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Background: Although the general seroprevalence of hepatitis C virus (HCV) infection in Hong Kong is <0.5 %, Hong Kong is still striving for HCV elimination owing to barriers in care cascade encompassing linkage-to-care (LTC), treatment initiation and adherence. We aimed to evaluate the feasibility of a pilot model of micro-elimination to strengthen the HCV care cascade for high-risk groups in Hong Kong., Methods: We initiated the pilot Conquering Hepatitis vIa Micro-Elimination (CHIME) program which adopts an integrated care approach involving outreach visits to halfway house or drug rehabilitation centers run by non-governmental organizations. Participants with history of injection drug use (PWID), recreational drug use, or imprisonment were included. We performed point-of-care test for anti-HCV with reflex HCV RNA testing. LTC with government-subsidized direct acting antiviral was provided to viremic participants. We compared the impact on the care cascade with a cohort of HCV patients (17.8 % PWID) under usual care., Results: 396 participants (62.9 % PWID) were screened and 187 (47.2 %) were viremic, of which 29.8 % had cirrhosis. Proportion with LTC, treatment initiation and adherence were 76.5 % and 63.7 %, 90.9 % and 85.8 %, and 90.0 % and 92.2 %, for the CHIME program and usual care, respectively. The CHIME program was significantly associated with higher odds of LTC (OR 1.797, 95 % CI 1.221-2.644). Non-engagement in care (affecting 37.9 % participants with HCV viremia) was associated with unemployment (OR 2.165, 95 % CI 1.118-4.190)., Conclusion: The pilot CHIME program demonstrated feasibility of an integrated approach to consolidate the HCV care cascade in high-risk populations in Hong Kong., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: LY Mak is an advisory board member of Gilead Sciences and received speaker's fees from AbbVie. WK Seto received speaker's fees from AstraZeneca, is an advisory board member and received speaker's fees from Abbott, received research funding from Alexion Pharmaceuticals, Boehringer Ingelheim, Pfizer and Ribo Life Science, and is an advisory board member, received speaker's fees and researching funding from Gilead Sciences. MFY is an advisor/consultant for and/or received grant/research support from AbbVie, Aligos Therapeutics, AiCuris, Antios Therapeutics, Arbutus Biopharma, Arrowhead Pharmaceuticals, Assembly Biosciences, Bristol-Myers Squibb, Clear B Therapeutics, Dicerna Pharmaceuticals, Finch Therapeutics, Fujirebio Incorporation, GlaxoSmithKline, Gilead Sciences, Immunocore, Janssen, Roche, Silverback Therapeutics, Sysmex Corporation, Tune Therapeutics, Vir Biotechnology and Visirna Therapeutics. The other authors have nothing to disclose., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Hong Kong has a relatively low incidence rate of COVID-19 across the globe. Nevertheless, ethnic minorities in Hong Kong, especially South Asians (SAs) and Southeast Asians (SEAs), face numerous physical, mental, social, economic, cultural and religious challenges during the pandemic. This study explores the experiences of SA and SEA women in a predominantly Chinese metropolitan city., Methods: Ten SA and SEA women were recruited and face-to-face interviews were conducted. Questions about participants' daily life experience, physical and mental health conditions, economic situation and social interaction amid COVID-19 pandemic were asked to assess the impact of COVID-19., Results: SAs and SEAs have a distinctive family culture, and women experienced significant physical and mental impact of COVID-19 due to their unique gender role in the family. In addition to taking care of their family in Hong Kong, SA and SEA women also had to mentally and financially support family members residing in their home countries. Access to COVID-related information was restricted due to language barrier. Public health measures including social distancing imposed extra burden on ethnic minorities with limited social and religious support., Conclusions: Even when COVID-19 incidence rate is relatively low in Hong Kong, the pandemic made life even more challenging for SAs and SEAs, which is a community already struggling with language barriers, financial woes, and discrimination. This in turn could have led to greater health inequalities. Government and civil organizations should take the social determinants of health inequalities into account when implementing COVID-19-related public health policies and strategies., (© 2023. The Author(s).)

Background: Primary care patients, especially those with an older age, are one of the most vulnerable populations for post-COVID-19 symptoms. Identifying predictors of post-COVID symptoms can help identify high-risk individuals for preventive care., Methods: Out of 977 primary care patients aged 55 years or above with comorbid physical and psychosocial conditions in a prospective cohort in Hong Kong, 207 patients infected in the previous 5-24 weeks were included. The three most common post-COVID-19 symptoms (breathlessness, fatigue, cognitive difficulty), which lasted beyond the 4-week acute infection period, were assessed using items from the COVID-19 Yorkshire Rehabilitation Scale (C19-YRS), together with other self-reported symptoms. Multivariable analyses were conducted to identify predictors of post-acute and long COVID-19 symptoms (5-24 weeks after infection)., Results: The 207 participants had a mean age of 70.8 ± 5.7 years, 76.3% were female, and 78.7% had ≥2 chronic conditions. In total, 81.2% reported at least one post-COVID symptom (mean: 1.9 ± 1.3); 60.9, 56.5 and 30.0% reported fatigue, cognitive difficulty, and breathlessness respectively; 46.1% reported at least one other new symptom (such as other respiratory-related symptoms (14.0%), insomnia or poor sleep quality (14.0%), and ear/nose/throat symptoms (e.g., sore throat) (10.1%), etc.). Depression predicted post-COVID-19 fatigue. The female sex predicted cognitive difficulty. Receiving fewer vaccine doses (2 doses vs. 3 doses) was associated with breathlessness. Anxiety predicted a higher overall symptom severity level of the three common symptoms., Conclusion: Depression, the female sex, and fewer vaccine doses predicted post-COVID symptoms. Promoting vaccination and providing intervention to those at high-risk for post-COVID symptoms are warranted., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Zhang, Chung, Chan, Xu, Zhou, Tam, Lee, Sit, Mercer and Wong.)

Background: Emerging evidence suggests neighborhood greenness is associated with physical activity; however, the sitting-specific associations with multi-source greenness metrics remain unclear, especially in high-density cities., Objectives: This cross-sectional study examined: 1) the associations of street-view greenness (SVG) and traditional greenness metrics (i.e., Normalized Difference Vegetable Index (NDVI) and park density) with sitting time; 2) the potential moderating/mediating roles of objective/perceived air pollution and perceived roadside noise; and 3) how the associations vary by demographics and socioeconomic status., Methods: Interview survey data of 1977 adults in Hong Kong from 2014 and 2015 was linked to environmental data. Using an object-based image classification algorithm, SVG was derived from Google Street View images, capturing human-viewed street-level greenery. NDVI was derived from Landsat 8 satellite images using the normalized difference between the near-infrared and red bands. Park density was calculated by point density. In the main analyses including regressions, parallel mediation, interaction, and stratified models, the environmental metrics were measured within a 1000-m Euclidean buffer of residence., Results: SVG and park density were negatively associated with sitting time after adjusting for covariates including physical activity while NDVI was not significantly associated with sitting time, and results were robust with 800-1800 m Euclidean and 1400-1800 m network distance. Greenness-sitting associations were not moderated/mediated by perceived air pollution/roadside noise while SVG-sitting associations were moderated by objective NO 2 , O 3 , and PM 2.5 and mediated by O 3 . SVG-sitting associations differed by age, having under-school-aged children, birthplace, education, and occupation type while associations between traditional greenness metrics and prolonged sitting showed no significant population heterogeneity., Conclusions: SVG appears to be more accurate in estimating exposure than traditional metrics to reflect greenness-sitting associations, objective air pollution moderating and mediating roles, and population heterogeneity, which emphasizes the importance of street-level greenness planning for health promotion in terms of reducing sitting time., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim: Residential greenness was theoretically associated with health-related consumption behaviors concerning the socio-ecological model and restoration environment theory, but empirical studies were limited, especially in high-density cities. We examined the associations of residential greenness with unhealthy consumption behaviors (infrequent breakfast consumption, infrequent fruit consumption, infrequent vegetable consumption, alcohol drinking, binge drinking, cigarette smoking, moderate-to-heavy smoking, and heavy smoking) using street-view and conventional greenness metrics in high-density Hong Kong., Methods: This cross-sectional study employed survey data from 1,977 adults and residence-based objective environmental data in Hong Kong. Street-view greenness (SVG) was extracted from Google Street View images using an object-based image classification algorithm. Two conventional greenness metrics were used, including normalized difference vegetation index (NDVI) derived from Landsat 8 remote-sensing images and park density derived from a geographic information system database. In the main analyses, logistic regression analyses together with interaction and stratified models were performed with environmental metrics measured within a 1000-m buffer of residence., Results: A standard deviation higher SVG and NDVI were significantly associated with fewer odds of infrequent breakfast consumption (OR = 0.81, 95% CI 0.71-0.94 for SVG; OR = 0.83, 95% CI 0.73-0.95 for NDVI), infrequent fruit consumption (OR = 0.85, 95% CI 0.77-0.94 for SVG; OR = 0.85, 95% CI 0.77-0.94 for NDVI), and infrequent vegetable consumption (OR = 0.78, 95% CI 0.66-0.92 for SVG; OR = 0.81, 95% CI 0.69-0.94 for NDVI). The higher SVG was significantly associated with less binge drinking and the higher SVG at a 400-m buffer and a 600-m buffer were significantly associated with less heavy smoking. Park density was not significantly associated with any unhealthy consumption behaviors. Some of the above significant associations were moderated by moderate physical activity, mental and physical health, age, monthly income, and marital status., Conclusions: This study highlights the potential beneficial impact of residential greenness, especially in terms of street greenery, on healthier eating habits, less binge drinking, and less heavy smoking., Competing Interests: Declaration of Competing Interest The authors declare there is no conflict of interest., (Copyright © 2023 Elsevier GmbH. All rights reserved.)

