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Stroke-related knowledge, behaviors and beliefs of Chinese Canadians and EuroCanadians : a basis for… Wang, Jiawei 2006

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Stroke-related Knowledge, Behaviors and Beliefs of Chinese Canadians and EuroCanadians: A Basis for Culturally-sensitive Physical Therapy by JIAWEIWANG Bachelor of Medicine, Fudan University, People's Republic of China, 1996 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (REHABILITATION SCIENCES) THE UNIVERSITY OF BRITISH COLUMBIA October 2006 ©JIAWEI WANQ 2006 Abstract Background: Stroke is a leading cause of death particularly in Chinese Canadians (CCs) who are among the fastest growing group of immigrants. The needs of CCs in relation to health education related to stroke have not been well documented. This study attempts to address this gap-Purpose: To examine the stroke-related health knowledge, behaviors and beliefs of CCs in relation to EuroCanadians (ECs), and examine the effect of acculturation of the CCs on these variables. Design: A descriptive study based on a self-administered survey questionnaire of samples of CCs and ECs. Subjects and Methods: A cross-sectional survey of 103 CCs and 101 ECs from the Lower Mainland of BC. The questionnaire consisted of four parts: stroke-related knowledge, health behaviors, health beliefs, and demographic information. Results: Compared with ECs, CCs were less awareness of stroke risk factors, and its major warning signs, and of an appropriate response to someone showing signs of stroke. Potential health information sources that were identified included mass media, family and friends. CCs are less likely to smoke and drink alcohol than ECs and less physical activity. CCs have room for improvement with respect to dietary habits similar to ECs, but these differed somewhat for the " two groups. CCs reported experiencing more stress from all causes than ECs. Years in Canada appear to have little relationship to stroke-related knowledge, behaviors and beliefs reported by CCs. Discussion and Conclusions: Our findings confirmed the findings of studies that have examined diets and physical activity of Asian immigrants in other countries. Theoretical dimensions of culture helped explain differences in stroke-related knowledge, behaviors, and beliefs between the CCs and ECs. By enhancing their understanding of differences and similarities between these groups, physical therapists may enhance the cultural sensitivity and appropriateness of interventions. iii Table of Contents ABSTRACT ii LIST OF TABLES vii ACKNOWLEDGEMENTS ix CHAPTER 1 INTRODUCTION 1 B A C K G R O U N D A N D RATIONALE 1 OBJECTIVES : 3 DEFIN1TON OF TERMS 4 CHAPTER 2 LITERATURE REVIEW 6 STROKE IN C A N A D A A N D CHINA 6 CCs IN C A N A D A 7 K N O W L E D G E OF STROKE OF CCs 9 Risk factors for Stroke 9 Stroke Risk Awareness : 10 H E A L T H BEHAVIORS OF CCs 11 Smoking And Alcohol Consumption , 12 Physical Activity 13 Dietary Habits 13 Stress '. '. 15 H E A L T H BELIEFS B A S E D ON TRADITIONAL CHINESE PHILOSOPHIES 15 C U L T R U A L CHARACTERISTICS OF CHINESE IN H E A L T H C A R E 1 7 Confucianism 17 Hofstede's Five Cultural Dimensions 18 STROKE PREVENTION A N D EDUCATION P R O G R A M S '. 22 Primary, Secondary And Tertiary Prevention Of Stroke 23 Health Education 24 iv PURPOSE A N D R E S E A R C H QUESTIONS 26 Purpose 26 Research Questions 26 CHAPTER 3 METHODS 28 R E S E A R C H DESIGN 28 S A M P L I N G • 28 Sample Size 28 Inclusion Criteria 28 Recruitment and General Procedure 29 O V E R V I E W OF THE QUESTIONNAIRE. : . 30 Content 30 Translation 33 Pretest 33 STATISTICAL A N A L Y S I S : 34 CHAPTER 4 RESULTS 36 SOCIODEMOGRAPHIC CHARACTERISTICS 36 H E A L T H PROFILE OF RESPONDENTS 37 STROKE-RELATED K N O W L E D G E . 38 Risk Factors And Warning Signs 38 Reaction to Stroke Signs in Household : 40 Source of Information About Stroke 40 S T R O K E - R E L A T E D BEHAVIORS 41 Smoking And Alcohol Consumption 41 Physical Activity 41 Dietary Habits : 42 Stress 42 STROKE-RELATED BELIEFS 43 L E N G T H OF RESIDENCE IN C A N A D A FOR CCs 45 RELATIONSHIPS BETWEEN HEALTH BELIEFS A N D HEALTH BEHAVIORS 47 Smoking And Alcohol Consumption 47 Physical Activity . 48 Dietary Habits..: '. 49 Stress 50 C H A P T E R 5 DISCUSSION AND CONCLUSIONS 51 OVERVIEW: •'.. ' • 51 REPRESENTATIVENESS OF THE S A M P L E :•. 51 COMPARISON OF HEALTH AND STROKE-RELATED K N O W L E D G E BY ETHNIC GROUP AND GENDER 52 INTERRELATIONSHIPS BETWEEN HEALTH A N D STROKE-RELATED BEHAVIORS A N D BELIEFS FOR THE TWO ETHNIC GROUPS '. 54 COMPARISON OF HEALTH KNOWLEDGE, BEHAVIORS A N D BELIEFS OF CCS BASED ON LENGTH OF RESIDENCE IN C A N A D A 62 IMPLICATIONS FOR CONSTRUCTING TARGETING, A N D DELIVERING HEALTH EDUCATION PROGRAMS TO MEET THE NEEDS OF CCs 64 LIMITATIONS 67 FUTURE STUDIES 68 CONCLUSIONS... ' . . . / ' . '. : 70 R E F E R E N C E S 72 APPENDICES , 85 APPENDIX A: QUESTIONNAIRE (ENGLISH) 85 APPENDIX B: QUESTIONNAIRE (SIMPLIFIED CHINESE) 94 APPENDIX C: QUESTIONNAIRE (TRADITIONAL CHINESE) 103 APPENDIX D: CERTIFICATE OF APPROVAL 112 List of Tables No. Title Page 1 Sociodemographic characteristics by ethnic group 113 2a Health profile by ethnic group 114 2b Health profile by gender within each ethnic group 115 3a Knowledge of stroke risk factors and warning signs by ethnic group 116 3b Knowledge of stroke risk factors and warning signs by gender within each ethnic group 117 4a Reaction to stroke signs in household by ethnic group 119 4b Reaction to stroke signs in household by gender within each ethnic group 119 5a Source of information about stroke by ethnic group 120 5b Source of information about stroke by gender within each ethnic group 121 6a Smoking and alcohol consumption by ethnic group . 122 6b Smoking and alcohol consumption by gender within each ethnic group 123 7a Physical activity by ethnic group 124 7b Physical activity by gender within each ethnic group 125 8a Dietary habits by ethnic group 126 8b Dietary habits by gender within each ethnic group 127 9a Stress experiences by ethnic group 128 9b Stress experiences by gender within each ethnic group 129 10a General health beliefs by ethnic group 130 10b General health beliefs by gender within each ethnic group 131 11a Health beliefs related to activities to reduce stress by ethnic group 133 l ib Health beliefs related to activities to reduce stress by gender within each ethnic group 134 12a Health beliefs related to activities to reach longevity by ethnic group 135 12b Health beliefs related to activities to reach longevity by gender within each ethnic group 136 No. Title Page 13 Sociodemographic characteristics of Chinese Canadians based on median number of years lived in Canada (10 years) 137 14 Health profile of Chinese Canadians based on median number of years lived in Canada (10 years) 138 15 Chinese Canadians' knowledge of stroke risk factors and warning signs based on median number of years lived in Canada (10 years) 139 16 Chinese Canadians' reaction to stroke signs in household based on median number of years lived in Canada (10 years) 140 17 Chinese Canadians' source of information about stroke based on median number of years lived in Canada (10 years) 140 18 Smoking and alcohol consumption of Chinese Canadians based on median number of years lived in Canada (10 years) 141 19 Physical activity of Chinese Canadians based on median number of years lived in Canada (10 years) 142 20 Dietary habits of Chinese Canadians based on median number of years lived in Canada (10 years) 143 21 Stress experiences of Chinese Canadians based on median number of years lived in Canada (10 years) 144 22 General health beliefs of Chinese Canadians based on median number of years lived in Canada (10 years) 145 23 Chinese Canadians' health beliefs related to activities to reduce stress based on median number of years lived in Canada (10 years) 146 24 Chinese Canadians' health beliefs related to activities to reach longevity based on median number of years lived in Canada (10 years) 147 Acknowledgements I would like to thank my supervisor, Dr. Elizabeth Dean, for her kind help, patient guidance, continuous support and encouragement throughout my graduate study. I also wish to thank Dr. Zhenyi Li and Dr. Lyn Jongbloed for serving on my committee and contributing valuable insights to my research work. I would like to thank the faculty, staff, and students of the School of Rehabilitation Sciences, University of British Columbia, for providing such a stimulating and enjoyable environment during my study. I would like to express thanks for the financial support of the University of British Columbia. Special thanks to all the participants in this study. Without them, this study could not be completed. Finally, I would like to thank my family and friends for their continuous understanding and encouragement. ix Chapter 1 Introduction Background and rationale Stroke is a leading cause of death in Canada (Heart and Stroke Foundation of Canada, 2002). Approximately 40,000 to 50,000 people in Canada experience a new or recurrent stroke each year (Heart and Stroke Foundation of Canada, 2002). About 3.25 million people have hypertension including 1.44 million men and 1.81 million women (Statistics Canada, 2001). Also, stroke is a primary contributor to long-term disability among adults in Canada. In 1998, meeting the healthcare needs of people with stroke cost the Canadian economy $1.4 billion (Health Canada, 1998). A major component of this cost is rehabilitation services including physical therapy. As a group, Chinese Canadians (hereafter CCs) constitute one of the fastest growing and most diverse in Canada; ethnic Chinese are the largest Asian subgroup in Canada. They now account for 20% of Canada's total immigration intake, and the Chinese language has become the third most-spoken language in Canada (Citizenship and Immigration Canada, 2001). Of 27% of Chinese immigrants living in the province of BC, most choose to live in the Lower Mainland (Statistic Canada, 2003). Compared with EuroCanadians (hereafter ECs), Chinese immigrants have a lower rate of stroke, however, a high prevalence of stroke risk factors among Chinese immigrants suggests this group warrants special attention with respect to the stroke prevention (Sheth, Nair, Nargundkar, Anand, & Yusuf, 1999; Tso & Moe, 2002). 1 To a large extent, stroke is preventable. Reducing modifiable risk factors can decrease the incidence of stroke. Health education has been considered a primary component of stroke prevention, and in the management of people with stroke to help prevent a future stroke as well as to manage their condition (World Health Organization [WHO] STEPS-Stroke). Optimal prevention of stroke includes primary, secondary, and tertiary prevention strategies. To implement such prevention effectively in groups at risk however, healthcare professionals including physical therapists need to understand an individual's beliefs about the cause of stroke and its risk factors, and the role of lifestyle behaviors and their modification on stroke reduction. Health beliefs and behaviors are influenced by many factors including culture, age, and gender. Modification of lifestyle risk factors such as smoking, excessive alcohol consumption, physical inactivity have been recommended to lower stroke risk (Heart and Stroke Foundation of Canada, 1997). Understanding these risk factors among Chinese immigrants would provide a basis for stroke prevention and health education. Information is limited on how Chinese immigrants perceive those risk factors in their lives and their capacity to modify their risk, and how acculturation impacts their beliefs about their risk of stroke. An understanding of the knowledge, attitudes, and beliefs about stroke of Chinese immigrants could have important implications for prevention. The literature to date however is sparse. Most studies focus on populations in North America and China. Investigations of Chinese immigrants in Canada are relatively few. Thus, little is known about the level of knowledge of Chinese immigrants about stroke risk factors and warning signs. Thus, evidence to support the content of health education and its targeted delivery to Chinese people to effect optimal health 2 outcomes, is also unclear. The health beliefs and behaviors of Chinese immigrants have been shaped by traditional Chinese philosophies such as Confucianism, Yin-Yang, and Qi theories (Ni, 1995; Ou, Huang, Hampsch-Woodill, & Flanagan, 2003). Thus, investigation of health knowledge, behaviors, and beliefs related to stroke with special attention to culture as an explanatory variable among Chinese immigrants, could fill a gap in our existing knowledge. To date, quantitative studies are lacking on the impact of culture and acculturation on the health and healthcare needs of Chinese immigrants. In particular, studies are indicated to evaluate the needs of CCs in relation to health education on hypertension and stroke. Cultural characteristics of CCs have been described based on Hofstede's cultural theory. On cultural theory domains, Chinese people are described as scoring high in power distance, low in individualism, high in masculinity, low in uncertainty avoidance and high in long-term orientation (Hofstede, 1991; Hofstede & Bond, 1988). Some beliefs and behaviors related to health and disease can be explained by such cultural factors. Furthermore, the role of social factors on the determinants of the health and wellbeing such as social support, the role of family role, and help-seeking may be particular important in the Chinese population, and these attributes are closely linked to culture. Objectives The objective of this study was to assess and compare the health knowledge, beliefs, and behaviors related to stroke among CCs and ECs residing in the Lower Mainland of BC, Canada, and to examine how these may vary based on factors such as gender, age, education, and other descriptive and demographic characteristics. In addition, the interrelationships among these variables between the two groups were evaluated. The results will help provide an evidence base on which health education strategies for CCs can be developed and specifically tailored to this group's needs, with respect to stroke prevention and during the course of physical therapy management following a stroke. Definition of terms Immigrant population: Population that is foreign born and granted landed immigrant status by the immigration authorities. Chinese Canadian: A person of Chinese descent or origin who was born in or immigrated to Canada. In this study, it specifically refers to first generation Chinese immigrants. EuroCanadian: A person of European descent or origin. Due to the difference of inclusion criteria, in this study, it refers to a person who is born in Canada but has European ancestry. Culture: Culture is the collective programming of the human mind that distinguishes the members of one human group from those of another. Culture in this sense is a system of collectively held values (Hofstede, 1980). Ethnicity: This term involves aspects of culture, but is not the same as culture. The term focuses on the cultural characteristics of a particular group, that is, the norms, values, attitudes, and behaviors that are typical of an ethnic group and that stem from a common culture of origin 4 transmitted across generations (Phinney, 1996). A number of ethnic groups might adhere to similar cultural values in general but practice their belief systems in different ways. The boundaries of who belongs to an ethnic group can be fluid (Shiang, Kjellander, Huang, & Bogumill, 1998). Chapter 2 Literature Review Stroke in Canada and China Stroke is the fourth leading cause of death in Canada resulting in over 16,000 deaths annually (Heart and Stroke Foundation of Canada, 2002). In 2001, the mortality rate per 100,000 was 34.2 for both sexes, including 34.2 for men and 37.1 for women (Statistics Canada, 2001). Approximately 40,000 to 50,000 people in Canada experience a new or recurrent stroke each year (Heart and Stroke Foundation of Canada, 2002). 33% of survivors of stroke are under 65 years of age. 80% of Canadians between 20 and 59 years of age have at least one risk factor for stroke (Heart and Stroke Foundation of Canada, 2003). Data from Statistics Canada (2001) also showed that in 2001-2002 about 3.25 million people had hypertension including 1.44 million men and 1.81 million women. Further, stroke is considered as a primary contributor to long-term disability among adults in Canada. Of those Canadians who reported having had a stroke, 77.2% reported having to restrict their activities and 78.5% required assistance with activities of daily living (Heart and Stroke Foundation of Canada, 2003). Stroke is also an expensive illness to manage and has an enormous economic impact in Canada. Specifically, it cost the Canadian economy $1.4 billion (Health Canada, 1998). Acute care costs associated with stroke are approximately. $27,500 annually per patient (Heart and Stroke Foundation of Canada, 2002). In 1998, long-term stroke-related disability cost $4.16 billion (Health Canada, 1998). A major component of this cost is rehabilitation services including physical therapy 6 since physical therapy has an essential role in the prevention of hypertension and atherosclerosis, both implicated in the etiology of stroke, and the acute and chronic management of stroke. As in Canada over the past few decades, stroke has been a principal cause of death in the People's Republic of China. The World Health Organization (WHO) has estimated a total of 2.7 million stroke deaths in Asia in 2000, including 1.6 million deaths in China (Wong, Huang, Gao, Lam, & Chan, 2001). The annual mortality rate for stroke from 1986 to 2000 was 154.7 per 100, 000 population (Yang et al., 2004). Data on stroke-related prevalence and mortality among Chinese immigrants in Canada are limited. Compared with ECs however, CCs have been reported to have a lower prevalence of stroke. Although mortality from cerebrovascular disease appears to be declining for both ECs and CCs, slight disparities in mortality in gender have been observed between the two ethic groups (Sheth et al., 1997). Based on chart audit study which reviewed the charts of patients between 1994 and 1999, cardiovascular diseases was less common in CC than in EC patients (Tso & Moe, 2002).. The number of elderly people in the population who have high risk profiles of stroke can be expected to increase, thus, the need for a range of health services required to manage stroke effectively including rehabilitation and health education both in Canada and China, are needed. CCs in Canada Canada has experienced a boom in immigration and, in turn, continued cultural 7 diversifications of its population. The number of immigrants, 5.4 million as of the 2001 Census, has reached the highest in the last 70 years, which represented 18.4% of Canada's total population (Statistics Canada, 2003). By the year 2017, the immigrant population is projected to be to 7.3 to 9.3 million, accounting for 22% of the national population (Statistics Canada, 2005). TheChinese have become the largest group of immigrants in Canada. Between 1980 and 2000, nearly 0.8 million Chinese immigrants arrived in Canada (Citizenship and Immigration Canada, 2001). The Chinese have also been the largest visible minority group in 2001, with a total of 1 million individuals identifying themselves as Chinese, accounting for 3.5% of the total national population and 26% of the visible minority population (Statistics Canada, 2003). The People's Republic of China was the leading country of birth among individuals who immigrated to Canada in the 1990s and the Chinese language has become the third most common mother tongue in Canada (Statistics Canada, 2003). Recently, immigration data have shown that BC attracted 27% of Chinese immigrants to Canada in 2003. Most Chinese immigrants in BC live in the lower mainland (Statistics Canada, 2003). The majority of Chinese immigrants originate from mainland China, Hong Kong, and Taiwan. Although they speak various Chinese dialects, depending on their birthplaces, the major Chinese languages spoken are Cantonese and Mandarin (BC Stats, 1998; BC Stats, 2003). 60% of Chinese immigrants who arrived between 2000 and 2003 have received 13 years or more of schooling and 21% of them reported having English language skills (Hansen, 2003). Significant Chinese immigration to BC and other parts of Canada, is anticipated over the foreseeable future (BC Stats, 1998). Knowledge of stroke of CCs Risk factors for stroke According to the WHO, stroke is defined as "rapidly developing clinical signs of focal (or global) disturbance of cerebral function lasting more than 24 hours (unless interrupted by surgery or death) with no apparent cause other than of vascular origin (WHO MONICA Project Principal Investigators, 1988). The Framingham Heart Study identified the major risk factors for stroke as hypertension, diabetes mellitus, hyperlipidemia, and smoking (Wolf, 2004). The Heart and Stroke Foundation of Canada reported that smoking, physical inactivity, high blood pressure, dyslipidemia, obesity, and diabetes are largely responsible for the epidemic of stroke (Heart and Stroke Foundation of Canada, 1999). A random telephone survey conducted in Saskatchewan further supported that poor diet (40%), hypertension (36%) and stress (36%) were the most important risk factors of stroke in the Canadian population (Ramsden, Shuaib, Reeder, Khan, & Liu, 1994). Hypertension has been identified as the most important risk factor for stroke in Chinese people (Zhang, Attia, D'Este, & Yu, 2004). Based on long-term epidemiological and clinical studies, lifestyle interventions (such as healthy eating, physical activity, and smoking cessation) have a marked effect on reducing blood pressure, and the risk of heart disease and stroke (Jamrozik, Broadhurst, Anderson, & Stewart-Wynne, 1994; Luedemann et al., 2002; Fang, Foo, Fung, Wylie-Rosett, & Alderman, 2003; Truelsen, Nielsen, Boysen, & Gronbaek, 2003). Some authorities however have disputed the degree to which lifestyle factors impact stroke, e.g., smoking (Herman et al., 1983; Khaw, Barrett-Connor, Suarez & Criqui, 1984) and alcohol consumption (Harmsen, Rosengren, 9 Tsipogianni, & Wilhelmsen, 1990). Difficulty in measuring lifestyle behaviors (Gordis, 1979) may explain these findings. Observational studies on the other hand support a primary role for modifying lifestyle-related risk factors in stroke prevention among Chinese immigrants in North America. Fang et al. (2003), for example, reported that reduced intake in sugar and salt and increased exercise markedly reduced stroke risk among Chinese immigrants in the US. Given the fact that strategies directed at promoting healthy lifestyles and hypertension control reduce the frequency, severity and impact of stroke on Canadian society (Young & Hachinski, 2003), the Canadian Hypertension Society in collaboration with other health authorities, have for many years, called for awareness of lifestyle modifications and issued guidelines with respect to physical activity, diet, smoking cessation, moderate alcohol use, and weight loss in an effort to reduce hypertension, which is a major risk factor for stroke (Canadian Hypertension Education Program, 2005). Stroke risk awareness Stroke risk awareness is low in North America. A population-based telephone interview survey in the US reported impressive findings. 