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Introduction
Health studies have often highlighted a relationship between asthma and smoking (Lee, Forey, & Coombs, 2012). Indeed, most researchers claim that most people who have asthma and smoke, at the same time are in double jeopardy because, as if tobacco smoke is not bad enough, their asthmatic condition could be triggered by irritants contained in the tobacco smoke, thereby leading to allergic inflammation of the bronchial tubes (Dutra, Williams, Gupta, Kawachi, & Okechukwu, 2014).
This condition could lead to excessive mucus production, chronic cough and phlegm (Lee et al., 2012). For many asthmatic patients, tobacco irritants not only manifest in the aforementioned symptoms, but also make breathing difficult. This is in addition to the shortness of breath that they suffer periodically and the typical respiratory issues caused by cigarette smoking, such as emphysema, which they may suffer experience as well (Gilreath, Chaix, King, Matthews, & Flisher, 2012).
The relationship between asthma and smoking explains why many adults who develop asthma past their 50th birthdays often have a history of smoking tobacco (Dutra et al., 2014). Our topic of study is centered on exploring the relationship between asthma incidence and smoking among adult African Immigrants in California.
We need to conduct this study because African immigrants are a relatively understudied group. Furthermore, they are mostly underinsured than the general American population and experience significant variations, in terms of education and income outcomes, relative to other ethnic groups as well (Dutra et al., 2014). Indeed, because of their low socioeconomic status, studies have shown that they often experience inadequate medical care, which is often characterized by improper diagnosis of medical conditions (Dutra et al., 2014; Gilreath et al., 2012).
This problem often creates an inadequate recognition of asthma severity and the under-prescription of controller medications by health care service providers. Besides poor socioeconomic conditions, African immigrants also suffer from other risk factors such as environmental exposures (because of the difficult working conditions they are often subject to) and respiratory tract infections that are often associated with low-income living (Dutra et al., 2014).
This study would have a positive impact on social change because it would help to reduce the impact of asthma incidences within the target population. Such an outcome would come from understanding the relationship between smoking and asthma. For example, if we establish a positive relationship between the two variables, we could reduce the impact of smoking and minimize the impact of asthma at the same time. Similarly, if we establish no significant relationship between smoking and asthma within the target population, we could focus on other areas of health intervention to reduce the incidence of asthma among African immigrants in California. This study could also help to promote positive social change by informing health policy decisions regarding smoking and asthma management in the state of California.
Theoretical/Conceptual Framework
The socio-ecological theory will be the main conceptual framework for this study. Introduced in the 1970s by sociologists coming from the Chicago School, and revised by Bronfenbrenne throughout the 1970s and 1980s, this theory has been used to merge behavioral issues and anthropology issues in health studies (Moore, de Silva-Sanigorski, & Moore, 2013). The theory has five nested levels of interlocking behavioral and anthropology factors interpersonal, organization, community, individual, and policy enabling environments. The diagram below shows how these levels interact.
A key contribution of this theory to different fields of health and psychology is the understanding that the true comprehension of human growth should occur through a complete understanding of the ecological system, which supports or influences their behaviors (Yakob & Ncama, 2016).
The rationale for using this theoretical framework in this study stems from its ability to show different levels of personal and environmental factors affecting human behaviors and health outcomes. It does so by considering the complex interplay between the five layers of personal and environmental factors mentioned. We also justify its application in this study because it has been used to successfully prevent domestic violence, child abuse, and promote community health (among other contributions in public health) (Gilioli, Caroli, Tikubet, Herren, & Baumgärtner, 2014). Its success in community health promotion is the main motivator for applying it in this study.
This theoretical framework is relevant to our research issue because it would help us to uncover the personal and environmental factors that could explain an association between asthma and smoking among African immigrants (Onono et al., 2015). Concisely, smoking is a personal issue that is often associated with environmental factors, such as culture, peer influence, stress and such like factors. Similarly, asthma is a personal and environmental issue because it could be triggered or exacerbated by biological or environmental factors. Immigration also changes the environmental context that could affect human health outcomes.
In this regard, this fact could help to explain the environmental issues of African immigrants in California that could affect their health status. In this regard, this theory is useful to our research study because it provides a holistic perspective of our research issue. More specifically, it incorporates all our research variables because smoking is a sociological (behavioral) issue, while the health issues (asthma) affecting African immigrants living in California could be moderated by environmental factors.
Approach for the Study
The quantitative approach is applicable to this research because our main source of research information the CHIS dataset and codebook is quantitative in nature. There are different types of research approaches in quantitative studies. The main ones include descriptive research, correlation research, quasi-experimental research, and experimental research (Jacobsen, 2016). The correlation approach is the main approach to this study because it focuses on determining the existence and extent of a relationship between two or more variables.