(1) Background: Hypertension (HT) is the most common chronic condition, affecting approximately 1.13 billion people worldwide. Despite freely available blood pressure (BP) devices in primary care (PC) clinics, many patients do not regularly screen for HT and are untreated. (2) Methods: This study investigated the proportion of PC patients who did not screen for HT and the underlying reasons in Hong Kong. An explanatory mixed-method cross-sectional study was conducted in 2020, which included a questionnaire survey, office BP measurements, and subsequent semi-structured interviews. Adult patients who had no diagnosis of HT were recruited in a large PC clinic by convenience sampling. The relationships between not having HT screening and sociodemographic data were investigated by logistic regression. Twenty-four patients were purposefully sampled (based on demographics) and were interviewed until data saturation. (3) Results: Among 428 participants, 190 (44.4%) had not had HT screening in the last two years, but 197 (46.0%) had HT. No HT screening in the last two years or ever was associated with being male, being single, being of younger age, having no family history of HT, having no clinic visits in the last two years, employment status, and self-perceived HT condition. Most participants (77.8%) misinterpreted their BP readings. Individual, social, and healthcare service barriers were identified in patients' interviews. Many PC patients had no regular HT screening but around half had elevated BP. (4) Conclusion: The study results indicate that the barriers to HT screening were multifactorial. HT screening in PC is urgently needed.

Background: Different childhood experiences may affect adult health differently., Objective: To explore the association of different types of positive childhood experiences(PCEs) and adverse childhood experiences (ACEs) with risky behaviours and mental health indicators, andhow PCEs and ACEs are associated with health outcomes in the context of each other., Method: This was an exploratory cross-sectional online survey including 332 university students in Hong Kong. ACEs (abuse and household challenges), PCEs (perceived safety, positive quality of life, and interpersonal support), risky behaviours (smoking, binge drinking, and sexual initiation), and mental health indicators(depression, anxiety, loneliness, self-rated health, multimorbidity, meaning in life, and life satisfaction)were measured., Results: The multivariable logistic regression analysis indicated cumulative effects of PCEs in lowered risks of depression, anxiety, loneliness, as well as better self-rated health, life satisfaction, and meaning in life ( p  < .05), after adjusting for ACEs. Results also indicated that ACEs had an increasing relationship with poorer mental health indicators, such as anxiety, loneliness, and life satisfaction ( p  < .05), after adjusting for PCEs. There was also an adverse association between having ≥4 ACEs with smoking and binge drinking. In addition, each type of PCE and ACE was significantly associated with one or more risky behaviours and mental health indicators. Stratified results showed that PCEs had stronger associations with mental health indicators in participants with fewer ACEs. Furthermore, ACEs had stronger associations with mental health indicators in participants with more PCEs than in those with fewer PCEs., Conclusions: In this study, PCE was proven to be an independent protective factor against poor mental health after accounting for ACE. ACE was also proven to be an independent risk factor for poor mental health and risky behaviours. These findings suggest a crucial need for the active promotion of PCEs and the prevention of child maltreatment. The results of subtypes and stratifications can be taken into consideration when developing targeted interventions in the future., Highlights: PCE is an independent protective factor against poor mental health after accounting for ACE. ACE is an independent risk factor for poor mental health and risky behaviours.PCEs and ACEs have different associations with health outcomes in the context of one another., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Public rental housing (PRH) for low-income families has been shown in several studies to be associated with poor health status and obesity. However, the causes of this health disparity are controversial, and the associations and pathways between PRH and obesogenic behaviors remain unknown. Using cross-sectional survey data of 1977 adults living in Hong Kong (aged or over 18) together with multi-source GIS-based environmental data, we examined the associations between PRH and obesogenic behaviors and the extent to which those associations can be explained by neighborhood food and physical environment. The unhealthy food environment, which relates with infrequent fruit and vegetables consumption, was calculated based on the relative density of fast food restaurants and convenience stores to grocery stores. The physical activity environment, which relates to physical inactivity and prolonged sitting, was assessed in terms of density of sports facilities and street greenery, separately. Regressions and mediation analyses show that PRH was negatively associated with physical inactivity directly and also indirectly via higher sports facilities density; however, PRH was positively associated with unhealthy diet largely directly and positively associated with prolonged sitting indirectly via less street greenery. We advanced the international literature of PRH health impact assessment and its environmental health pathways by providing evidence from the least housing-affordable city in the world. The findings provide planning implications in formulating a healthier PRH community for these low-income PRH households and mitigating health disparities induced by housing type.

Background: Social distancing and "stay-at-home" orders are essential to contain the coronavirus outbreak; however, there are growing concerns about physical and other mental distress in older people. Apart from quantitative data, their feelings, thoughts, and experience are essential to inform the implementation of patient-centered health care policy., Aim: This study explained the psychosocial effects of COVID-19 on Hong Kong Chinese older people., Design and Setting: This was a qualitative study. Twenty-three participants aged between 63 and 86 were recruited in primary care through purposive sampling., Method: Semi-structured in-depth telephone interviews were conducted to explore participants' experience during the COVID-19 pandemic. Grounded theory was used to analyze the data., Results: Three themes, nine subthemes, and 24 quotes were identified. The 3 themes included the psychological response of fear, annoyance, and worrisome; social isolation leading to loneliness and physical exhaustion; and the coping strategies in adversity. Fear was the major emotional response, which was not entirely explained by the uncertainty of the disease, but also the embedded routines norms and values. Loneliness was aggravated by the depleted family and community support. Physical distancing had intensified ones physical demand on self-care, especially among those with comorbid illnesses. The use of digital tools and telecommunications maintained the social connection, but the overexposure had led to a vicious cycle of anxiety and distress., Conclusion: Self-isolation has disproportionately affected older individuals whose only social contact is out of the home. Online technologies can be harnessed to provide social support networks and a sense of belonging, but its adaptive and positive uses should be encouraged. Interventions can also involve more frequent telephone contact with significant others, close family and friends, voluntary organizations, or health-care professionals, or community outreach teams. Enhancing the values of older people's in calamity through active engagement may also potentially reduce the detrimental effect of social isolation.

Background: Due to active involvement with patients for COVID-19 treatments, nurses are susceptible to adverse psychological outcomes amid the COVID-19 pandemic. Despite the distress, studies have suggested that nurses are able to experience positive changes (i.e. posttraumatic growth; PTG) during the pandemic. Research on other populations has also indicated that COVID-19-specific worries and work-related coping resources are associated with people's positive changes during the pandemic., Objective: This study examined how socio-demographic characteristics, COVID-19-related worries, and work-related variables (satisfaction with work and workplace pandemic guidelines) were associated with PTG among nurses in Hong Kong., Methods: Nurses ( N  = 1510) working in hospitals and community settings were recruited through nursing associations in Hong Kong between 8 August 2020 and 22 September 2020. They were invited to complete a cross-sectional survey measuring their sociodemographic characteristics, COVID-19 worries, and satisfaction with work and workplace pandemic-control measures., Results: Results from hierarchical regressions found that those working non-full-time ( β  = -0.06), affiliating with a religion ( β  = 0.24), having higher COVID-19-related worries and psychological distress ( βs ranging from 0.12-0.15), and having higher work satisfaction ( β  = 0.14) were associated with higher PTG ( ps  < .05). Moreover, a significant interaction between psychological distress and satisfaction with workplace pandemic control guidelines emerged in explaining PTG ( β  = 0.08, p < .05), such that guideline satisfaction was only associated with higher PTG among those with higher distress ( β  = 0.09, p = .03), but not those with lower distress ( β  = -0.05, p > .05)., Conclusions: Nurses in Hong Kong did report positive changes amid the COVID-19 pandemic. Future studies could focus on the contributing factors of PTG to design for effective strategies to enhance resources for nurses to promote positive psychosocial outcomes., Competing Interests: No potential conflict of interest was reported by the author(s)., (© 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.)