20% of respondents, who were adults living in Michigan, were not aware of any stroke risk factors, and almost 30% were not aware of any stroke warning signs (Reeves, Hogan, & Rafferty, 2005). Further, the elderly population which is at high risk for stroke, were the least knowledgeable segment of the population about stroke risk factors and warning signs (Pancioli et al., 1998; Ferris et al., 2005) and Asia (Cheung et al., 1999). In addition, women in the US, regardless their ethnicity and age, scored low in being able to correctly identify the warning signs of stroke (Ferris et al., 2005). 10 Of the scant number of studies that have studied the Chinese and their health knowledge, these have been conducted mostly on populations in North America and China. Overall, little is known about the level of knowledge of stroke risk factors, and warning signs among CCs and their health education heeds including where would they access stroke-related health information. Health behaviors of CCs Lifestyle substantially influences health. In contrast to genetic or biological influences such as age and gender, lifestyle can be modified. Since the first Canada Health Survey in 1978-1979, several national and provincial surveys have been conducted to examine the role of health behavior change as an education intervention and strategy to promote optimal health in Canadians (Kendall, Lipskie, & MacEachern, 1997; Statistics Canada, 1998). With respect to immigrants, acculturation is an additional factor that influences health behaviors. Acculturation is the process by which immigrants incorporate the values, attitudes and behaviors of the dominant prevailing culture. It provides an additional framework for understanding the relationship between migration and changes in health following migration (Health Canada, 2004). Briefly, it is the degree to which the culture of the majority of people is adopted by a minority culture within the dominant one. Length of residence in the host culture has been used as an indicator to measure the effect of acculturations on the health of immigrants (Kaplan, Chang, Newsom, & McFarland, 2002; Song et al., 2004; Lopez-Gonzalez, Aravena, & Hummer, 2005). With respect to Chinese immigrants living in western societies, they 11 experience a gradual and continuous process of adopting a western lifestyle, although not entirely abandoning the traditions from their country of origin that are thousands of years old (Lee & Huang, 2001). Smoking and alcohol consumption Smoking and alcohol use are two health behaviors that are often studied and reported in the immigrant health literature. Based on self-report data, the Canadian Tobacco Use Monitoring Survey showed that 21.7% of Canadians smoke, including 23.9% men and 19.6% women (Gilmore, 2002). Chinese immigrants were much less likely to be smokers and much more likely to have never smoked (PICA & Lucille, 2004). Gender differences in smoking rates among Chinese immigrants however are striking. Smoking rates among Chinese immigrant men are more than four times higher than for the women. This finding is comparable to the statistics in the US (Shelley et al., 2004) and China (Yang et al , 1999). Chinese American men are more likely to smoke than their female counterparts, 29% and 4%, respectively. Approximately 31% of Chinese immigrants reported they experience second-hand exposure in their living environment (i.e., home, workplace, school or other public places) every day or almost every day (PICA & Lucille, 2004). With respect to alcohol consumption, data from the Cultural Communities Survey in Quebec in 1998/1999 (PICA & Lucille, 2004) revealed that 44% of Chinese immigrants 15 years of age and older, abstained from alcohol or were former drinkers. Compared with the 83% current drinkers among Quebecers overall, only 56% of Chinese immigrants were current drinkers. Further, more Chinese immigrant men were drinkers than women (68% versus 44%). 12 Physical activity Physical activity, whether at home, at work, as a means of transportation or recreation, has a beneficial influence on a person's health status. Chinese immigrants in North America (the US and Canada) reported spending less time participating in vigorous activity, sleeping and walking, but more hours sitting, than Chinese people in China (Lee et al.,T994). Another survey of people living in Chinese communities in Canada pointed out that although a similar proportion of CCs 15 years of age and over, reported engaging in leisure-time physical activity at least three times a week (20 minutes a session), more CCs (33% versus 27% in general) had not engaged in any leisure-time physical activity during the same timeframe. No difference between the sexes was observed in the Chinese communities (PICA & Lucille, 2004). In addition, Chinese in North America weighed more than Chinese in China (Lee et al., 1994). Many Chinese immigrant seniors in the US walked in the early morning and had a routine of stretching, arm swinging, Tai Chi, walking, or some combination (Belza et al., 2004). Despite the benefits of physical activity and the health needs of Chinese immigrants in Canada, information is limited regarding how Chinese immigrants in Canada perceive physical activity in terms of its health effects. Dietary habits Compared to the diets of western countries, the traditional Chinese diet is richer in plant-based foods as opposed to foods high in animal protein which has been associated with high blood pressure and stroke (Campbell & Junshi, 1994; Campbell, Parpia, & Chen, 1998; Zhou et al., 2003). For people in rural China, animal protein intake was only 10% of US intake and fat intake was less than half that in the US. However, fiber intake was three times higher 13 (Campbell et al., 1998). The main source of red meat in the Chinese diet was pork. This traditional dietary preference, rich in plant-based foods, is more consistent with good health compared with a western diet which is high in animal protein and refined carbohydrate and fat. Dietary acculturation which refers to the process that occurs when members of a minority group adopt the eating patterns or food choices of the host country also applies to Chinese immigrants (Satia et al., 2001). Over time, Chinese immigrants in Canada and the US consume more western foods (such as meat and dairy products) and less Chinese traditional foods with some exceptions (Lee et al., 1994; Satia et al., 2001). Compared with less acculturated Chinese women, those who were more acculturated reported higher-fat dietary behaviors and had increased fruit and vegetable intake since immigration (Satia et al., 2001). Rice remained an important staple in the diets of Chinese immigrants while other traditional foods were replaced by cereal, bread, and sandwiches. Milk was consumed only for breakfast by most, while cheese, yogurt and other dairy products were often not eaten at all (Tan & Watson, 2004). However, inconsistent data with respect to dietary practices of Chinese immigrants exists. Some researchers reported that Chinese immigrants in Canada and the US consumed more red meats, particularly beef, more dairy products and fruits, but less soybean products and vegetables than the Chinese in China (Lee et al., 1994), while Lv and Cason (Lv & Cason, 2004) recently reported increased consumption of seven food groups (i.e., grains, vegetables, fruits, meat/meat alternatives,.dairy products, fats/sweets, and beverages) by Chinese immigrants. Higher education, higher income and longer length of living in the host country were reported to be 14 associated with increased dietary consumption of grains, vegetables, fruits, fats/sweets, and beverages (Lv & Cason, 2004). Stress Immigrants are likely to experience stress from a variety of sources including economic circumstances, social and personal isolation, and negative attitudes (Berry, 1980). Stress such as unemployment and poverty have adverse effects on society and the community as well as the family and individual. When compounded with having immigrated, the probability of experiencing stress can be amplified. Such "acculturative stress" is most typically felt by immigrants who are faced with the turmoil of leaving their homeland and adapting to a new society (Al-Issa, 1997), It can have substantial physical and psychological impact (Beiser, 2005). For example, studies have recently reported a higher rate of depressive symptoms among CC seniors originally from mainland China and Taiwan, than in the general Canadian population (Lai, 2004; Lai, 2005). A negative attitude towards aging, poor general physical health, poor financial status, lower level of identification with Chinese health beliefs, and low income are associated with depressive symptoms (Lai, 2004a; Lai, 2004b). Health beliefs based on traditional Chinese philosophies Chinese health belief systems are based on concepts that are distinct from those of European cultures (Shon & Ja, 1982; Lee, 1982). The Yin-Yang theory was first documented by The Yellow Emperor's Classic of Internal Medicine (HuangDi Nei Jing) 2500 years ago as a method of defining and explaining the nature of phenomena, including health and illness (Ni, 15 1995). The term Yin-Yang is used to express the dual opposite qualities of matter. Yin represents those counteractive properties, like water, coldness, stillness, inhibition, and darkness while those proactive properties, such as fire, heat, movement, brightness, outward, and upward direction are represented by yang. In addition, the concepts of Yin-Yang have also been applied in traditional medicine to describe both anatomic parts and physical functions (Ni, 1995; Ou et al., 2003). Qi (or Chi) is known as energy. Qi must be allowed to flow freely and smoothly through the whole body to maintain good health (Ni, 1995). Although the theoretical and diagnostic basis of traditional Chinese medicine rooted in Chinese philosophies cannot be explained in terms of western anatomy and physiology, it has given rise to a different perspective of beliefs on health and disease among Chinese people (Hesketh & Zhu, 1997). For instance, many Chinese people believe that imbalance of yin-yang is the cause of all diseases (Ni, 1995). Various therapeutic methods such as mind-spiritual methods (e.g., Qigong and Tai chi) and some other natural methods (e.g., acupuncture, moxibustion, and herbal medicine) have been used in traditional Chinese medicine to help enhance the body's resistance to disease and also prevent disease by improving the inter-connections among body systems (Lu, Jia, Xiao, & Lu, 2004). Torsch & Ma (2000) reported that the Chinese immigrant elders in the US tended to explain their emotional and physical illnesses in terms of an imbalance of yin and yang. They also viewed imbalance or disharmony of body and mind as leading to a weakening of the positive Qi (life energy) and causing illnesses. In addition, the majority of investigated Chinese immigrant elders believed that massage, Taiji quart, and Qi gong (Chinese health exercises) 16 were useful healing practices for promoting the free circulation of Qi and blood through the body, which helps prevent diseases and maintain health. Cultural characteristics of Chinese in healthcare Confucianism Confucianism has been the dominant ideology in Chinese philosophy since the Han Dynasty (206BC-220AD) and has directed social, political, educational, and moral thought in Chinese society up to the present day (Tsai, 2001). Confucian values are infused throughout Asian societies and are considered to be the roots of the culture (Oh, 1991). Confucianism strongly emphasizes obedience, the importance of rank and hierarchy, and the need for harmonious social relations (Hofstede & Bond, 1988). Benevolence, righteousness, loyalty, filial piety, and virtue are key characteristics and concepts in Confucianism (Tsai, 2005). Filial piety, a central family value to the Chinese, can be defined as the expression of responsibility, respect, sacrifice, and family harmony that regulates children's attitudes and behavior towards family-based support (Sung, 2000). For example, elders should be respected and adult children should treat their parents with deference and courtesy, have concern for them, and care for and support them. In addition, Confucian culture has exerted positive influences on the development of Chinese traditional medical ethics. Based on the foundation of Confucian ethics, attitudes of 'thinking about patients and thinking for patients' have been developed in medical ethics and provide a basis for establishing satisfactory physician-patient relationships within the culture (Guo, 1995). 17 Confucianism has implications for medical ethics. For instance, according to the doctrines of Confucianism, the human body was contributed by the parents and no damage and injury can be inflicted upon it. As a consequence, surgery and autopsy have traditionally been viewed as immoral (Guo, 1995). Chinese society, which ranks high on the Confucian dimension, emphasizes values associated with the teachings of Confucius, which has a great influence on people's personal and social behaviors (Tan & Chee, 2005). Dean (2001) reported the need to understand the influences of Buddhism, Taoism as well as Confucianism on the health, ill health, healthcare seeking behavior, and response and reaction to health and ill health, in Chinese people, and that understanding this perspective may be central to optimizing healthcare outcomes. Furthermore, the notion of longevity appears engrained historically in Confucianism and Chinese culture as a philosophical construct, and may impact the health beliefs and behaviors of Chinese people. Thus, an understanding of the beliefs and behaviors of CCs compared with those of ECs, and how beliefs about longevity influence stroke-related beliefs and behaviors may be important in designing culturally sensitive and appropriate healthcare and prevention strategies and programs. Because stroke is largely a preventable tragedy and that risk factors for stroke are prevalent in the Chinese, health and prevention health programs and strategies, therefore need to be optimally effective, with a consideration of cultural factors, to prevent stroke or reduce risk of a second stroke, as well as in learning how to manage the effects of one's stroke. Hofstede 'sfive cultural dimensions Hofstede (1991) hypothesized that cultures around the world have several cultural 18 dimensions in common which he termed individualism versus collectivism, power distance, masculinity versus femininity, and uncertainty avoidance. Hofstede examined these factors in the Chinese and other Asian cultures that were not included in his original sample, and as a result, added a new dimension named Confucian dynamism to his work (Hofstede & Bond, 1988). (1) Individualism versus collectivism The cultural dimension of individualism and collectivism refers to the extent to which people feel they are supposed to take care of or to be cared for, by themselves, their families or organizations to which they belong. With respect to an index of individualism, the Chinese scored very low at 20 compared to 80 by Canadians. The low ranking indicates the Chinese are more collectivistic or much less individualistic in orientation than Canadians and people from other western countries (Hofstede, 1991). Traditional Chinese society places less emphasis on individual rights, self-expression, and self-determination than western societies. Qualities such as function, harmony, and responsibility are stressed more than individual rights. Familial relationships assume primary importance (Hofstede, 1991). Statistics from the Government of Canada (1998a; 1998b) report that more Chinese immigrants in Canada live with their immediate family compared with other immigrants and Canadian-born people. The same source revealed that Chinese senior immigrants aged 65 years and over, were more likely to live with their adult children compared with Canadian-born seniors. Family plays a central role in healthcare decision making in Chinese society. Cong (Cong, 2004) pointed out that the doctor-family-patient relationship plays a more important role in medical practice in mainland China than the doctor-patient relationship. Whether the patient is 19 informed or how much the patient should be informed, depends upon the collective decision of the family. Moreover, most doctors prefer to inform the family members first rather than the patient. This is a prime example of a collectivistic orientation in healthcare decision making rather than an individualistic one (Cong, 2004). Despite its westernization, Hong Kong culture remains strongly family-centered, and healthcare decisions are also often made by the family rather than the individual (Fan & Tao, 2004). In contrast, in Western cultures that tend to be high in individualism, medical decisions generally cannot be made without the primary participation and consent of the patient. In these cultures, healthcare decision-making by physicians without input from the patient is regarded negatively as being paternalistic, and even unethical (Ip, Gilligan, Koenig, & Raffin, 1998). (2) Power distance The cultural dimension of power distance refers to the degree of inequality among people which the population of a country considers as normal. China, for example, distinguishes itself in having a substantially higher power distance ranking of 80 compared with Canada's 39, and the world average of 55 (Hofstede, 1991). This score is partly explained by the strong influence of Confucianism, in which Chinese culture places great value on maintaining harmony in interpersonal relations through respect for hierarchy. In ancient China, doctors were respected as highly as the Confucian politicians who were highly revered for bringing peace and prosperity to the community (Tsai, 2001). Moreover, doctors today are generally perceived as a 'second parent' by Chinese patients and deference to the doctor for decision-making is the norm (Cong, 2004). 20 The perceptions of students in China and Australia with respect to their experiences of how business is conducted have been compared. The Chinese students' perceptions were consistent with a higher power distance orientation. They commented that decisions are made by supervisors or managers without consultation with others prior to decision making. Australia students on the other hand were more likely to report that consultation was important before a final decision is made (Bassett, 2004). Although not related to healthcare, this study demonstrated that even in the young people from two cultures that are at different ends the power distance spectrum, the influence of the construct on their general perceptions is strong. (3) Uncertainty avoidance The cultural dimension of uncertainty avoidance refers to the degree to which people in a culture prefer, based on their comfort level, structured vs. unstructured situations. Compared with Canadians overall, Chinese people scored lower in Uncertainty Avoidance Index. This suggests that the Chinese are less comfortable with ambiguity and uncertainty, and have less tolerance for diverse opinions. 'Ambiguity' has been defined as one of eight cultural characteristics of relevance in the context and process of negotiation (Woo & Prud'homme, 1999). (4) Masculinity versus femininity The cultural dimension of masculinity and femininity refers to the extent to which a culture is comfortable with dominance, assertiveness, competitiveness, and acquisition of material possessions. Interestingly, the difference between Chinese and western cultures is not as marked as in other dimensions (Hofstede, 1991). Hofstede (1991) states that 'masculinity 21 pertains to societies in which social gender roles are clearly distinctfemininity pertains to societies in which social gender roles overlap'. In China, male dominance is firmly entrenched. Women have a long history of being submissive and obedient to the men in their lives: father, then husband, then son. Women traditionally select professions consistent with their nurturing role as wife and mother within the family context, e.g., nurses, maids, or cooks (Chia, Moore, Lan, Chuang, & Cheng, 1994). Chinese men on the other hand assume leadership roles in decision making, which extends to decision making about healthcare within the family. Based on a survey conducted in Taiwan, family members, especially fathers and husbands, are the first to be notified of a patient's health status, even prior to the patient's being consulted by the physician. When the patient is a father or a husband, the eldest son is the individual the physician informs (Tai & Tsai, 2003). (5) Long-term versus short-term orientations Long-term orientation values focus on the future, e.g., saving money and persistence. Short-term orientation values focus on the past and present. Chinese societies including China, Hong Kong, Taiwan, and Singapore are ranked as being more future- and long-term oriented cultures, whereas countries such as Canada, the UK, and the US, are more past and short-term oriented cultures. Compared with the average score of 45 among the 23 countries surveyed for which scores have been calculated, Canadians had a score of 23, the lowest ranking on the dimension of long-term orientation (Hofstede, 1991) Stroke prevention and education programs 22 Primary, secondary and tertiary prevention of stroke To a large extent, stroke can be prevented. The WHO has reported that the occurrence of stroke, particularly in people under 65 years of age, is. a failure of primary prevention in both developed and developing countries. About three quarters of strokes in middle-aged men and women can be explained by an adverse risk factor profile (WHO STEPS-Stroke). Optimal prevention of stroke requires the use of primary, secondary, and tertiary prevention strategies. Primary prevention is aimed at the general population and is achieved through risk factor identification and modification, by either lifestyle changes or by medical intervention (Heart and Stroke Foundation of Canada, 1997). Although family history, age, gender, and ethnicity are non-modifiable risk factors for stroke, people can modify lifestyle behaviors that are linked with stroke such as smoking, obesity, diet, diabetes, inactivity, high blood pressure, and high blood cholesterol (Heart and Stroke Foundation of Canada, 1997). Secondary prevention is directed toward patients who have had a transient ischemic attack or ischemic stroke. It can increase survival through early identification and management of the stroke (Heart and Stroke Foundation of Canada, 1997). The main focus of secondary prevention is to change lifestyle to lower risk, and identify and treat underlying conditions such as atrial fibrillation. The Heart and Stroke Foundation of Canada (1997) advocates quitting smoking and reducing exposure to environmental tobacco smoke, losing weight, eating healthfully, and being physically active as key ways to lower the risk of stroke recurrence. Tertiary prevention is directed toward people who have had a stroke. Such prevention is incorporated into the rehabilitation management program