It aligns with our research topic because we also strive to investigate the association between asthma incidence and smoking among adult African immigrants in California. Thus, the justification for using the correlation approach rests in the fact that it seeks to find out and interpret relationships between different variables (Guest, 2014).
As highlighted in this paper, our research topic is centered on investigating the association between asthma incidence and smoking among adult African immigrants in California. The research variables for this study include asthma, as the dependent variable, smoking as the independent variable, and age, sex, years since immigration, marital status, alcohol use, education level, income level, and employment status as mediating variables, or covariates.
Definitions
Asthma (Dependent variable)
A respiratory condition characterized by the presence of spasms in the nasal cavity. It often causes difficulty in breathing and an inflammation of the lungs. Some common symptoms include wheezing, coughing, and shortness of breath.
Smoking (Independent variable)
The inhalation of tobacco smoke through the burning of cigarettes. Smoking is often a behavioral issue characterized as a recreational drug habit.
Socio-ecological Model (SEM)
A model for understanding the interaction between personal and ecological effects of human behavior. The model is often used to identify behavioral and organizational leverage points that could be used to improve human health outcomes.
California Health Interview Survey (CHIS)
One of the largest health surveys in America that provides population-based, standardized health-related data. The data is often obtained from 58 counties within America and is collected using telephone surveys.
Assumptions
According to Whaley (2014), assumptions are things that are believed to be true, but cannot be verified by the researcher. One key assumption in this study is that the findings from the California Health Interview Survey are credible and reliable. In other words, we believe that this information is free from errors because the dataset forms the bedrock of our research findings. We also assume that the findings obtained in this study are representative of all African immigrants, regardless of their social or cultural affiliations.
The assumptions outlined in this review are necessary in the processing of the research findings because, without them, it would be difficult to guarantee the relevance of the research study. Furthermore, by stating these assumptions, it is easier for consumers of the research findings to understand the extent of reliability associated with the information explained, as well as the extent to which they should regard the information as true.
Scope and Delimitations
This research seeks to explore the relationship between smoking and asthma among adult African immigrants in California. Specific aspects of the research that are addressed in the research problem include smoking habits, asthma incidence, and African immigrants as the main target group. We chose this research focus because it has a high internal validity since the California Health Interview Survey, which is our main source of data, investigated different health outcomes/issues. Stated differently, it did not only focus on our variables (smoking and asthma were only two variables among many).
Therefore, the likelihood that the respondents thought the survey was only investigating the relationship between smoking and asthma is low. Hegde (2015) considers this feature as a strong predictor of internal validity and calls it the double-blind technique, where the respondents and the researcher both do not understand what the investigative process represents. One boundary of the study is the inclusion of only African immigrant groups. We also only included smoking and asthma incidences as key variables in the study, thereby excluding other variables that existed in the CHIS dataset. Additionally, as highlighted through our conceptual framework, we also only focused on personal and environmental factors affecting the relationship between smoking and asthma. The theories we excluded from the study, but were closely related to the research problem, include the stems theory, social learning theory, and social exchange theory.
They were excluded from the study because they did not have a health-related focus. Based on the external validity of this review, this study is mostly generalized to African immigrants living in California. It will be difficult to extrapolate the same findings to the same ethnic group in other states because different states have different health policies and socioeconomic conditions that may affect the research outcomes.
Limitations of the Study
According to Mangal and Mangal (2013), limitations of a study often refer to issues that are outside a researchers control. One key limitation of our study is that the findings obtained are limited to the time (or period) the data presented in the California Health Interview Survey was collected. This limitation could affect the immigration status of the target population, the population sample and socioeconomic conditions of the time.
We also assume that the limitations associated with the collection of data portrayed in the CHIS would also be the same limitations in our study. The limitation transferred from the CHIS could affect the trustworthiness of our research findings. For example, researcher bias or existing stereotypes surrounding Africans could have affected the formulation of information in the CHIS. Thus, the validity and reliability of our findings are intertwined with the reliability and validity of the findings presented in the CHIS (Bowling, 2014).
Summary and Conclusion
In this section, we have shown that researchers have always investigated the relationship between smoking and asthma. Particularly, they have demonstrated that these two variables share a positive relationship because increased smoking often increases asthma incidences. Their findings have also shown that smoking often causes irritation along the air pathways, thereby leading to asthma. Similarly, they have also shown that the habit damages hair-like structures (cilia) along the air pathways, leading to an exacerbation of the condition.