Background: Along with individual-level factors, vaccination-related characteristics are important in understanding COVID-19 vaccine hesitancy. This study aimed to determine the influence of these characteristics on vaccine acceptance to formulate promotion strategies after considering differences among respondents with different characteristics. Methods: An online discrete choice experiment was conducted among people aged 18-64 years in Hong Kong, China, from 26 to 28 February 2021. Respondents were asked to make choices regarding hypothetical vaccination programmes described by vaccination-related characteristics-the attributes derived from a prior individual interview. Subgroup analysis was performed to identify the differences in vaccination-related characteristics among respondents with different personal characteristics. Results: A total of 1,773 respondents provided valid responses. The vaccine efficacy and brand were the most important factors affecting acceptance, followed by the exemption of quarantine for vaccinated travelers, safety, venue for vaccination, vaccine uptake of people in their lives, and recommendations by general physicians or government. Frequent exposure to vaccination information on social media has been associated with increasing vaccine refusal. Substantial preference heterogeneity for the attributes was found among people of different ages, incomes, chronic conditions, and previous acceptance of influenza vaccines. Conclusion: The findings provided evidence to formulate interventions to promote vaccine uptake, including the provision of vaccination at housing estate or workplaces, involvement of general physicians and interpersonal communication in vaccine promotion and information dissemination, and exemption of quarantine for vaccinated people. Moreover, social media is a significant information channel that cannot be neglected in the dissemination of official information., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Wang, Wong, Cheung, Yau, Chung, Wong, Dong, Wong and Yeoh.)

Although coronavirus disease (COVID-19) outbreaks have been relatively well controlled in Hong Kong, containment remains challenging among socioeconomically disadvantaged persons. They are at higher risk for widespread COVID-19 transmission through sizable clustering, probably because of exposure to social settings in which existing mitigation policies had differential socioeconomic effects.

The severity of COVID-19 infections could be exacerbated by the epidemic of chronic diseases and underlying inequalities in social determinants of health. Nonetheless, there is scanty evidence in regions with a relatively well-controlled outbreak. This study examined the socioeconomic patterning of COVID-19 severity and its effect modification with multimorbidity in Hong Kong. 3074 local COVID-19 cases diagnosed from 5 July to 31 October 2020 were analyzed and followed up until 30 November 2020. Data on residential addresses, socio-demographic background, COVID-19 clinical conditions, and pre-existing chronic diseases of confirmed cases were retrieved from the Centre for Health Protection and the Hospital Authority. Results showed that, despite an independent adverse impact of multimorbidity on COVID-19 severity (aOR = 2.35 [95% CI = 1.72-3.19]), it varied across the socioeconomic ladder, with no significant risk among those living in the wealthiest areas (aOR = 0.80 [0.32-2.02]). Also, no significant association of the area-level income-poverty rate with severe COVID-19 was observed. In conclusion, the socioeconomic patterning of severe COVID-19 was mild in Hong Kong. Nonetheless, socioeconomic position interacted with multimorbidity to determine COVID-19 severity with a mitigated risk among the socioeconomically advantaged. Plausible explanations include the underlying socioeconomic inequalities in chronic disease management and the equity impact of the public-private dual-track healthcare system.

Objectives: To assess the prevalence of potentially inappropriate medication (PIM) use in Hong Kong older patients visiting general outpatient clinics (GOPCs) between 2006 and 2014 and to identify factors associated with PIM use among older adults visiting GOPCs in 2014., Design: Cross-sectional study., Setting: GOPC., Participants: Two study samples were constructed including a total of 844 910 patients aged 65 and above from 2006 to 2014 and a cohort of 489 301 older patients in 2014., Measurements: Two subsets of the 2015 American Geriatrics Society Beers criteria-PIMs independent of diagnosis and PIMs due to drug-disease interactions-were used to estimate the prevalence of PIM use over 12 months. PIMs that were not included in the Hospital Authority drug formulary or with any specific restriction or exception in terms of indication, dose or therapy duration were excluded. Characteristics of PIM users and non-PIM users visiting GOPCs in 2014 were compared. Independent associations between patient variables and PIM use were assessed by stepwise multivariable logistic regression analysis., Results: The 12-month period prevalence of PIM use decreased from 55.56% (95% CI 55.39% to 55.72%) in 2006 to 47.51% (95% CI 47.37% to 47.65%) in 2014. In the multivariable regression analysis, the strongest factor associated with PIM use was the number of different drugs prescribed (adjusted OR, AOR 23.01, 95% CI 22.36 to 23.67). Being female (AOR 0.89, 95% CI 0.85 to 0.87 for males vs females) and having a greater number of GOPC visits (AOR 1.83, 95% CI 1.78 to 1.88) as well as more than six diagnoses (AOR 1.43, 95% CI 1.36 to 1.52) were associated with PIM use., Conclusions: The overall prevalence of PIM use in older adults visiting GOPCs decreased from 2006 to 2014 in Hong Kong although the prevalence of PIM use was still high in 2014. Patients with female gender, a larger number of medications prescribed, more frequent visits to GOPCs, and more than six diagnoses were at higher risk for PIM use., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background : During the coronavirus disease 2019 (COVID-19) pandemic, the implementation of social distancing and home confinement measures may elevate the risk of vitamin D deficiency particularly for infants. This study aimed to quantify changes in vitamin D level among infants and toddlers in Hong Kong after the COVID-19 outbreak. Methods: We recruited 303 infants and toddlers aged 2-24 months by stratified random sampling from 1 June 2019 to November 30, 2020. Regression models were used to estimate the effect of time on infants' serum 25-hydroxyvitamin D (25(OH)D) level overall and by age groups before and after the outbreak. Interrupted time series (ITS) analysis was performed to examine the sustained effect of COVID-19 on their serum 25(OH)D level. Results: The ITS results showed no immediate reduction in serum 25(OH)D level among infants, but a decreasing trend was observed in the subsequent months post-outbreak at a monthly decline rate of -6.32 nmol/L. When analyzed by age group, the magnitude of post-outbreak reduction in 25(OH)D was stronger among younger infants (aged 2-6 months). Conclusion: Guidelines and recommendations should be given to pregnant women and mothers to ensure sufficient vitamin D level in their infants during the COVID-19 period.

Recent evidence suggests that breastfeeding may increase the risk of vitamin D deficiency in offspring. However, it is unclear whether increased risk results from breastfeeding alone, or whether it is associated together with other risk factors. This study surveyed 208 infant-mother dyads recruited by stratified random sampling in different districts of Hong Kong. Mothers were asked to complete a questionnaire on their demographics, history of risk behavior, and feeding practices. Peripheral blood samples were collected from infants to determine their vitamin D status. Among all infant participants, 70 were vitamin D insufficient or deficient. Being breastfed, being a girl, having a multiparous mother, and the use of sun cream were found to be the strongest risk factors for vitamin D insufficiency during infancy (all p < 0.05), after mutual adjustment. The cumulative risk model displayed a dose-response pattern between the number of risk factors and the risk of vitamin D insufficiency during this period. Our findings indicate the risk profile of infants with insufficient vitamin D. Guidelines and recommendations on healthy diet and lifestyle should be provided to mothers during the early stage of pregnancy to increase the likelihood of adequate levels of vitamin D in their offspring.

Background : Standard precautions prevent the spread of infections in healthcare settings. Incompliance with infection control guidelines of healthcare workers (HCWs) may increase their risk of exposure to infectious disease, especially under pandemics. The purpose of this study was to assess the level of compliance with the infection prevention and control practices among HCWs in different healthcare settings and its relationship with their views on workplace infection control measures during the COVID-19 pandemic. Methods : Nurses in Hong Kong were invited to respond to a cross-sectional online survey, in which their views on workplace infection and prevention policy, compliance with standard precautions and self-reported health during pandemics were collected. Results : The respondents were dissatisfied with workplace infection and prevention policy in terms of comprehensiveness (62%), clarity (64%), timeliness (63%), and transparency (60%). For the protective behavior, the respondents did not fully comply with the standard precautions when they were involved in medical care. Their compliance was relatively low when having proper patient handling (54%) and performing invasive procedures (46%). A multivariate analysis model proved that the level of compliance of the standard precautions was positively associated with the satisfaction on infection control and prevention policy among high risk group (0.020; 95% CI: 0.005-0.036), while older respondents had higher level of compliance among the inpatient and outpatient groups (coefficient range: 0.065-0.076). The higher level of compliance was also significantly associated with working in designated team and having chronic condition of the respondents among high-risk and inpatient groups. Conclusions : Standard precautions are the most important elements to reduce cross-transmission among HCWs and patients while the satisfaction on infection control and prevention policy would increase the compliance among the high-risk group. An overall suboptimal compliance and poor views on the infection prevention and control guidelines is a warning signal to healthcare system especially during pandemics.

