shown that heart disease amongst migrant communities rises with their increased duration of residence in Australia (Young, 1992). It has also been shown that indigenous Australians, people from rural and remote areas, and people from lower socioeconomic backgrounds and non-English speaking background are more at risk than the rest of the Australian population. As seen in Chapter Four, there are some Australian studies that address factors which may influence the incidence of coronary heart disease amongst migrant communities in Australia. However, none relate to an Arabic-speaking community, particularly the Australian-Lebanese. This study was designed to address the limited information about one of the largest Arabic speaking communities in Australia. It involved investigating the prevalence of CHD risk factors and examining which demographic factors, attitudes and behaviours predict the presence of risk factors for cardiovascular disease.

119 5.2 Objectives of the Study

To date, there have been no studies undertaken to determine patterns of cardiovascular disease among Australian-Lebanese in Melbourne. Previous researchers have identified many factors that have the potential to influence and increase the risk of cardiovascular disease amongst different immigrant groups (as discussed in Chapter Four). These factors include age, gender, education, income, stress due to immigration, length of stay in the host country and the adoption of adverse health behaviours such as smoking, increased dietary fat intake, and weight gain, once in the new country.

This study was designed specifically to examine the above factors in an attempt to determine their effect on the cardiovascular health of a sample of adult Australian- Lebanese. The objectives of the study were to determine which demographic factors, attitudes and health beliefs among this Australian-Lebanese sample predict:

1. unhealthy behaviours, namely: physical inactivity, poor dietary habits, obesity, cigarette smoking, alcohol intake, hypertension and high cholesterol levels,

2. knowledge of cardiovascular risk factors, 3. perceptions of own health,

5.3 Sampling Strategy

Research in Australia and overseas has provided well documented evidence of particular sampling problems encountered in research involving ethnic minority groups (Chaturverdi, & McKeigue, 1994; Ecob, & Williams, 1991; Minas, Lambert, Kostov, Boranga, 1996). These difficulties include various definitions of ethnicity, achieving meaningful sampling size, obtaining relevant population denominators and determining appropriate sampling and recruitment strategies (Chaturverdi, & McKeigue, 1994). Due to these difficulties standard random sampling techniques are time consuming and too expensive to be employed successfully (Small, Yelland, Lumley, 1999). Many researchers have therefore utilised non-random sampling strategies in studying ethnic communities, such as snowball sampling from contacts within ethnic community leaders and organisations (Brown, Alexander, McDonald, Mills-Ever, 1997), sampling from geographical areas known to have high concentrations of a particular ethnic group (Plunkett, & Quine, 1996), or using lists of names provided by ethnic health providers (Rissel, 1997) and using surnames to identify and sample particular ethnic groups (Nicoll, Bassett, Ulijaszek, 1986).

5.3.1 Recruitment of Subjects

Two of these non-random strategies were utilised in this study: the snowball sampling strategy and the sampling of geographic areas with high concentrations of Australian-Lebanese. A list of 788 Australian-Lebanese households was compiled with the help of Lebanese community leaders, religious leaders and community members who gave the names and telephone numbers of Australian- Lebanese residing in the geographic areas with high concentrations of Australian- Lebanese at the time of the study (ABS, 1991). These areas were Broadmeadows,

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Brunswick, Coburg, Doncaster, Northcote, Preston and Templestowe. Accordingly, socio-economic status was comprehensively covered by the inclusion of suburbs in which Australian-Lebanese from lower socio-economic backgrounds lived, namely the northern suburbs such as Broadmeadows and Coburg, those suburbs in which families from the middle socio-economic background lived such as Northcote Brunswick and Preston, and the eastern suburbs where those who were more affluent lived such as Doncaster and Templestowe.

An attempt was made to utilise the Telecom Database but it soon became apparent that it was impossible to distinguish Lebanese surnames from surnames of other Arabic speaking communities, such as Syrians, Palestinians, Jordanians and Egyptians residing in Melbourne.

Two hundred Australia-Lebanese subjects were therefore selected to participate in this study utilising a systematic sampling technique whereby every seventh family name on the list was contacted by telephone and the respondents were invited to participate in this study. This systematic sampling technique helped to provide a representative sample of the source population (Skodol-Wilson, 1989).

5.3.2 Inclusion Criteria

Subjects who met the following criteria were eligible to participate in the study:

a. all Lebanese born female and male subjects between the ages of 20 -69 who were residing permanently in Melbourne, and

b. all Australian born female and male subjects of Lebanese born parents between the ages of 20-69 who were residing permanently in Melbourne.

5.3.3 Exclusion Criteria

Pregnant female subjects were excluded from the study to rule out changes in physical measurements such as weight, waist circumference and blood pressure which could be associated with pregnancy rather than a change of lifestyle.

5.3.4 Ethical Considerations

All individuals who participated in this project received verbal and written explanation (in both English and Arabic languages) of the procedures involved and the benefits expected from the study. All respondents were asked to sign an informed consent form (provided in both English and Arabic) prior to the commencement of the interview. All participants were also advised that they were able to withdraw at any time during the interview if they so wished. Anonymity of participants and confidentiality of all the data were guaranteed during the process of data collection, and it was explained that all results would be reported only as group data so that no individual could be identified.

