Chapter two

2.1 Background

Stroke is a leading cause of death and disability worldwide, and smoking is a well-established
risk factor for stroke. The harmful effects of smoking on cardiovascular health are well-
documented, including its link to increased risk for heart disease, stroke, and peripheral
vascular disease. Despite this, smoking remains a prevalent behaviour in many populations,
including Palestinian people.

Palestinian people have experienced a high burden of stroke and cardiovascular disease in
recent years, with stroke being a significant cause of morbidity and mortality. The prevalence of
smoking among Palestinian people is also relatively high, with studies reporting that
approximately 20% of Palestinian adults smoke cigarettes.

The negative health consequences of smoking among Palestinian people are of great concern,
given the increased risk of stroke associated with this behaviour. Despite this, there is limited
research on the relationship between smoking and stroke risk among Palestinian people
specifically.

Understanding the relationship between smoking and stroke risk among Palestinian people is
important for several reasons. First, identifying the factors that contribute to stroke risk in this
population can help inform targeted interventions to prevent stroke and improve
cardiovascular health. Second, understanding the impact of smoking on stroke risk in this
population can help raise awareness about the negative consequences of smoking and inform
public health policies aimed at reducing smoking prevalence.

Therefore, this study aims to investigate the relationship between smoking and stroke risk
among Palestinian people and to identify potential mediating factors that may impact this
relationship.

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2.2 similar studies
Worldwide studies:

1. Di Carlo et al. (1999): This case-control study examined the association between
cigarette smoking and stroke. The study included 274 stroke patients and 365 control
subjects. The results showed that cigarette smoking was significantly associated with an
increased risk of stroke, particularly among younger people and women.

2. Fidan et al. (2011): This study investigated the effect of smoking cessation on the risk of
stroke. The study included 166 patients who quit smoking and 132 patients who
continued smoking. The results showed that smoking cessation significantly reduced the
risk of stroke, especially among younger patients.

3. Huxley and Woodward (2011): This systematic review and meta-analysis examined the
association between cigarette smoking and coronary heart disease in women compared
with men. The study included data from 27 prospective cohort studies. The results
showed that smoking was a stronger risk factor for coronary heart disease in women
than in men.

4. Ovbiagele and Saver (2008): This study examined the "smoking-stroke paradox", which
refers to the observation that smokers have a lower risk of ischemic stroke than non-
smokers, despite smoking being a known risk factor for stroke. The study reviewed the
evidence and proposed several potential mechanisms for the paradoxical effect.

5. Shinton and Beevers (1989): This meta-analysis examined the relation between cigarette
smoking and stroke. The study included data from 26 observational studies. The results
showed that cigarette smoking was a significant risk factor for stroke.

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Palestinian Studies:

1. Abdul-Rahim et al. (2009): This cross-sectional study investigated the prevalence,

pattern, and risk factors of cigarette smoking among Palestinian university students. The
study included 3057 students from four Palestinian universities. The results showed that
the prevalence of cigarette smoking was high among male students (46.7%) and
relatively low among female students (7.9%).

2. Awartani et al. (2016): This study examined the prevalence, attitudes, and knowledge of
smoking among Palestinian school-aged children. The study included 1375 students
from 20 schools in the West Bank. The results showed that the prevalence of smoking
among students was low (3.5%), but many students had positive attitudes toward
smoking.

3. Jarrar et al. (2018): This cross-sectional study investigated the prevalence and associated
risk factors of cigarette smoking among nursing students at a Palestinian university. The
study included 412 nursing students. The results showed that the prevalence of
cigarette smoking was relatively low (9.7%), but male students and those with family
members who smoked were more likely to smoke.

Chapter three

3.1 Introduction

The purpose of this study is to investigate the effect of smoking on increasing stroke risks
among Palestinian people. This study aims to identify the prevalence of smoking among the
Palestinian population, as well as the associated risk factors for stroke, and to determine the
correlation between smoking and stroke incidence.