in conjunction with improving an 23 individual's ability, and reducing disability and suffering, with a view to optimizing overall functional capacity and quality of life (Heart and Stroke Foundation of Canada, 1997). Stroke rehabilitation including physical therapy interventions is often encompassed in tertiary prevention. It is an active process initiated during acute hospitalization, progressed for those with residual impairments to a systematic program of rehabilitation services, and continued after the individual returns to the community. It enables people with stroke to maximize physical function and opportunities for returning to an active and productive life (Gresham et al., 1997). Physical therapists work with other health professionals in addressing each individual's unique health education needs in term of assessment, and the structure of the content and its delivery. Furthermore, stroke prevention needs to be incorporated into a comprehensive prevention strategy geared toward the prevention of vascular disease overall, given the overlap of coronary artery disease, peripheral vascular disease, and cerebral vascular disease (Heart and Stroke foundation of Canada, 1997). Health education Given the increasing number of immigrants to Canada from around the world, the cultural appropriateness and sensitivity of healthcare have become priorities in multicultural Canada (Romanow, 2002). The government-mandated Romanow Report in 2002 stated that 'health professionals should reflect the diversity of Canadian and understand the ethnic and cultural backgrounds of the population they serve'. Similarly, Healthy People 2000 (US Department of Health and Human Service) called for judicious assessment of a minority population before developing healthcare interventions by stating 'Special population groups 24 often need targeted preventive efforts, and such efforts require understanding of the needs and the particular disparities experienced by these groups. General solutions cannot always be used , to solve specific problems.' Effective health education is considered a primary component of stroke prevention, and in the management of people with stroke to help prevent a future stroke as well as to manage the manifestations of an existing stroke (WHO STEPS-Stroke). People with a higher level of education are likely to have greater health-related knowledge, healthcare resources, and problem-solving abilities, which lead to a healthier lifestyle and reduced risk of mortality (Winkleby, Darius, Frank, & Fortmann, 1992). Cultural factors may be directly or indirectly associated with health-related behaviors and acceptance and adoption of health promotion programs (Pasick, D'Ohofrio, & Otero-Sabogal, 1996). Although no single definition of culture has been universally accepted, there is general agreement that culture is evidenced by a group's values, norms, practices, systems of meaning, way of life, and other social factors (Hughes, Seidrhan & Williams, 1993) Thus, the success of health education likely reflects multiple factors including its cultural relevance, appropriateness, and sensitivity. Optimizing physical therapy effectiveness for CCs who are at risk of or have had a stroke, through culturally-sensitive care, could help improve the satisfaction with, and cost benefit of care for this group. Although the Canadian government and healthcare providers are increasingly aware of the need for 'culturally sensitive access', little is known about the impact of culture and acculturation on Chinese immigrants' health and healthcare in Canada. In particular, little is known about the specific needs of CCs in relation to health education about • 25 stroke and its risk factors. An understanding of the health knowledge, beliefs, and behaviors of CCs and their interrelationships however could help fill a gap in our current knowledge. Translation of these findings to improve the effect of health education in this cohort constitutes a potentially important step toward the prevention and management of stroke in this population and possibly other lifestyle related conditions common to western cultures. Purpose of study and research questions Purpose This study was designed to contribute to a more complete understanding of the knowledge, behaviors, and beliefs related to stroke and its risk factors in the Chinese community in Canada. I investigated the health knowledge, beliefs, and behaviors related to stroke among CCs and ECs residing in Lower Mainland, BC, and also examined how health knowledge, behaviors, and beliefs varied based on factors such as gender, age, and education. The interrelationships of these variables were also evaluated. Research Questions With respect to CCs and ECs: (i) How do health knowledge, behaviors and beliefs compare by ethnic group and gender? (ii) How do the interrelationships between health knowledge, behaviors and beliefs compare? With respect to CCs: 26 (iii) How do health knowledge, behaviors and beliefs of CCs compare based on length of residence in Canada? (iv) How should health programs and strategies be constructed, targeted, and delivered to meet the needs of CCs? The results have implications for developing health education strategies for CCs with respect to stroke prevention and during the course of physical therapy management. In addition, the results will shed light on the health knowledge, behaviors, and beliefs of ECs, and suggest areas of future research to ensure that health education is being appropriately designed and targeted for this group also. 27 Chap t e r 3 Me thods Research design A cross-sectional survey was performed on a convenience sample of ECs and CCs in the Lower Mainland of BC, Canada. Sampling Sample size Subjects included ECs and first-generation CCs residing in the Lower Mainland of BC. This study focused on first-generation CCs, and ECs, who constitute the dominant culture, and served as the reference group. As the total Chinese population in the Lower Mainland totaled 342,700 in 2001 (Statistic Canada, 2003), the sample size of each group in this study was estimated as 102 each, based on Creative Research Systems, with 95% confidence and 9% confidence interval (Creative Research Systems, 2003). Inclusion criteria The inclusion criteria for participation of the EC group were those who 1) were born in Canada and residing in Canada, 2) had European ancestors, 3) were 40 years of age or older, and 4) were able to read and write English sufficiently to understand and complete the questionnaire (self-reported). The inclusion criteria for participation in the CCs were those who 1) were first-generation of immigrants born in China (including Mainland China, Taiwan, and Hong 28 Kong) and immigrated to Canada after 18 years of age, 2) were 40 years of age or older, and 3) were able to read and write Chinese sufficiently to understand and complete the questionnaire (self-reported). The study was approved by the ethics review board of the University of British Columbia. Submission of the completed questionnaire constituted consent of each respondent to participate in the study. Recruitment and general procedure A sample of convenience was recruited in the vicinity of community centers, libraries, places of worship, and public places primarily in Vancouver, Richmond, and Burnaby from September through December 2005. Recruitment notices with a brief listing of eligibility criteria in English and in simplified and traditional Chinese, were posted in public places such as libraries and community centers in the Lower Mainland. Wdrd-of-mouth and referrals from participating subjects were also used to recruit subjects. On initial contact with potential participants, the eligibility criteria were reviewed, and followed by an explanation of the purpose of the study. Respondents could choose to complete the questionnaire on site and return it immediately, or they could complete the questionnaire at their leisure and return it to the investigators in a stamped, self-addressed envelope within two weeks. The CCs selected one of the two Chinese versions (simplified or traditional Chinese) of the questionnaire based on their self-reported comfort and competence in reading and writing either version. 29 Overview of the questionnaire Content The survey instrument was a questionnaire consisting mostly of closed-ended questions and several open-ended questions. It was designed based on a comprehensive literature review, and selected items that would best assess knowledge, behaviors and beliefs related to stroke, of the CCs and ECs. The questionnaire was designed with four parts 1) knowledge of stroke, 2) health behaviors related to stroke, 3) heath beliefs related to stroke, and 4) respondent's descriptive and sociodemographic characteristics. The questionnaire required about 30 minutes to complete. Five open-ended questions were used to assess the respondents' knowledge of stroke. Respondents were to list any risk factors they were aware of, and any warning signs. The responses to these open-ended questionnaires were tabulated based on common words and analyzed differently than for the closed-ended questions. Specifically, these responses were coded and categorized. No response was treated as 'missing data', as it was necessary to differentiate this response from responses such as T don't know' or 'no idea'. Other open-ended questions included how would they respond if someone was apparently having a stroke, and where would they go to access stroke-related information. The responses to these questions were similarly coded. The content of questions in the knowledge part of the questionnaire was similar to that used in a 1995 population-based survey of 17,634 households in the US (Pancioli et al., 1998). Four major dimensions of health behaviors were examined, namely, smoking, alcohol 30 consumption, physical activity, dietary habits, and stress. Four questions assessed the respondent's smoking status including smoking habits and exposure to second-hand smoking. Because self-reported smoking has been reported to be a valid indicator of actual smoking behavior (Patrick et al., 1994), respondents were categorized as 'never smoked', 'seldom smoke' or 'usually smoke' by providing frequency information on smoking. The average number of cigarettes per week and the frequency of exposure to second-hand smoking were also asked. Alcohol consumption was assessed by asking the amount of alcohol consumed in an average day. Respondents were also asked if they used smoking or alcohol to handle stress. Questions on physical activity from the International Physical Activity Questionnaire (IPAQ) were replicated in part (IAPQ, 2002) to assess the type of physical activity an individual typically engaged in, and its intensity, duration, and frequency. Because the IPAQ is based on the activity levels of people between 15 and 70 years of age, selected respondents younger than 70 years were asked to provide the intensity, type of vigorous activity, moderate activity, walking during the last 7 days. The pattern of activity was categorized into three levels: low, moderate and high based on the IAPQ scoring protocol. Sedentary behavior like sitting was examined by asking the number of hours of sitting on an average weekday. Items including the number of servings of the major four food groups and sugar, salt, oil, fast-food, were included to assess daily average dietary intake and eating habits. These were based on Canada's Food Guide to Healthy Eating (Health Canada, 2005) and The Food Guide Pagoda by the Chinese Nutrition Society (The Chinese Nutrition Society, 2005). The four food groups contain grain products, vegetables and fruit, milk products, meat and alternatives (Health 31 Canada, 2005). Questions were also designed to assess the type and degree of life stressors. These questions have been used previously in cross cultural surveys by members of our research team (Al-Mazeedi & Dean, 2006; Wong & Dean, 2006). Respondents were asked to identify the level of stress they experienced in 7 contexts. Beliefs related to stroke were assessed by rating health-related behaviors with a Likert scale. These behaviors included dietary habits, exercise, smoking, alcohol consumption, and stress management. Respondents rated the perceived importance of each behavior to overall health. Moreover, respondents were asked to choose the changes of activities they believed to help reduce stress. Finally, 4 open-ended questions were used to establish what the respondent believed was important to a 'long healthy life' (longevity). The last section of survey contained questions on the descriptive and sociodemographic characteristics including gender, age, personal income, highest education level, native language and language spoken at home, and work status. Length of living in Canada was asked of the CCs. Respondents also provided information on their personal health history and their family history to establish their risk factors for stroke, to establish their current health profiles. Other questions including most recent blood pressure and cholesterol status, duration of night's sleep, were also assessed. In addition, respondents were asked to report their weight and height. These self-reported weights and heights were used to calculate body mass index (BMI is weight in kg/height in m2). . 32 Translation The questionnaire was circulated in three language versions, namely, English (Appendix A) and simplified and traditional Chinese (Appendix B & Appendix C, respectively). Two native Chinese translators, bilingual in English and Chinese, translated the English version of the questionnaire into the simplified Chinese version using the back-translation method, commonly used in cross-cultural research (Hambleton, 1993). In the current study, the original English version was first translated to the simplified Chinese version, and then translated back into English. Equivalence of items in terms of the cultural context was examined. Little refinement was needed based on back-translation. As noted, most CCs from mainland China are able to read and write simplified Chinese whereas the majority of people from Taiwan and Hong Kong read and write traditional Chinese. Although there is not much difference in the scripts, in an effort to ensure the full understanding of the questionnaire, a traditional Chinese version was developed by converting the simplified Chinese version by Word 2003 and then having it examined by a reviewer who is familiar with both scripts. Pretest The English version of the questionnaire was pre tested in 4 ECs. They provided feedback on the clarity and comprehensibility of the instructions to the questionnaire and the questions themselves. One modification was made in the dietary section. Original questions designed to assess people's dietary habits asking the amount of food consumed in grams or pounds in four major food groups were considered detailed. They were replaced by asking for 33 the number of servings in the above food categories with a detailed instruction example to each question. Statistical analysis Data were analyzed with the Statistical Package for the Social Sciences (SPSS version 12). The analysis was divided into three parts. First, a descriptive analysis was performed to examine differences within each ethnic group and between groups. Descriptive statistics such as frequencies and percentages, and means and standard deviations (SD) were used to summarize the descriptive and demographic information of the respondents, and to summarize the responses to the questions related to stroke-related knowledge, and health behaviors and beliefs for each ethnic group. All analyses were performed separately for men and women. Chi-square analysis was used to compare group differences between the CCs and ECs for categorical variables. Independent sample t-test was used to examine group differences for the continuous variables. Between group differences were examined based on ethnic group and within group differences were analyzed based on gender and age. Sociodemographic status measures including age, gender, personal income, education, and length of residence in Canada were also assessed to be used as control variables. Next, bivariate correlations including the Kendall's tau (rk) correlation statistics, were used to examine the direction and strength of association between selected behaviors and beliefs. The sign of the coefficient indicates the direction of the relationship, and its absolute value indicates the strength, with larger absolute values indicating stronger relationships. A crosstabs 34 procedure was used to assess the association between two categorical (normal or ordinal) variables in behavior and belief. In addition, one-way analysis of variance was used to examine the variables of interest between the groups based on level of importance of their health beliefs. With respect to the analysis of stress-related variables, crosstabs ordinal-by-ordinal measures were performed among total subjects to examine the relationship between experiences from stress with the beliefs on the activities that help reduce stress. The p level was set at 0.05. 35 Chapter 4 Results Sociodemographic characteristics A total of 318 questionnaires (154 in English, 164 in Chinese) were distributed in the lower mainland of BC. Of the 211 questionnaires returned, 7 questionnaires (3 in English, 4 in Chinese) were discarded due to incomplete data. Finally, 101 were from ECs and 103 from CCs (respond rates were 67.5% and 65.2%, respectively). The respond rate for the total population was 66.4%. A summary of the descriptive and demographic data of the subjects who completed the questionnaire is presented in Table 1. About 45.6% of the CCs and 48.5% of the ECs were women. Mean ages of the CCs and the ECs were 51.5 years (SD 9.5, range: 40 to 89 years) and 54.2 years (SD 11.8, range: 40 to 82 years), respectively. However, no differences were observed for age and gender between two ethnic groups (gender: ^=0.17, p=0.680; age: t=l .82, p=0.070). Both groups reflected similar proportions of highest education level of high school or equivalent (25.2% of CCs, 30.7% of ECs, p=0.386) and post secondary education (70.9% of CCs, 69.3% of ECs, p=0.806). More CCs reported having only elementary education or less (3.90% of CCs, 0% of ECs, p=0.045). Little difference was observed in employment status. Compared with ECs, fewer CCs reported being employed (55.3% compared with 60.4%), retired (17.7% compared with 27.7%) or unemployed (2.9% compared with 7.9%). However, more CCs reported being homemakers (24.3% compared with 4.0%, p=0.000). With respect to personal income, 88.4% of 36 CCs and 87.9% of ECs reported earning less than $70,000 Cdn. However, compared with the ECs, the CCs were more highly represented in the income category of less than $19,999 Cdn (35.0%) compared with 18.2%, p=0.007), and less well represented in the category of income range between $20,000 Cdn and $69,999 Cdn (53.4% compared with 68.7%, p=0.026). Mean length of residence in Canada for CCs was 12.7 years (SD 9.5, range: 1 to 43 years). 64.1% Of the CCs were born in Mainland China, while 13.6% and 24.3% were born in Hong Kong or Taiwan, respectively. The majority of CCs reported Mandarin as their first-language (78.6% Mandarin compared with 21.5% Cantonese). The CCs were more likely to speak Mandarin or Cantonese at home (68.9% Mandarin and 21.4% Cantonese). Health profile of respondents 72.8% of CCs and 62.4% of ECs reported normal body weight (body mass index (i.e., BMI calculated from reported height and weight) 18.50-24.99). 23.3% of CCs and 33.7% of ECs reported being overweight (BMI>25) and 4.0% of ECs and 3.9% of CCs reported being underweight (BMK18.5). No gender difference was found within each group (Tables 2a and 2b). The majority of CCs and ECs reported that they had had their blood pressure and blood cholesterol checked within the past 6 months at the time of survey (76.0% and 53.4% for the CCs, and 71.3% and 58.4% for the ECs). The CCs and ECs reported selected health problems like hypertension (14.6% and 17.8%), diabetes (4.9% and 4.0%), heart disease (5.0% and 3.9%), stroke (1.9% and 0%) and high blood cholesterol (24.1% and 12.5%). Compared with the ECs, fewer CCs reported a family history of diabetes (%2=9.91, p=0.002) and heart diseases (x2=7.27, p=0.007). Additionally, at least 24.1% of CCs and 17.8% of ECs and reported 1 health problem out of diabetes, heart disease, stroke and hypertension and high blood cholesterol. No gender differences were detected with respect to the above selected health problems and family history (Tables 2a and 2b). Stroke-related knowledge Risk factors and warning signs Knowledge of stroke risk factors by ethnicity and gender are shown in Tables 3a and 3b. The CCs listed 'hypertension' (39.6%), 'stress' (21.8%) and 'high cholesterol' (18.8%) as the top three risk factors for stroke. For ECs, 'smoking' (57.6%), 'hypertension' (44.4%) and 'obesity' (38.4%o) were most frequently cited. A higher percentage of CCs answered 'do not know' (22.8% of CCs compared with 12.1% of ECs, p=0.047). Differences were also detected when identifying 'smoking', 'obesity'.and 'inactivity' as the risk factors for stroke between CCs and ECs (smoking: 10.9% compared with 57.6%, p=0.000; obesity: 9.9% compared with 38.4%, p=0.000; inactivity: 8.9% compared with 23.2%, p=0.006). Overall, although CCs were more likely to identify fewer risk factors for stroke than ECs (CCs: 1.6, SD 1.4; ECs: 2.4, SD 1.4; t=4.10, p=0.000), men and women within each group provided similar number of risk factors (CCs: t=-0.58, p=0.561; ECs: t=-0.06, p=0.953). Gender differences in knowledge of stroke risk factors were found in three situations: a higher proportion of EC men listed 'stress' (x2 =4.37, p=0.037), a higher proportion of EC women listed 'hereditary' (x2=3.87, p=0.049), and a higher proportion of CC women identified 'high cholesterol' (x =5.20, p=0.022) as risk factors. The warning signs of stroke, regardless of correctness, named by at least 5% of the total 38 respondents are shown in Tables 3a, 3b and 3c. The most common warning signs identified by C C s were 'dizziness' (38.6%), 'headaches' (31.7%) and 'numbness' (23.8%). ECs identified 'numbness' (34.3%), dizziness (27.3%) and vision problems (27.3%) as the top three warning signs of stroke. Differences were observed between the C C s and ECs with respect to identifying the following stroke risk factors: 'weakness', 'vision problems' and 'shortness of breath' (weakness: 4.0% compared with 14.1%, p=0.0T2; vision problems: 9.9% compared with 27.3%, p=0.002; shortness of breath: 1.0% compared with 7.1%, p=0.028). The National Institute of Neurological Disorders and Stroke in the. U S (NINDS) describes the five primary warning signs for stroke as 1) sudden weakness or numbness of the face, arm, or leg; 2) sudden dimness or loss of vision, particularly in one eye; 3) sudden difficulty speaking or understanding speech; 4) sudden severe headache with no known cause; and 5) unexplained dizziness, unsteadiness, or sudden falls, especially with any of the other signs. Based on these established warning signs of stroke, the C C s identified fewer signs than the ECs (CCs: 1.1 and SD 0.9; E C : 1.6 and SD 1.2; t=4.65, p-0.000). 