This data has often been presented as a general relationship between smoking and asthma. Specialized studies have often focused on age differences and income groups to explain the same relationship. Those that have further broken down the demographic divide have investigated the relationship between smoking and asthma among specific immigrant groups such as Hispanics and Asians. The relationship between smoking and asthma among African immigrants is a relatively under-researched area because studies have always neglected this immigrant group.
This paper seeks to fill this research gap by exploring the relationship between smoking and asthma among adult African immigrants. As highlighted above, the main variables are smoking (independent variable) and asthma as the dependent variable. Our main source of data will be the CHIS. Since we are using the quantitative co-relational research approach, reliability and validity issues associated with the data collection process of the CHIS mostly limit us.
Nonetheless, we assume that the information contained in the CHIS is reliable and credible. We also assume that the findings presented in this report will be representative of all adult African immigrants in California. Using the socio-ecological model, the present study would fill the aforementioned research gap by highlighting the personal and environmental factors that could affect the relationship between the variables under study (smoking and asthma).
This study will help us to understand whether there is an association between smoking and asthma incidences among adult African immigrants in California. From our findings, we will be able to ascertain whether the research outcome will be consistent with other research studies, which have shown a positive relationship between the two variables. The findings of this study could have a positive impact on social change because they could help to reduce the impact of asthma incidences within the target population. Furthermore, they could inform policy decisions affecting the research issue.
Literature Review
Introduction
This literature review section is divided into different sections. The first section outlines the literature search strategy which includes information about the accessed library database and the search engines used to get information about past research studies that have explored the research issue. In this section, we also list the search terms and provide a combination of the same to present an outline of how we derived relevant research materials from the databases. Lastly, in this section of the report, we explain that the main literatures consulted in this paper are peer-reviewed articles in the form of books, journals, and credible website sources.
All the sources consulted in this review are not more than five years old (they are published between 2012 and 2017). The main section of this chapter is the analysis of relevant literature, which contains a review of more than 60 articles. Through an analysis of this literature, we outline the research gap that will be filled through an exploration of the research topic. The subsequent section of this report is the literature search strategy.
Literature Search Strategy
The literature search was conducted from reputable sources of peer-reviewed articles available from Google Scholar, Google Books, NCBI, and MEDLINE. Most of the articles sourced from these databases are openly available. The key research terms used to get the articles were African, Immigrants, Asthma, and Smoking. Most of these terms were derived from the variables under study and the nature of the research topic. Excluded from the review were research articles that were published earlier than 2012. We also excluded articles that came from commercial websites, blogs and other online sources that were unreliable. There was a strong bias to include only articles that were peer-reviewed.
Conceptual Framework
In this paper, we have shown that the socio-ecological model will be the main conceptual framework for our study. However, other researchers have used other types of conceptual frameworks to explore the interaction between human factors and environmental factors while trying to assess or predict health outcomes. For example, Kapp, Simoes, DeBiasi, and Kravet (2016) used the systems theory to investigate how immigration patterns affect health outcomes in America.
Jayasinghe (2015) also used the same conceptual framework to explain how social issues affect health outcomes. Both researchers said that the systems theory provided a reliable conceptual framework for understanding how natural and social systems interact. They also said that the same framework properly conceptualized population health outcomes as dynamic, open, and adaptive systems. Broadly, these researchers have managed to demonstrate that human health outcomes are products of interrelated parts of subsystems, thereby enhancing our understanding of interactions between micro-meso-macro levels of health (Jayasinghe, 2015).
Researchers have also used the social construction theory as another conceptual framework for understanding the interrelations between different health variables. As highlighted in the works of researchers such as Onono et al. (2015), this theoretical foundation explains how socio-cultural and historical factors often shape peoples health outcomes. This theory would have been relevant to our research issue because it has been used by many researchers to explain the lived experiences of oppressed or minority communities. However, the main flaw of this theory (regarding its use in our research study) is its excessive bias on cultural and historical factors as a predictor of health outcomes. In this regard, it has no proper consideration of other factors that could affect health outcomes.
The main issue to point out in this analysis is that these conceptual frameworks have mostly been used to effect change or institute human behavioral changes as a prerequisite for their use. This focus does not explain the nature of our study because it does not institute change. Instead, it strives to describe a health phenomenon. The socio-ecological model adopts a broader view of health issues. This is why it was the most appropriate model for the paper.
Effects of Immigration on Health
Different researchers have explored the relationship between immigration and asthma. Such is the case of Cabieses, Uphoff, Pinart, Antó and Wright (2014) who conducted a systematic review to analyze the effect of immigration on the relationship between asthma and smoking. They conducted this review according to the guidelines stipulated in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and found that there were significant differences in allergic reactions for populations that lived in their countries of origin and those that emigrated to other countries (Cabieses et al., 2014).
