Background
South Asians, defined as people originating from Pakistan, India, Bangladesh, Nepal or Sri Lanka, represent one of the largest ethnic visible minority groups in Canada contributing to approximately 4.8% of the total Canadian population [
1]. South Asians include individuals with diverse cultural and religious backgrounds. According to Statistics Canada, the number of people of South Asian origin in Canada is growing considerably faster than the overall population and is expected to grow three-fold by 2031 [
1,
2].
Evidence suggests that significant disparities in rates of cardiometabolic conditions and health behaviours persist among various ethnic groups in Canada [
3]. South Asian communities face an intersection of biological and social determinants of health that places them at a higher risk of various cardiometabolic conditions [
1,
3]. Individuals of South Asian descent generally have an elevated risk of developing heart disease, diabetes and other cardiometabolic conditions at an earlier age as compared to the general population, which creates a higher burden on the public health system [
3,
4]. Therefore, it is very crucial to target this population with health promotion and disease prevention initiatives.
Compared with general public health education as a health promotion strategy, interventions that assess individual risk, create a supportive environment for health, and strengthen community action, result in better outcomes [
5,
6]. Considering the multiple socio-cultural barriers faced by new immigrants transitioning to Canada, health promotion programs that are culturally appropriate and accessible are needed [
6]. Religious institutions and other faith organizations are becoming increasingly popular settings in which to conduct health promotion initiatives [
6,
7]. Since many South Asian communities identify religion as a social support mechanism, interventions targeting these communities in religious institutions such as temples may be an important pathway for reducing the risk of cardiometabolic conditions in this high-risk population [
8]. Given the paucity of scientific evidence on the effectiveness of community-based health assessment programs targeting South Asian populations in Canada, this study is one of the first to implement and test the feasibility of a culturally-salient, evidence-based health promotion and disease prevention initiative in a religious setting (a local Sikh temple) to improve cardiometabolic risk factors among South Asian immigrants in Canada.
South Asian immigrants may therefore be considered a marginalized population. Community Paramedicine at Clinic (CP@clinic) is a program that has previously been effective in other marginalized populations. It is a risk assessment, chronic disease prevention, and health promotion program that was developed for older adults in subsidized housing. The program is implemented by a community paramedic and has been tested in a cluster randomized trial. The results of the trial showed that CP@clinic decreased EMS calls, improved quality of life, and decreased chronic disease risk factors [
9]. Paramedics have been shown to be able to develop trusting relationships with marginalized populations in CP@clinic [
10]. Also, the intervention is easy to implement in community settings and requires minimal resources which may therefore be appropriate to be implemented in South Asian community settings.
The primary objective of this study was to assess the feasibility of a weekly or bi-weekly CP@clinic program targeting the South Asian population in the Riverdale area, which is home to Hamilton’s largest proportion of new South Asian immigrants [
11]. Specifically, whether the key components of the CP@clinic program (e.g. paramedic-led sessions, risk assessments, referrals, reports to primary care) can be feasibly implemented in a South Asian community setting. The secondary objective of the study was to describe cardiometabolic risk factors observed in this high-risk population to inform a future full-scale study and health promotion and disease prevention initiatives.
Discussion
This feasibility study showed that the key components of CP@clinic can feasibly be implemented in a South Asian community setting. Implementing health-related programming in a culturally comfortable setting may offer a feasible approach to identifying individuals at high risk of developing cardiometabolic conditions. Our study was one of the first to assess the feasibility of using community paramedics and volunteers to implement a culturally-salient, evidence-based health promotion and disease prevention initiative, in a religious setting (a local Sikh temple in Hamilton, Ontario) to improve cardiometabolic risk factors among South Asians in Canada. We were able to recruit a total of 71 participants in this setting using student volunteers. A similar feasibility study of a cardiovascular screening program in a South Asian population in Alberta, Canada stated that places of worship play a strong social and cultural role in South Asian communities and are therefore, becoming increasingly popular settings within which to conduct health promotion initiatives [
6]. Their study, similar to ours, concluded that implementing a volunteer-led health promotion program in religious settings was feasible.
There were no technical or legal challenges experienced in implementing CP@clinic with this population and setting, and paramedic services already had community paramedic staff available, although more paramedic staff resources would have been beneficial. Additionally, we demonstrated the acceptability of the program at a culturally sensitive facility through steady attendance rates, repeat attendance, and the increase in enrollment at the sessions held in the local temple, in comparison to the recreation centre. Moving the sessions from the recreation centre to the local Sikh Temple led to a substantial increase in the number of participants attending (
n = 19 versus
n = 52, respectively). Fewer individuals from this population used the recreation centre as compared to visiting the local temple and therefore, it was not a convenient location to hold the sessions. The lead student volunteer supported this view and identified the temple setting as being more convenient, educational and supportive of the CP@clinic program. Furthermore, the location of the program at the local temple allowed good access to a large proportion of this high-risk population who were visiting from local areas surrounding in Hamilton as well as the Greater Toronto Area (GTA), to attend religious ceremonies. There was a clear demand for the program as staff were, on occasions, overwhelmed with the number of participants attending the program which suggests the need for more volunteers or paramedics staffing the program. A qualitative study in London evaluated the National Health Services (NHS) cardiovascular health assessment program (NHS Health Checks) in religious settings, including South Asian temples. Their study found that participants found that advantages of implementing in religious and community settings included accessibility and community encouragement [
17]. Therefore, our study findings and others in the literature suggests that religious institutions such as temples may provide valuable opportunities for health promotion and disease prevention initiatives to target specific high-risk communities.