Background: Given the public health responses to previous respiratory disease pandemics, and in the absence of treatments and vaccines, the mitigation of the COVID-19 pandemic relies on population engagement in nonpharmaceutical interventions. This engagement is largely driven by risk perception, anxiety levels, and knowledge, as well as by historical exposure to disease outbreaks, government responses, and cultural factors., Objective: The aim of this study is to compare psychobehavioral responses in Hong Kong and the United Kingdom during the early phase of the COVID-19 pandemic., Methods: Comparable cross-sectional surveys were administered to adults in Hong Kong and the United Kingdom during the early phase of the epidemic in each setting. Explanatory variables included demographics, risk perception, knowledge of COVID-19, anxiety level, and preventive behaviors. Responses were weighted according to census data. Logistic regression models, including effect modification to quantify setting differences, were used to assess the association between the explanatory variables and the adoption of social distancing measures., Results: Data from 3431 complete responses (Hong Kong, 1663; United Kingdom, 1768) were analyzed. Perceived severity of symptoms differed by setting, with weighted percentages of 96.8% for Hong Kong (1621/1663) and 19.9% for the United Kingdom (366/1768). A large proportion of respondents were abnormally or borderline anxious (Hong Kong: 1077/1603, 60.0%; United Kingdom: 812/1768, 46.5%) and regarded direct contact with infected individuals as the transmission route of COVID-19 (Hong Kong: 94.0%-98.5%; United Kingdom: 69.2%-93.5%; all percentages weighted), with Hong Kong identifying additional routes. Hong Kong reported high levels of adoption of various social distancing measures (Hong Kong: 32.6%-93.7%; United Kingdom: 17.6%-59.0%) and mask-wearing (Hong Kong: 98.8% (1647/1663); United Kingdom: 3.1% (53/1768)). The impact of perceived severity of symptoms and perceived ease of transmission of COVID-19 on the adoption of social distancing measures varied by setting. In Hong Kong, these factors had no impact, whereas in the United Kingdom, those who perceived their symptom severity as "high" were more likely to adopt social distancing (adjusted odds ratios [aORs] 1.58-3.01), and those who perceived transmission as "easy" were prone to adopt both general social distancing (aOR 2.00, 95% CI 1.57-2.55) and contact avoidance (aOR 1.80, 95% CI 1.41-2.30). The impact of anxiety on adopting social distancing did not vary by setting., Conclusions: Our results suggest that health officials should ascertain baseline levels of risk perception and knowledge in populations, as well as prior sensitization to infectious disease outbreaks, during the development of mitigation strategies. Risk should be communicated through suitable media channels-and trust should be maintained-while early intervention remains the cornerstone of effective outbreak response., (©Leigh Bowman, Kin On Kwok, Rozlyn Redd, Yuanyuan Yi, Helen Ward, Wan In Wei, Christina Atchison, Samuel Yeung-Shan Wong. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.03.2021.)

Objectives: Globally, the COVID-19 pandemic has overwhelmed many healthcare systems, which has hampered access to routine clinical care during lockdowns. Informal home care, care provided by non-healthcare professionals, increases the community's healthcare capacity during pandemics. There is, however, limited research about the characteristics of informal home care providers and the challenges they face during such public health emergencies., Design: A random, cross-sectional, population-based, RDD, telephone survey study was conducted to examine patterns of home care, characteristics of informal home care providers and the challenges experienced by these care providers during this pandemic., Setting: Data were collected from 22 March to 1 April 2020 in Hong Kong, China., Participants: A population representative study sample of Chinese-speaking adults (n=765) was interviewed., Primary and Secondary Outcome Measures: The study examined the characteristics of informal home care providers and self-reported health requirements of those who needed care. The study also examined providers' self-perceived knowledge to provide routine home care as well as COVID-19 risk reduction care. Respondents were asked of their mental health status related to COVID-19., Results: Of the respondents, 25.1% of 765 provided informal home care during the studied COVID-19 pandemic period. Among the informal home care providers, 18.4% of respondents took leave from school/work during the epidemic to provide care for the sick, fragile elderly and small children. Care providers tended to be younger aged, female and housewives. Approximately half of care providers reported additional mental strain and 37.2% reported of challenges in daily living during epidemic. Although most informal home care providers felt competent to provide routine care, 49.5% felt inadequately prepared to cope with the additional health risks of COVID-19., Conclusion: During public health emergencies, heavy reliance on informal home healthcare providers necessitates better understanding of their specific needs and increased government services to support informal home care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: In response to population aging, there is a need for health systems to focus on care for chronic disease, specifically palliative care, while focusing on people-centered care. The objective of this study is to explore the healthcare system enablers and barriers to the provision of quality palliative and end-of-life care from the perspective of healthcare professionals., Materials and Methods: Using purposive sampling, fifteen focus group interviews and nine individual interviews involving 72 healthcare providers were conducted. Primary qualitative data were collected between May 2016 and July 2017. All recorded discussions were transcribed verbatim and analyzed. A thematic framework was developed., Results: The provision of quality palliative and end-of-life care is influenced by the interaction and integration of nine sub-themes under four identified themes: (1) political context; (2) organization setting; (3) support to patients, caregivers, and family members, and (4) healthcare workers and the public., Conclusions: Integration of palliative and end-of-life care is an important pillar of healthcare service to improve quality of life by addressing patients' values, wishes and preference, and assist their family to handle challenges at the end stage of life. Further improvements to the service framework would be required, specifically in the political framework, multidisciplinary approach, and readiness and competence in healthcare workers and community. These were highlighted in our study as key components in service provision to ensure that patients can receive continuous and integrated care between hospitals and the community as well as dignified care at the end stage of life.

Background: We examined the association of housing affordability with physical and mental health in Hong Kong, where there is a lack of related research despite having the worst housing affordability problem in the world, considering potential mediating effect of deprivation., Methods: A stratified random sample of 1978 Hong Kong adults were surveyed. Housing affordability was defined using the residual-income (after housing costs) approach. Health-related quality of life was assessed by the Short-Form Health Survey version 2 (SF-12v2), from which the physical component summary (PCS) and mental component summary (MCS) measures were derived. Multivariable linear regressions were performed to assess associations of housing affordability with PCS and MCS scores, adjusting for sociodemographic, socioeconomic and lifestyle factors. Mediation analyses were also conducted to assess the mediating role of deprivation on the effect of housing affordability on PCS or MCS., Results: Dose-response relationships were observed between housing affordability and mean PCS score ( β (95% CI) compared with the highest affordable fourth quartile: -2.53 (-4.05 to -1.01), -2.23 (-3.54 to -0.92), -0.64 (-1.80 to 0.51) for the first, second and third quartiles, respectively) and mean MCS score ( β (95% CI): -3.87 (-5.30 to -2.45), -2.35 (-3.59 to -1.11), -1.28 (-2.40 to -0.17) for the first, second and third quartiles, respectively). Deprivation mediated 34.3% of the impact of housing unaffordability on PCS and 15.8% of that on MCS., Conclusions: Housing affordability affects physical and mental health, partially through deprivation, suggesting that housing policies targeting deprived individuals may help reduce health inequality in addition to targeting the housing affordability problem., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Poverty and ill-health are closely inter-related. Existing studies on the poverty-health vicious cycle focus mainly on less developed countries, where the identified mechanisms linking between poverty and ill-health may not fit the situations in developed Asian regions. This study aims to qualitatively explore the perceived mechanisms and drivers of the poverty-health vicious cycle among major stakeholders in the healthcare setting in Hong Kong., Methods: Data were collected via focus group interviews with social workers (n = 8), chronically ill patients (n = 8), older adults (n = 6), primary care doctors (n = 7) and informal caregivers (n = 10). The transcribed data were then closely read to capture key themes using thematic analyses informed by social constructivism., Results: In this highly developed Asian setting with income inequality among the greatest in the world, the poverty-health vicious cycle operates. Material and social constraints, as a result of unequal power and opportunities, appear to play a pivotal role in creating uneven distribution of social determinants of health. The subsequent healthcare access also varies across the social ladder under the dual-track healthcare system in Hong Kong. As health deteriorates, financial hardship is often resulted in the absence of sufficient and coordinated healthcare, welfare and labour policy interventions. In addition to the mechanisms, policy drivers of the cycle were also discussed based on the respondents' perceived understanding of the nature of poverty and its operationalization in public policies, as well as of the digressive conceptions of disease among different stakeholders., Conclusions: The poverty-health vicious cycle has remained a great challenge in Hong Kong despite its economic prosperity. To break the cycle, potential policy directions include the adoption of proportionate universalism, social integration and the strengthening of medical-social collaboration.

