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BACKGROUND: This study aimed to investigate factors related to high stress levels among the general population in China during the novel coronavirus disease (COVID-19) pandemic when its containment measures were in place and to identify the most stressed populations. METHODS: A nationwide study was conducted online among 5,039 adults in all 31 provinces in mainland China between March 1 and March 16, 2020. Bivariate analysis and multivariate logistic regressions were performed to explore the related factors of high perceived stress. RESULTS: Among all respondents, 36.0% reported a high level of stress. Respondents in Hubei province (the epicenter) were more likely to report high stress levels than those in low epidemic areas. Respondents who went outside every day or every other day reported greater odds of experiencing a high level of stress than those who went outside every 8-14 days. People with higher risk perceptions were more prone to report high stress levels. Respondents aged 16-35 were more likely to report high stress than respondents aged 46 or older. Lower household income and lower health literacy were related to increased odds of reporting high stress levels. LIMITATIONS: We used a convenience sample and self-reported survey data. CONCLUSIONS: We identified risk factors for high stress levels related to the epidemic (epidemic intensity in residential areas, risk perception, and frequency of going outside) and other vulnerabilities (younger age, low household income, low health literacy). Our findings can directly inform interventions and policies for mitigating stress among the general population for this or future epidemics.

To tackle unhealthy eating among adolescents, it is crucial to understand the dietary knowledge, attitudes, and practices (KAP) on which adolescent eating habits are based. This qualitative study identifies the gaps in KAP by exploring what Chinese adolescents know, perceive, and practice regarding healthy eating to better inform targeted interventions for this important health problem. Parent–adolescent dyads were purposively sampled based on, for example, the dietary intake, age, and gender of the adolescent and household income, and each completed a 30 to 60 min interview. Twelve themes were synthesized: knowledge: (1) dietary recommendations, (2) health outcomes of healthy eating, (3) nutrition content in food, and (4) access to healthy meals; attitudes: (5) outcome expectation for healthy eating, (6) food preferences, and (7) self-efficacy regarding adopting healthy eating; and practices: (8) going grocery shopping for healthy food, (9) eating home-prepared meals. (10) eating out in restaurants or consuming takeaway food, (11) fruit and vegetable consumption, and (12) snacking, perceived unhealthy eating to be low risk, made unhealthy choices regarding snacking and eating out, and had insufficient fruit and vegetable intake. Programs should emphasize the positive short-term health outcomes of healthy eating and empower adolescents to acquire food preparation skills to sustain healthy eating habits.

Workplace violence (WPV) in the health sector is a global public health issue. The magnitude of WPV is a particular concern in China’s health system. To examine the potential causes of WPV, we analyzed 3,045 qualitative responses to an open-ended question in a survey with health workers in the Zhejiang province, China. We adapted a four-level socio-ecological framework (societal/systemic, community/organizational, interpersonal, and individual) to thematically analyze the data. Ten sub-themes emerged. Within the societal/systemic level, we identified three sub-themes: (a) lack of legislation against WPV, (b) suboptimal accessibility and affordability of health services due to maldistributed health resources, commercialized health services, and inadequate health insurance, and (c) unregulated mass media reports. Within the community/organizational level, three sub-themes emerged: (a) lack of supportive health facility leadership, (b) inaction by government authorities, and (c) inefficient law enforcement agencies. Within the interpersonal level, two sub-themes were identified: (a) poor provider–patient communication and (b) distrust between health workers and patients. Finally, we identified the personal characteristics of health workers (e.g., competence and professionalism) and patients (e.g., sociodemographic background and expectations/satisfaction) as two individual-level sub-themes. We recognized interactions among different levels. The weak state of Chinese legislation in this area and lack of high-level political will and guidance (societal/systemic) has left health facilities and law enforcement agencies (community/organizational) unclear about how to address WPV. The maldistribution of quality health resources (societal/systemic) has led to overcrowded outpatient clinics at higher-level care facilities (community/organizational). In light of the insufficient government funding and profit-oriented health services (societal/systemic), health workers were motivated to seek profits by providing unnecessary services, which compromised their professionalism (individual). Provider–patient relationships deteriorated (interpersonal), and patients sometimes held unrealistically high expectations associated with high medical expenses (individual). We propose multisectoral prevention strategies to address WPV in the health sector at all levels using a socio-ecological framework.