They also found that the level of development in the host countries significantly affected the level of asthma developed by the immigrants. Fox, Entringer, Buss, DeHaene, and Wadhwa (2015) have also demonstrated that immigrants who lived in developed countries had higher rates of asthma compared to those who lived in less developed countries. The researchers also established that there was a strong influence of the environment on the development of asthmatic conditions among the sample populations (Fox et al., 2015). Additionally, they established a higher prevalence of asthma among second generation immigrants compared to first generation immigrants because the latter group was not exposed to the environmental conditions of the host countries as much as the former group.
This assertion showed that the length of stay in the host country was directly related to the development or seriousness of asthmatic conditions. These findings were consistent with research studies conducted by Ro (2014), which upheld the same conclusion across sample groups of different nationalities, study populations and age groups. However, he established differences across these social groups when the linear model was used (Ro, 2014). The differences also emerged when the respondents compared the findings across early and later stages of immigration. Differences in time of residence also yielded the same outcomes.
In a different study to investigate asthma incidences among Asian immigrants living in America, Becerra, Scroggins and Becerra (2014) established that Chinese, Filipino, South Asian, and Japanese immigrants reported a positive relationship between asthma and immigration. The same was true for Korean immigrants because the study showed that there was a positive relationship between asthma prevalence and immigration status (Becerra et al., 2014). The researchers used a linear regression model to come up with the findings after relying on data prepared by the California Health Interview Survey 2001-2011.
Garcia-Marcos et al. (2014) also conducted a study to investigate whether immigration affects asthma incidences among immigrants and came up with the same findings. In other words, they established that immigrants to western countries often adopt the same allergic reactions that host populations suffer from. The researchers used a mixed method approach to conduct the review by first gathering data using questionnaires from 13-14 year old immigrants living in the USA. They also gathered the views of parents who had children aged 6-7 years old using secondary research data (Garcia-Marcos et al., 2014).
Their findings showed a weak association between immigration and higher incidences of asthma. Thus, they believed that the reduced risk of asthma was often related to immigrants who had lived in America for the shortest time. This finding is consistent with the views of Lopez and Golden (2014) who say an increased stay in the host countries, often leads to the loss of protective pre-immigration environment that would have otherwise helped immigrants to lower their risk of asthma.
Corlin, Woodin, Thanikachalam, Lowe, and Brugge (2014) investigated how immigration affected the health outcomes of Chinese immigrants and after sampling the health outcomes of more than 147 immigrants, they established that the immigrant population had better health outcomes compared to the native populations. The researchers also used bivariate and multivariate models to compare the prevalence of diseases among the two population groups, as well as the clinical biomarkers associated with the study focus (Corlin et al., 2014). To explain their findings, the researchers said that healthier diets, minimal exposure to cigarette smoke and increased physical activity among the Chinese immigrants was mostly responsible for their positive health outcomes.
A study by Camacho-Rivera, Kawachi and Bennett (2015) also investigated the relationship between immigration and health outcomes by exploring the effect of race, ethnicity and country of origin on the risk of developing asthma. The researchers used 2,558 non-Hispanic white and Hispanic children to investigate this research phenomenon and found that lifetime asthma incidence was prevalent in less than 9.1% of the population (Camacho-Rivera et al., 2015).
They also found no significant differences in asthma rates between Hispanic and non-Hispanic respondents. This study highlighted the importance of moving beyond racial or ethnic classifications to develop policies surrounding asthma management because these classifications often mask different subgroups of people who are at high risks of asthma.
Barr et al. (2016) conducted a study to test whether ethnicity is a dependent variable in the prediction of asthma incidences among immigrant populations in the US by analyzing whether the condition was prevalent among Hispanics and Puerto Ricans more than other immigrant groups. They found that asthma was more prevalent among second-generation Hispanic and Puerto Rican immigrants than first generation immigrants were (Barr et al., 2016). They partly explained this finding using differences in smoking patterns among the sampled population groups. Their study included a sample of 16,415 Hispanics and Latinos (Barr et al., 2016).
In a different study to evaluate asthma admissions using ethnic variations, Sheikh et al. (2016) found that South Asian immigrants reported the highest hospital admissions attributed to asthma. These findings were developed after evaluating two main ethnic groups whites and South Asian immigrants. However, the researchers failed to take into account sex-related differences that would have affected health outcomes. Benchimol et al. (2015) also used South Asian immigrants as a sample group to estimate the incidence of asthma and immune-mediated diseases among immigrants in western countries. They used population-based cohorts of respondents who suffered from asthma and diabetes to undertake the review and found that adults from South Asia had a higher predisposition to asthma compared to other ethnic immigrant groups (Benchimol et al., 2015).