79.2% of C C s and 72.7% of ECs correctly identify at least one warning sign, 30.7% of C C s and 52.5% of ECs correctly listed at least two or more warning signs, and 7.9% of CCs and 26.3% of ECs correctly listed three or more. Men and women in each group however identified a similar number of warning signs of stroke. The number of risk factors increased with higher personal income (F=5.61, p=0.004) and education (F=3.70, p= 0.026) while correct identification of established warning signs did not increase with personal income and higher education. Overall, there was no difference in terms of reported histories of diabetes, heart disease, hypertension, and previous history of stroke, 39 between respondents who did not know any risk factors or established warning signs, and those who knew one or more. Reaction to stroke signs in household When asked how they would respond if someone in the household showed signs of stroke, fewer CCs reported that they would call an ambulance or visit a hospital emergency room (84.2% of CCs compared with 96.0% of ECs, p=0.005) and more CCs were likely to answer 'do not know' (Table 4a). Men and women in either group responded similarly to this question (Table 4b). Source of information about stroke Tables 5a and 5b show the responses to the question regarding access to resource information on stroke and its risk factors, by ethnic group and gender. The most frequently cited sources of information about stroke by CCs were mass media (newspapers 39.6%, books 32.7%, magazines 13.9%, television 11.9%) and personal acquaintances (family or friends 18.8%,) rather than professionals (doctors: 4.0%, medical facilities: 6.9%). In addition, compared with the ECs, the CCs selected the above mass media (newspapers: p=0.000, television: p=0.006; . magazines: p=0.002, books: p^O.000) and family or friends (p=0.000) as primary source of information about stroke. In contrast, the ECs more frequently named the Internet (61.6% compared with 9.9%, p=0.000), doctors (42.4% compared with 4.0%, p=0.000), libraries (4.0% compared with 0%, p=0.041) and medical facilities (36.4% compared with 6.9%, p=0.000). More CCs were unable to name any source of information (15.8% of CCs compared with 2.0% of ECs, p=0.000). Within each group, more EC women reported they would access 'libraries' for 40 information on stroke than EC men (Table 5b). Stroke-related Behaviors Smoking and alcohol consumption The majority of both groups reported having 'never smoked' (71.8% of CCs and 82.2% of ECs). Similar proportions of CCs and ECs reported they 'usually smoke'. However, more CCs reported they 'seldom smoked' (x2=8.22, p=0.004). Only 9.7% of CCs and 5.9% of ECs reported frequent exposure to second-hand smoking (Table 6a). CCs were likely to identify themselves as non-drinkers (81.0% CCs and 60.4% ECs, p=0.001) and fewer CCs had 1 to 2 alcohol drinks per day (11.3% CCs and 35.6% ECs, p=0.000). More CCs never used smoking or alcohol to handle stress (x2=5.59, p=0.019). More CC women than men reported being non-smokers and never handling stress with smoking or alcohol (89.3 % compared with 51.1% and 81.8% compared with 53.2%, respectively) (Table 6b). Physical activity Based on the scoring protocol of the International Physical Activity Questionnaire (IPAQ, 2002) short form, the majority of CCs and ECs reported being moderately physically active (39.6% compared with 66.7%). ECs were more likely to engage in moderate physical activity than CCs (x =13.2, p=0.000). However, more CCs than ECs had low physical activity levels (x =30.85, p=0.000). The proportions of CCs and ECs who engage in a high level physical activity did not differ (x =3.16, p=0.076). In general, CCs had lower MET-minutes/week scores (MET or! metabolic equivalent provides an index of intensity of exercise) on vigorous-intensity, 41 moderate-intensity and walking and total score. The CCs reported similar levels of sedentary activities such as sitting, as the ECs (Table 7a). Within each group, men and women did not differ in three level of physical activity ' (Table 7b). The EC women had higher MET-minutes/week score on vigorous-intensity, moderate-intensity, walking and total score. The CC women scored lower than CC men on moderate-intensity, walking and total (Table 7b). Dietary habits Dietary habits by ethnicity and gender are presented in Tables 8a and 8b. Compared with the ECs, the CCs reported fewer servings per day in 3 out of 4 major categories, i.e., vegetables and fruits (t=3.92, p=0.000), meats and alternatives (t=2.13, p=0.034), milk or dairy products (t=6.11, p=0.000). Moreover, the CCs reported less consumption of sugar and higher consumption of salt per day (sugar: t=2.17, p=0.032; salt: t=-3.86, p=0.000). No group differences were observed for consumption of grains and oil. The majority of CCs and ECs ate fast food or high fat food less than once per week (65.1% compared with 67.3%) and 9.7% of CCs and 5.0% of ECs ate 3 or more fast foods or high fat food per week. No difference was detected within gender in either group except the women in the CC and the EC groups reported less consumption of grain than their male counterparts (Table 8b). Stress Tables 9a and 9b show the stressors experienced by ethnic group and gender. The majority of the CCs and the ECs experienced low or moderate stress and only 8.7% of CCs and 8.9% of ECs reported high stress. However, the CCs reported experiencing a great deal of stress 42 from all listed situations, i.e., 'family or marriage' (x2 = 10.7, p=0.001), 'away from home' (x2 = 13.85, p=0.000), 'work' tf=437, p=0.037)), 'lack of work' (x2=14.72, p=0.000), 'few friends' (X2=6.51, p=0.011), 'sickness'(x2=16.34, p=0.000)> 'sickness in family' (x2=9.54, p=0.002). The CCs were also more likely to sleep fewer hours each night (6.7 h compared with 7.2 h, t=3.63, p=0.000). The CC women were more likely to experience a great deal stress from having 'few friends' than CC men. The EC men reported experiencing less stress than EC women (Table 9b). Stroke-related beliefs General health beliefs by ethnic group are presented in Tables 10a and 10b. When asked to identify the degree of importance of some stroke-related health behaviors to overall health, more than 50% of CCs and ECs thought most of the listed behaviors in the categories of diet, exercise, not smoking, not drinking, bodyweight were very important with one exception, i.e., only 36.3% of CCs reported that 'taking vitamins and supplements' as very important. Moreover, fewer ECs identified behaviors like 'eating grain-based food' (x2 = 3.99, p=0.046), taking vitamins and supplement (x2 = 6.06, p=0.014), 'exercising regularly' (x2 - 32.9, p=0.000) along with 'maintaining a normal healthy body weight' (x2 = 3.92, t=0.048) very important to overall health'. In addition, 'not smoking' (x2 = 7.46, p=0.006) and 'not drinking alcohol or drinking in moderation' (x =4.17, p=0.041) were viewed as not important to overall health' by more CCs than ECs. Other behavior like 'drinking plenty of water every day' was considered very important. 4 3 C C m e n a n d w o m e n i d e n t i f i e d to a s i m i l a r d e g r e e the i m p o r t a n c e o f a l l h e a l t h b e h a v i o r s c i t e d , to o v e r a l l h e a l t h . E C w o m e n , h o w e v e r , w e r e m o r e l i k e l y to i d e n t i f y ' e a t i n g f r u i t s a n d v e g e t a b l e s ' a n d ' n o t s m o k i n g ' as very important c o m p a r e d w i t h E C m e n ( T a b l e 1 0 b ) . W i t h r e s p e c t to b e l i e f s r e g a r d i n g the d e g r e e s e l e c t e d a c t i v i t i e s h e l p to r e d u c e s t ress ( T a b l e s 11a a n d l i b ) , C C s w e r e l e ss l i k e l y to b e l i e v e that ' p h y s i c a l a c t i v i t y o r e x e r c i s e ' ( 5^=38 .00 , p = 0 . 0 0 0 ) , ' s l e e p ' (x 2=8.10, p = 0 . 0 0 4 ) , ' t i m e w i t h o r t a l k i n g to f r i e n d s ' (x 2=6.98, p = 0 . 0 0 8 ) , ' t i m e w i t h o r t a l k i n g to f a m i l y ' (%2=7.99, p = 0 . 0 0 5 ) , ' m u s i c ' (%2=6.29, p = 0 . 0 1 2 ) a n d ' e a t i n g ' (% = 2 0 . 7 7 , p = 0 . 0 0 0 ) a re m o s t e f f e c t i v e i n r e d u c i n g s t ress ( a g rea t d e a l ) . M o r e C C s b e l i e v e d that ' i n o w n c o u n t r y ' (x 2 =35.70, p = 0 . 0 0 0 ) , ' be t t e r l i v i n g c o n d i t i o n ' (x 2 =15.56, p = 0 . 0 0 0 ) o r ' m o r e m o n e y ' (x = 4 . 4 8 , p = 0 . 0 0 2 ) c a n r e d u c e m o d e r a t e o r h i g h s t ress i n l i f e ( T a b l e 11a) . W i t h i n e a c h g r o u p , C C w o m e n w e r e m o r e l i k e l y to c o n s i d e r that ' r e l a x a t i o n ' (x 2=4.32, p = 0 . 0 3 8 ) , m u s i c ' (x 2=6.74, p = 0 . 0 0 9 ) c a n h e l p r e d u c e stress o n the h i g h e s t d e g r e e (a g rea t d e a l ) w h i l e E C w o m e n w e r e m o r e l i k e l y t o c o n s i d e r ' t i m e w i t h o r t a l k i n g to f a m i l y ' (x 2=4.31, p = 0 . 0 3 8 ) . C C w o m e n w e r e m o r e l i k e l y to c o n s i d e r that ' m o r e m o n e y ' w o u l d r e d u c e m o d e r a t e o r h i g h s t ress t h a n C C m e n (x 2=4.74, p = 0 . 0 3 0 ) ( T a b l e l i b ) . W i t h r e spec t to h e a l t h b e l i e f s r e l a t e d to a c t i v i t i e s n e c e s s a r y f o r a l o n g h e a l t h y l i f e , b o t h g r o u p s i d e n t i f i e d the n e e d f o r p e o p l e to c o n s u m e ' m o r e v e g e t a b l e s a n d f r u i t s ' ( C C s : 4 3 . 3 % , E C s : 5 1 . 6 % ) , ' b a l a n c e d d i e t ' ( C C s : 3 0 . 3 % , E C s : 3 0 . 1 % ) , a n d ' l o w fa t o r n o fas t f o o d ' ( C C s : 2 1 . 4 % , E C s : 3 9 . 8 % ) . H o w e v e r , C C s w e r e m o r e l i k e l y to r e c o m m e n d ' m o d e r a t e o r l e ss c o n s u m p t i o n o f m e a t ' (x 2 =13.85, p = 0 . 0 0 0 ) , ' m o d e r a t e o r m o r e c o n s u m p t i o n b e a n s / t o f u ' (x 2=6.06, p = 0 . 0 1 4 ) , ' l e s s o i l ' (x 2 =10.25, p = 0 . 0 0 1 ) . A h i g h e r p e r c e n t a g e o f E C s r e c o m m e n d e d ' l e s s s a l t ' (x 2=5.30, p = 0 . 0 2 1 ) , 44 'low fat/no fast food' (x =7.60, p=0.006). In addition, CCs were more likely to recommend light physical activity (e.g., walking, dancing, gardening, golfing, and bowling). Most ECs and CCs recommended 'not drinking alcohol' or 'drinking alcohol in moderation'. CCs however were more likely to believe 'no alcohol drinking' (x =10.67, p=0.001) is necessary for a long healthy life, and less likely to recommend 'drinking alcohol in moderation' (x2=13.38, p=0.000). No gender differences were detected except more EC women believed 'no smoking' was consistent with a long healthy life (x2=6.48, p=0.011) compared with EC men (Tables 12a and 12b). Older people (older than 50 years old) and people with high personal income (higher than $70,000 Cdn) reported 'avoiding processed food' (x2=4.23, p=0.040) and 'low fat/no fast food' (x2=6.44, p=0.011) respectively, to attain a long healthy life. Length of residence in Canada for CCs The data for the CCs were stratified based on the median number of years lived in Canada (10 years) to examine the effect of length of residence in Canada on the stoke-related knowledge, behaviors and beliefs. Table 13 summarizes the sociodemographic characteristics of CCs based on the split of median number of residence (10 years) in Canada. CCs who had lived in Canada more than 10 years were on average older (54.0 y (SD 10.2) compared with 48.6 y (SD 7.8) (t=-3.05, p=0.003). They were more likely to originate from Hong Kong, report Cantonese as their native language (20.4% compared with 6.1%, p=0.035) and speak Cantonese at home (31.5% compared 10.2%, p=0.009). No differences between the two above groups were observed with respect to highest level of education, employment status, 45 personal income and health profile (Tables 13 and 14). People in the two CC groups reported a comparable number of stroke risk factors (t=-0.75, p=0.454) and established stroke warning signs (t=0.55, p=0.585) (Table 15). A greater proportion of the CC group who had lived in Canada more than 10 years cited 'Smoking' (17.3% compared with 4.1%, p=0.033) as a primary stroke risk factor. In addition, the two CC groups reported similar responses if someone in the household showed signs of stroke (^ 2 =0.02, p=0.890) (Table 16). 'Newspapers' (36.7% and 43.3% ) and 'books' (34.7% and 30.7%) were two frequently cited resources when asked about accessing information about stroke by the two groups. However, CCs who had lived in Canada less than 10 years were more likely to cite using the internet to access information on stroke (x2=4.41, p=0.036,) (Table 17). CCs had lived in Canada more than 10 years were more likely to be 'non-drinker' (/2=3.92, p=0.048) (Table 18). Because our activity rating scale, the IPAQ (IPAQ, 2002), was based on people less than 70 years of age, we analyzed those individuals in our cohort who were within this age range. The majority of the two CC groups reported low levels of physical activity (46.8% compared with 46.9%). CCs who had lived in Canada less than 10 years, had lower MET-minutes/week scores on walking and total score, and higher MET-minutes/week scores on moderate-intensity. The two CC groups showed patterns of sedentary activity (Table 19). The two CC groups reported similar consumption of grains, vegetables and fruits, meats and alternatives, milk or dairy products. Moreover, no differences were observed for consumption of sugar, salt and oil per day, and the frequency of high fat or fast food intake per week (Table 20). The two CC groups showed no difference with respect to their experiencing a 46 great deal of stress from seven categories (Table 21) Also, no differences were observed with respect to'stress level'and'sleep time'(Table 21). When asked to identify the degree of importance of some stroke-related health behaviors to overall health, the two CC groups attributed similar importance of most listed behaviors to overall health However, a higher percentage of CCs who had lived in Canada for. more than 10 years reported 'exercising regularly' (x2=4.17, p=0.041) as being somewhat important (Table 22). With respect to beliefs and the degree to which selected activities reduced stress, these individuals were more likely to report 'physical activity or exercise' (x2=4.59, p=0.032) and 'hobbies' (x =5.85, p=0.016) reduced stress to the greatest degree (a great deal) compared with those CCs who had lived in Canada for 10 years or less. CCs lived in Canada for 10 years or more were more likely to believe 'more self discipline control' would reduce moderate or high stress. In addition, they also recommended 'no smoking' (x2=4.66, p=0.03) and 'drinking alcohol in moderation' (x =4.75, p=0.029) in order to live a long healthy life (Table 24). Relationships between health beliefs and health behaviors Smoking and alcohol consumption The direction and the strength of association of beliefs and behaviors on smoking were examined by performing Kendall's tau (rk) ordinal-by-ordinal correlation test. For the total subjects, people who considered 'not smoking' more important to overall health were more significantly likely to smoke less (rk=-0.27, p=0.000). However, this relationship is rather weak. 47 Similarly, a negative and "weak relationship was found in the total population (rk=-0.24, p=0.000) between the beliefs on 'not drinking or drinking in moderation' and the frequency of alcohol drinking. In other words, people who believed 'not drinking or drinking in moderation' more important to overall health drank less. Additionally, the beliefs on the importance of 'not drinking alcohol or drinking in moderation' negatively correlated to the behavior of using smoking or alcohol drinking to handle stress (rk=-0.17, p=0.008) in the general population. No such relationship was found between beliefs on the importance of 'not smoking' and behavior 'of using smoking or alcohol drinking to handle stress' (rk=-0.07, p=0.323). Moreover, data were stratified respectively based on age, education level, personal income level to perform the similar correlation tests. Since the age distribution was non-normal for CCs, it was recoded into two categories based on spilt of median age of whole CCs (50 years old). CCs fell in one of the following categories: 1) younger than 50 years old (rk=-0.50, p=0.002), 2) men (rk=-0.50, p=0.003), 3) received education more than post-secondary or 4) had personal income less than 19,999 (rk=-0.45, p=0.006) were found less likely to drink alcohol as they considered more importance of not drinking or drinking in moderation to overall health. People younger than 50 years old were less likely to use smoking to handle stress as they believed not smoking was more important to overall health (rk=-0.34, p=0.048). Physical activity The total population aged less than 70 years were classified into three levels of physical activities: low, moderate and high. Kendall's tau (rk) ordinal-by-ordinal correlation tests were also performed to examine the beliefs on importance of regular exercise and the actual level of 48 physical, activities. The level of physical activity increased significantly with the degree of importance of exercise on the overall health in total subjects (p=0.000). However, the positive relationship is weak (rk=0.30). CCs in one of the following groups: 1) younger than 50 years old (rk=0.26, p=0.042), 2) women (rk=0.36, p=0.001), 3) only received high school br equivalent education (rk=0.05, p=0.007), or 4) had personal income less than 19,999 (rk=0.30, p=0.004) or more than 70,000 (rk=0.66, p=0.001) were more likely to have a positive relationship between the level of physical activity and beliefs on the importance of exercise on overall health. No similar relationships were found in ECs. Dietary habits For the total subjects, 'servings of grains per day' was selected as dependent variable and 'importance of eating a lot of grains-based food' as dependent variable to compare means of servings within different belief groups. Results showed that the servings of grains per day differed in increased fairly regular increments across three belief categories. However, no difference of behaviors among the three level of beliefs (F=0.96, p=0.944) was found. Similarly, serving of fruits and vegetables increased across belief categories. Individuals who believed 'eating a lot of fruits and vegetable' were very important to overall health were more likely to eat more servings of vegetables and fruits per day (x2= 4.68, p=0.032). Difference of behaviors among the three level of beliefs was found (F=4.681, p=0.032). 62.1% of CCs and 78% of ECs believed that eating a low-fat diet was 'very important' to overall health, among these individuals, 34.4% of CCs and 15.4% of ECs ate high fat or fast 49 food more then 1 time a week (x =0.63, p=0.371). Furthermore, among the individuals who ate high fat or fast food more then 1 time a week, 2.8% of CCs and 3.0% of ECs believed that eating a low-fat diet was 'not important'. However, no significant relationship was observed between 'eating a low-fat diet' important to overall health and the frequency of having high-fat food of fast food per week in both groups (CCs: rk=-0.012, p=0.893; ECs: rk=-0.034, p=0.724). Stress No relationships were found between belief about stress reducers and the sources of stress from 'family/marriage' (rk=0.02, p=0.728); 'few friends' (rk=0.01, p=0.854), 'lack of work' (rk=0.07, p=0.298), 'work' (rk=0.03, p=0.674), respectively. Stress level was stratified into two categories: low or moderate, and high. No relationship was found between stress and beliefs about stress reducers such as 'better relationship within the family/at work' (x2=0.48, p=0.827), 'more self discipline control' (x =0.05, p=0.827), 'being in my own country' (x =1.20, p=0.273), and 'better living conditions' (x2=0.41, p=0.520). 50 Chapter 5 Discussion and Conclusions Overview The Discussion of this thesis consists of eight parts that parallel the research questions. These parts include a description of the representativeness of the sample; a comparison of health knowledge by ethnic group and gender; a description of the interrelationships between health beliefs and behaviors for the two ethnic groups; a comparison of health knowledge, beliefs, and behaviors of CCs based on length of residence in Canada; and then the implications of the findings of this study for constructing, targeting, and delivering health education programs to meet the needs of CCs in comparison to ECs. Then, the limitations of the study are described, followed by directions for future research. Finally, the overall conclusions are drawn. Representativeness of the sample For the purposes of evaluating stroke-related knowledge, behaviors, and beliefs of CCs and ECs, we sampled subjects from the Lower Mainland of BC. To secure a cross sectional sample of the populations of interest, we sampled from public places at random times of the day, in three municipalities across the Lower Mainland. These municipalities, namely, Burnaby, Richmond, and Vancouver, were selected because they have the highest reported numbers of CCs. These cities are characterized by differences in personal and family income levels, which contributed to heterogeneity within our samples. We also sampled the ECs, who comprised the 51 reference group, from these cities as well. The proportion of men and women in each group was comparable, as well as that for age distribution. We have no reason to believe that the respondents in either ethnic group were not representative of the individuals from those groups living in the three targeted cities in the Lower Mainland. We do not presume however, that respondents from either group are representative of CCs and ECs living in other parts of Canada. In fact, that ECs differ with respect to, at least, health behaviors across Canada, has been established. People from eastern Canada report less healthy lifestyles and poorer health than those in western Canada, particularly, in the Lower Mainland of BC (Institute for Clinic Evaluation Science, 2006). Whether this trend is reflected in the various immigrant groups settling across Canada warrants scientific verification based on longitudinal studies to capture the effect of acculturation. Comparison of health and stroke-related knowledge by ethnic group and gender This study of people's knowledge concerning stroke risk factors and warning signs identified some gaps. Compared with ECs, CCs were found to have less awareness of risk factors, and major warning signs, and of an appropriate response to someone showing signs of stroke. In this study, 'hypertension' was identified by CCs most often as a stroke risk factor. Studies conducted in South Korea (Kim & Yoon, 1997) and Hong Kong (Cheung et al, 1999) also reported that high blood pressure was the most frequently identified risk factor of stroke. However, a smaller proportion of CCs (4.0 % to 11.9%) identified heart disease, obesity, drinking alcohol, diabetes, and inactivity as stroke risk factors, which supports that 52 community-based stroke prevention programs should focus on lifestyle behaviors changes. It is also of interest that as low as 10.9% of CCs listed "smoking" as a risk factor for stroke in this study whereas 57.6% of ECs identified "smoking" as the most common risk factor for stroke. This finding may reflect the social acceptability of smoking in Chinese society as well as less knowledge of Chinese people about the deleterious effects of smoking on health (Yu, Chen, Kim, & Abdulrahim, 2002; Gong et al, 1995). In the present study, the most common stroke warning, signs for stroke reported by CCs and ECs were 'dizziness' and 'numbness'. Similarly, Pancioli and colleagues (1998) reported that the most common stroke warning signs reported by respondents were 'dizziness' and 'numbness' in a population-based telephone interview survey. In addition, 79.2% of the CCs in our study and 72.7% of the ECs correctly identified at least one of five established warning signs. This result is higher than that reported in other population-based studies, i.e., 57% in an Ohio study (Pancioli et al., 1998) and 49.8% in an Australia urban population study (Sug, Heller, Levi, Wiggers, & Fitzgerald, 2001). Given that 15.8% of the CCs however were unable to identify what they would do if someone in the household showed signs of stroke, and only 7.9% of CCs correctly identified three or more warning signs, further supported that the CC community warrants been targeted with respect to the design and dissemination of culturally-sensitive stroke-related health education including warning signs and emergency response. Consistent with the findings of a study of Hong Kong Chinese (Cheung et al., 1999), the mass media (i.e., newspapers, magazines, books, and television) and personal acquaintances (i.e., friends and family) were identified as potential sources of stroke-related knowledge in our cohort. 