Background Inappropriate antibiotic prescribing practices predispose to resistance emergence. Despite the inclusion of the topic in medical school curricula worldwide, it is uncertain whether newly graduated medical interns have confidence in proper antibiotic prescription. Objectives This study aimed to explore the antibiotic prescribing behaviours of the medical interns in Hong Kong and their barriers to appropriate antibiotic prescription. Methods Two focus groups were conducted among medical interns with training experiences in different public hospitals. Their prescribing behaviours and barriers were further examined with a questionnaire survey just before completion of internship. Results Focus group interviews identified a variety of hospital workplace cultures, including inappropriate empirical prescriptions and dosages, interns’ passive roles in prescribing antibiotics and varied guidelines between different departments. Defensive medicine and lack of clinical experience were other barriers encountered. The interns believed that the incorrect practice learnt would perpetuate in their minds and affect their future practice. The top barriers reported by the survey respondents were adaptation to prescription culture of different hospitals (93.5%), lack of experience in antibiotic prescription (88.3%), inadequate knowledge in the choice of antibiotics (85.7%) and compliance with the seniors’ instructions (80.6%). However, some focus group participants perceived weaker barriers in paediatric departments which provided close monitoring of antibiotic use. Conclusions Inadequate knowledge and low confidence in antibiotic prescription led to the passive role of medical interns in antibiotic prescription, predisposing to future inappropriate practice. Inconsistent guidelines and prescription cultures between different hospitals and departments might further exacerbate their barriers.

Background: Primary care physicians (PCPs) in rural township health centers are the most easily accessible doctors to the residents in rural China, which covers 35% of the population. High prevalence of depression was reported among rural left-behind elderly and children as many workers had migrated to urban cities. Aim: This study explored mental health care provision by PCPs in rural China and the association with their training background. Methods: Rural township health centers in both developed and less developed counties of Zhejiang Province, China were chosen as the study sites. A total of 697 PCPs completed questionnaires between December 2019 and January 2020, and the number of valid questionnaires was 673, with a valid response rate of 79.3%. Results: The rural PCPs reported a median range of seeing 1 to 5 mental health patients per week. Over two-thirds (68.2%) of the respondents had never received any training on treating common mental health disorders (depression and anxiety) while 20.3% received at most 2 days of training; 6.4% received 3 to 20 days of training; and 5.1% received over 20 days of training. PCPs with mental health training were significantly associated with better mental health care in terms of confidence and practice characteristics (e.g. having patients who brought up mental health issues, providing follow-up), while years of practice made a difference in practice but not confidence. Conclusions: Training is the key determinant of the practice of mental health care by the PCPs in rural China. Our findings have implications for national policy to target two-thirds of rural PCPs who received no mental health training.

Healthy eating is vital in preventing obesity and long-term non-communicable diseases. This study explores potential family facilitators of, barriers to and strategies for healthy eating among adolescents in Chinese families to guide the development of effective interventions in the future. Parent–adolescent dyads were purposively sampled by age, gender, fruit and vegetable intake and household income. Key family factors were identified by thematic analysis. Fourteen themes under five domains were identified: family health with (1) illness experienced in the family; parental knowledge of (2) dietary recommendations, (3) the preparation of healthy food and (4) healthy food choice; parental attitudes towards (5) the importance of healthy eating and (6) the priority of family health; socioeconomic factors of (7) time concerns and (8) cost concerns; and food parenting practices in (9) nutritional education, (10) role modeling, (11) food provision, (12) child involvement, (13) parental supervision and (14) the cultivation of food preference. Useful strategies included incorporating healthy ingredients in adolescents’ favorite recipes and providing a variety of fruit and vegetables at home. There is a need to empower parents with practical nutrition knowledge, to be more authoritative in food parenting practices, to discuss healthy eating with children and to acquire practical skills related to time- and cost-saving healthy cooking.