Background: Individual-level deprivation takes into account the non-monetary aspects of poverty that neither income poverty nor socio-economic factors could fully capture; however, it has rarely been considered in existing studies on social inequality in obesity. Therefore, we examined the associations of deprivation, beyond income poverty, with both general and abdominal obesity., Methods: A territory-wide two-stage stratified random sample of 2282 community-dwelling Hong Kong adults was surveyed via face-to-face household interviews between 2014 and 2015. Deprivation was assessed by a Deprivation Index specific to the Hong Kong population. General obesity was defined as body mass index (BMI) ≥ 25 kg/m2, while abdominal obesity was defined as waist circumference (WC) ≥ 90 cm/80 cm for male/female. Multivariable binary logistic regressions were performed., Results: Deprivation was independently associated with abdominal obesity (odds ratios (OR) = 1.68; 95% confidence intervals (CI): 1.27-2.22); however, no significant association was found with general obesity (OR=1.03; CI: 0.77-1.38). After additional adjustment for BMI, deprivation remained strongly associated with abdominal obesity (OR=2.00; CI: 1.41-2.83); and after further adjustment for WC, deprivation had a marginal inverse association with general obesity (OR=0.72; CI: 0.51-1.01)., Conclusions: Deprivation is an important risk factor of abdominal obesity and plays a critical role in capturing the preferential abdominal fat deposition beyond income poverty., (© The Author(s) 2018. Published by Oxford University Press on behalf of Faculty of Public Health. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Although Hong Kong is one of the richest cities in the world and has some of the best health outcomes such as long life expectancy, little is known about the people who are unable to access healthcare due to lack of financial means. Cross-sectional data from a sample of 2,233 participants aged 18 or above was collected from the first wave of the "Trends and Implications of Poverty and Social Disadvantages in Hong Kong" survey. Socio-demographic factors, lifestyle factors, and physical and mental health conditions associated with people who were unable to seek medical services due to lack of financial means in the past year were examined using forward stepwise logistic regression analyses. Of the 2,233 participants surveyed, 8.4% did not seek medical care due to lack of financial means during the past year. They were more likely to be income-poor. With respect to physical and mental health, despite having less likelihood to have multimorbidity, they tended to have higher levels of both anxiety and stress, poorer physical and mental health-related quality of life, and suffer from more severe disability and pain symptoms affecting their daily activities, when compared to the rest of the Hong Kong population. People who were denied of medical care due to financial barriers are generally sicker than people in the general Hong Kong population, implying that those with greater healthcare needs may have financial difficulties in receiving timely and appropriate medical care. Our findings suggest that inequity in healthcare utilization remains a critical issue in Hong Kong., Competing Interests: The authors have declared that no competing interests exist.

Background: The association of dietary sugar intake and skeletal health remains uncertain in the elderly. We aimed to investigate the association of sugar intake with the bone health and mortality of Chinese elderly., Methods: An analysis was conducted through an 11-year longitudinal study (Mr. and Ms. OS Hong Kong). Four thousand Chinese elderly aged 65 and older were recruited from the local community between 2001 and 2003. Sugar intake was assessed at baseline by a validated 329-item Food Frequency Questionnaire and a local sugar database. The bone mineral density (BMD) was examined at baseline and the fourth year follow-up by a dual-energy X-ray absorptiometry. Data on the incidence of non-traumatic fractures (total, hip and osteoporotic sites) and all-cause mortality were collected. The multivariable logistic and Cox regression models were used to test the associations of sugar intake with bone health and all-cause mortality., Results: No significant association was observed between sugar intakes and BMD changes in the fourth year's follow-up. During a total 34,483 person years' follow-up, we documented 433 non-traumatic fractures and 769 deaths. Although lack of significant association with the incidence of non-traumatic fractures, high added sugar intakes were significantly associated with a low risk of all-cause mortality among the elderly with a hazard ratio of 0.750 (95% CI: 0.590-0.954, P for trend = 0.007) in the highest quintile compared with that in the lowest quintile., Conclusion: The amount of sugar consumed by the Chinese elderly did not pose any risk of bone loss and fracture. Moreover, high sugar intake of the elderly was associated with a low rate of all-cause mortality., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Meaning in life is not only a significant component of psychological well-being, but also a neglected issue with clinical importance that needs to be studied further, especially its association with health and healthcare utilization., Objective: To study the level of meaning and its association with happiness, health and healthcare utilization among the elderly in Hong Kong., Methods: A cross-sectional survey via telephone was conducted among 1000 elderly aged 60 years or above in Hong Kong., Results: Higher level of meaning was associated with being quite/very happy, and better health status (better self-rated health status, less chronic illnesses, lower level of frailty, no limitation of activities) before and after adjustments. It was also associated with decreased likelihood of healthcare utilization (number of medications intake, hospitalization and Acute and Emergency (A&E) admission) before and after adjusted for socio-demographics. Path analysis showed that, the association of meaning with hospitalization, A&E admission and medication use was significantly mediated by health status among the elderly., Limitations: This cross-sectional study might not include all the potential associated factors and mediators., Conclusions: The sense of meaning is associated with happiness and may contribute to health and healthcare utilization among the Chinese elderly. Studies are needed to further look into the potential mechanisms. Meaning in life might be a promising interventional target for successful aging of the elderly., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Introduction: The management of human epidermal growth factor receptor 2 (HER2)-positive breast cancer has changed dramatically with the introduction and widespread use of HER2-targeted therapies. There is, however, relatively limited real-world information about the effectiveness and safety of trastuzumab emtansine (T-DM1) in Hong Kong Chinese patients. We assessed the efficacy and toxicity profiles among local patients with HER2-positive advanced breast cancer who had received T-DM1 therapy in the second-line setting and beyond., Methods: This retrospective study involved five local centres that provide service for over 80% of the breast cancer population in Hong Kong. The study period was from December 2013 to December 2015. Patients were included if they had recurrent or metastatic histologically confirmed HER2+ breast cancer who had progressed after at least one line of anti-HER2 therapy including trastuzumab. Patients were excluded if they received T-DM1 as first-line treatment for recurrent or metastatic HER2+ breast cancer. Patient charts including biochemical and haematological profiles were reviewed for background information, T-DM1 response, and toxicity data. Adverse events were documented during chemotherapy and 28 days after the last dose of medication., Results: Among 37 patients being included in this study, 28 (75.7%) had two or more lines of anti-HER2 agents and 26 (70.3%) had received two or more lines of palliative chemotherapy. Response assessment revealed that three (8.1%) patients had a complete response, eight (21.6%) a partial response, 11 (29.7%) a stable disease, and 12 (32.4%) a progressive disease; three patients could not be assessed. The median duration of response was 17.3 (95% confidence interval, 8.4-24.8) months. The clinical benefit rate (complete response + partial response + stable disease, ≥12 weeks) was 37.8% (95% confidence interval, 22.2%-53.5%). The median progression-free survival was 6.0 (95% confidence interval, 3.3- 9.8) months and the median overall survival had not been reached by the data cut-off date. Grade 3 or 4 toxicities included thrombocytopaenia (13.5%), raised alanine transaminase (8.1%), anaemia (5.4%), and hypokalaemia (2.7%). No patient died as a result of toxicities., Conclusions: In patients with HER2-positive advanced breast cancer who have been heavily pretreated with anti-HER2 agents and cytotoxic chemotherapy, T-DM1 is well tolerated and provided a meaningful progression-free survival of 6 months and an overall survival that has not been reached. Further studies to identify appropriate patient subgroups are warranted.

Using data collected from 25,780 Hong Kong citizens in a household survey, this study aimed to investigate the association between having regular source of primary care and hospitalization amongst people with and without multimorbidity (two or more chronic conditions). Potential interaction effects of regular primary care with multimorbidity were also examined. Results revealed a significant association between having regular source of primary care from General Practitioners and reduced hospitalization amongst respondents with multimorbidity (RR = 0.772; 95% CI = 0.667-0.894), adjusting for other potential confounding factors (i.e., socio-demographic factors and medical insurance and benefits). In contrast, having regular Specialist care was significantly associated with increased risk of hospitalization among both people with multimorbidity (RR = 1.619; 95% CI = 1.256-2.087) and without multimorbidity (RR = 1.981; 95% CI = 1.246-3.149), adjusting for potential confounders. A dose-response relationship between the number of chronic diseases and hospitalization was also observed, regardless of whether participants had regular source of primary care or not; relative risks and predicted probabilities for hospitalization were generally greater for those without regular source of primary care. Further studies are warranted to explore the role of healthcare system, informatics, organizational and practice-related factors on healthcare and functional outcomes.