53 Based on a study conducted in Quebec, CCs chose health professionals (i.e., doctors and medical facilities) less often as sources of health information. Language barriers and a limited number of Chinese-speaking health professionals may explain this finding. Additional evidence comes from studies that report CCs experience language barriers with respect to health service utilization (Li & Rosenblood, 1994; Ma, 1999; Ma, 2000). Language appears fundamental to accessing appropriate healthcare resources as well as healthcare itself. Given stroke is largely a preventable tragedy, measures and means of reaching Chinese immigrants with stroke-related and potentially other healthcare information, is a priority. Furthermore, compared with ECs, family and friends were reported more often as being sources of information. This supports the collectivistic character of Chinese people based on Hofestede's framework of individualism-collectivism (Hofstede, 1991). Our results supported that people from collectivistic cultures tend to turn to each other for support particularly in serious matters such as those related to health. Interrelationships between health and stroke-related behaviors and beliefs for the two ethnic groups Smoking and alcohol consumption Although the majority of both ethnic groups believed that not smoking was very important for health, more CCs than ECs believed that it was not so important. This belief is reflected in the reported smoking behavior of our CC cohort. The proportion of CCs who never smoked was 71.8%, which was less than the ECs rate of 82.2% and the total non-smoking rate of the general population of Canada (Gilmore, 2003), but it is closer to the rate for CCs in the 54 Quebec study (PICA & Lucille, 2004), and higher than the rate in China (Yang et al., 1999). These results reflect a strong culture of consumer advocacy for smoking in the CCs who were first-generation immigrants from China. In addition, the results support the selection bias of • Canadian immigration criteria which favor people who are in good health and potentially less likely to smoke. More CC women (89.3% as opposed to 51.1% of CC men) identified themselves as 'non-smokers', which is consistent with the findings of several studies conducted in China and other countries (Gong et al, 1995; Yang et al, 1999; Shelley et al, 2004). Traditional Chinese values appear to protect youth and women but support smoking among men (Chen, Unger, & Johnson, 1999). The findings in this study are consistent with this observation. Smoking is less socially acceptable however for Chinese women. Another possible explanation is that less culturally acceptable behaviors such as smoking among Chinese women may be under reported (Johansson, Wikman, Ahren, Hallmans, & Johansson, 2001). With respect to alcohol consumption, the same pattern of belief was observed as for smoking. That is, abstinence from or moderate alcohol consumption was believed to be very important for health, however, more CCs reported that such moderation was not important. With respect to reported alcohol consumption in our study, the majority of CCs (81.0%) reported not drinking alcohol and 15.0% of the CCs reported drinking 1 or 2 servings per day. Moreover, the majority of CCs were more likely to never drink alcohol and more likely to believe in the health benefit of alcohol abstinence compared with the ECs. The CCs' beliefs about alcohol consumption and their drinking habits may appear somewhat discrepant. These findings however are consistent with studies reporting low alcohol consumption among Chinese in North America 55 (Chi, Lubben, .& Kitano, 1989; PICA & Lucille, 2004). Although disputes exist about the \ influence of cultural values related to alcohol consumption among Chinese people, a possible culturally-based explanation related the emphasis on responsibility towards others according to Confucian tradition, which promotes moderate drinking if at all, and discourages drinking to the point of inebriation (Caetano, Clark, & Tarn, 1998). Other cultural factors in Asian societies such as embarrassment caused by facial flushing after the ingestion of alcohol and 'saving face' also may contribute to lower alcohol consumption in CCs (Parrish et al., 1990). Alcohol-induced loss of self control is viewed negatively within Confucian-heritage countries. Given these cultural overlays, the behavior of alcohol consumption can be better understood within psychological and social contexts, as described by Li and co-workers, as opposed to the narrow biomedical framework (Li & Rosenblood, 1994). With respect to gender difference, one study reported that Asian American women were more likely to abstain or consume less alcohol than their male counterparts (Chi et al., 1989). We did not observe a gender difference in alcohol consumption however, among the CCs in our cohort. Physical activity Differences were observed between the two ethnic groups with respect to their beliefs about the importance of physical activity and health. Almost all the ECs believed that regular exercise was very important for health (none believed it was not important), whereas the CCs believed it was somewhat to very important (with several believing it was not important). These beliefs were reflected in the reported physical activity of each group. The majority of ECs 5 6 reported exercising at a moderate to high level whereas most of the CCs reported exercising at a low level. Consistent with current recommendation for physical activity for optimal health, the dosage of exercise does not need to be high. People in Asia are likely to have higher levels of general daily physical activity because of less access to cars, labor saving conveniences, and sedentary recreational pursuits. In part, this higher level of daily physical activity (perhaps low in intensity but high in volume) may contribute to lower body weight, less obesity, and long life expectancy, of people in these cultures. In a cross cultural study of people in China and in the US, the US had a higher proportion of very active people compared with China as well as a greater proportion of sedentary people (Kim, Popkin, Siega-Riz, Haines, & Arab, 2004). Similarly, in our study, more CCs reported lower physical activity than ECs. Due to the different definitions of intensity of physical activity and different measures of physical activity, no meaningful comparisons with other studies in the literature can be made, thus, no firm conclusions can be drawn. Respondents reporting being less physically active however is consistent with physical activity, at least highly strenuous activity, being potentially less valued in Chinese cultures. Compared with the ECs, fewer CCs believed 'regular exercising' was 'very important' to overall health, and more CCs recommended 'light physical activity' to attain a long healthy life. This belief was consistent with their self-reported physical activity, which reflected adherence to traditional beliefs about low physical activity. Overall, compared with middle- and low-income countries, physical activity tends to be reduced in high-income countries based on the prevalence of lifestyle conditions associated with 57 sedentary living (Kim et al., 2004). This trend has been associated with sedentary occupations, and recreational activities including computer use and television viewing (Kim et al., 2004). Furthermore, time pressures in high-income countries such as Canada and the US, may preclude people in the work force from being as physically active and engaging in physical activity as much as they would choose. Physical activity is now appreciated as being singularly important to health, even about some other lifestyle behaviors. This discordance between belief and behavior related to physical activity warrants being addressed in public health geared toward the population and sub groups, as well as the individual. Dietary habits People who are generally in good health require different amounts of food depending on their age, body size, and activity level. Although the Chinese Food Guide Pagoda (The Chinese Nutrition Society, 2005) and the Canada's Food Guide (Health Canada, 2005) differ in food categorization and the units of serving size, both guides recommend consuming large amounts of grains, and vegetables and fruits, and consuming moderate to low amounts of meat, milk and dairy products (Painter, Rah, & Lee, 2002). In this study, the self-reported number of servings of vegetables and fruits, meat and alternatives, and milk and other dairy products consumed per day by CCs, was lower than that for ECs. The number of servings however of the four primary food groups by the CCs was lower than that recommended by the Canada Food Guide. Both groups fell below the minimum number of five daily servings of grains and of vegetables and fruits. This finding is consistent with that of the most recent Canadian Community Health Survey in regard to insufficient intake of vegetables and fruits per day (Statistics Canada, 2006). 58 One possible methodologic explanation is the measure of daily food consumption. By asking the respondent to report on the number of 'servings per day', the CCs may have been challenged by having to estimate the serving size, as their diets traditionally include dishes that mix the food groups (Lee, Lee, Ladenla, & Miike, 1994). Moreover, the lower consumption of milk and dairy products, and sugar, and greater salt consumption per day also reflected a traditional Chinese dietary pattern (The Chinese Nutrition Society, 2005; Li et al., 2005). No difference was observed between the two groups with regard to fat or fast food intake. The fact that people in western societies are becoming more sensitive to fat intake and that reduced fat has become culturally desirable, and that people tend to under report negative attributes, the ECs may have under reported their daily fat intake. Alternatively, the CCs may have acculturated to western levels of fat and fast food consumption. In absolute terms however indulging in high fat foods and fast foods less that once a week, that was reported by two thirds of each group, does not appear excessive. Traditional Chinese beliefs play an important role in the dietary habits of Chinese living in North America (Satia et al., 2002). One study examining factors that influence the dietary habits of Chinese people living in North America revealed that traditional Chinese beliefs are strongly associated with healthy dietary habits (Satia et al., 2002). The Okinawan diet which has been strongly influenced by a long tradition of Chinese ideas related to longevity is an example of the effect of such beliefs (Cockerham & Yamori, 2001; Sho, 2001). In the present study, CCs made the following dietary recommendations for a long healthy life (i.e., longevity): 1) more vegetables and fruits (43.4%), 2) a balanced diet (30.3%), 3) moderate servings of grains 59 (21.2%), 4) moderate meat consumption or less (20.2%), and 5) low fat consumption and no fast food (21.4%). The CCs were more likely to recommend beans and tofu as favorable foods than the ECs. Additional evidence came from the responses to the closed-ended questions addressing the beliefs about the importance of dietary behaviors to overall health. The majority of CCs (from 61.1% to 86.4%) viewed the positive dietary behaviors listed in the questionnaire, as being very important to overall health, with the exception of taking vitamins and supplements (36.3%) which the ECs valued more highly. Of these behaviors, the daily consumption of vitamins and supplements, unless medically indicated, is the most disputed. Some authorities argue that supplemental vitamins contribute only to vitamin-rich urine, rather than good health, and to the profits of their manufacturers. Stress Apparent cultural differences emerged between the two ethnic groups with respect to the experience of stress, and effective means of addressing stress, and beliefs about the role of stress reducers and their effectiveness. Compared with the ECs in the study, the CCs reported greater stress with respect to family life, work or lack of work, personal illness or of a family member, and having few friends. Not surprisingly, CC women reported having few friends which they reported as being particularly stressful. More CC women than E C women were homemakers thus they have less opportunity to have their social needs met, in the same way that their husbands may be when participating in the workforce. These findings emphasize that immigrants are at risk with respect to stress-related conditions, and that chronic stress may result from the accumulation of multiple stressors of daily living. A substantial body of literature has indicated 60 that immigration which demands emotional, social, cultural, educational, and economic adjustment is highly stressful to individuals and families. Potential stressors include learning a new language, having a limited education, difficulty obtaining adequate Or meaningful employment, low socioeconomic status, stressed family life, and change in sociopolitical and immigration status (Thomas, 1995). Cross cultural studies based on Hofstede's cultural theory have been used to study the experience of stress cross culturally. He proposed that individuals from collectivistic cultures are more susceptible to social influences and depend on close interpersonal relationships and networks (Hofstede, 1991). However, the findings in this study contrasted with cultural theory. Fewer CCs for example believed that social support (e.g., time with/talking to friends and family) would greatly help to reduce stress. Moreover, they believed changes in socioeconomic status (e.g., better living condition, more money, and living in one's native country) could reduce moderate or high stress. Stress, perhaps excessive stress, has become almost an accepted component of modern life in industrialized countries such as Canada. Knowing how to identify and manage one's stress is important in offsetting its deleterious health effects. The CCs at least based oh the limitations of our questionnaire study appeared to have fewer management strategies^  The ECs consistently believed that stress can be effectively reduced with a range of activities including physical activity, music hobbies, and sleeping. Although the CCs believed that being away from family and friends were prime sources of stress, they were less inclined than the ECs to report they, reduced their stress a great deal, with time with family and friends. Although not reported to 61 contribute to the same degree of stress relief, the CCs did report stress reduction when their living and economic conditions improved. The lower personal income reported by the CCs compared with the ECs is consistent with this as a potential source of stress to CC immigrants. Comparison of health knowledge, behaviors and beliefs of CCs based on length of residence in Canada The relationship between acculturation and the health behaviors has been well studied among Chinese immigrants in North America. For example, a recent study of Chinese Americans did not find a link between years in the US and tobacco use (Yu et al., 2002 ), whereas, an association between years in the US and smoking prevalence has been reported (Thirandam, Fong, Jang, Louie, & Forst, 1998). Although we did not observe an association between smoking and length of residence in Canada, valid comparison with other studies was not possible due to different definitions of acculturation and measurements used. However, discrepancies between adult male smoking rates in Mainland China and those for CCs in our study and Chinese Americans in American studies support a link between acculturation and tobacco use (Shelly et al, 2004). Studies are needed to examine this relationship with standardized definitions and methodology. More acculturated CCs, i.e., those having lived in Canada longer, were more likely to report 'not drinking alcohol' compared with ECs. CCs who were more acculturated were more likely to believe 'no smoking' or 'drinking alcohol in moderation' are consistent with good health, which needs to be reinforced in health education targeted at this group, in the interests of 6 2 a healthy Canadian society. The two CC groups, i.e., those that had lived in Canada less than ten years, and those who had lived in Canada ten years or more, did not differ in regard to physical activity and recommended levels! However, more CCs believed that exercising regularly is somewhat important to overall health. It is generally acknowledged that acculturation to western society reduces physical activity and potentially leads to obesity and other lifestyle conditions (Kumanyika et al, 2002). A study examining dietary acculturation among Chinese Americans and CCs revealed that, younger and highly-educated women were likely to have higher-fat food and increased vegetables and fruits since immigration (Satia, Patterson, Kristal, Hislop, & Pineda, 2001). Some other studies also reported that acculturated first-generation Chinese Americans have increased fats, sweets and soft-drink consumption (Satia et al., 2002). However, in the present study, no difference was observed between the two CC groups stratified based on years in Canada. This finding support that CCs retained traditional dietary habits, which for the most part, are consistent with health, or dietary acculturation is a long process. With respect to stress, no difference in reported stress was observed between two CC groups. Further studies are needed however to examine further the complexities of stress and acculturation particularly in Asian immigrants. Psychosocial and mental problems are often viewed as a character weakness in Confucian-heritage countries, thus these conditions are stigmatizing. There is a tendency to experience these problems somatically. Somatic complaints are viewed as being more legitimate, and are not culturally stigmatizing. 63 Comparable with other cross cultural studies, studies related to stress and its management, are confounded by methodological issues that limit comparison of the results. Nonetheless, high levels of stress are experienced by immigrants and this does not appear to be reduced with time in the country. Studies are needed to examine why, with familiarity with the culture, and integration, stress is not alleviated. Reports of unrelenting stress are likely to manifest as primary lifestyle-related health, or as secondary contributors to these complaints. It is conceivable that with the passage of time, people from Asia experience less taboos and barriers to articulating stress and seeking assistance. Thus, less reluctance to report stress by longer term CC residents of Canada may give the appearance that the experience of stress had not changed over the years. Implications for constructing, targeting, and delivering health education programs to meet the needs of CCs The findings of our study have implications for the content and delivery of prevention strategies and stroke-related education resource materials. The purpose of the material on stroke prevention and education should be clearly apparent to the CCs with the objectives of the material clearly stated. The reader is not likely to pay attention to written materials if he or she does not understand the content (Doak, Doak, & Root, 1996). Since people are generally interested in information that helps them resolve life challenges and problems (Knowles, 1984), the materials should only include information that is presented in a culturally sensitive and relevant manner to CCs. Written material that focus on behaviors and provide 'how-to' 64 information are recommended (Hoffmann & Worrall, 2004), thus, recommendation like 'it is important to eat vegetables every day' would be appropriate. According to Hofstede's culture theory, North Americans (such as Canadians) score particularly high on ratings of individuals, low power distance, where Asians (such as Chinese) are high on collectivism and power distance. Our findings also support these theoretical constructs. CCs differed ECs in regard to obtaining source of stroke-related information from family and friends. Therefore, because of the cultural importance of family in Chinese culture, the process of stroke-related health education, planning needs to be intergenerational, with key family members included. Further, these cultural attributes would suggest that targeting the CC community and building on the ripple or snowballing effects would be of value. Specifically, relaying on educating the community as a whole, in addition, to high risk groups within the CC community, to exert influence on friends and family members who may be at risk. Based on the findings of this study, we also recommend that stroke-related knowledge of CCs be improved especially with respect to 1) major stroke risk factors, especially obesity, drinking alcohol and diabetes, 2) major warning signs, especially weakness and vision problems, and 3) appropriate action if stroke warning signs are apparent. Specifically, health education should emphasize that stroke is a medical emergency and requires immediate attention by calling 911. Moreover, information and advice on stroke prevention and education should play a bigger part in the daily practice of healthcare professionals including physical therapists and through community accessed facilities used by CCs. Data on the health behavior of CCs can provide a sound basis for developing prevention 65 and education programs designed to reduce the prevalence of high-risk lifestyle behaviors. Strategies to reduce behavioral risk factors for stroke need to emphasize different risk factors among CCs, especially in relation to smoking among CC men, increasing physical activity in both CC men and women, promoting healthier dietary habits (i.e., based on established international guidelines, increasing the number of servings from all four major food group, especially milk/dairy products) and stress management. In an effort to provide quality information on stroke prevention and education, more attention should be paid to CCs, to strengthen their understanding and appreciation, and potentially related beliefs, with respect to physical activity. These include increased activity is indicated particularly for 1) CCs older than 50 years of age, 2) men, and targeted particularly to those in the middle level of personal income and 4) those with an education level higher than post-secondary or only with elementary schooling. In addition, the importance of vegetables and fruits needs to be emphasized in the daily diets of CCs. People from Confucian-heritage countries are known for their work ethic. Even in children, leisure time and time away from purposeful pursuits, particularly academic in nature, are viewed as being frivolous. Thus, targeting information to CCs about regular physical activity, would perhaps best be framed in terms of being physical activity as a part of the day, vs. taking additional time to attend a gym or an exercise class. Gyms and exercise classes may be culturally unfamiliar, and focus undue attention to the individual to be embraced fully by the CC community. 