This finding contradicted the view of many studies highlighted in this literature review because other studies have consistently shown that immigrants from other countries had a lower risk of developing asthma compared to host populations. However, the explanation for this inconsistency could stem from the fact that the findings of Benchimol et al. (2015) are mostly attributed to a genetic predisposition to the disease among South Asian immigrants.
Mahmoudi (2016) conducted a broader review involving more than 40 countries to understand the effect of immigration on asthma incidences and found that immigration was associated with a low incidence of asthma. He developed these findings after conducting a survey of more than 326,000 adolescents from more than 40 countries. The survey also included a population of 207,000 children from 30 countries (Mahmoudi, 2016). However, the association between immigration and asthma incidence was limited to affluent countries.
Reed and Barosa (2016) have also explored the role of nativity in explaining the advantage enjoyed by immigrants compared to their host populations, when it comes to asthma prevalence. To explain this advantage, they explored the health outcomes of two groups of immigrants refugees and non-refugees. The findings revealed that refugees were disadvantaged when it came to access to health care services, thereby suffering poor health outcomes compared to their non-refugee counterparts. Comprehensively, these studies show there is an association between asthma and immigration, with immigrants suffering lower incidences of asthma compared to host populations.
Effect of Environmental Exposures on Health
In an effort to understand the effects of environmental exposures on health, Im et al. (2015) outlined the case of a researcher, Johnson, who used an innovative framework to separate a host of factors affecting asthma incidences into different constituents. His analysis concentrated on factors that affect the design, construction and conditions of the dwellings, which immigrants lived in. The researcher found that the risk of developing asthma was directly correlated to the nature and type of dwelling (Im et al., 2015). Im et al. (2015) said this relationship was a product of the interaction between culture and environment.
In a separate study, Rumrich and Hänninen (2015) found that the complexity associated with asthma management was directly associated with the immigrants ability to communicate fluently in English and partly on whether they were born in the U.S, or not. They also established that asthma was more severe for immigrants who were relatively acculturated to their host countries, compared to those who were not (Rumrich & Hänninen, 2015). Their findings corresponded with a similar study by Chiu et al. (2016), which highlighted the lower incidence of asthma among new immigrants compared to those who had been in the host nations for a long time. This comparison implies that western risk factors increased the risk of developing asthma. This fact was supported by studies, which investigated the same issue among Arab-Americans (Im et al., 2015).
In a research study conducted by Rottem, Geller-Bernstein and Shoenfeld (2015), it was established that environmental factors and the age of immigration affected peoples predisposition to asthma. The study went further to explain that the level of immunoglobin E was relatively higher among immigrants compared to the local population, thereby decreasing their predisposition to asthma (Rottem et al. 2015). The researchers also explored the possibility of a reversal of allergies because of parasitic infections. In this regard, they proposed that secondary prevention guidelines should be introduced to immigrants before they settle in their host nations, as a strategy to prevent asthma attacks (Rottem et al. 2015).
Studies that have tried to explore the impact of the environment on the health of immigrants have found it difficult to isolate the environment from other socioeconomic factors affecting immigrants that would ultimately affect their health as well (Okechukwu, Souza, & Davis, 2014). For example, a study by Guruge, Birpreet, and Samuels-Dennis (2015) to investigate the impact of environmental conditions on older women immigrants in Canada found that SES, cultural beliefs, gender norms, and influences of the physical and social environment weighed heavily on immigrant health. The studies also showed that older immigrant women were more likely to have health problems because of poor access to health care services and the underutilization of preventive health services (Guruge et al., 2015).
Martinez et al. (2015) say that some of the problems faced by immigrants living in America are partly caused by unfavorable immigration policies. For example, they say unfavorable immigration policies often affect access to health care issues (Martinez et al., 2015). They came up with these findings after reviewing eight health databases, which showed that anti-immigrant sentiments often affected the health outcomes of immigrants because it limited their ability to access health care services. Rhodes et al. (2015) have also come up with similar findings after investigating the effect of immigration policies on immigrant health in America.
Flynn, Carreón, Eggerth, and Johnson (2014) say that understanding the impact of someones work environment on their health goes beyond merely understanding how their work presents social hazards and risks to their wellbeing. Indeed, as explained by Arcury (2014), someones work also affects other aspects of their social wellbeing, and by extension, their health (work is the major incentive for many people who emigrate to the U.S).
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