The Human Papillomavirus (HPV) vaccine has the great potential to prevent HPV-related infections for millions of women and men worldwide. However, the success of the vaccine is highly dependent on the vaccination rate. Factors influencing the attitudes of undergraduate students towards HPV vaccination should be studied. This is a cross-sectional survey that was conducted to estimate the HPV vaccination rate among undergraduate students in Hong Kong, and to identify the predictors of their attitude towards HPV vaccination. The results showed that the HPV vaccination rate was 13.3%. Factors related to knowledge of vaccination were the main predictors of the students' attitude towards vaccination (there were seven predictors, with B = 1.36 to 2.30; p < 0.05), followed by gender (B = -1.40; p < 0.05), acceptable maximum price (B = 0.35; p < 0.05), and willingness to receive the HPV vaccine if it can protect against cervical/anal cancer and genital warts (B = -1.90; p < 0.001). The regression model that was developed based on the predictors had a moderate effect size (adj-R² = 0.33). To conclude, the HPV vaccination rate among undergraduate students in Hong Kong was low. They should be provided with more active education and activities to promote HPV vaccination to improve their knowledge on the subject.

The role of fruit and vegetable (FV) intake in relation to prostate health remains inconclusive. This 4-year longitudinal study aims to explore the association of FV intake and the development of lower urinary tract symptoms (LUTS, a cluster of chronic urinary symptoms occurring in bladder, prostate and urethra), incidence of symptomatic benign prostatic hyperplasia (BPH) and erectile dysfunction (ED) in Chinese elderly men. Data were obtained from a 4 years longitudinal study (Mr OS Hong Kong, the largest prospective study on bone health in Chinese elderly). Two thousand Chinese men aged 65 years and older were recruited from the local community, of whom 1998 (99.9%) at baseline and 1564 (78.2%) at 4-year follow-up reported data on LUTS, which were evaluated by a validated International Prostate Symptoms Scale (IPSS). Erectile function was evaluated by the International Index of Erectile Dysfunction-5 (IIEF-5) questionnaires at 2- (n = 386) and 4-year (n = 475) follow-ups. Dietary intake was assessed using a validated food frequency questionnaire at baseline. Analysis was conducted using multivariate linear and logistic regression. For total FV and most of their subclasses, moderate consumption had the lowest mean changes of LUTS; we thus applied the moderate levels as the reference in the regression models. The high levels of total FV intake (>350  g/1000  kcal/day) were significantly associated with reduced IPSS by scores of -1.174 ± 0.459 (or -17.3% of basal IPSS, P = 0.011) relative to the moderate groups (250-350  g/1000  kcal/day). FV consumption had no significant association with the score change of ED or the odds of sexual activities at 4-year (all P > 0.05). High intake of dark and leafy vegetables (>50  g/1000  kcal/day) significantly reduced the risk of LUTS progression by 37.2% [odds ratio (OR) (95% confidence interval, 95% CI): 0.628 (0.466∼0.848), P = 0.002] or risk of symptomatic BPH by 34.3% [OR (95% CI): 0.657 (0.442-0.976), P = 0.038] after 4 years compared with the moderate group (25-50  g/1000  kcal/day). Adequate FV intakes, especially dark and leafy vegetables, were associated with improved LUTS among Chinese elderly men, but lack an association with ED and sexuality., Competing Interests: The authors declare that they have no competing interests. All the authors declare no conflict of interest.

Background: The increase in non-communicable disease (NCD) is becoming a global health problem and there is an increasing need for primary care doctors to look after these patients although whether family doctors are adequately trained and prepared is unknown., Objective: This study aimed to determine if doctors with family medicine (FM) training are associated with enhanced empathy in consultation and enablement for patients with chronic illness as compared to doctors with internal medicine training or without any postgraduate training in different clinic settings., Methods: This was a cross-sectional questionnaire survey using the validated Chinese version of the Consultation and Relational Empathy (CARE) Measure as well as Patient Enablement Instrument (PEI) for evaluation of quality and outcome of care. 14 doctors from hospital specialist clinics (7 with family medicine training, and 7 with internal medicine training) and 13 doctors from primary care clinics (7 with family medicine training, and 6 without specialist training) were recruited. In total, they consulted 823 patients with chronic illness. The CARE Measure and PEI scores were compared amongst doctors in these clinics with different training background: family medicine training, internal medicine training and those without specialist training. Generalized estimation equation (GEE) was used to account for cluster effects of patients nested with doctors., Results: Within similar clinic settings, FM trained doctors had higher CARE score than doctors with no FM training. In hospital clinics, the difference of the mean CARE score for doctors who had family medicine training (39.2, SD = 7.04) and internal medicine training (35.5, SD = 8.92) was statistically significant after adjusting for consultation time and gender of the patient. In the community care clinics, the mean CARE score for doctors with family medicine training and those without specialist training were 32.1 (SD = 7.95) and 29.2 (SD = 7.43) respectively, but the difference was not found to be significant. For PEI, patients receiving care from doctors in the hospital clinics scored significantly higher than those in the community clinics, but there was no significant difference in PEI between patients receiving care from doctors with different training backgrounds within similar clinic setting., Conclusion: Family medicine training was associated with higher patient perceived empathy for chronic illness patients in the hospital clinics. Patient enablement appeared to be associated with clinic settings but not doctors' training background. Training in family medicine and a clinic environment that enables more patient doctor time might help in enhancing doctors' empathy and enablement for chronic illness patients.

Introduction: Multimorbidity has been well researched in terms of consequences and healthcare implications. Nevertheless, its risk factors and determinants, especially in the Asian context, remain understudied. We tested the hypothesis of a negative relationship between socioeconomic status and multimorbidity, with contextually different patterns from those observed in the West., Methods: We conducted our study in the general Hong Kong (HK) population. Data on current health conditions, health behaviours, socio-demographic and socioeconomic characteristics was obtained from HK Government's Thematic Household Survey. 25,780 individuals aged 15 or above were sampled. Binary logistic and negative binomial regression analyses were conducted to identify risk factors for presence of multimorbidity and number of chronic conditions, respectively. Sub-analysis of possible mediation effect through financial burden borne by private housing residents on multimorbidity was also conducted., Results: Unadjusted and adjusted models showed that being female, being 25 years or above, having an education level of primary schooling or below, having less than HK$15,000 monthly household income, being jobless or retired, and being past daily smoker were significant risk factors for the presence of multimorbidity and increased number of chronic diseases. Living in private housing was significantly associated with higher chance of multimorbidity and increased number of chronic diseases only after adjustments., Conclusions: Less advantaged people tend to have higher risks of multimorbidity and utilize healthcare from the public sector with poorer primary healthcare experience. Moreover, middle-class people who are not eligible for government subsidized public housing may be of higher risk of multimorbidity due to psychosocial stress from paying for the severely unaffordable private housing.

Lifestyle factors have been linked to bone health, however little is known about their combined impact on bone. Cardiovascular disease (CVD) and osteoporosis are 2 major public health problems that share some common pathophysiology. We aimed to assess whether higher adherence to American Heart Association diet and lifestyle recommendations (AHA-DLR) was associated with better bone health in Chinese elderly.This was a cross-sectional study using data from the largest population-based study on osteoporosis in Asia (Mr and Ms Os, Hong Kong). The study recruited 4000 independent walking Chinese men and women aged ≥65 year. Information on demographic, health, and lifestyle factors was obtained by standardized questionnaires. An overall lifestyle score was estimated based on a modified adherence index of AHA-DLR. Bone mineral measurements of the whole body, total hip, lumbar spine, and femoral neck were made by dual-energy X-ray absorptiometry.Most lifestyle factors alone were not significantly associated bone mass. Overall lifestyle score in the highest quartile compared with the lowest quartile had significantly better bone mass at all sites in a dose-response manner. Every 10-unit of lifestyle score increase was associated with 0.005, 0.004, and 0.007 g/cm increases of bone mineral density (BMD) at whole body, femur neck, and total hip, respectively (all P < 0.05), and 13.2% (odds ratio 0.868; 95% CI 0.784, 0.961) decreased risk of osteoporosis at total hip after adjustment for potential covariates.Our study suggested that greater adherence to an overall healthy lifestyle for CVD risk reduction was associated with better bone mass among Chinese elderly.

Objective: To examine the diagnostic performance of shorter versions of Alcohol Use Disorder Identification Test (AUDIT), including Alcohol Consumption (AUDIT-C), in identifying risky drinkers in primary care settings using conventional performance measures, supplemented by decision curve analysis and reclassification table., Study Design and Setting: A cross-sectional study of adult males in general outpatient clinics in Hong Kong. The study included only patients who reported at least sometimes drinking alcoholic beverages. Timeline follow back alcohol consumption assessment method was used as the reference standard. A Chinese translated and validated 10-item AUDIT (Ch-AUDIT) was used as a screening tool of risky drinking., Results: Of the participants, 21.7% were classified as risky drinkers. AUDIT-C has the best overall performance among the shorter versions of Ch-AUDIT. The AUC of AUDIT-C was comparable to Ch-AUDIT (0.898 vs 0.901, p-value = 0.959). Decision curve analysis revealed that when the threshold probability ranged from 15-30%, the AUDIT-C had a higher net-benefit than all other screens. AUDIT-C improved the reclassification of risky drinking when compared to Ch-AUDIT (net reclassification improvement = 0.167). The optimal cut-off of AUDIT-C was at ≥5., Conclusion: Given the rising levels of alcohol consumption in the Chinese regions, this Chinese translated 3-item instrument provides convenient and time-efficient risky drinking screening and may become an increasingly useful tool.