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To achieve these aims, a quantitative research design will be employed, using a cross-sectional
survey method. The study population will consist of Palestinian adults aged 18 years and above,
residing in the West Bank and Gaza Strip. The sample size will be calculated based on the
prevalence of smoking and stroke incidence in the Palestinian population, using a confidence
level of 95% and a margin of error of 5%.

Data collection will be conducted through a structured questionnaire, which will be

administered in face-to-face interviews. The questionnaire will include questions on
demographic information, smoking habits, and medical history, including previous stroke
incidence. Data analysis will be carried out using descriptive and inferential statistical methods.

The findings of this study will provide insight into the effect of smoking on stroke risks among
Palestinian people and will contribute to the development of effective strategies for stroke
prevention and control.

1.2 Research setting

Data collection will take place in healthcare facilities, community centers, and other public
places where participants can be easily accessed. The healthcare facilities that will be included
in this study will be selected based on their accessibility and the range of services they provide,
including primary healthcare centers, hospitals, and specialized clinics.

Overall, the research setting for this study will aim to provide a comprehensive and
representative sample of the Palestinian population in the West Bank, while ensuring ethical
and cultural considerations are taken into account.

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3.3 pilot study
The pilot study will involve recruiting 20-30 participants who are current smokers, non-smokers,
or former smokers with a history of stroke. Participants will be recruited from primary health
care centers and hospitals in the West Bank.

3.4 Population and Sampling

3.4.1. Sampling method

The sampling method for this study will involve a multi-stage cluster sampling technique, which
is a widely used method for selecting representative samples from large populations. The multi-
stage cluster sampling technique involves selecting participants in two or more stages.

The first stage of the sampling method will involve selecting clusters, which are defined as
geographical areas that contain a group of individuals with similar characteristics. For this
study, clusters will be defined as primary health care centers and hospitals in the West Bank.

In the second stage of the sampling method, participants will be selected from within each
cluster. To ensure that the sample is representative of the population, a systematic sampling
technique will be used to randomly select participants from a list of eligible individuals provided
by each cluster.

3.4.2 Sample size

The sample size for this study will be determined using a sample size calculator and will be
based on the prevalence of stroke and smoking in the Palestinian population, as well as the
expected effect size. The study aims to recruit at least 250 participants from different clusters in
the West Bank.

To ensure that the sample is representative of the Palestinian population, the research team
will ensure that the selected clusters include participants from both urban and rural areas, as
well as a diverse range of socio-economic backgrounds. The research team will also work
closely with local health authorities to ensure that the sampling method is culturally sensitive
and respectful.

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3.4.3 Inclusion criteria

1. Palestinian residents of the West Bank aged 18 years or older.

2. Able to provide informed consent.

3. Have a history of smoking or have never smoked.

4. Have no history of stroke or have had a stroke in the past.

3.4.4 Exclusion criteria

1. Participants who are unable to provide informed consent

2. Participants who have a history of neurological disorders other than stroke

3. Participants who have a history of significant comorbidities

4. Participants who are pregnant or breastfeeding

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3.5. Research methodology

3.5.1 Research design

The study will use a cross-sectional design to examine the relationship between smoking and
stroke risk in Palestinian residents of the West Bank. Cross-sectional studies are ideal for
investigating associations between exposure and outcome variables in a population at a specific
point in time.

Participants who meet the inclusion criteria will be recruited from hospitals, primary care
clinics, and community centers across the West Bank. Data on smoking status, medical history,
lifestyle factors, and potential biomarkers of stroke risk will be collected using self-reported
questionnaires, physical and neurological assessments, and biological samples.

3.5.2 Data collection tools

The following data collection tools will be used to gather information from study participants:

1. Self-Reported Questionnaires: Participants will be asked to complete self-reported

questionnaires to provide information on their smoking status, medical history, lifestyle
factors, and potential risk factors for stroke. The questionnaires will be available in Arabic,
the native language of the Palestinian people.

2. Medical Records: With the participants' consent, medical records will be obtained from
hospitals and clinics to provide additional information on medical history and
comorbidities.

The self-reported questionnaires will be designed based on existing validated

questionnaires used in previous stroke and smoking research studies.