Most studies highlighted the association between psychological distress and socioeconomic status (SES). There were weaker explanations for distress found in the middle classes, especially in Asian countries. We conducted a questionnaire survey with 1626 adult Chinese primary-care attenders from 13 private and 6 public clinics in different districts of Hong Kong. Their demographic background and distress level measured by GHQ-12 were analysed. We found that respondents with younger age, better education, and lower income were more likely to be distressed. In a multiple logistic regression model, age and income, but not education, were significant predictors for distress. Highest rates of distress were found among the unemployed (45.5%) and the students (37.1%), followed by service workers and shop sales workers (33.0%), associate professionals (32.0%), and clerks (29.2%). Craftworkers (9.1%), plant and machine operators (11.5%), and retired people (12.8%) were least likely to be distressed, followed by professionals (21.0%). Apart from SES, the findings suggest that young age, academic and job stressors, and low self-esteem are significant factors for distress. These factors may be intensified in a Chinese context by peer comparison resulting in a state of relative deprivation.

Background Public toilets are a common transmission vector of infectious diseases due to environmental contamination. Research on Chinese people’s hygiene practices in public lavatories are lacking. This study examined Chinese people’s hygiene practices in public lavatories in Hong Kong. Methods We conducted qualitative interviews and a self-administered questionnaire survey with local residents from June 2016 to April 2018. Four focus group discussions and three individual interviews informed the design of the questionnaire. We recruited interviewees and survey respondents via social service centers. The interviews and questionnaire focused on the public’s daily practices and hygiene behaviors in public toilets. Content analysis of qualitative data was conducted. Multivariable logistic regressions were used to examine the association between age and toilet hygiene behaviors. Results Our qualitative component revealed a range of handwashing practices, from not washing at all, washing without soap, to washing for a longer time than instructions. Other toilet use practices were identified, such as not covering toilet lid before flushing and stepping on toilet seats due to dirtiness, and spitting into toilet bowls or hand basin. Totally, 300 respondents completed the questionnaire. Among them, 212 (70.9%) were female and 246 (86.1%) were aged 65 or below. More than two thirds always washed hands with soap (68.7%) and dried hands with paper towels (68.4%). Up to 16.2% reported stepping on toilet seats and 43.9% never covered the toilet lid before flushing. Over one fourth (26.4%) spit into squat toilets/ toilet bowl. Regression analyses showed that the elderly group were less likely to report stepping on toilet seats (adjusted odds ratio, AOR = 0.17, 95%CI 0.03–0.88), flushing with the toilet lid closed (AOR = 0.40, 0.16–0.96), but more likely to spit into squat toilets/ toilet bowl (AOR = 4.20, 1.50–11.74). Conclusions Hong Kong Chinese’s compliance to hygiene practices in public toilets is suboptimal. Stepping on toilet seat is a unique Chinese practice due to the dirtiness of toilet seats. Spitting practices may increase the risk of airborne infectious diseases and need improvement. Measures are needed to improve toilet hygiene behaviors, including public education campaigns and keeping toilet environment clean.