Associations of multimorbidity and income with hospital admission were investigated in population samples from 3 widely differing health care systems: Scotland (n = 36,921), China (n = 162,464), and Hong Kong (n = 29,187). Multimorbidity increased odds of admissions in all 3 settings. In Scotland, poorer people were more likely to be admitted (adjusted odds ratio [aOR] = 1.62; 95% CI, 1.41-1.86 for the lowest income group vs the highest), whereas China showed the opposite (aOR = 0.58; 95% CI, 0.56-0.60). In Hong Kong, poorer people were more likely to be admitted to public hospitals (aOR = 1.68; 95% CI, 1.36-2.07), but less likely to be admitted to private ones (aOR = 0.18; 95% CI, 0.13-0.25). Strategies to improve equitable health care should consider the impact of socioeconomic deprivation on the use of health care resources, particularly among populations with prevalent multimorbidity., (© 2015 Annals of Family Medicine, Inc.)

Background: Chronic low back pain is a serious global health problem. There is substantial evidence that physicians' attitudes towards and beliefs about chronic low back pain can influence their subsequent management of the condition., Objectives: (1) to evaluate the attitudes and beliefs towards chronic low back pain among primary care physicians in Asia; (2) to study the cultural differences and other factors that are associated with these attitudes and beliefs., Method: A cross sectional online survey was sent to primary care physicians who are members of the Hong Kong College of Family Physician (HKCFP). The Pain Attitudes and Beliefs Scale for Physiotherapist (PABS-PT) was used as the questionnaire to determine the biomedical and biopsychosocial orientation of the participants., Results: The mean Biomedical (BM) score was 34.8+/-6.1; the mean biopsychosocial (BPS) score was 35.6 (+/- 4.8). Both scores were higher than those of European doctors. Family medicine specialists had a lower biomedical score than General practitioners. Physicians working in the public sector tended to have low BM and low BPS scores; whereas physicians working in private practice tended to have high BM and high BPS scores., Conclusion: The lack of concordance in the pain explanatory models used by private and public sector may have a detrimental effect on patients who are under the care of both parties. The uncertain treatment orientation may have a negative influence on patients' attitudes and beliefs, thus contributing to the tension and, perhaps, even ailing mental state of a person with chronic LBP.

To delineate the temporal dynamics between alcohol tax policy changes and related health outcomes, this study examined the age, period and cohort effects on alcohol-related mortality in relation to changes in government alcohol policies. We used the age-period-cohort modeling to analyze retrospective mortality data over 30 years from 1981 to 2010 in a rapidly developed Chinese population, Hong Kong. Alcohol-related mortality from 1) chronic causes, 2) acute causes, 3) all (chronic+acute) causes and 4) causes 100% attributable to alcohol, as defined according to the Alcohol-Related Disease Impact (ARDI) criteria developed by the US Centers for Disease Control and Prevention, were examined. The findings illustrated the possible effects of alcohol policy changes on adult alcohol-related mortality. The age-standardized mortality trends were generally in decline, with fluctuations that coincided with the timing of the alcohol policy changes. The age-period-cohort analyses demonstrated possible temporal dynamics between alcohol policy changes and alcohol-related mortality through the period effects, and also generational impact of alcohol policy changes through the cohort effects. Based on the illustrated association between the dramatic increase of alcohol imports in the mid-1980s and the increased alcohol-related mortality risk of the generations coming of age of majority at that time, attention should be paid to generations coming of drinking age during the 2007-2008 duty reduction.

Mindfulness-based interventions are increasingly being used in various populations to improve well-being and reduce psychological afflictions. However, there is lack of a validated mindfulness measurement in the Chinese language. This study validated the Chinese version of the Five Facet Mindfulness Questionnaire (FFMQ-C) in both a community sample of 230 adults and a clinical sample of 156 patients with significant psychological distress. Results showed a good test-retest reliability (.88) and a high internal consistency (.83 in the community sample and .80 in the clinical sample). Mindfulness as measured by FFMQ-C has moderate to large correlations with psychological distress and mental well-being. Two of the five subscales (describing and acting with awareness) showed incremental validity over the others in predicting psychological symptoms and mental health. Confirmatory factor analysis confirmed the five-factor structure of the FFMQ-C and demonstrated adequate model fit. A 20-item short form scale (FFMQ-SF) was developed using the proposed comprehensive criteria. These findings indicate that the FFMQ-C is reliable and valid to measure mindfulness in a Chinese population. Further study is needed to evaluate the psychometric properties of FFMQ-SF., (© The Author(s) 2013.)

Background: Upper respiratory tract infection (URTI) has a significant healthcare burden worldwide. Considerable resources are consumed through health care consultations and prescribed treatment, despite evidence for little or no effect on recovery. Patterns of consultations and care including use of symptomatic medications and antibiotics for upper respiratory tract infections are poorly described., Methods: We performed a retrospective review of computerized clinical data on patients presenting to all public primary care clinics in Hong Kong with symptoms of respiratory tract infections. International Classification of Primary care (ICPC)codes used to identify patients included otitis media (H71), streptococcal pharyngitis (R72), acute URTI (R74), acute sinusitis (R75), acute tonsillitis (R76), acute laryngitis (R77), and influenza (R80). Sociodemographic variables such as gender, age, chronic illness status, attendance date, type and duration of drug prescribed were also collected., Results: Of the 5,529,755 primary care consultations for respiratory symptoms from 2005 to 2010, 98% resulted in a prescription. Prescription patterns of symptomatic medication were largely similar across the 5 years. In 2010 the mean number of drugs prescribed per consultation was 3.2, of which the commonly prescribed medication were sedating antihistamines (79.9%), analgesia (58.9%), throat lozenges (40.4%) and expectorant cough syrup (33.8%). During the study period, there was an overall decline in antibiotic prescription (8.1% to 5.1%). However, in consultations where the given diagnosis was otitis media (H71), streptococcal pharyngitis (R72), acute sinusitis (R75) or acute laryngitis (R76), over 90% resulted in antibiotic prescription., Conclusion: There was a decline in overall antibiotic prescription over the study period. However, the use of antibiotics was high in some conditions e.g. otitis media and acute laryngitis a. Multiple symptomatic medications were given for upper respiratory tract infections. Further research is needed to develop clinical and patients directed interventions to reduce the number of prescriptions of symptomatic medications and antibiotics that could reduce costs for health care services and iatrogenic risk to patients.

Background: This study aimed to examine the prevalence, risk factors, detection rates and management of primary care depression in Hong Kong., Methods: A cross-sectional survey containing the PHQ-9 instrument was conducted on waiting room patients of 59 primary care doctors. Doctors blinded to the PHQ-9 scores reported whether they thought their patients had depression and their management., Results: 10,179 patients completed the survey (response rate 81%). The prevalence of PHQ-9 positive screening was 10.7% (95% CI: 9.7%-11.7%). Using multivariate analysis, risk factors for being PHQ-9 positive included: being female; aged ≤34 years; being unmarried; unemployed, a student or a homemaker; having a monthly household income < HKD$30,000 (USD$3,800); being a current smoker; having no regular exercise; consulted a doctor or Chinese medical practitioner within the last month; having ≥ two co-morbidities; having a family history of mental illness; and having a past history of depression or other mental illness. Overall, 23.1% of patients who screened PHQ-9 positive received a diagnosis of depression by the doctor. Predictors for receiving a diagnosis of depression included: having higher PHQ-9 scores; a past history of depression or other mental health problem; being female; aged ≥35 years; being retired or a homemaker; being non-Chinese; having no regular exercise; consulted a doctor within the last month; having a family history of mental health problems; and consulted a doctor in private practice.In patients diagnosed with depression, 43% were prescribed antidepressants, 11% were prescribed benzodiazepines, 42% were provided with counseling and 9% were referred, most commonly to a counselor., Conclusion: About one in ten primary care patients screen positive for depression, of which doctors diagnose depression in approximately one in four. At greatest risk for depression are patients with a past history of depression, who are unemployed, or who have multiple illnesses. Patients most likely to receive a diagnosis of depression by a doctor are those with a past history of depression or who have severe symptoms of depression. Chinese patients are half as likely to be diagnosed with depression as non-Chinese patients. Over half of all patients diagnosed with depression are treated with medications.