The use of medical records will provide additional information on medical history and
comorbidities.

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Outcome measures
o Validity

To ensure the validity of the study, we will use validated measures for assessing smoking status,
medical history, and lifestyle factors.

o Reliability

We will conduct a pilot study to test the data collection tools and procedures before initiating
the main study.

3.5.3 Data collection procedure

1. Recruitment: Participants will be recruited from primary care clinics and hospitals in the
West Bank region of Palestine.

2. Screening: Potential participants will be screened for eligibility based on the inclusion and
exclusion criteria.

3. Informed Consent: Participants who meet the eligibility criteria and agree to participate
will sign an informed consent form.

4. Baseline Assessment: The research team will administer the baseline assessment, which
includes the data collection sheet described earlier in this proposal.

5. Data Analysis: The data will be analyzed using appropriate statistical methods to evaluate
the association between smoking and stroke incidence, as well as the effect of other risk
factors.

Overall, the data collection procedure will be conducted in a systematic and standardized
manner to ensure the validity and reliability of the study findings..

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3.5.4 Statistical analysis

The statistical analysis will include descriptive statistics, bivariate analysis, multivariate logistic
regression analysis, sensitivity analysis, and a significance level of p < 0.05. The analysis will be
conducted using software such as SPSS or R and will be presented in tables and figures. The goal
of the analysis is to evaluate the association between smoking and stroke incidence, as well as
the effect of other risk factors.

Overall, the statistical analysis will be conducted in a rigorous and transparent manner to
ensure the validity and reliability of the study findings. The results of the statistical analysis will
be presented in tables and figures and interpreted in the context of the study objectives and
research questions.

3.5.5 Ethical considerations

The research will be conducted with the highest level of ethical standards in mind. This includes
obtaining informed consent from study participants, ensuring that their privacy and
confidentiality are protected, minimizing potential harm to participants, and obtaining ethical
approval from a relevant institutional review board.

Informed consent will be obtained from all participants before their inclusion in the study. This
includes providing them with information about the study's purpose, methods, potential risks
and benefits, and their right to refuse or withdraw from the study at any time. Participants will
be informed that their participation is voluntary and that their decision to participate or not will
not affect their medical care or any other benefits to which they may be entitled.

To protect participants' privacy and confidentiality, all study data will be kept confidential and
will only be accessible to the research team. Data will be stored securely, and participants will
be assigned unique identifiers to ensure that their identities are not disclosed. Additionally, the
study will comply with relevant privacy laws and regulations.

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References

 Redon, J., Olsen, M. H., Cooper, R. S., Zurriaga, O., Martinez-Beneito, M. A., Laurent,
S., ... & Azizi, M. (2014). Stroke mortality and trends from 1990 to 2006 in 39 countries
from Europe and Central Asia: implications for control of high blood pressure. European
Heart Journal, 35(13), 750-756. https://doi.org/10.1093/eurheartj/eht533
 The definition of stroke
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5298424/
 The Palestinian Central Bureau of Statistics (PCBS) announces the preliminary results of
the “Smoking and Tobacco Consumption Survey, 2021” on the World No Tobacco Day
(May 31st , 2022)
https://www.pcbs.gov.ps/site/512/default.aspx?lang=en&ItemID=4246
 Hu, J., Li, X., Li, Y., Li, W., & Li, H. (2015). Effect of smoking on carotid artery intima-
media thickness in healthy middle-aged adults: a systematic review and meta-analysis.
PloS One, 10(9), e0137200. https://doi.org/10.1371/journal.pone.0137200
 World Health Organization. (2019). WHO report on the global tobacco epidemic, 2019:
Offer help to quit tobacco use. World Health Organization.
https://www.who.int/publications/i/item/9789241516204
 Palestine Central Bureau of Statistics. (2021). Population, housing and establishment
census - 2017. https://www.pcbs.gov.ps/site/881/default.aspx#Population
 National Center for Chronic Disease Prevention and Health Promotion. (2021). Smoking
and tobacco use: Data and statistics. Centers for Disease Control and Prevention.
https://www.cdc.gov/tobacco/data_statistics/index.htm
 DiClemente, R. J., Salazar, L. F., & Crosby, R. A. (2013). Health behavior theory for public
health: Principles, foundations, and applications. Jones & Bartlett Publishers.