66 Limitations This study has several limitations. First, our primary tool was a survey questionnaire thus is subject to the limitations of self-reported data. Second, we used convenience samples that volunteered to participate in the study, thus may not fully reflect the opinions of the general population. Third, the generalizability of the findings of this study may be limited by the modest sample size. Fourth, there are limitations related to the accuracy of answers given by questionnaire and interviews in this study. For example, in the dietary assessment, asking 'servings per day' to assess typical food consumption may not precisely measure the dietary intakes of the CCs because Chinese do not typically measure food portions comparable to ECs. Our study could be challenged methodogically. To represent the dominant cultural group in Canada, we described a reference group, the ECs, to serve as a basis of comparison for the findings of the CCs. However, one would argue that an EC with cultural roots in Poland is distinct from one with roots in Spain or London. Our reference group however was primarily constituted of individuals from the U K (i.e., England, Scotland, and Wales) and Ireland. We would argue that the cultural mosaic of Canada comprises influences from a range of European countries, and we have no reason to belief that these were represented disproportionately in our sample. Although language fluency is considered the best predictor of acculturation, duration of residence and immigration status either singly or together, have been used to assess the degree of acculturation in examining the relationship between health and acculturation (Shelly et al., 2004). Acculturation indicators reported in the literature include language familiarity and usage, 67 ethnic interaction, involvements in some cultural groups and activities (Burnam, Hough, Karho, Escobar, & Telles, 1987). The effect of acculturation on lifestyle practices may be small compared with other socioeconomic, environmental, and biological factors'(e.g., in relation to patterns of tobacco use (US Department of Health and Human Services, 1998; Shelly et al, 2004). Thus, inconsistency in ways of accessing the effects of acculturation contributes to the difficulty of comparing cross cultural studies. Similar methodologic issues also arise when attempting to compare lifestyles cross culturally. Future studies The literature related to health knowledge, behaviors, and beliefs of immigrant groups including Chinese immigrants in Canada, is scant. Of the few studies that have been reported, definition of terms such as 'Chinese' and 'acculturation' may not be defined or, if such terms are defined, their definitions may not be standardized. These issues are highly problematic when attempting to make meaningful comparisons across studies. Our study focused on stroke-related and health knowledge, behaviors, and beliefs of CCs and ECs living in the Lower Mainland of BC. It is known that the health behaviors of people in this area, and potentially health knowledge and beliefs, are not reflective of other parts of Canada. Thus, the study needs to be replicated in different geographic regions of the country. Our sample size was relatively modest, thus, replication and extension of the work should increase the sample size and statistical power of the study. Only now is an interest in the health needs of immigrant groups and cultural influences emerging in Canada/Replication of the present study in other cultural groups including First 68 Nations people would be helpful in not only understanding the unique needs of the diverse groups that constitute Canada, but enable investigators to make cross cultural comparisons. Such studies will broaden our understanding of the multidimensional aspects of health behaviors and beliefs and how to harness this knowledge and translate it into positive health behavior change. Understanding beliefs and how beliefs can be positively, yet non coercively, promoted to maximize health is an ethical challenge, as well as health care challenge. Promoting positive health beliefs that translate into positive health behavior extends beyond merely providing health education. This study has helped to examine the interrelationships between knowledge, behaviors, and beliefs to help augment the health of Canada's population. Finally, whether our findings are unique to Chinese immigrants who have immigrated to Canada, or whether they pertain to Chinese who have immigrated to other places, in particular western countries, needs to be studied. This study focused on the health knowledge, behaviors, and beliefs of CCs in relation to ECs. However, although much is known about the relationship between lifestyle factors and health, and lifestyle diseases, strategies to effect positive health behavior change in the dominant culture, that is, within the ECs, has had modest success at best, with the prevalence of most of these conditions not decreasing to the degree that they could. Our data lend support for discordance between the beliefs and behaviors of the EC group, which also need to be addressed in future studies to augment health and prevention outcomes in this group. Because this group is dominant, the social and economic impact of the effects of lifestyle conditions in this group is enormous, and constitutes a considerable burden to the healthcare system in Canada, and 6 9 economy. Future studies would also benefit from stratifying ECs into their respective nationalities, to examine for distinctions among these with respect to health and stroke-related knowledge, behaviors, and beliefs. Conclusions Contemporary physical therapists are committed to health and wellness, and disease prevention in every person, thus, education is a primary tool for effecting positive health practices. Such education however needs to translate knowledge from the psychological and sociological literature, to effectively alter health behaviors and beliefs. Health education without attention to cultural diversity within and between culturally distinct groups could explain the poor outcomes of traditional health education. The prevalence of risk factors related to lifestyle in Canadians and lifestyle conditions has put these concerns at the forefront of healthcare priorities in Canada, hence, at the forefront of the concerns addressed by health care providers including physical therapists. Health education directed towards clients and patients has not experienced the benefits and outcomes that it should have, given the strength of the association between lifestyle behaviors and health and ill health. In part, this may be explained by the diversity among people with respect to their health beliefs and behaviors, and cultural factors that influence their access and understanding of lifestyle risk factors and their susceptibility to lifestyle conditions such as high blood pressure and stroke. Thus, understanding differences cross culturally about health-related knowledge, behaviors, and beliefs is fundamental to effective health education. The dimension of culture is particularly important in healthcare today in 70 high-income countries such as Canada that attract large numbers of immigrants. CCs are distinct from ECs living in the Lower Mainland of BC with respect to stroke-related knowledge, behaviors, and beliefs, and these differences have potentially important implications for prevention, strategies and health education delivery. Not only is there is a paucity Of studies related to the health of CCs in the literature, but the few studies that have been reported, there are methodologic inconsistencies that preclude meaningful comparisons. Some differences can be explained however based on cultural theory. Barriers exist for CCs in Canada that can explain lower knowledge about their risks for stroke, e.g., language and access to Chinese-speaking health professionals. 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Nutrient intakes of middle-aged men and women in China, Japan, United Kingdom, and United States in the late 1990s: the INTERMAP study. J Hum Hypertens, 17(9), 623-30. 84 APPENDIX A: QUESTIONNAIRE (ENGLISH) The School of The University of British Columbia T 325, Third Floor, Koerner Pavilion 2211 Wesbrook Mall, Vancouver BC Rehabilitation Canada V6T 2B5 voice: (604) 822-7398 fax: (604) 822-7624 Sciences e-mail: elizdean@interchange.ubc.ca IMPROVING THE HEALTH OF CHINESE IMMIGRANTS AND NATIVE BORN CANADIANS Professor Elizabeth Dean, PhD, PT Jiawei Wang, BSc Med Research Subjects Information Line, Research Services, University of British Columbia: (604) 822-8598 We are very interested in culturally sensitive health care in Canada. We are conducting a study to learn about the health beliefs and behaviors of Chinese immigrants and native born Canadians of European decent. We would very much appreciate it if you would take 20 minutes to complete this short questionnaire. You will be asked about some of your health beliefs and things that you do for your health. At the end we ask a few questions about you, so.we know the types of people who have responded to the questionnaire. Every participant's response is very important. Jiawei is a graduate student with the School of Rehabilitation Science of the University of British Columbia. She will be recruiting participants for this study. This survey is part of her research. We would greatly appreciate your completing the questionnaire, returning it to Jiawei, or mailing it in the enclosed return envelope. It will only take a few minutes of your time to answer the questions, and you might find doing so an enjoyable experience. Should you prefer to mail it to us, feel free to do so. For the information to be most useful, please complete your questionnaire and answer every question as well as you can. Because only a relatively small number of people are being surveyed, your response is very important. Your answers will be strictly confidential. Please do not hesitate to contact us if you have any problems in completing the questionnaire. If you would like to know the results of the study, we shall be happy to send you a summary of the results in Chinese or English. Thank you in advance for your time and effort. 85 THE UNIVERSITY OF BRITISH C O L U M B I A Knowledge, Behaviors and Beliefs of Stroke Questionnaire Part I: Please answer the following questions. 1. What are some common risk factors of stroke? 2. What are some common warning signs of stroke? 3. What would you do if someone in your household shows signs of stroke? 4. Where would you go to access general information about stroke? Select the most appropriate answer by circling the choice or checking the box. Fill out the blanks. Smoking status: 5. Do you smoke cigarettes, cigars or a pipe, or ingest tobacco in another form? (1) Never (2) Almost never (3) Seldom (4) Sometimes (5) Usually (6) Almost always (7) Always 6. If you smoke, how many cigarettes, cigars or pipe do you smoke in a typical day? ('0' if you don't smoke) Number: 7. On how many days a week do you smoke? ('0' if you don't smoke) Number: 8. Do you live with or are you frequently around people who smoke? (1) Never (2) Almost never (3) Seldom (4) Sometimes (5) Usually (6) Almost always (7) Always 86 Alcohol consumption: 9. Typically, how many alcoholic drinks do you have in a typical day? ('0' if you don't drink) Number: Note: One drink is equal to: A glass of beer (350 ml) /A glass of wine (150 ml) /A shot glass of liquor (50 ml). 10. Do you use smoking or alcohol as a way of handling stressful situations in your life? (1) Never (2) Almost never (3) Seldom (4) Sometimes (5) Usually (6) Almost always (7) Always Physical activity: Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time. 11. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling? _ _ _ _ _ days per week • No vigorous physical activity, please go to question 13. 12. How much time did you usually spend doing vigorous physical activities on one of those days? -. hours per day Or minutes per day • Don't know, or not sure. Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time. 13. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking. days per week • No moderate physical activity, please go to question 15. 14. How much time did you usually spend doing moderate physical activities on one of those days? hours per day Or minutes per day • Don't know, or not sure. Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure. 15. During the last 7 days, on how many days did you walk for at least 10 minutes at a time? days per week • No walking, please go to question 17. 87 16. How much did you usually spend walking on one of those days? hours per day Or minutes per day • Don't know, or not sure. Think about the time you spent sitting on weekdays during the last 7 days. This includes time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television. 17. During the last 7 days, how much time did you spend sitting on a week day? ' hours per day Or minutes per day • Don't know, or not sure Dietary intake: In a typical day, how many servings of the following do you eat? 18. Grains. 1 serving equals: 1 slice of bread OR 1/2 cup of pasta or rice OR 1 small muffin OR 1/2 bagel, pita or bun Your intake: servings 19. Vegetables and fruits. 1 serving equals: 1 medium sized fruit or vegetable OR 1 cup of salad OR 1/2 cup ofjuice OR 1/2 cup of canned or frozen fruits or vegetables Your intake: ; servings 20. Meat and alternatives. 1 serving equals: 50-100 grams (2-4 oz.) fish, poultry, or meat OR 2 tbsp of peanut butter OR 1/3 cup of tofu OR 1-2 eggs Your intake: servings 21. Milk/dairy products. 1 serving equals: 1 cup of milk OR 50 grams (2 oz.) of cheese OR 3/4 cup of yogurt Your intake: servings 22. If you are not sure of the amount of servings, please list the food name and size for each food group. 23. How many teaspoons of the sugar do you eat or consume in a typical day (including when these are mixed into food)? Number: 88 24. How many teaspoons of the salt do you eat or consume in a typical day (including when these are mixed into food)? Number: 25. How many teaspoons of the oil do you eat or consume in a typical day (including when these are mixed into food)? Number: 26. How frequently do you eat high fat or fast foods in a typical week? (1) Less than once a week (2) 1-2 times a week (3) 3 or more times a week Stress: 27. For each potential cause of stress, identify the level of stress you experienced by checking (V ) from the following categories: , A great deal Somewhat Little to none Family/marriage Away from home Work Lack of work Few friends Sickness Sickness in family Others, please specify: 28. You sleep hours a night on average and: (l)Sleep soundly (2) Don't sleep well 29. Stress in your life is (1) Low (2) Moderate (3) High 30. If stress is moderate or high, what needs to change to reduce your life stress (You can select more than one choice)? (1) Better relationships within the family/at work (2) More self discipline control to control stress in my life (3) Being in my own country (4) Better living conditions (5) More money (6) Others 89 Part II: 31. Please rate each of the following health behaviors on a scale from 0 to 4 depending on how important you think that behavior is for your overall health. 0 = Not important 1 = A little important 2 = Somewhat important 3 = Very important 4 = Extremely important (1) Eating a diet that is low in fat 0 1 2 3 4 (2) Eating lots of grains-based food 0 1 2 3 4 (3) Eating lots of fruits and vegetable 0 1 2 3 4 (4) Drinking plenty of water every day 0 1 2 3 4 (5) Taking vitamins and mineral supplements regularly 0 1 2 3 4 (6) Exercising regularly 0 1 2 3 4 (7) Not smoking cigarettes 0 1 2 3 4 (8) Not drinking alcohol or drinking in moderation 0 1 2 3 4 (9) Maintaining a normal healthy body weight 0 1 2 3 4-32. If you believe that stress can be controlled, to what degree do you believe the following activities help to reduce stress? 0 = Not at all 1 = Somewhat 2 (1) Physical activity/exercise 0 1 2 (2) Work 0 1 2 (3) Relaxation 0 1 2 (4) Sleep 0 1 2 (5) Hobbies 0 1 2 (6) Time with/talking to friends 0 1 2 (7) Time with/talking to family 0 1 2 (8) Television 0 1 2 (9) Music 0 1 2 (10) Eating 0 1 2 (11) Smoking 0 1 2 (12) Other (identify) a. 0 1 2 b. 0 1 2 33. For a long healthy life, what type of diet would you recommend for people to eat? 90 34. For a long healthy life, what type and amounts of physical activity and exercise would you recommend for people? 35. What type of behavior related to smoking and alcohol consumption that are consistent with a long healthy life? Part III: 36. Your gender is: (l)Male (2) Female 37. Your age: 38. Your height is feet and inches or cm. 39. Your weight is lbs or kg. 40. Compared with people of your age and gender, your weight is: (1) Much below average (2) A little below average (3) Average (4) A little above average (5) Much above average 41. When was the last time your blood pressure was checked? (1) < 6 months (2) 6-12 months (3) 13-24 months (4)>2 years The blood pressure was (expressed two numbers): / or • Don't know 42. When was the last time your cholesterol was checked? (1) < 1 month (2) 1-3 months (3) 4-6 months (4) 6-12 months (5)>lyear It was: (1) Low (2) Average (3) High (4) Don't know 91 43. Your health history: Conditions Check (V ) if you have any of the following conditions Check (V ) if taking medication for these conditions Heart disease High blood pressure Stroke Cancer Diabetes or blood sugar problems Lung diseases (For example, bronchitis, emphysema, asthma) Arthritis Osteoporosis Other, please specify: 44. Your family history (including mother, father, brothers, sisters): Conditions Family history Check (V ) if 'yes' High blood pressure No relatives with this condition One relative with this condition Two relatives with this condition Three or more relatives with this condition Chest pain (angina) or heart attack No relatives with this condition One relative with this condition after 60 years of age Two relatives with this condition after 60 years of age One relative with this condition before 60 years of age Two or more relatives with this condition before 60 years of age Diabetes or blood sugar problems No relatives with this condition One or more relatives with adult-onset diabetes One or more relatives with childhood diabetes 45. Your highest level of education is: (1) No formal education (2) Elementary school (3) Technical or trade school (4) High school (5 College/university diploma or degree (6) Postgraduate degree 46. What type of work are you doing now? (l)Homemaker (2) Not employed (3) Retired (4) Other, please specify: _ 47. What kind of occupation did you train for? (1) Business, finance and administration (2) Management (3) Professional (4) Sale and service (5) Trades, transport and equipment operator (6) Other, please specify: 48. Your personal income per year is: (1) < $19,999 (2) $20,000 to $39,999 (3) $40,000 to $69,999 (4) $70,000 to $99,999 (5) > $100,000 49. Your birth place is: (1) Canada (2) Mainland China (3) Hong Kong (4) Taiwan 50. A: Your native language is: (1) English (2) Mandarin (3) Cantonese (4) French (5) Other, please specify: B: The language you speak at home is: (1) English (2) Mandarin (3) Cantonese (4) Min Nan dialect (5) Other, please specify: 51. A: You have lived in Canada for years. B: You are living in: (1) Burnaby (2) Coquitlam (3) Richmond (4) Surrey (5) Vancouver (6) Other, please specify: 52. Your personality type (with the pen cross the line where your personality fits best between the two extremes): 0 100% I am relaxed, can assert myself, I tend to be competitive, aggressive not time stressed, speak slowly striving, time pressured, fast speech This is the end of the questionnaire, thank you for participating. APPENDIX B: QUESTIONNAIRE (SIMPLIFIED CHINESE) Rehabilitation The School of Sciences WW The University of British Columbia T 325, Third Floor, Koerner Pavilion 2211 Wesbrook Mal l , Vancouver BC Canada V6T 2B5 voice: (604)822-7398 fax: (604)822-7624 e-mail: elizdean@interchange.ubc.ca l R ] # i $ § j H - f 1 i d ^ : E l i z a b e t h D e a n , PhD, PT f o J ^ T ^ S A : J i a w e i W a n g , BSc Med U B C W f M ^ H ^ : (604) 822-8598 * ^ f n l # f K ) ^ g A Jiawei M. UBC x^mM&^%^f±.mw,±^%'iio M ^ M 4 M - t ^ o m^uMmm^m^, m%im»smm^mn° & 94 1. W^MiMtS i t^ f f -^? 2. 4 , M ^ « F ^ ^ J E W ^ « ^ + ^ ? 3. ^ ^ ^ a ^ A W ^ M ^ H t ^ w ^ f f i ^ t B m . m ^ m n r ^ m i 4. l ^ A I P J I t f I i J ^ ^ 4 W ? f ^mnmm&M&M, . # & n % m % L ¥ t t W o ^ m ^ m m m ^ o ( l ) M S f ( 2 ) A ^ W (3)$4> (4)WHt (5) '(6) t £ & * £ # (7) ' J H - P O " ) $ S : 7. W ^ « » ^ f K ) A i ( ^ ? 0n*^M^"O") M : 95 8. Wf$;£.ffi*; m^mmm^x^-^ ( f e » s ) ? (5) (6) (7) mm-. 9. -~mm&, mw-^^m^m? mm-. • ® —m$=$ii35omftii$m&i5ogftpM&fflm5om7ti&/g&Mo 10. m ^ m m m , mm^m. ^Rmmnt^^mtktn . (1) Jk^mM (2) f L ^ S W (3) (4) WBT ( 5 ) ( 6 ) ( 7 ) ^ A *m %m x u.^umwxmmmjix^, xmmx^^^mtxmmwxm^ nx_ />Ht 9 6 ^ A />^ r is. ftwm* Ijftm^: 1 JtW® Mlc 1/2 fFM<tiffl(0&)Mtf%' M 1 W&ffi(muffin) m 1/2 8i/M&gl(bagel), j££0Pf(pita)M</'M0&(bun) 19. » # J « 0 i fj^#T- I <t**m£'hMikMm&MM M i m m (saiad) m 1/2 jfM/fM 1/2 rtMMMM$c& 20. $mRK-t° 1 fo^T: 50-100 j£(2-4 £^)M#M'f% M 2M&#£0 m 1/3 MM 1-2 1 fltrT": 1 f f i f 50 %(2&nj)ffimm(cheese) M . 3/4 ff&tffl (yogurt) 97 2 3 . wsr - A r t , m^m^^mmmm mmwrnm^ mm-. 26. -&^%~m ,' mz&n-km m^^m^im? wnw 1-2 & • (3)^m 3 WH&YK n x —ibb mm/mm MM 2S.imx^±^m /hate M (i) §f ? # « ( 2 ) I f ?# W 2 9 . & ® fa^m, • ( 2 ) *m ( 3 ) s ( 3 ) ^ r s s u^mmm. (4> 3i. ffl o PJ 4 zim^imymiMi^m^xmm^: (l) fftJUKf^  0 1 2 3 4 98 ( 2 ) A a # f f l # | £ 1 r t J 0 1 2 3 4 ( 3 ) XmizmMMRym 0 1 2 3 4 ( 4 ) ^AAMzK 0 1 2 3 4 ( 5 ) W M # i M f f l ^ / ±»r ^ h ?5 f f i J 0 1 2 3 4 . ( 6 ) ^ m W i ^ m f ^ ) ] 0 1 2 3 4 (7) ^Rm 0 1 2 3 4 ^A^mm^mmm 0 1 2 3 4 ( 9 ) imiEizmmpK 0 1 2 3 4 \ ) W t i ^ m ^ m . 