Permission to conduct the study was obtained from the Human Research Ethics Committee of the RMIT University. The conduct of the study and the management of the data conformed to the University’s requirements. Following completion of the data collection, candidature and responsibilities for completion of the study were transferred to Victoria University due to the relocation of the principal supervisor.

123 5.4 Instrumentation

The study used three instruments to obtain the data. The first was the questionnaire adopted from the National Heart Foundation Risk Factor Prevalence Study (NHFRFPS) conducted in 1989, in collaboration with the Commonwealth Department of Community Services and Health (DCSH). The questionnaire was translated into the Arabic language and participants were given the choice of answering in English or Arabic since depending on their preference, since the researcher was fluent in both languages (see Appendix 3a and 3b).

The second part of this survey involved the assessment of physical measurements, including height and weight for the calculation of body mass index, waist and hip circumferences and blood pressure. These measurements were taken on site and followed the protocols developed for the National Heart Foundation of Australia Risk Factor Prevalence Study 1989. These instruments are explained in full detail below.

The third part involved a semi-structured interview adapted from the Survey of Factory Women Workers conducted by the Heart Research Centre (1993-1994) (see Appendix 4).

5.4.1 The Risk Factor Assessment Questionnaire

As stated, this study used the questionnaire developed for the National Heart Foundation Risk Factor Prevalence Study (NHF RFPS, 1990). This questionnaire was designed to elicit information about the participants’ demographic and socioeconomic characteristics, including the following: age, gender, marital status, number of children, living arrangements, birthplace, level of schooling and education, employment status, income and occupation. Medical history and medical conditions were investigated, including reported high blood pressure, high cholesterol levels and high triglyceride, history of angina, heart attack, stroke, heart disease, diabetes and the type of treatment if any, for these conditions. Information was also gathered about the time since participants had their blood pressure and cholesterol levels last tested. Alcohol intake, smoking habits, dietary habits, exercise patterns were also investigated.

5.4.2 Physical Measurements

Physical measurements of weight, height, waist and hip circumferences and blood pressure were obtained by the following methods:

5.4.2.1 Weight

A digital scale was used to measure weight. The scale was placed on a hard surface of the participant’s house, usually in the kitchen or the bathroom. Each participant was requested to remove shoes, heavy outer clothes (such as jumpers, cardigans, or jackets), belts, mobile telephones from their waist. They were also asked to empty from their pockets heavy coinage, wallets and keys. Participants were allowed to remain only in their dresses, skirts and blouses or pants and shirts. The same scale was used for all participants and it was calibrated four times. The

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weight of each participant was recorded to the nearest tenth of a kilogram following the NHFRFPS method.

5.4.2.2 Height

Stature was measured against a straight wall with a height scale taped on it in either the bathroom or the kitchen of the participant’s home. Participants were measured in socks or stockings or bare feet. Participants were instructed to stand with their back against the wall and to look straight ahead so that the ear passage formed a horizontal line with the lower eyelid edge. A ruler was used as a sliding horizontal bar that rested gently on the head compressing the hair. The height was measured to the nearest centimeter following the NHFRPS method.

5.4.2.3 Waist and Hip Circumferences

While still in their light clothing participants were asked to remain facing the researcher. A non-stretch tape was used to measure the waist and hip circumference. Facing the participant, the researcher identified the narrowest point between the ribs and the hips of the participant as being the natural waist. In cases where the natural waist was difficult to identify, several measurements were taken to identify the lower edge of the ribs and the supra-iliac crest and the smallest of these measurements was identified as that person’s waist line.

Two readings were taken for each subject and measured to the nearest centimetre. The average of both readings was then recorded as the waist circumference of the participant.

Using the same non-stretch tape, measurement of the hip circumference was undertaken with the researcher viewing the participant from the side to see the maximum extension of the buttocks. The tape was then used around the hips at a horizontal plane and the measure was taken to nearest centimetre. Two readings were obtained for the hip circumference and the average of those readings was then recorded as the hip circumference.

5.4.2.4 Blood Pressure

Blood pressure was measured using a normal mercury sphygmomanometer placed on the dining room table or the kitchen table of the participant’s home. The sphygmomanometer scale was always facing the researcher. Steps were taken to ensure that the middle of the mercury scale was level with the researcher’s eyes to minimize any error resulting from reading at an angle.

The subject was seated with the right arm resting on the table to allow for the cubital fossa to be at a level with the heart. This required adjustment in several cases where the arm of the subject was raised on a folded blanket or towel in order to maintain this level. Two cuff sizes were made available, one with a bladder width of 18-20 cm to accommodate

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obese individuals and the other with a 13 cm standard cuff size for the average individuals. There was no need in this study to use the small cuff which is usually required for individuals with very thin arms.

The brachial artery was pulsated with the cuff placed 2 centimeters above the elbow band. The cuff was then inflated until the pulse disappeared. The cuff was rapidly deflated. The researcher then waited for half a minute before inflating the cuff again to 30 mm Hg above the palpated systolic pressure noted before. The air was then released from the cuff very slowly. The first clear tapping was recorded as systolic pressure and was noted to the nearest 2 mm Hg. As the pressure was lowered and at the point where no sound was heard, the researcher recorded the diastolic pressure reading. After five minutes a second reading of the participant’s blood pressure was recorded using the same techniques. The average of the two readings was then recorded as the final systolic and diastolic blood pressure reading of the subject.