Background and Objectives: Many studies have shown the adverse effects of air pollution on respiratory health, but few have examined the effects of air pollution on service utilisation in the primary care setting. The aim of this study was to examine the association between air pollution and the daily number of consultations due to upper respiratory tract infections (URTIs) in general outpatient clinics (GOPCs) in Hong Kong., Methods: Daily data on the numbers of consultations due to URTIs in GOPCs, the concentrations of major air pollutants, and the mean values of metrological variables were retrospectively collected over a 3-year period (2008-2010, inclusive). Generalised additive models were constructed to examine the association between air pollution and the daily number of consultations, and to derive the relative risks and 95% confidence intervals (95% CI) of GOPC consultations for a unit increase in the concentrations of air pollutants., Results: The mean daily consultations due to URTIs in GOPCs ranged from 68.4 to 253.0 over the study period. The summary relative risks (and 95% CI) of daily consultations in all GOPCs for the air pollutants PM10, NO2, O3, and SO2 were 1.005 (1.002, 1.009), 1.010 (1.006, 1.013), 1.009 (1.006, 1.012), and 1.004 (1.000, 1.008) respectively, per 10 µg/m(3) increase in the concentration of each pollutant., Conclusion: Significant associations were found between the daily number of consultations due to URTIs in GOPCs and the concentrations of air pollutants, implying that air pollution incurs a substantial morbidity and increases the burden of primary health care services.

Background: Caregivers of people with chronic conditions are more likely than non-caregivers to have depression and emotional problems. Few studies have examined the effectiveness of mindfulness-based stress reduction (MBSR) in improving their mental well-being., Methods: Caregivers of persons with chronic conditions who scored 7 or above in the Caregiver Strain Index were randomly assigned to the 8-week MBSR group (n = 70) or the self-help control group (n = 71). Validated instruments were used to assess the changes in depressive and anxiety symptoms, quality of life, self-efficacy, self-compassion and mindfulness. Assessments were conducted at baseline, post-intervention and at the 3-month follow-up., Results: Compared to the participants in the control group, participants in the MBSR group had a significantly greater decrease in depressive symptoms at post-intervention and at 3 months post-intervention (p < 0.01). The improvement in state anxiety symptoms was significantly greater among participants in the MBSR group than those of the control group at post-intervention (p = 0.007), although this difference was not statistically significant at 3 months post-intervention (p = 0.084). There was also a statistically significant larger increase in self-efficacy (controlling negative thoughts; p = 0.041) and mindfulness (p = 0.001) among participants in the MBSR group at the 3-month follow-up compared to the participants in the control group. No statistically significant group effects (MBSR vs. control) were found in perceived stress, quality of life or self-compassion., Conclusions: MBSR appears to be a feasible and acceptable intervention to improve mental health among family caregivers with significant care burden, although further studies that include an active control group are needed to make the findings more conclusive.

Background: There is limited evidence to support the use of facemasks in preventing infection for primary care professionals. Negative effects on communication has been suggested when the physician wears a facemask. As communication skills and doctor patient relationship are essential to primary care consultations, the effects of doctor's facemask wearing were explored., Method: A randomised controlled study was conducted in primary care to explore the effects of doctors wearing facemasks on patients' perception of doctors' empathy, patient enablement and patient satisfaction. Primary care doctors were randomized to mask wearing and non mask wearing clinical consultations in public primary care clinics in Hong Kong. Patients' views were gathered using the Consultation and Relational Empathy (CARE) Measure, Patient Enablement Instrument (PEI) and an overall satisfaction rating scale. The effects of face mask wearing were investigated using multilevel (hierarchical) modelling., Results: 1,030 patients were randomised to doctor-mask wearing consultations (n = 514) and non mask wearing consultations (n = 516). A significant and negative effect was found in the patients' perception of the doctors' empathy (CARE score reduction -0.98, p-value = 0.04). In the more established doctor-patient relationship, the effect of doctors' mask wearing was more pronounced (CARE score reduction -5.67, p-value = 0.03)., Conclusion: This study demonstrates that when doctors wearing a facemask during consultations, this has a significant negative impact on the patient's perceived empathy and diminish the positive effects of relational continuity. Consideration should be taken in planning appropriate use of facemasks in infectious disease policy for primary care and other healthcare professionals at a national, local or practice level., Clinical Trial Registration: This trial was registered on Chinese Clinical Trial Register (ChiCTR). Registration no.: ChiCTR-TTRCC-12002519. URL: http://www.chictr.org/en/proj/show.aspx?proj=3486. Due to administrative error, registration of trial did not take place until after the trial started on 1st August 2011 and registration number was released on 21st September 2012.

Background: Strengthening primary care is key to Hong Kong's ongoing health system reform. Primary care remains unregulated, private sector dominated and financed mainly out-of-pocket. This study sought to examine the association between patients' socioeconomic status (SES), source of health payments and the quality of primary care they accessed to inform policy discussions., Methods: Data was collected from 1,994 respondents in a stratified random telephone survey with a 68% response rate, using the validated primary care assessment tool (PCAT). Education, household-income and type of housing were selected as indicators of SES. Multivariable ordinal logistic regression models were created to examine associations between indicators of SES and scores of quality., Results: Higher household-income was most significantly associated with better experiences of quality. Respondents with HK$ 15000-39999 (USD1934-5158) and HK$ 40000 (USD5159) and above were 47% (OR 1.47, 95% CI 1.10-1.96) and 2 times (OR 2.07, 95% CI 1.38-3.09) more likely to experience better quality than the lowest-income group respectively. Income group HK$ 40000 (USD5159) and above was 84% more likely to have better utilization (OR 1.84, 95% CI (1.21-2.78), and 2 times more likely to receive better comprehensiveness (OR 1.90, 95% CI 1.26-2.87). Patients who used only private insurance were 80% (OR 1.80, 95% CI 1.20-2.68) more likely to experience better quality than those who paid out-of-pocket., Conclusions: Our results show that the quality of primary care experienced in HK tended to be higher for those who had higher income and private insurance, and were able to pay out-of-pocket for the care. This indicated that the inequality in primary care is likely to be related with the private dominated primary care system in Hong Kong. More public responsibility on primary health care should be sought for in HK and similar contexts to reduce the inequality in primary care.

A cross-sectional relationship between lower urinary tract symptoms (LUTS) and depressive symptoms was previously reported among Southern Chinese men; however, the temporal relationship was unclear. Our objective is to evaluate the temporal relationship between moderate to severe lower urinary tract symptoms and clinically significant depressive symptoms in elderly Chinese men aged 65 in a prospective manner. In a prospective cohort of 2,000 Chinese men aged 65 to 92 years in Hong Kong, we studied the association of having moderate to severe LUTS at baseline and having clinically relevant depressive symptoms at year 2 follow-up. After excluding men with prostate or bladder cancer or surgery (n = 20) and lost to follow-up (n = 254), data on 1,726 subjects were analyzed. LUTS were measured by the International Prostate Symptom score; and clinically relevant depressive symptoms were measured by the Geriatric Depression Scale. The multiple logistic regressions showed that the presence of moderate-to-severe LUTS at baseline were significantly associated with increased risk for being depressed at two-year follow-up, with adjustments for demographic, lifestyle, medical factors, weight status and stressful life events (OR = 2.97; CI: 1.70-5.20). Association remained significant with additional adjustments for baseline GDS score (OR = 1.88; CI: 1.03-3.41). LUTS are important risk factors in predicting the presence of clinically relevant depressive symptoms. In elderly men, increased awareness and possible screening are needed to detect the increased risk of clinically relevant depressive symptoms.

Background: In Hong Kong Emergency Departments (EDs), the timeliness of providing high-quality services has been compromised by the increasing attendance of non-emergent patients in addition to the unpredictable arrival of emergency patients., Objectives: We sought to quantify the impact of the presence of emergent patients and other related factors on the delay in service for non-emergent patients., Methods: We conducted a retrospective study in patients who visited the ED of a large hospital in Hong Kong from July 1, 2009 to June 30, 2010. We estimated waiting and length of stay (LOS) for individual non-emergent patients registered during day and evening shifts. Using multiple linear regression, we estimated waiting time and LOS as a function of the presence of emergent patients and other related factors such as patient demographics and clinical factors. In particular, we evaluated the influence of the arrival or presence of emergent patients on the odds of violating the 120-min waiting time target for semi-urgent patients., Results: The arrival of a new emergent patient prolonged the waiting time and LOS of a non-emergent patient by 14.9% (95% confidence interval [CI] 14.2-15.5) and 10.8% (95% CI 10.6-11.0), respectively. An additional patient-hour needed for an emergent patient increased the probability of violating the waiting time target for non-emergent patients (odds ratio 2.3, 95% CI 2.2-2.4)., Conclusions: The arrival of an emergent patient significantly prolonged the waiting time and LOS for non-emergent patients. Discouraging non-urgent ED utilization and building a real-time decision-support system are critical methods needed to relieve staff pressure and guide contingent resource reallocation when emergent patients arrive., (Copyright © 2013 Elsevier Inc. All rights reserved.)