0 1 2 2 ) l.fi--: 0 1 2 3 ) jM v #m 0 1 2 4 ) B §8E 0 1 2 5 ) / A * g 0 r ^ ^ J 0 1 2 6) m B % ~ m ^ m M m % 0 1 2 7 ) ^P ^ A — ^ e ^ n ^ A i i ^ i S 0 1 2 8 ) # t % M 0 1 2 9) Vf^% 0 1 2 1 0 ) R f e ^ l S 0 1 2 1 1 ) n ^ g 0 1 2 1 2 ) 4 ^ £ ( i i i £ B j ) a. 0 1 2 b. 0 1 2 3 4 . ^ M - ^ M i i - r x ^ ^ ^ ^ , « # A i n f f ^ ^ i n i d f i f i f t ^ i ^ ^ ^ ? 35. mm-^mm^wm, mA%&mmmmijmmfc&m 99 36. i m a m : (1)^ (2) & 37. # 38. ^ n U * H f : m*m 3 9 . i m w m : : & r ? m _ m ( i ) AAi&x^mmiM. (2) tmi^^wmiM. (3) A ^ w ^ m f i (4) m r m ^ m m i t (5) A A J W T O ^ M 41. ^ M - W J a ^ L j i ^ : ( l ) 6 ^ r t (2)6-12j^rt (3)13-24 J ! (4) 2 ^ f j ^^jxfiLjl{tAm^(WM^M): _____/___ i ^ t t o n ^ p i t 42. mmmf^Himmmmm? . ( l ) l ^ H r t (2) 1-3 P*3 (3) 4-6 I ! ft (4) 6-12 ^ (5) l ^ l o Iin@lfl: (1)^K (2)jT£^ (3){|§if& (4)^£pit 43. »^AMl§tff#1: 4jju±^ iSjiriLji; mat 100 w 3 ^ m^mm^Batm • l -t* 60 # &±mmMJ&RBM:ffi l -t* 60 # W T l » E ^ SitfcJi 2 -t- 60 $ ( ^ T H ^ J S J ^ S t t 3cMMi&mBkkM l ^ J t ^ J i c E j ^ S $ A M 45. i m m n % L ^ 7 k ¥ % : ( i ) s g a i E ^ w ( 3 ) ? 7 J ^ (5 A^ -/*?4 ( 2 ) / h ^ i t t , (4) ft-T4^^^ (6) 5Jf 46.^g|tWIRik^: ( 1 ) f«Ji :^-( 3 ) m t ( 4 ) ^ , i f i j r ^ : 4 7 . ^^^iifr^^rM^SR«l^? ( 1 ) g g r & f J l ( 2 ) MM^M ( 3 ) ^ i k ^ T r t A ^ ( 4 ) f8^J§g£ ( 6 ) ^ , itij^Hj: 101 48. m^AfotE&A&l%j: ( 1 ) < $19,999 (2) $20,000 to $39,999 (3) $40,000 to $69,999 (4) $70,000 to $99,999 (5) > $100,000 49.&ftjHi£ifeJt: ( 1 ) » A ( 2 ) ^ 3 ^ ( 3 ) # 2 § (4)^rM 5 0 . A : M # i ^ : ( i ) ^ . (2)ixi# (3)r^Ri§ (4) mm WRS-. ( l )^ i§ ( 2 )#U£ ' ( 3 ) T ^ T S (4)|I)p|iS ( 5 ) ^ : 51. A: m&$Q^X'4l%T ¥ = ( l)*^tt(Burnaby) (2) SM#(Coquitlam) (3) ^iJ^^(Richmond) (4) fta(Surrey) (5) i^ff^(Vancouver) ( 6 ) ^ ^ : 52. MM&fcmm (imm±^m&mm-fc) 0 : 100% APPENDIX C: QUESTIONNAIRE (TRADITIONAL CHINESE) The School of The University of British Columbia T 325, Third Floor, Koerner Pavilion 2211 Wesbrook Mall, Vancouver BC Canada V6T2B5 voice: (604) 822-7398 fax: (604) 822-7624 e-mail: elizdean(g)jnterchange.ubc.ca Rehabilitation Sciences f ^ i f S J a M S : Elizabeth Dean, PhD, PT f n l ^ l i i f S A : Jiawei Wang, BSc Med U B C f 4 # f M M H : (604) 822-8598 WXmmMmMA Jiawei ML UBC A « ^ W ^ M t l ? I ± f i J m £ o i t & I B i M i w w - t ^ o m^immm^mitm, m^m^im^mm. m. 103 2. ^Rmmmnm^w^imi 3. $nm^^a^AW^a^iuw«^^f£ai3i, m-tmmm^mi 4. ^^ip^siwiw^taw^w? i i i i i M f i ^ i , m E ^ m i w i w & t t W o ^m^mmmo W.M: 5. im^mmmmt^^mnmm^ ( 1 ) « & T T (2) U T O W (3) Wy (4) WB^ (5) m.% (6) tfc$£Mfr (7) 7. ^MMf^ff j^Srj i? du^miM" o") 104 8. B f ^ t , m m m m m x ^ - m m c m m m i ) ? (i) (2) m^m o) w/>. (4) (5) Mft (6) t m m n (7) -MfsgM 350 m7fp$m m 150 mft^M&mm so mftMM&m* 10 . (i) « a w (5) m.% (2) U T O W (3) _s/> (4) WB# (6) bk^MTt (7) 1 1 . ^ 7 ^ ^ ' i m m ^ m m m m . ^ , mm, mmmm, f m % m n m m m m mm _ x timb ? 14. ^ mmmtiimmm^, xtmxm^Mm & KM 105 i s . £ i § ^ 7 x ^ , immi&m&'p&ft 10ftm? mm* mx *m 1 8 . 1 £ « | m 1/2 0m&S(bagel), MUM'pita)M^MMMbun) l « / f W 7 W l ^ j£ Iff(salad) J£ l/lffMtf mitsmmM: ® 2 0 . mmR.^ n^mn-. 50-100 %(2-4&w)M> &m & 2mmrt£w m MffMm M 1-2 i m 1 i m n : 1 M 50 j £ ( 2 ^WD&JPLm (cheese) i£ 3/4 m m (yogurt) 22. ium&^Mjmmmm, mm&m^mm^m^wm* 106 23. :£zps-Aft, i&itm&'j>mmmm mmmmwm) ? mm • (2) ^ 1 1 - 2 ^ (3) @ i i 3 ^ H # ^ . . • tSA — l i b 29. ttim^m, mmmmmvm (3 ) s (i) H£#gcEfcixf i^Ai i§S{£ (2) (3) i B f i l l (4) (5)^mm . (6) M I ITI)o 107 3 = i m n m 4 = s i ( 2 ) xmrnmrnmiuM ( 3 ) x m ^ m m m R y m ( 4 ) § A A « 7 J C " ( 5 ) WStlMJlfflif (6) W ^ i « f T i l ® J (7) ^ r & M (8) jfmmwj?mm,m wimiEnmmmn. 0 1 0 1 .0 1 0 1 0 1 0 1 0 1 0 1 0 1 2 2 2 2 2 2 2 2 2 3 2 . m m m m m m ^ & m m , m m m m r m m m n m ^ m m m m m f c mm® ? ( i t m m & m ^ m m ) o=-§mm i=mmm 2=n±\m ( 1 ) mimmmm ( 2 ) X f p ( 3 ) M M ( 4 ) i i l g ( 5 ) ? & < « ? r ^ £ i f j (6) OT£-|En£OT£MIS (7) f 0 ^ A — m m Amis (8) mmm (9) nwn ( 1 0 ) RgmrH ( 1 1 ) i ^ M ( 1 2 ) %mmmw) a. b. 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 0 1 2 3 3 . H £ K W - # 3 4 . ^ w H @ M i t j i i i i & £ ? r 5 > m m A m m m m u m m m m ^ m m m m m 108 35. mmm-mmmmmm&, mm^mmmmjimmzmim 36. ^ 6tJ'f4S'J: (l ' )f§ (2)& 37. f » ^ M = M 38. H f i , ^ : _ _ « M __ 39. « f f m : ^ J f ^ ^ 40. fn | i l t tS ! J fn^^A+@tb . « f t m ^ : • ( i ) AA»¥^fgmf@ (2) m«5^¥i%fisfs (3) A i ^ s ^ ^ f i m f i 41. : 0)6fMft (2)6-12 (3)13-24 E (4)2^M ^F^iflisfgAii^ mmmmtm • / I K ^ ^ O • ^ M I 42. ^M5fif+®0#flifI!J»iiIt@I? ? ( l ) l fMft (2) 1-3 £ ft (3) 4-6)3 ft' (4) 6-12 n ft ( 5 ) l^ttf » ® | ? f l : (l)flrffi (2)±FJ£ (3)fl?^ (4)^DiI 43. l&«lfMA«Hi U: M ' If ?T£J M ' If ?T£J 109 4 4 . i^mmnmm^mm^mm^mm) mm M i l l i m 6o mAi&mm&Mm&km. 2 m 60 ^ ± ^ ^ E l ^ M 0 I t b ^ i f i 60 ^ T ^ ^ M ^ M S i f c b ^ 2 m 60 a i ^ T ^ J g ^ M ^ i f c b ^ 4 5 . imMMm^ymm • ( l ) Y t S ^ I E ^ i f ' (2) yhm^Cit (3 ) W W ^ J ^ H ( 3 ) 5 i ^ ' mmm-. 110 47. ItMB^i-frSliM^Mi ( i ) i M f i wmmmm (5) m% - mmmmtt (6) g f f e >If :• 48. imxmmkAmm: (1) < $19,999 (3) $40,000 to $69,999 ( 5 ) > $100,000 (2) $20,000 to $39,999 (4) $70,000 to $99,999 "49. » £ B £ » : so. A : m m m ^ . ( W i g (2) tpm*M ( 3 ) (4) (2) i ( 3 ) JfUClS (4) rilg ( 5 ) S f f t i : B: im.mk\mmm-5 1 . A : / ^ i ] n ^ A ^ 7 (3 ) JSmiS ( 4 ) ^ P f l S (5 ) S f - _ : (1) ^^fcb(Burnaby) (2) ^ ##(Coquitlam) (3) ^J^X(Richmoncl) (4) Hft(Surrey) (5)2 l(Vancouver) (6) fiff£:_ 52. (if m±±&m&m3ffiMm 0 100% 111 Table 1. Sociodemographic characteristics by ethnic group E u r o C a n a d i a n s n = 1 0 l ' C h i n e s e C a n a d i a n s n = 1 0 3 M e a n S D M e a n S D t P A g e . 54.20 11.84 51.46 9.54 1.82 0.070 Y e a r s l i v e d i n C a n a d a 12.66 9.48 N o . % N o . % x2 P G e n d e r Male 49 48.51 47 45.63 0.17 0.680 Female 52 51.48 56 54.37 E d u c a t i o n Elementary school or less 0 0.00 4 3.88 4.00 0 . 0 4 5 * Technical/trade school/high school 31 30.69 26 25.24 0.75 0.386 College/university/postgraduate 70 69.31 73 70.87 0.06 0.806 E m p l o y m e n t Employed 61 60.40 57 55.34 0.54 0.465 Home maker 4 3.96 25. 24.27 17.25 0 . 0 0 0 * * Not employed 8 7.92 3 2.91 1.50 0.221 Retired 28 27.72 18 17.68 3.07 0.080 P e r s o n a l i n c o m e < $19,999 18 . 18.18 36 34.95 7.43 0 . 0 0 7 * * $ 20,000 - S 69,999 68 68.69 55 53.40 4.96 0 . 0 2 6 * >$ 70,000 13 13.13 12 11.65 0.10 0.749 B i r t h P l a c e Mainland China - 64 64.14 Hong Kong - 14 13.59 Taiwan - 25 24.27 N a t i v e l a n g u a g e Mandarin - - 81 78.64 English 98 97.03 - -Cantonese - - 22 21.46 French 3 2.97 - -L a n g u a g e s p e a k i n g a t h o m e Mandarin 71 68.93 English 100 99.00 3 2.91 Cantonese - 22 21.36 Min Nan Dialect - 6 5.83 Other 1 1.00 1 0.97 1. n varies across subscales * p <0.05, ** P<0.0\ 113 Table 2a. Health profile by ethnic group EuroCanadians Chinese Canadians n=103' No. % No. % P Body mass index (BMI) 2 < 18.50 (underweight) 4 3.96 4 3.88 0.00 0.975 18.50-24.99 (normal) 63 62.38 75 72.83 2.54 0.111 BMI > 25 (overweight) 34 33.66 24 23.30 2.69 0.101 Diabetes 4 3.96 . 5 4.85 0.10 0.755 Heart disease 5 4.95 4 3.88 0.14 0.710 Hypertension 18 17.82 15 14.56 0.40 0.528 Stroke 0 0.00 2 1.94 1.98 0.159 High cholesterol level 9 12.50 19 24.05 3.77 0.052 Family history of diabetes 40 40.82 21 20.39 9.91 0.002** Family history of heart disease 36 36.73 20 19.61 7.27 0.007** Family history of hypertension 53 52.48 50 48.54 0.32 0.575 1. n varies across subscales 2. Based on guidelines by World Health Organization (WHO). ** P<0.0\ Table 2 b . Health profile by gender within each ethnic group EuroCanadians Chinese Canadians Men n=49* Women n=52' Men n=47' Women n=56* No. % No. % x2 P No. % No. % x2 P Body mass index (BMI) 2 < 18.50 (underweight) 2 4.08 2 3.85 0.00 0.950 0 0.00 4 7.14 3.49 0.062 18.50-24.99 (normal) 26 53.10 37 71.15 3.52 0.601 37 78.72 38 67.86 1.52 0.217 BMI > 25 (overweight) 21 42.90 13 25.0 3.60 0.058 10 21.28 14 0.25 0.20 0.656 Diabetes 3 6.12 1 1.92 1.17 0.279 3 6.38 2 3.57 0.44 0.509 Heart disease 3 6.12 2 3.85 0.28 0.598 0 0.00 4 7.14 3.49 0.062 Hypertension 8 16.33 10 19.23 0.15 0.703 10 21.28 5 8.93 3.13 0.077 Stroke 0 0.00 0 0.00 - - 1 . 2.13 1 1.79 0.02 0.899 High cholesterol level 4 11.76 5 13.16 0.03 0.858 11 30.56 8 20.00 1.13 0.289 Family history of diabetes 18 37.50 22 44.00 0.43 0.513 10 21.28 9 16.07 0.46 0.498 Family history of heart disease 16 33.33 20 40.00 0.47 0.493 10 21.28 10 21.74 0.19 0.622 Family history of hypertension 21 42.86 20 38.46 0.20 0.653 22 46.81 28 50.00 0.10 0.747 1. n varies across subscales Table 3a. Knowledge of stroke risk factors and warning signs by ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s n = 1 0 l ' n = 1 0 3 2 N o . % N o . % x2 P K n o w l e d g e o f S t r o k e r i s k f a c t o r s Do not know 12 12.12 23 22.77 3.92 0 . 0 4 7 * Hypertension 44 44.44 40 39.60 0.48 0.488 Stress 15 15.15 22 21.78 1.46 0.227 Poor eating 22 22.22 14 13.86 2.37 ' 0.124 Smoking 57 57.58 11 10.89 48.56 0 . 0 0 0 * * High cholesterol 11 11.11 19 18.81 2.33 0.127 Obesity 38 38.38 10 9.90 22.24 0 . 0 0 0 * * Heart disease 2 2.02 12 11.88 0.00 1.000 Drinking/alcohol 8 8.08 10 9.90 0.20 0.653 Diabetes 3 3.03 4 3.96 0.13 0.720 Inactivity 23 23.23 9 8.91 7.63 0 . 0 0 6 * * Hereditary 13 13.13 8 7.92 1.44 0.229 K n o w l e d g e o f s t r o k e w a r n i n g s i g n s Do not know 10 10.10 15 14.85 1.03 0.310 Dizziness3 27 27.27 39 38.61 2.91 0.088 Numbness3 34 34.34 24 23.76 2.72 0.100 Headaches3 32 32.32 32 31.68 0.10 0.924 Weakness3 14 14.14 4 3.96 6.33 0 . 0 1 2 * Pain 19 19.19 14 13.86 1.03 0.680 Slurred speech3 24 24.24 14 13.86 3.50 0.061 Vision problems3 27 27.27 10 9.90 10.01 0 . 0 0 2 * * Shortness of breath 7. 7.07 1 0.99 4.81 0 . 0 2 8 * A v e r a g e N o . o f M e a n ( S D ) M e a n ( S D ) t P Stoke risk factors Established stroke warning signs 2.38(1.43) 1.58(1.16) 1.57 (1.36) 1.11 (0.88) 4.10 4.65 0 . 0 0 0 * * 0 . 0 0 0 * * 1. Valid n=99 2. Valid n=l 01 3. Established warning signs of stroke based on the National Institute of Neurological Disorders and Stroke, US. */?<0.05, ** PO.01 116 Table 3b. Knowledge of stroke r isk factors and warning signs by gender within each ethnic group EuroCanadians Chinese Canadians Men n=48 Women n=51 Men n=47 Women n=54 Knowledge of stroke risk factors No. . % No. % P No. % No. % x2 P Do not know 7 14.89 5 9.80 0.32 0.571 13 27.66 10 18.52 1.19 0.275 Hypertension 19 40.43 25 49.02 0.89 0.345 16 34.04 24 44.44 1.14 0.286 Stress 11 23.40 4 7.84 • 4.37 0.037* 9 19.15 13 24.07 0.36 0.550 Poor eating 14 29.79 8 15.69 2.6 0.107 6 12.77 8 14.81 0.09 0.767 Smoking 25 53.19 32 62.75 1.15 0.283 7 14.89 4 7.41 1.45 0.228 High cholesterol 3 6.38 8 15.69 2.23 0.135 5 10.64 14 25.93 5.20 0.022* Obesity 15 31.91 23 45.10 2.01 0.157 5 10.64 5 9.26 0.05 0.816 Heart disease 2 4.26 0 0.00 2.17 0.141 5 10.64 7 12.96 0.13 0.718 Drinking/alcohol 6 12.77 2 3.92 2.45 0.118 6 12.77 4 7.41 0.81 0.368 Diabetes 1 2.13 2 3.92 0.28 0.594 3 6.38 1 1.85 1.36 0.244 Inactivity 15 31.91 8 15.69 3.36 0.067 4 8.51 5 9.26 0.02 0.896 Hereditary 6.38 10 19.61 3.87 0.049* 4 8.51 4 7.41 0.04 0.838 Average No. of Mean (SD) Mean (SD) t P Mean(SD) Mean (SD) t P Stoke risk factors 2.38 (1.53) 2.39(1.36) -0.06 0.953. 1.49(1.41) 1.65 (1.32) -0.58 0.561 *p<0.05 Table 3b. Knowledge of stroke risk factors and warning signs by gender within each ethnic group (continued) EuroCanadians Chinese Canadians Men Women Men Women n=48 n=51 n=47 n=54 Knowledge of stroke warning signs No. % No. % x2 P No. % • No. % x2 P Do not know 4 8.33 6 11.76 0.32 0.571 7 14.89 8 14.81 0.00 1.000 Dizziness' 13 27.08 14 27.45 0.00 0.964 19 40.43 20 37.04 0.12 0.727 Numbness1 14 29.17 20 39.22 1.11 0.293 9 19.15 15 27.78 1.03 0.309 Headaches' 16 33.33 16 31.37 0.04 0.836 17 36.17 15 27.78 0.82 0.366 Weakness1 10 20.83 4 7.84 3.44 0.064 1 2.13 3 5.56 0.78 0.378 Pain 12 25,00 7 13.73 2.03 0.155 6 12.77 8 14.81 0.09 0.767 Slurred speech' 8 16.67 16 31.37 2.91 0.088 7 14.89 7 12.96 0.08 0.780 Vision problems' 17 35.42 10 19.61 3.12 0.076 4 8.51 6 11.11 0.19 0.663 Shortness of breath 6 12.50 1 1.96 4.18 0.041* 0 0.00 1 1.85 0.88 0.348 Average No. of Mean (SD) Mean (SD) t P Mean (SD) Mean (SD) t P Established stroke warning signs 1.59(1.09) 1.58 (1.23) 0.04 0.97 1.19(1.01) 1.04 (0.75) 1.01 0.316 1. Established warning signs of stroke based on the National Institute of Neurological Disorders and Stroke, US. * /? < 0.05 Table 4a. Reaction to stroke signs in household by ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s n = 1 0 l ' n = 1 0 3 2 N o . % N o . % I2 P D o not know 4 4.04 16 15.84 7.74 0 . 0 0 5 * 911/ Emergency room 95 95.96 85 84.16 1. Valid n=99 2. Valid n=101 Table 4b. Reaction to stroke signs in household by gender within each ethnic group E u r o C a n a d i a n s M e n W o m e n n = 4 8 n=51 C h i n e s e C a n a d i a n s M e n W o m e n n=47 n=54 N o . % N o . % P N o . % N o . % I2 P Do not know 911/ Emergency room 3 45 6.25 93.75 1 50 1.96 98.04 1.17 0.279 8 39 17.02 97.87 8 14.81 46 85.19 0.09 0.762 Table 5a. Source of information about stroke by ethnic group EuroCanadians n = 1 0 l ' Chinese Canadians n=103 2 No. % No. % x2 P Do not know . 2 2.02 16 15.84 11.66 0 . 0 0 0 * * Television 2 2^02 12 11.88 7.47 0 . 0 0 6 * * Newspapers 1 1.01 40 39.60 45.69 0 . 0 0 0 * * Magazines 2 2.02 14 13.86 9.52 0 . 0 0 2 * * Doctors 42 42.42 4 3.96 47.11 0 . 0 0 0 * * Family/friends 2 2.02 19 18.81 15.00 0 . 0 0 0 * * Books 8 8.08 33 32.67 18.55 0 . 0 0 0 * * Medical books 11 11.11 6 5.94 1.72 0.190 Internet 61 61.62 10 9.90 58.40 0 . 0 0 0 * * Libraries 4 4.04 0 0.00 4.16 0 . 0 4 1 * Medical facilities 36 36.36 7 6.93 25.66 0 . 0 0 0 * * 1. Valid n=99 2. Valid n=101 */?<0.05,-**/><0.01 Table 5b. Source of information about stroke by gender within each ethnic group EuroCanadians Chinese Canadians Men n=48 Women n=51 Men n=47 Women n=54 No. % No. % I1 P No. % No. % 5C2 P Do not know 0 0.00 2 3.92 1.92 0.166 7 14.89 9 16.67 0.00 0.956 Television 2 4.17 0 0.00 2.17 0.141 7 14.89 5 9.26 1.29 0.256 Newspapers 0 0.00 1 1.96 0.95 0.329 16 34.04 24 44.44 1.14 0.286 Magazines 0 0.00 2 3.92 1.92 0.166 4 8.51 10 18.52 2.11 0.147 Doctors 21 43.75 21 41.18 0.07 0.796 .2 4.26 2 3.70 0.02 0.888 Family/friends 1 2.08 1 1.96 0.00 0.964 9 19.15 10 18.52 0.08 0.933 Books 3 6.25 5 9.80 0.42 0.520 16 34.04 17 31.48 0.08 0.784 Medical books 4 8.33 7 13.73 0.73 0.394 3 6.38 3 5.56 0.03 0.860 Internet 31 64.58 30 58.82 0.35 0.146 4 8.51 6 11,11 0.19 0.663 Libraries 0 0.00 4 7.84 4.00 0.045* 0 0.00 0 0.00 - -Medical facilities 19 39.58 17 33.33 0.42 0.518 4 8.51 3 5.56 0.34 0.560 *p<0.05 Table 6 a . Smoking and alcohol consumption by ethnic group E u r o C a n a d i a n s n = 1 0 l ' C h i n e s e C a n a d i a n s n = 1 0 3 ' N o . % N o . % I1 P S m o k i n g s t a t u s Never 83 82.18 74 71.84 3.07 0.080 Seldom 8 7.92 23 22.33 8.22 0 . 0 0 4 * * Usually 10 9.90 6 5.83 1.17 0.279 O f t h o s e w h o s m o k e s e l d o m o r u s u a l l y , n u m b e r s o f c i g a r e t t e s p e r d a y 0 8 44.44 . 19 65.52 2.02 0.155 1-20 8 44.44 10 34.48 0.47 0.495 >20 2 11.11 0.00 0 3.37 0.067 S e c o n d - h a n d s m o k i n g Never 42 41.58 37 35.92 0.69 0.407 Seldom 53 52.48 56 54.37 0.07 0.787 Usually 6 5.94 10 9.71 1.00 0.317 N u m b e r s o f a l c o h o l i c d r i n k s p e r d a y 0 61 60.40 81 81.00 10.29 0 . 0 0 1 * * 1-2 36 35.64 15 15.00 11.31 0 . 0 0 0 * * 3-4 4 3.96 4 4.00 0.00 1.000 H a n d l e s t ress b y u s i n g s m o k i n g / a l c o h o l Never 53 52.48 70 68.63 5.59 0 . 0 1 9 * Seldom 46 45.54 30 29.41 5.64 0 . 0 1 8 * Usually 2 1.98 2 1.96 0.00 1.000 1. n varies across subscales * P O . 0 5 , ** P<0.0\ Table 6b. Smoking and alcohol consumption by gender within each ethnic group E u r o C a n a d i a n s M e n W o m e n n=49* n = 5 2 ' C h i n e s e C a n a d i a n s M e n W o m e n n = 4 7 ' n = 5 6 ' N o . % N o . % x2 P N o . % N o . % x2 P S m o k i n g s t a tus Never 37 75.51 46 8.85 2.89 0.089 24 51.06 50 89.29 18.46 0 . 0 0 0 * * Seldom 7 14.29 1 0.19 5.29 0 . 0 2 1 * 17 36.17 6 10.71 9.55 0 . 0 0 2 * * Usually 5 10.20 5 0.96 0.01 0.92 6 12.77 0 0.00 7.59 0 . 0 0 6 * * O f t hose w h o s m o k e s e l d o m o r u s u a l l y , n u m b e r s o f c i g a r e t t e s p e r d a y 0 7 58.33 1 16.67 2.81 0.094 16 69.57 3 50.0 0.81 0.369 1-20 4 33.33 4 66.67 1.8 0.180 7 30.43 3. 50.0 - ->20 1 8.33 1 16.67 0.28 0.596 0 0.00 0 0.00 - -S e c o n d - h a n d s m o k i n g Never 22 44.90 20 3.85 0.43 0.512 16 34.04 21 37.50 0.13 0.715 Seldom 24 48.98 29 5.58 0.47 0.495 26 55.32 30 53.57 0.03 0.860 Usually 3 6.12 3 0.58 0.01 0.932 5 10.64 5 8.93 0.09 0.77.1 N u m b e r s o f a l c o h o l i c d r i n k s p e r d a y 0 32 65.31 29 56.86 0.96 0.327 35 76.09 46 85.19 1.34 0.248 1-2 16 32.65 20 39.22 0.37 0.542 9 1.9.57 6 11.11 1.39 0.238 3-4 1 2.04 3 5.88 1.71 0,191 2' 4.35: 2 3.70 0.03 0.869 H a n d l e s t ress b y u s i n g s m o k i n g / a l c o h o l Never 23 46.94 30 57.69 1.17 0.279 25 53.19 45 81.82 8.89 0 . 0 0 3 * * Seldom 26 53.06 20 38.46 2.17 0.141 20 42.55 10 18.18 7.68 0 . 0 0 6 * * Usually 0 0.00 2 3.85 1.92 0.166 2 4.26 0 0.00 2.24 0.118 1. n varies across subscales ** p < 0.01 Table 7a. Physical activity by ethnic group EuroCanadians n^lOl 1 Chinese Canadians n=103' Physical activity level2 No. % No. % I1 P Low level 8 9.52 45 46.88 30.85 0.000** Moderate level 56 66.67 38 39.58 13.17 0.000** High level 20 23.81 13 13.54 3.16 0.076 Type of physical activity Vigorous MET-minutes/week score2 100.00 0.00 Days of vigorous activities per week (median) 1.00 0.00 Minutes of vigorous activities per day (median) 12.50 0.00 Moderate MET-minutes/week score2 220.00 40.00 Days of moderate activities per week (median) 2.00 1.00 Minutes of moderate activities per day (median) 27.50 10.00 Walking MET-minutes/week2 924.00 396.00 Days of walking per week median) 7.00 4.00 Minutes of walking per day (median) 40.00 30.00 Total physical activity MET-minutes/week score2 1244.00 436.00 Hours of sitting per day 5.00 5.00 1. n varies across subscales 2. Based on the IPAQ scoring protocol. Vigorous MET-minutes/week = 8.0 * vigorous-intensity activity minutes * vigorous-intensity days Moderate MET-minutes/week = 4.0 * moderate-intensity activity minutes * moderate days Walking MET-minutes/week = 3.3 * walking minutes * walking days Total physical activity MET-minutes/week = sum of Walking + Moderate + Vigorous MET-minutes/ week scores. **/? < 0.01 Table 7b. Physical activity by gender within each ethnic group EuroCanadians Men Women n=49* n=52' Chinese Canadians Men Women n=47' n=56' Physical activity level 2 No. % No. % x2 P No. % No. % x2 P Low level 5 11.90 3 7.14 0.55 0.457 16 38.10 29 53.70 2.31 0.128 Moderate level 29 69.05 27 64.29 0.21 0.644 18 42.86 20 37.04 0.34 0.563 High level 8 19.05 12 28.57 1.05 0.306 8 19.05 5 9.26 1.94 0.164 Type of physical activity 2 Vigorous MET-minutes/week score2 30.00 180.00 0.00 0.00 Days of vigorous activities per week (median) 0.50 1.50 0.00 0.00 Minutes of vigorous activities per day (median) 7.50 15.00 0.00 0.00 Moderate MET-minutes/week score2 80.00 240.00 60.00 40.00 Days of moderate activities per week (median) 1.00 2.00 1.00 1.00 Minutes of moderate activities per day (median) 20.00 30.00 15.00 10.00 Walking MET-minutes/week2 693.00 1039.50 363.00 346.50 Days of walking per week median) 7.00 7.00 4.00 3.50 Minutes of walking per day (median) 30.00 45.00 30.00 30.00 Total physical activity MET-minutes/week 2 803.00 1459.50 456.00 386.50 score Hours of sitting per day 4.00 6.00 5.00 4.50 1. n varies across subscales 2. Based on the IPAQ scoring protocol. Vigorous MET-minutes/week = 8.0 * vigorous-intensity activity minutes * vigorous-intensity days Moderate MET-minutes/week = 4.0 * moderate-intensity activity minutes * moderate days Walking MET-minutes/week = 3.3 * walking minutes * walking days Total physical activity MET-minutes/week = sum of Walking + Moderate + Vigorous MET-minutes/ week scores. t o Table 8a. Dietary habits by ethnic group EuroCanadians Chinese Canadians n= =101* n=103' Mean SD Mean SD t P Servings of grains per day 2.97 1.31 3.25 1.85 -1.26 0.208 Servings of vegetables and fruits per day 3.82 1.74 2.88 1.67 3.92 0.000** Servings of meat and alternatives per day 2.27 1.26 1.94 0.89 2.13 0.034* Servings of milk/dairy products per day 2.21 1.04 1.28 1.11 6.11 0.000** Teaspoons of sugar per day 2.04 2.10 1.51 1.24 2.17 0.032* Teaspoons of salt per day 0.94 0.73 1.36 0.79 -3.86 0.000** Teaspoons of oil per day 2.04 1.50 1.70 1.19 1.79 0.074 Frequency of high fat or fast food intake per week No. % No. % x2 P Less than once a week 68 67.33 67 65.05 1.48 0.224 1-2 times a week 28 27.72 26 25.24 0.63 0.428 3 or more times a week 5 4.95 10 9.71 1.24 0.265 1. n varies across subscales *p<0.05, ** P<0.0] Table 8b . Dietary habits by gender within each ethnic group EuroCanadians Chinese Canadians Men n=49* Women n=52' Men n=47* Women n=56' Mean SD Mean SD t P Mean SD Mean SD t P Servings of grains per day 3.40 1.27 2.58 .1.23 3.28 0.001** 3.65 2.14 2.93 1.52 1.99 0.049* Servings of vegetables and fruits per day 3.69 1.66 3.94 1.82 -0.72 0.476 2.74 1.68 3.00 1.67 -0.78 0.436 Servings of meat and alternatives per day 2.55 1.29 2.00 1.17 2.25 0.027 2.02 0.95 1.88 0.83 0.83 0.409 Servings of milk/dairy products per day 2.27 0.91 2.15 1.16 0.54 0.594 1.35 1.20 1.23 1.04 0.52 0.603 Teaspoons of sugar per day 2.14 1.87 1.94 2.31 0.48 0.634 1.55 1.46 1.48 1.04 0.29 0.774 Teaspoons of salt per day 0.98 0.80 0.90 0.66 0.52 0.606 1.39 0.74 1.33 0.84 0.40 0.689 Teaspoons of oil per day 2.02 1.46 2.06 1.55 -0.12 0.902 1.68 1.40 1.71 0.99 -0.14 0.888 Frequency of high fat or fast food intake per week No. % No. % x2 P No. % No. % x2 P Less than once a week 29 59.18 39 75.00 2.87 0.090 30 63.83 37 66.07 0.06 0.813 1-2 times a week 16 32.65 12 23.08 1.16 0.283 14 29.79 12 21.43 0.95 0.331 3 or more times a week 4 8.16 1 1.92 2.09 0.972 3 6.38 7 • 12.50 1.09 0.296 1. n varies across subscales *p<0.05, **/><0.01 Table 9a . Stress experiences by ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s n=101 n = 1 0 3 N o . % N o . % P E x p e r i e n c e d a g r e a t d e a l s t ress f r o m Family/marriage 16 15.84 37 35.92 10.69 0 . 0 0 1 * * Away from home 2 1.98 18 17.48 13.85 0 . 0 0 0 * * Work 13 12.87 26 24.27' 4.37 0 . 0 3 7 * Lack of work 7 6.93 28 27.18 14.72 0 . 0 0 0 * * Few friends 2 1.98 12 11.65 6.51 0 . 0 1 1 * Sickness 14 13.86 40 38.83 16.34 0 . 0 0 0 * * Sickness in family S t r e s s e x p e r i e n c e d f r o m o t h e r r e a s o n s S t r e s s l e v e l 21 7 20.79 6.93 42 9 40.78 8.74 9.54 0.23 0 . 0 0 2 * * 0.632 Low 41 40.59 48 46.60 0.75 0.387 Moderate 51 50.50 46 44.66 0.70 0.404 High 9 8.91 9 8.74 0.00 0.964 M e a n S D M e a n S D t P H o u r s o f s l e ep 7.23 1.02 6.68 1.15 3.63 0 . 0 0 0 * * */><0.05, ** PO.01 128 Table 9b . Stress experiences by gender within each ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s M e n n = 4 9 W o m e n n=52 M e n n=47 W o m e n n=56 N o . % N o . % x2 P N o . % ' N o . % x2 p Experienced a great deal stress from Family/marriage 7 14.29 9 17.31 0.17 0.677 15 31.91 22 39.29 0.60 0.437 Away from home 0 0.00 2 3.85 1.92 0.166 9 19.15 9 16.07 0.17 0.682 Work 5 10.20 8 15.38 0.61 0.437 13 27.66 12 21.82 0.54 0.462 Lack of work 5 10.20 2 3.85 1.58 0.209 16 34.04 12 21.43 2.05 0.152 Few friends 1 2.04 1 1.92 0.00 0.964 2 4.26 10 17.86 4.59 0 . 0 3 2 * Sickness 9 18.37 5 9.62 1.62 0.203 20 42.55 20 35.71- 0.50 0.478 Sickness in family 8 16.33 13 25.00 1.15 0.283 18 38.30 24 42.86 0.22 0.639 S t r e s s e x p e r i e n c e d f r o m o t h e r r e a s o n s 2 4.08 5 9.62 1.20 0.274 4 8.51 5 8.93 0.01 0.938 S t r e s s l eve l Low 25 51.02 16 30.77 6.46 0 . 