ObjectivesAlthough the topic of antibiotic misuse is taught in medical schools, interns (fresh medical graduates) still encounter barriers to appropriate antibiotic prescription when they practice in hospitals under supervision. The impact of teaching in medical school, antibiotics stewardship program (ASP), and prescription guidelines was uncertain. This study explored the medical interns’ views on antibiotic use and resistance, and their perceived enablers to appropriate antibiotic prescription.MethodsTwo focus groups were conducted among medical interns with rotation experiences in different public hospitals of Hong Kong. The identified themes about attitudes to antibiotic resistance and enablers to appropriate antibiotic prescription were further examined by a questionnaire survey with 77 respondents.ResultsThe interns had lower preferences for tackling antibiotic resistance as they feared of delayed prescriptions. Guidelines provided by international evidence-based clinical resources and the interns’ working hospitals were stronger enablers to appropriate antibiotic use than education materials from schools and the government. Qualitative findings revealed that the interns were aware of the existing ASP but doubted its effectiveness as it failed to get the prescribers’ attention. They followed guidelines in their wards but perceived guidelines from local health authorities user-unfriendly. Knowledge from medical school was not very applicable. Varying prescribing practices between hospitals and the densely placed hospital beds made it difficult to prevent the spread of antimicrobial resistance.ConclusionsMinimizing delayed prescription is of a higher priority than tackling antibiotic resistance in medical interns’ perspective. Interventions should target guidelines in hospitals and simplify the interface of local guidelines.

Background Benefits of intercalation during an undergraduate medical degree are well-recognized. The University of Hong Kong implemented a compulsory Enrichment Year (EY) in its Bachelor of Medicine and Bachelor of Surgery degree programme (MBBS) in 2016. In their third year of study, students could work on an area of interest in any of three programme categories (i) intercalation/ university exchange (IC); (ii) research (RA); (iii) service/ humanitarian work (SH). This study aimed to explore the barriers, enablers, and overall student learning experiences from the first cohort of EY students in order to inform future development of the EY. Methods An exploratory sequential mixed-method study in 2019-20. Twenty students were purposively selected to attend three semi-structured focus group interviews. Conventional thematic analysis was employed and results assisted the design of a cross-sectional questionnaire. Sixty-three students completed the questionnaire. ANOVA or chi-square test was used to compare the difference in student’s characteristics, barriers, enablers and perspectives on EY between programme categories. Adjusting student’s characteristics, logistic regressions were conducted to identify the effect of programme categories on the EY experience. Results Most students (95% in the questionnaire) agreed that EY was worthwhile and more rewarding than expected. EY was positively regarded for enhancing personal growth and interpersonal relationships. The main barriers were financial difficulties, scholarship issues and insufficient information beforehand. A few students had practical (i.e. accommodation, cultural adaptation) problems. Potential enablers included better financial support, more efficient information exchange and fewer assignments and preparation tasks. Similar barriers were encountered by students across all three categories of EY activities. Conclusions Personal growth was the most important benefit of the EY. Barriers were consistent with those identified in the literature except for cultural adaptation, which could be related to Hong Kong’s unique historical context. Financial limitation was the most concerning barrier, as it could result in unequal access to educational opportunities. Better and timely access to scholarships and other funding sources need to be considered. Trial registration Ethics approval was obtained from the local Institutional Review Board of The University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW 19-585).

Toilet hygiene is an important preventive measure for infectious diseases, including severe acute respiratory syndrome (SARS) and COVID-19. This study explored public’s opinions on improving toilet environment and hygiene practices in Hong Kong. A mixed-method approach was applied. We conducted 4 focus groups plus 3 individual interviews among the Hong Kong Chinese, followed by a questionnaire survey with 300 respondents recruited from various districts. Difference in response distributions between groups with different demographics was tested by Pearson χ2 test. Instead of advocating for advanced toilet facilities, respondents were mostly concerned about basic hygiene issues. Malfunctioning facilities resulting from poor toilet management, such as clogged toilets, stained facilities, and problematic flushing systems, were most cited as barriers to toilet hygiene practices. Three quarters of the survey respondents expressed concerns over worn and poorly maintained toilets, shortage of janitors, and cleansing supplies. However, respondents who were older ( P < .001), less educated ( P < .001), and had lower income ( P = .001) were significantly more likely to find hygiene conditions in public toilets satisfactory. The findings reflected the substandard of the current provisions as a developed city in Asia. Enhanced efforts by the government to maintain basic toilet supplies and facilities is the key to improving public compliance to toilet hygiene practices.