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Appendixes

Data Collection Sheet

Data Collection Sheet:

Participant ID: ____________

Date of Enrollment: ____________

Demographics:

Age: ____________

Gender: ____________

Education Level: ____________

Occupation: ____________

Marital Status: ____________

Medical History:

Have you been diagnosed with a stroke before? (Yes/No)

Have you been diagnosed with hypertension? (Yes/No)

Have you been diagnosed with diabetes? (Yes/No)

Have you been diagnosed with heart disease? (Yes/No)

Have you been diagnosed with other chronic illnesses? (Yes/No)

Smoking History:

Do you currently smoke cigarettes? (Yes/No)

If yes, how many cigarettes do you smoke per day? ____________

Age at which you started smoking: ____________

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Total years of smoking: ____________

Lifestyle Factors:

Do you engage in regular physical activity? (Yes/No)

If yes, how many days per week and how many minutes per day? ____________

Do you follow a healthy diet? (Yes/No)

Family History:

Has anyone in your family been diagnosed with a stroke before? (Yes/No)

Has anyone in your family been diagnosed with hypertension? (Yes/No)

Has anyone in your family been diagnosed with diabetes? (Yes/No)

Has anyone in your family been diagnosed with heart disease? (Yes/No)

Consent for Medical Records:

Do you consent to the release of your medical records for research purposes? (Yes/No)

If yes, please provide the name and contact information for your healthcare provider: ____________

Consent form

Title of Study: The Effect of Smoking in Increasing Stroke Risks among Palestinian People

Researcher: [Researcher's name

Purpose of Study:

The purpose of this study is to investigate the relationship between smoking and the risk of
stroke among Palestinian people.

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Procedures:

You will be asked to complete a survey that asks about your smoking habits and medical
history. The survey will take approximately 15 minutes to complete. Your responses will be
confidential.

Risks and Benefits:

There are no known risks associated with this study. However, you may benefit from increased
awareness of the health risks associated with smoking.

Confidentiality:

Your responses will be kept confidential and anonymous. Your name will not be used in any
publication or presentation resulting from this study.

Participant's Rights:

Your participation in this study is voluntary. You have the right to refuse to participate or
withdraw from the study at any time without penalty. You may ask questions about the study
at any time.

Contact Information:

If you have any questions or concerns about the study, please contact the researcher at
[Researcher's contact information].

Consent:

By signing below, I acknowledge that I have read and understand the information provided
above, and I voluntarily agree to participate in this study.

Signature: _______________________

Date: _________________________

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Information sheet
Title of Study: The Effect of Smoking in Increasing Stroke Risks among Palestinian People

Researcher: [Researcher's name]

Purpose of Study:

The purpose of this study is to investigate the relationship between smoking and the risk of
stroke among Palestinian people.

Procedures:

You will be asked to complete a survey that asks about your smoking habits and medical
history. The survey will take approximately 15 minutes to complete. Your responses will be
confidential.

Risks and Benefits:

There are no known risks associated with this study. However, you may benefit from increased
awareness of the health risks associated with smoking.

Confidentiality:

Your responses will be kept confidential and anonymous. Your name will not be used in any
publication or presentation resulting from this study.

Participant's Rights:

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Your participation in this study is voluntary. You have the right to refuse to participate or
withdraw from the study at any time without penalty. You may ask questions about the study
at any time.

Contact Information:

If you have any questions or concerns about the study, please contact the researcher at
[Researcher's contact information].

Data Protection:

The researcher will adhere to all data protection regulations in place in Palestine, including the
General Data Protection Regulation (GDPR) and the Palestinian Personal Data Protection Law.

Approval:

This study has been approved by the [Institutional Review Board or Ethics Committee].

Thank you for considering participating in this study. If you have any questions or concerns,
please do not hesitate to contact the researcher.

Signature: _______________________

Date: _________________________

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