0 1 1 * 24 51.06 24 42.86 0.69 0.405 Moderate 21 42.86 30 57.69 0.81 0.369 20 42.55 26 46.43 0.16 0.694 High 3 6.12 6 11.54 0.60 0.438 3 6.38 6 10.71 0.60 0.438 M e a n S D M e a n S D t P M e a n S D M e a n S D t P H o u r s o f s l eep 7.03 1.05 7.42 0.96 -1.96 0.053 6.55 0.79 6.55 0.98 -0.10 0.309 * p < 0.05 Table 10a. General health beliefs by ethnic group EuroCanad ians n = i n i 1 Chinese Canad ians 11 l u l n=103' Importance of the fo l lowing health behaviors to overa l l health No. % No. % x2 P Eating a low-fat diet Not important 1 0.99 1 0.97 0.00 1.000 Somewhat important 22 21.78 38 36.89 5.61 0.018* Very important 78 77.23 64 62.14 5.49 0.019* Eating grains-based Not important 1 0.99 4 3.88 1.79 0.181 food Somewhat important 25 24.75 36 34.95 • 2.53 0.112 Very important 75 74.26 63 61.17 3.99 0.046* Eating fruits and Not important 0 0.00 0 0.00 -vegetables Somewhat important 4 3.96 14 13.59 - -Very important 97 96.04 89 86.41 5.88 0.153 Drinking plenty of Not important 0 0.00 2 1.94 1.98 0.159 water every day Somewhat important 17 16.83 20 19.42 0.23 0.632 Very important 84 83.17 81 78.64 0.68 0.411 Taking vitamins and Not important 7 6.93 15 14.71 3.18 0.075 supplements Somewhat important 40 39.60 50 49.02 1.82 0.177 Very important 54 53.47 37 36.27 6.06 0.014* Exercising regularly Not important 0 0.00 7 6.86 7.18 0.007** Somewhat important 2 1.98 26 25.49 23.88 0.000** Very important 99 98.02 69 67.65 32.88 0.000** Not smoking Not important 2 1.98 12 11.65 7.46 0.006** Somewhat important 11 10.89 7 6.80 1.06 0.303 Very important 88 87.13 84 81.55 1.20 0.274 Not drinking alcohol Not important 4 3.96 12 11.65 4.17 0.041* or drinking in moderation Somewhat important 16 15.84 19 18.45 0.69 0.407 Very important 81 80.20 72 69.90 2.88 0.090 Maintaining a normal Not important 0 0.00 5 4.85 5.03 0.025* healthy body weight Somewhat important 12 11.88 18 17.48 1.27 0.260 Very important 89 88.12 80 77.67 3.92 0.048* 1. n varies across subscales . * p < 0.05, ** PO.01 Table 10b. General health beliefs by gender within each ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s M e n n = 4 9 ' W o m e n n = 5 l ' M e n n = 4 7 ' W o m e n n = 5 6 ' I m p o r t a n c e o f t h e f o l l o w i n g h e a l t h b e h a v i o r s t o o v e r a l l h e a l t h N o . % N o . % x2 P N o . % N o . % x2 P Eating a low-fat diet Not important 0 0.00 1 1.92 0.95 0.329 0 0.00 1 1.79 0.85 0.357 Somewhat important 14 28.57 8 15.38 2.58 0.109 17 36.17 21 37.50 0.02 0.890 Very important 35 71.43 43 82.69 1.82 0.177 30 63.83 34 60.71 0.11 0.750 Eating grains-based food Not important 0 0.00 1 1.92 0.95 0.329 2 4.26 2 3.57 0.03 0.858 Somewhat important 14 28.57 11 21.15 0.75 0.388 18 38.30 18 32.14 0.43 0.514 Very important 35 71.43 40 76.92 0.40 0.528 27 57.45 36 64.29 0.50 0.478 Eating fruits and vegetables Not important 0 0.00 0 0.00 - - 0 0.00 0 0.00 - -Somewhat important 4 8.16 0 0.00 - - 6 12.77 8 14.29 - -Very important 45 91.84 52 100.00 4.42 0 . 0 3 5 * .41 87.23 48 . 85.71 0.05 0.823 Drinking plenty of water every day Not important 0 0.00 0 0.00 - -1 2.13 1 1.79 0.02 0.899 Somewhat important Very important 10 39 20.41 79.59 7 45. 13.46 86;54 0.87 0.351 7 39 14.89 82.98 13 42 23.21 75.00 1.13 0.97 0.288 0.325 1. n varies across subscales. * p < 0.05 Table 10b. General health beliefs by gender within each ethnic group (continued) E u r o C a n a d i a n s C h i n e s e C a n a d i a n s M e n W o m e n M e n W o m e n n = 4 9 ' n =52 ' n = 4 7 ' n = 5 6 ' I m p o r t a n c e o f the f o l l o w i n g h e a l t h b e h a v i o r s to o v e r a l l h e a l t h N o . % N o . % x2 P N o . % N o . % x2 P Taking vitamins and Not important 3 6.12 4 7.69 0.10 0.757 8 17.02 7 12.73 0.37 0.541 supplements Somewhat important 20 • 40.82 20 38.46 0.06 0.810 21 44.68 29 52.73 0.66 0.418 Very important 26 53.06 28 53.85 0.01 0.938 18 38.30 19 34.55 0.15 0.695 Exercising regularly Not important 0 0.00 0 0.00 - - 2 4.35 5 8.93 0.83 0.363 Somewhat important 2 4.08 0 0.00 - - 10 21.74 16 28.57 0.62 0.431 Very important 47 95.92 52 100.00 2.17 0.141 34 73.91 35 62.50 1.50 0.220 Not smoking Not important 2 4.08 0 0.00 2.17 0.141 5 10.64 7 12.50 0.09 0.769 Somewhat important 9 18.37 2 3.85 5.31 0 . 0 2 1 * 3 6.38 4 7.14 0.02 0.879 Very important 38 77.55 50 96.15 7.79 0 . 0 0 5 * * 39 82.98 45 80.36 0.12 . 0.732 Not drinking alcohol Not important 4 8.16 0 0.00 4.42 0.036 5 10.64 7 12.50 0.09 0.768 or drinking in moderation Somewhat important 9 18.37 7 13.46 0.46 0.500 10 21.28 9 16.07 0.46 0.498 Very important 36 73.47 45 86.54 2.71 0.100 32 68.09 40 71.43 0.73 0.394 Maintaining a normal Not important 0 0.00 0 0.00 2 4.26 3 '• 5.36 0.07 0.796 healthy body weight Somewhat important 8 16.33 4 7.69 - - 9 19.15 9 16.07 0.17 0.682 Very important 41 83.67 48 92.31 1.80 0.181 36 76.60 44 78.57 0.06 0.810 1. n varies across subscales . * p < 0.05, ** P<0.0\ Table 11a. Health beliefs related to activities to reduce stress by ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s n = 1 0 1 ' n = 1 0 3 1 R e d u c e s t ress o n t h e h i g h e s t d e g r e e (a g r e a t d e a l ) N o . % N o . % x2 P Physical activity/exercise 89 88.12 47 47.47 37.95 0 . 0 0 0 * * Work 21 20.79 22 22.68 0.10 0.747 Relaxation 82 81.19 80 79.21 0.13 0.724 Sleep 90 89.11 75 73.53 8.10 0 . 0 0 4 * * Hobbies 63 62.38 50 51.02 2.61 0.106 Time with/taking to friends 69 68.32 50 50.00 6.98 0 . 0 0 8 * * Time with/talking to family 61 60.40 40 40.40 7.99 0 . 0 0 5 * * Television 16 15.84 20 20.62 0.76 0.384 Music 55 54.46 36 36.73 6.29 0 . 0 1 2 * Eating 30 29.70 5 5.10 20.77 0 . 0 0 0 * * Smoking 9 8.91 4 4.08 1.90 0.168 Others 19 18.81 9 9.18 3.81 0.051 C h a n g e s r e d u c e m o d e r a t e o r h i g h s t ress Better relationships within the family/at work 27 26.73 31 30.39 0.33 0.564 More self discipline control 36 35.64 25 24.51 2.99 0.084 In own country 4 3.96 39 38.24 35.70 0 . 0 0 0 * * Better living condition 11 10.89 33 32.35 15.56 0 . 0 0 0 * * More money 19 18.81 33 32.35 4.48 0 . 0 0 2 * * Others 22 21.78 20 19.61 0.15 0.702 1. n varies across subscales */?<0.05, ** P<0.0\ 133 Table l ib. Health beliefs related to activities to reduce stress by gender within each ethnic group EuroCanadians Chinese Canadians Men Women Men Women n=49' n=52* n=47' n=56* Reduce stress on the highest degree (a great deal) No. % No. % x2 P No. % No. % x2 P Physical activity/exercise 42 85.71 47 90.38 0.53 0.468 18 40.91 29 52.73 1.37 0.242 Work 10 20.41 11 21.15 0.01 0.924 11 25.58 11 20.37 0.37 0.542 Relaxation 41 83.67 41 78.85 0.39 0.535 33 70.21 47 87.04 4.32 0.038* Sleep 41 83.67 49 94.23 2.90 0.089 29 63.04 46 82.14 3.46 0.063 Hobbies 26 53.06 37 71.15 3.52 0.061 21 47.73 29 53.70 0.35 0.559 Time with/taking to friends 29 59.18 40 76.92 3.67 0.055 19 42.22 31 56.36 1.98 0.159 Time with/talking to family 28 57.14 33 63.46 4.31 0.038* 19 42.22 21 38.89 0.11 0.737 Television 7 14.29 9 17.31 0.17 0.677 7 15.91 13 24.53 1.09 0.296 Music 26 53.06 29 55.77 0.08 0.784 10 22.73 26 48.15 6.74 0.009** Eating 17 34.69 13 25.00 1.14 0.287 3 6.82 2 3.70 0.49 0.486 Smoking 7 14.29 2 3.85 3.87 0.066 2 4.55 2 3.70 0.03 0.865 Others 8 16.33 11 21.15 0.39 0.535 5 11.36 4 7.41 0.46 0.500 Changes reduce moderate or high stress Better relationships within the family/at work 14 28.57 13 25.00 0.16 0.686 13 28.26 18 32.14 0.18 0,671 More self discipline control 15 30.61 21 40.38 1.05 0.306 10 21.74 15 26.79 0.35 0.555 In own country 1 2.04 3 5.77 0.92 0.337 20 43.48 19 33.93 0.98 0.323 Better living condition 4 8.16 7 13.46 0.73 0.393 15 32.61 18 32.14 0.00 0.956 More money 11 22.45 8 15.38 0.82 0.364 20 43.48 13 23.21 4.74 0.030* Others 11 22.45 11 21.15 0.03 0.874 9 19.57 11 19.64 0.00 1.000 1. n varies across subscales. *p < 0.05, ** P<Q.0\ Table 12a. Health beliefs related to activities to reach longevity by ethnic group E u r o C a n a d i a n s C h i n e s e C a n a d i a n s n = 1 0 l ' n = 1 0 3 ' N o . % N o . % 5C2 P Moderate servings of Grains 19 . 20.43 21 . 21.21 0.02 0.894 More vegetables and fruits 48 51.61 43 43.43 1.29 0.257 Moderate or less consumption of meat 3 3.09 20 20.20 13.85 0 . 0 0 0 * * Moderate or more consumption of beans/tofu 0 0.00 6 5.83 6.06 0 . 0 1 4 * Moderate servings of milk/diary products 4 4.12 2 2.02 0.73 0.393 Less sugar 13 13.98 17 17.17 0.37 0.543 Less salt 12 12.90 4 3.88 5.30 0 . 0 2 1 * Less oil 4 4.30 19 19.39 10.25 0 . 0 0 1 * * Low fat/no fast food 37 39.78 21 21.43 7.60 0 . 0 0 6 * * Avoid processed foods 7 7.53 14 14.58 2.38 0.123 High fiber 5 4.95 5 4.85 0.00 0.975 Balanced diet 28 30.11 30 30.30 0.00 0.976 Light physical activity 37 39.78 56 56.57 5.41 0 . 0 2 0 * Vigorous physical activity 6 6.45 9 9.09 0.46 0.496 Both light and vigorous physical activity 22 23.66 22 22.22 0.06 0.813 No smoking 75 89.29 93 94.90 2.01 0.157 No alcohol drinking 32 39.02 61 63.54 10.67 0 . 0 0 1 * * Moderate alcohol drinking 48 58.54 30 31.25 13.38 0 . 0 0 0 * * 1. n varies across subscales. * p < 0.05, ** P<0.0\ Table 12b. Health beliefs related to activities to reach longevity by gender within each ethnic group EuroCanadians Chinese Canadians Men n=491 Women n=52' Men n=47' Women n=56\ No. % No. % x2 P No. % No., ' % x2 P Moderate servings of Grains 6 14.29 13 25.49 1.78 0.182 9 20.93 12 21.43 0.00 0.952 More vegetables and fruits 17 40.48 31 60.78 3.80 0.051 17 39.53 26 46.43 0.47 0.493 Moderate or less consumption of meat 1 2.22 2 3.85 0.21 0.645 10 23.26 10 17.86 0.44 0.507 Moderate or more consumption of beans/tofu 0 0.00 0 0.00 - - 2 4.26 4 7.14 0.39 0.533 Moderate servings of milk/diary products 2 4.44 2 3.85 0.22 0.883 2 4.65 0 0.00 2.66 0.103 Less sugar 4 9.52 9 17.65 1.26 0.261 10 23.26 7 12.50 1.98 0.160 Less salt 4 9.52 8 15.69 0.778 0.378 1 2.13 3 5.36 0.71 0.398 Less oil 2 4.65 2 4.00 0.02 0.877 7 16.67 12 21.43 0.35 0.555 Low fat/no fast food 15 35.71 22 43.14 0.530 0.467 9 21.43 12 2L43 0.00 1.000 Avoid processed foods 3 7.14 4 7.84 0.02 0.899 7 16.67 7 12.96 0.26 0.610 High fiber 3 6.12 2 3.85 0.28 0.598 2 4.26 3 5.36 0.07 0.796 Balanced diet 15 35.71 13 25.49 1.14 0.285 14 32.56 16 28.57 0.18 0.669 Light physical activity 17 39.53 20 40.00 0.00 0.694 23 53.49 33 58.93 0.29 0.588 Vigorous physical activity 4 9.30 2 4.00 1.08 0.299 4 9.30 5 8.93 0.00 0.950 Both light and vigorous physical activity 10 23.26 12 24.00 0.01 0.933 10 23.26 12 21.43 0.04 0.828 No smoking 33 80.49 42 97.67 6.48 0.011* 40 93.02 53 96.36 0.56 0.456 No alcohol drinking 18 43.90 14 34.15 0.82 0.365 27 64.29 34 62.96 0.02 0.893 Drinking alcohol in moderation 21 51.22 27 65.85 1.81 0.179 12 28.57 18 33.33 0.32 • 0.575 1. n varies across subscales. * p < 0.05 Table 13 Sociodemographic characteristics of Chinese Canadians based on median number of years lived in Canada (10 years) <10 years in Canada n=49 > 10 years in Canada n=54 Mean SD Mean SD t P Age 48.61 7.77 54.04 10.20 -3.05 0.003** No. % No. % x2 P Gender Male 22 44.90 25 46.30 0.02 0.887 Female 27 55.10 29 53.70 - -Education Elementary school or less 1 2.04 3 5.56 0.85 0.357 Technical/trade school/high school 10 20.41 16 29.63 1.04 0.309 College/university/postgraduate 38 77.55 35 64.81 2.57 0.109 Employment Employed 25 51.02 32 59.26 0.71 0.401 Home maker 14 28.57 11 20.37 0.94 0.332 Not employed 2 4.08 1 1.85 0.45 0.501 Retired 8 16.33 10 18.52 0.09 0.769 Personal income < $19,999 18 36.73 18 33.33 0.13 0.717 $20,000-$ 69,999 25 51.02 30 55.56 0.21 0.645 >$ 70,000 6 12.24 6 11.11 0.03 0.858 Birth Place Mainland China 32 65.31 32 59.26 0.40 0.528 Hong Kong 3 6.12 11 20.37 4.44 0.035* Taiwan 14 28.57 11 20.37 0.94 0.332 Native language Mandarin 44 89.80 37 68.52 6.92 0.009** Cantonese 5 10.20 17 31.48 - -Language speaking at home • English 0 0.00 3 5.56 2.80 0.094 Mandarin 42 85.71 29 53.70 12.29 0.000** Cantonese 5 10.20 17 31.48 6.92 0.009** Min Nan Dialect 2 4.08 4 7.41 0.52 0.472 Other 0 0.00 1 1.85 0.92 0.339 *p< 0.05 , **p<0.0\ Table 14. Health profile of Chinese Canadians based on median number of years lived in Canada (10 years) < 10 years in Canada > 10 years in Canada n=49* n=54' No. % No. % t1 • P Body mass index (BMI) 2 < 18.50 (underweight) 1 2.04 3 5.56 1.29 0.257 18.50-24.99 (normal) 40 81.63 35 64.81 3.67 0.055 BMI > 25 (overweight) 8 16.33 16 29.63 2.54 0.111 Diabetes 1 2.04 4 7.41 1.66 0.198 Heart disease 1 2.04 3 5.56 0.89 0.346 Hypertension 4 8.16 11 20.37 3.22 0.073 Stroke 2 4.08 0 0.00 2.25 0.134 High cholesterol level 10 27.78 9 22.50 0.28 0.596 Family history of diabetes 10 20.41 11 22.45 0.00 1.000 Family history of heart disease 12 24.49 7 12.96 2.27 0.132 Family history of hypertension 24 48.98 26 48.15 0.01 0.933 1. n varies across subscales 2. Based on guidelines by World Health Organization (WHO) Table 15. Chinese Canadians' knowledge of stroke risk factors and warning signs based on median number of years lived in Canada (10 years) <10 y e a r s i n C a n a d a n = 4 9 > 10 y e a r s i n C a n a d a n = 5 4 ' N o . % N o . % x2 P K n o w l e d g e o f S t r o k e r i s k f a c t o r s Do not know 11 22.45 12 23.08 0.01 0.938 Hypertension 18 36.73 22 42.31 0.33 0.567 Stress 10 20.41 12 23.08 0.11 0.746 Poor eating 9 18.37 5 9.62 1.62 0.203 Smoking 2 4.0.8 9 17.31 4.55 0 . 0 3 3 * High cholesterol 10 20.41 9 17.31 6.16 0.690 Obesity 5 10.20 5 9.62 0.01 0.920 Heart disease 4 8.16 8 15.38 1.26 0.262 Drinking/alcohol 3 6.12 7 13.46 1.52 0.217 Diabetes 1 2.04 5.77 0.92 0.337 Inactivity 5 10.20 4 7.69 0.20 0.658 Hereditary 5 10.20 3 5.77 0.68 0.410 K n o w l e d g e o f s t r o k e w a r n i n g s i gns Do not know 8 16.33 7 13.46 0.16 0.686 Dizziness2 19 38.78 20 38.46 0.00 0.975 Numbness2 13 26.53 11 21.15 0.40 0.526 Headaches2 16 32.65 16 30.77 0.04 0.840 Weakness2 2 4.08 2 3.85 0.00 0.950 Pain 5 10.20 9 17.31 1.07 0.302 Slurred speech2 8 16.33 6 11.54 0.48 0.487 Vision problems2 4 8.16 6 11.54 0.32 0.570 Shortness of breath 0 0.00 1 1.92 0.95 0.329 A v e r a g e N o . o f M e a n ( S D ) M e a n ( S D ) t P Stoke risk factors 1.47(1.23) 1.67(1.48) -0.751 0.454 Established stroke warning signs 0.88(0.81) 0.79 (0.83) 0.548 0.585 1 valid n=52 2 Established warning signs of stroke based on the National Institute of Neurological Disorders and Stroke, US. * p < 0.05 139 Table 16. Chinese Canadians' reaction to stroke signs in household based on median number of years lived in Canada (10 years) < 10 y e a r s i n C a n a d a > 10 y e a r s i n C a n a d a n = 4 9 n = 5 4 J N o . % N o . % : x2 Do not know 8 16.33 8 15.38 0.02 0.896 911/Emergency 4 1 8 3 6 ? ^ • 4 room 1. Valid n=52 ~ ~ Table 17. Chinese Canadians' source of information about stroke based on median number of years lived in Canada (10 years) < 1 0 y e a r s i n > 1 0 y e a r s i n C a n a d a C a n a d a n = 4 9 n = 5 4 ! N o . % N o . % x2 P Do not know 9 18.37 7 13.46 0.46 0.500 Television 6 ' 12.24 6 11.54 0.01 0.913 Newspapers 18 36.73 22 42.31 0.33 0.567 Magazines •'• 9 18.37 5 9.62 1.62 0.203 Doctors 3 6.12 1 •1.92 1.17 0.279 Family/friends 6 12.24 13 25.00 2.69 . 0.101 Books 17 34.69 16 30.77 0.18 0.674 Medical books 4 8.16 2 3.85 0.84 0.359 Internet 8 16.33 2 3.85 .. 4.41 0 . 0 3 6 * Libraries 0 0.00 0 0.00 . - -Medical facilities 4 8.16 3 5.77 0.22 0.636 1 Val id n-52 */><0.05 140 Table 18. Smoking and alcohol consumption of Chinese Canadians based on median number of years lived in Canada (10 years) < 10 y e a r s i n C a n a d a > 10 y e a r s i n C a n a d a n = 4 9 ' n = 5 4 ' N o . % N o . % P S m o k i n g s t a t u s Never 36 73.47 38 70.37 0.12 0.727 Seldom 12 24.49 11 20.37 0.25 0.616 Usually 1 2.04 5 9.26 2.44 0.118 O f those w h o s m o k e s e l d o m o r u s u a l l y , n u m b e r s o f c i g a r e t t e s p e r d a y 0 46 93.88 47 87.04 1.37 0.242 1-20 3 6.12 7 12.96 1.37 0.242 >20 0 0.00 0 0.00 S e c o n d - h a n d s m o k i n g Never 17 34.69 20 37.04 0.06 0.805 Seldom 27 55.10 29 53.70 0.02 0.888 Usually 5 10.20 5 9.26 0.03 0.872 N u m b e r s o f a l c o h o l i c d r i n k p e r d a y 0 35 72.92 46 88.46 3.92 0 . 0 4 8 * 1-2 9 18.75 6 11.54 1.02 0.313 3-4 ' 4 8.33 0 0.00 4.52 0 . 0 3 4 * H a n d l e s t ress b y u s i n g s m o k i n g / a l c o h o l Never 30 61.22 40 74.07 1.58 0.209 Seldom 17 34.69 13 24.07 1.58 0.209 Usually 1 2.04 1 1.85 0.00 0.933 1. n varies across subscales * p<0.05 Table 19. Physical activity of Chinese Canadians based on median number of years lived in Canada (10 years) < 10 years in Canada n=49' > 10 years in Canada n=54' No. % No. % x2 P Physical activity level2 Low level 22 46.81 . 23 46.94 0.00 1.00 Moderate level 19 40.43 19 38.78 0.03 0.869 High level 6 12.77 7 14.29 . 0.05 0.828 Type of physical activity 2 Vigorous MET-minutes/week score2 0.00 0.00 Days of vigorous activities per week (median) 0.00 0.00 Minutes of vigorous activities per day (median) 0.00 0.00 Moderate MET-minutes/week score2 60.00 50.00 Days of moderate activities per week (median) 1.00 1.00 Minutes of moderate activities per day (median) 15.00 12.50 Walking MET-minutes/week2 297.00 445.50 Days of walking per week median) 3.00 4.50 Minutes of walking per day (median) 30.00 30.00 Total physical activity MET-minutes/week score2 357.00 495 Hours of sitting per day 5.00 5.00 1. n varies across subscales 2. Based on the IPAQ scoring protocol. Vigorous MET-minutes/week = 8.0 * vigorous-intensity activity minutes * vigorous-intensity days Moderate MET-minutes/week = 4.0 * moderate-intensity activity minutes * moderate days Walking MET-minutes/week = 3.3 * walking minutes * walking days Total physical activity MET-minutes/week = sum of Walking + Moderate + Vigorous MET-minutes/ week scores. Table 20. Dietary habits of Chinese Canadians based on median number of years lived in Canada (10 years) < 10 y e a r s i n C a n a d a > 10 y e a r s i n C a n a d a n=49' n=54' M e a n SD M e a n SD t P Servings of grains per day 3.27 1.59 3.24 2.07 0.08 0.935 Servings of vegetables and fruits per day 2.83 1.52 2.93 1.81 -0.28 0.782 Servings of meat and alternatives per day 1.85 0.90 2.02 0.88 -0.93 0.353 Servings of milk/dairy products per day 1,44 1.09 1.15 1.12 1.32 0.191 Teaspoons of sugar per day 1.76 1.51 1.30 0.90 1.89 0.061 Teaspoons of salt per day 1.33 0.63 1.38 0.92 -0.28 0.783 Teaspoons of oil per day 1.88 1.41 1.54 0.93 1.46 0.147 F r e q u e n c y o f h i g h f a t o r fas t f o o d i n t a k e p e r w e e k N o . % N o . % x2 P Less than once a week 34 69.39 33 61.11 0.77 0.379 1-2 times a week 11 22.45 15 . 27.78 0.39 0.534 3 or more times a week 4 8.16 6 29.63 0.26 0.614 1. n varies across subscales Table 21. Stress experiences of Chinese Canadians based on median number of years lived in Canada (10 years) < 10 years in Canada n=49' > 10 years in Canada n=54* No. % No. % P Experienced a great deal stress from Family / marriage 17 34.69 20 37.04 0.06 0.805 Away from home 9 18.37 9 16.67 0.05 0.820 Work 9 18.75 16 29.63 1.63 0.202 Lack of work 13 26.53 15 27.78 0.02 0.888 Few friends 5 10.20 7 12.96 0.19 0.663 Sickness 19 38.78 21 38.89 0.00 1.000 Sickness in family 18 36.73 24 44.44 0.63 0.427 Stress level Low 21 42.86 27 50.00 0.53 0.468 Moderate 23 46.94 23 42.59 0.20 0.658 High 5 10.20 4 7.41 0.25 0.616 Mean SD Mean SD t P Hours of sleep 6.84 1.12 6.54 1.16 1.33 0.188 1. n varies across subscales */?<0.05 Table 22. General health beliefs of Chinese Canadians based on median number of years lived in Canada (10 years) < 1 0 y e a r s i n > 1 0 y e a r s i n C a n a d a C a n a d a n = 4 9 ' n=54 l I m p o r t a n c e o f t h e f o l l o w i n g h e a l t h b e h a v i o r s t o o v e r a l l h e a l t h N o . % N o . % x 2 P Eating a low-fat Not important 1 2.04 0 0.00 1.11 0.291 diet Somewhat important 18 36.73 20 37.04 0.11 0.975 Very important 30 61.22 34 62.96 0.03 0.856 Eating Not important 1 .2.04 3 5.56 0.85 0.357 grains-based food Somewhat important 15 30.61 21 38.89 0.71 0.379 Very important 33 67.35 30 55.56 1.50 0.220 Eating fruits and Not important 0 0.00 0 0.00 - -vegetables Somewhat important 5 10.20 9 16.67 0.91 0.339 Very important 44 89.80 45 83.33 - -Drinking plenty of Not important 2 4.08 0 0.00 2.25 " 0.134 water every day Somewhat important 10 20.41 10 18.52 0.06 0.808 Very important 37 75.51 44 81.48 0.55 0.460 Taking vitamins Not important 7 14.29 8 15.09 0.01 0.909 . and supplements Somewhat important 26 53.06. 24 45.28 0.62 0.433 Very important 16 32.65 21 39.62 0.54 0.465 Exercising Not important 4 8.16 3 5.66 0.25 0.617 regularly Somewhat important 8 16.33 18 33.96 4.17 0 . 0 4 1 * Very important 37 75.51 32 60.38 2.66 0.103 Not smoking Not important 6 12.24 6 11.11 0.032 0.858 Somewhat important 5 10.20 2 3.70 1.71 0.190 Very important 38 77.55 46 85.19 1.00 0.319 Not drinking Not important 6 12.24 6 11.11 0.03 0.858 alcohol or drinking in moderation Somewhat important 9 18.37 10 18.52 0.00 1.000 Very important 34 69.39 38 70.37 ' 0.01 0.913 Maintaining a Not important 3 6.12 2 3.70 0.33 0.569 normal healthy body weight Somewhat important 11 22.45 7 12.96 1.60 0.205 Very important 35 71.43 45 83.33 2.10 0.147 1. n varies across subscales * p < 0.05 Table 23. Chinese Canadians' health beliefs related to activities to reduce stress based on median number of years lived in Canada (10 years) < 10 years in > 10 years in Canada Canada n=49' n=54' Reduce stress on the highest degree ( a great deal ) No. % No. % i P Physical activity/exercise 17 36.17 30 57 69 4 59 0.032* Work 9 19.57 13 25 49 0 48 0.487 Relaxation 39 81.25 41 77 36 0 23 0.630 Sleep 37 77.08 38 70 37 0 59 0.443 Hobbies 18 38.30 32 • 62 75 5 85 0.016* Time with/taking to friends 25 52.08 25 48 08 0 16 0.689 Time with/talking to family 17 36.17 . 23 44 23 0 67 0.414 Television 8 17.02 12 24 00 0 72 0.396 Music 16 34.04 20 39 22 0 28 0.595 Eating 2 4.26 3 5 i 8 0 13 0.714 Smoking 1 2.13 3 5 i 8 0 88 0.348 Others 3 6.38 6 11 76 0 85 0.357 Changes reduce moderate or high stress Better relationships within the family/at work 14 29.17 17 31 48 0 06 0.800 More self discipline control 7 14.58 18 33 33 4 83 0.028* In own country 22 45.83 17 31 48 2 21 0.137 Better living condition 19 39.58 14 25 93 2 17 0.140 More money 17 35.42 16 29 63 0 39 0.530 Others 11 22.92 9 16 67 • 0 63 0.427 1. n varies across subscales * p < 0.05 Table 24. Chinese Canadians' health beliefs related to activities to reach longevity based on median number of years lived in Canada (10 years) < 10 years in Canada n=49' > 10 years in Canada n=54' No. % No. % x2 P Moderate servings of Grains 12 25.53 9 17.31 1.00 0.318 More vegetables and fruits 22 46.81 21 40.38 0.42 0.520 Moderate or less consumption of meat 10 21.28 10 19.23 0.06 . 0.800 Moderate or more consumption of beans/tofu 5 10.2 1 1.852 3.27 0.071 Moderate servings of milk/diary products 1 2.128 1 1.923 0.01 0.942 Less sugar 7 14.89 10 19.23 0.33 0.568 Less salt 2 4.082 2 3.704 0.01 0.921 Less oil 7 15.22 12 23.08 0.97 0.326 Low fat/no fast food 11 23.91 10 19.23 0.32 0.573 Avoid processed foods 8 18.18 6 11.54 0.84 0.358 High fiber 3 6.122 2 3.704 0.33 0.568 Balanced diet 13 27.66 17 32.69 0.30 0.586 Light physical activity 28 59.57 28 53.85 0.33 0.566 Vigorous physical activity 4 8.511 5 9.615 0.04 0.850 Both light and vigorous physical activity 10 21.28 12 23.08 0.05 0.830 No smoking 46 100 47 90.38 4.66 0.031* No alcohol drinking 26 57.78 35 68.63 1.22 0.270 Drinking alcohol in moderation 19 42.22 11 21.57 4.75 0.029* 1. n varies across subscales *p<0.05 

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