Background Domestic violence is common in the community. Many of its victims present to primary care physicians (PCPs) but are not being recognized and managed. The barriers, with specific reference to a Chinese cultural context, were investigated earlier. This paper explored the factors which facilitated the process of recognizing and managing suspected cases of domestic violence by PCPs in Hong Kong. Methods Four focus group interviews were conducted to explore in-depth the experiences of PCPs in recognition, management and referral of domestic violence cases from which facilitators were identified. The relevant themes were then investigated in a questionnaire survey with 504 PCPs working in public and private sectors. Results The focus group participants emphasized mood symptoms as useful indicators for probable abuse and continuity of care was important to unmask issues of domestic violence. The top facilitators perceived by the respondents of the survey included: a trusting doctor-patient relationship (99.8%), good communication skills (99.0%), patients’ unexplained bruises (96.3%), medical history (94.6%), and mood symptoms (94.4%). Further, the survey found that PCPs with longer years of practice, a medical degree obtained from Western countries, and postgraduate training in family counselling or psychological medicine perceived more facilitators in managing domestic violence. Conclusions Without a local screening policy and training protocol to manage domestic violence, PCPs regarded their skills in mental healthcare and good relationships with patients as the key facilitators. While training in mental health care helps PCPs manage domestic violence, a specific protocol emphasizing medical-social collaboration is anticipated to facilitate them to take a more proactive and effective stance from screening to management.

BackgroundHealth professionals including psychiatrists were reported to have stigmatising opinions on psychiatric patients. Their views may be affected by clinical, social and cultural factors.ObjectiveThis study explored the views of Chinese psychiatrists on stigmatisation of psychiatric patients.MethodsFocus group discussions with psychiatrists were conducted in Hong Kong. Their views towards stigmatisation of psychiatric patients and strategies to reduce stigmatisation were discussed.FindingsThe psychiatrists perceived the clinical needs to classify the patients according to the diagnoses and they did not see it as stigmatisation. They believed that some mental illnesses are characterised with violence or deviance, and were not completely curable. Instead of trying to eliminate stigma, they managed in ways that took social expectations into consideration. They might offer a relative vague diagnostic label to save the ‘face’ of the patients and secure greater acceptance for the illness from the public. They tended to accept family members to make decisions on behalf of the patients. Reconciling public interest and patients’ autonomy, they encouraged stable psychotic patients to live in the community but agreed to institutionalise those patients with violent behaviours.ConclusionWhile the psychiatrists argued that the diagnosis was not a form of stigma, they were sensitive enough and framed responses to patients in ways to minimise stigma. They tended to believe that stigma was inevitable given the nature of some psychotic disorders. Disguising the stigma appeared to be the common approach to deal with stigma in a Chinese context.Clinical ImplicationsThe psychiatrists, especially those practicing in a Chinese context, may consider a wider perspective of community mental health rehabilitation which is not limited to social stability but also social life.

Method A questionnaire survey was conducted among GPs. Of the 516 respondents, 76 (14.7%) had attended a one‑year postgraduate mental health training course. Results The GPs with mental health training saw significantly more patients with mental health problems per week (median class 11-15 versus 6-10) and treated a higher percentage of patients with mental health problems (median class 41-60% versus 21-40%). The differences remained significant, with odds ratios of 2.6 for both indicators after controlling for gender, healthcare setting and years of practice. Discussion Policies should promote training of GPs as part of the increasing workforce for mental healthcare. Estimated from the results, GPs with mental health training have nearly triple the number of consultations related to mental health, compared with other GPs (340 versus 120 per year).