Our study found that 46.5% participants had elevated BP compared to the hypertension prevalence of 23% among Canadians aged 20 to 79 years [
18]. However it should be noted that our results are only from a small convenience sample of our study population since this is a feasibility study. Among the 26 participants in the subgroup, 42.3% had a moderate or high risk of developing diabetes based on their CANRISK score and 65.4% had an indicator of cardiometabolic disease. Although exact comparisons cannot be made to national data due to lack of available data and differing sampling methods, a recent study on Canadian South Asians aged 18 to 78, identified 16.1% of the total participants having a moderate or high risk of developing diabetes based on their CANRISK score [
19]. This is much lower than the 42.3% observed in the current study. South Asians living in Canada have a higher prevalence and burden of diabetes and other cardiometabolic conditions compared to other ethnic groups [
3]. A feasibility of the NHS Health Checks in religious South Asian settings in the UK found that their program was feasible and at the same time disclosed a similar pattern of elevated cardiometabolic risks [
20] revealed by our study. Current literature have strongly encouraged health promotion initiatives and intervention strategies to reduce cardiometabolic risk factors among this high-risk group [
1,
5].
The findings of our study, though only from a small sample, are consistent with other literature that shows there is a considerable burden of cardiometabolic risk factors in a South Asian community, supporting the need for future public health efforts to reduce their risk. However, these should be explored in a full scale study, with a larger sample, in wider and more varied settings that include different South Asian subgroups. The increased incidence of diabetes in a South Asian population can be attributed to several factors such as ethnic predisposition and lifestyle factors including dietary patterns and inadequate physical activity [
21]. Dietary practices among South Asians often differ based on the form of religion practiced [
22]. For example, many Hindus are vegetarians and consume a diet rich in carbohydrates and poor in protein. In comparison, Muslims often consume meat and the potential for a higher fat intake increases their risk of obesity and other cardiovascular diseases [
22]. In addition, food preferences and health behaviors may also vary depending on the region of origin [
22,
23]. For example, Punjabi (North Indian) cuisine is famous for being rich in calories due to generous use of cream and butter, which makes North Indians more susceptible to developing heart disease and diabetes [
22]. Altogether, this study suggests that future research should be conducted to develop health promotion initiatives tailored to these diverse subpopulations within the South Asian community that could be implemented within a religious setting. Our study was unique in that it demonstrated the potential feasibility of using trained student volunteers as an option for a public health intervention to implement a community-based health assessment program in a South Asian community with a high proportion of recent immigrants. It should be noted that the involvement of volunteers in many countries seems to be increasing [
24] and therefore research involving volunteers is definitely needed. Furthermore, our program would not have been possible without volunteers as all of our community paramedics were Caucasian and our target population of older adults struggled with English. Therefore this novel feasibility study offered a way to showcase bringing this very needed community paramedic resource to a population in need of it, supporting equitable access. The volunteers played a crucial role in facilitating communication between the paramedics and the participants by helping with translation. They also helped the paramedics in conducting risk assessments and guiding participants to appropriate community resources, when needed. During the key informant interview, the lead student volunteer stated that being involved in the program was beneficial for students as it helped enhance their knowledge and understanding of community-based program planning and implementation.
However, one of the challenges to involve student volunteers was their availability and commitment to the program. Some of the possible reasons for the lack of commitment and inconsistent volunteer participation may include school work load, family responsibilities, and lack of interest or experience. Since the paramedics relied on student volunteers for translation, they were unable to collect complete data for all the participants. Therefore, this study suggests that a combination of student volunteers and a paid professional translator, or implementation by a health professional from the community who can speak the languages, may be required for successful dissemination of future health promotion initiatives conducted in a similar context.
There are some potential limitations of this feasibility study. First, the study participants were primarily North Indian and therefore, the findings may not be generalizable to other South Asian groups or religious settings. The study participants may also differ from the general South Asian population in terms of a variety of other factors, such as the priorities of the religious congregation, demographics, health concerns and interests. Thus, further formative research is essential to design and implement health promotion and disease prevention programs tailored to address specific interests and concerns of various subgroups within a community. Secondly, this study had a relatively small sample size and a lack of complete data for all participants. Though 63% of data were missing data for the whole assessment, we believe reporting our results was necessary to report the challenges of conducting such a program in the South Asian setting. Our program was successfully implemented but we learned that there were many issues that need to be considered before going into a full scale study, such as the high demand for an intervention in this setting, which requires additional paramedics and volunteers. Consequently, collecting follow-up data was unfeasible, which may also limit the generalizability of the study results to the larger general population. Since little is known about the impact of community-based health promotion interventions in religious settings within Canada, it is suggested that future research with this high-risk ethnic group should be conducted with a larger sample, and in different religious and cultural settings to effectively understand the potential impact of programs such as CP@clinic on the health outcomes in this population. Lastly there are some limitations in our feasibility assessment in that we were not able to assess. These were mainly the acceptability of the program from the paramedics’ perspective, from the Temple Management perspective and from the primary care providers perspective.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.