BackgroundWhile qualitative studies suggested that continuity of care by primary care physicians (PCPs) facilitated consultations for psychological problems, there was limited quantitative evidence. This survey compared management of psychological distress between patients with and without a regular PCP.MethodsA questionnaire survey was conducted with 1626 adult primary care attenders from 13 private and 6 public clinics in Hong Kong. Management of psychological distress between respondents with a regular PCP and those without were compared. Effects of demographic factors were adjusted for by multivariable logistic regression.ResultsAmong the 1626 respondents, 650 (40.0%) reported that they had ever experienced psychological distress. Of the 650 respondents experienced distress, 307 (47.2%) had a regular PCP. A significantly higher proportion of patients with a regular PCP than those without reported: (i) their PCPs sometimes/often asked about psychological problems [37.7 versus 20.1%, adjusted OR = 2.241]; (ii) they sometimes/often mentioned their psychological problems to PCPs [45.2 versus 24.9%, adjusted OR = 2.503]; and (iii) their distress had been treated by PCPs [22.1 versus 13.4%, adjusted OR = 1.702].ConclusionPatients with a regular PCP have around double odds of receiving mental health care. Continuity of care by PCPs should be emphasized in mental health care delivery.

Background: The World Health Organization (WHO) has called for integration of mental health into primary care for a decade. In Western countries, around 15% to 25% of patients with common mental disorders including mood and anxiety disorders seek help from primary care physicians (PCPs). The rate is only about 5% in China. Aims: This article reviews the Chinese findings on the barriers to primary care for common mental disorders and how they compared with Western findings. Methods: A narrative literature review was conducted, focusing on literature published from mid-1990s in English or Chinese. Patient, PCP and health system factors were reviewed. Results: Although Chinese and Western findings show similar themes of barriers, the Chinese have stronger barriers in most aspects, including under-recognition of the need for treatment, stigma on mental illness, somatization, worries about taking psychiatric drugs, uncertainties in the role, competency and legitimacy of PCPs in mental health care and short consultation time. Conclusion: Current policies in China emphasize enhancement of mental health facilities and workforce in the community. Our review suggests that patients’ intention to seek help and PCPs’ competency in mental health care are other fundamental factors to be addressed.

Doctors' profit-oriented practices in public institutions were widespread in China. Two major targets of the healthcare reform launched in 2009 were to curb the profit-making practices in public institutions and to encourage the citizens to use primary care. After 6 years, the status of profit-orientation of public institutions remains unknown. Compared with hospitals, there is no trend of increasing use of primary care. Our study aimed to explore the status of profit-orientation of public institutions and patients' utilization preference. The impacts of guanxi (personal relationship) on patients' utilization of healthcare and doctors' practices were also explored. From September 2014 to September 2015, we conducted focus group and individual interviews, followed by a survey with doctors (n = 1111) in Hangzhou, Zhejiang province. Thematic analysis, independent t-test and Fisher's exact test were conducted to analyse the data. This study found that 36.8% of survey respondents needed to consider making profits for their institutions, especially the hospital specialists. A total of 38.5% and 40.7% thought that their practices led to patients' worries of unnecessary drugs and tests, respectively. Doctors attributed their profit-oriented practices to institutions' agenda setting, poor salary and an organizational bonus system. Their awareness of breaching medical ethics created a guilt feeling and frustration. Nearly 65.0% reported patients' preference for hospital-based care even for minor conditions and 76.2% if the patient was a child. Ineffective gate-keeping mechanism, weak primary care and mistrust in community-based care were major reasons. More specialists than primary care practitioners (41.0 vs 21.5%, P < 0.001) said that patients would use guanxi to gain better services and 64.5% of doctors reported better dedication when patients were somehow connected. In conclusion, profit-orientated practice widely exists in public institutions. Patients generally prefer hospital-based services. Guanxi, which affects both patients' and doctors' practices, is more often used to access hospital-based services.

ObjectivesTo determine the prevalence of physical violence and threats against health workers and the aftermath in tertiary, secondary and primary care facilities in China.DesignA cross-sectional questionnaire study.Setting5 tertiary hospitals, 8 secondary hospitals and 32 primary care facilities located in both urban and rural areas of Zhejiang Province, China, were chosen as the study sites.ParticipantsA total of 4862 health workers who have contact with patients completed a survey from July 2016 to July 2017.Outcome measuresThe prevalence of physical violence, threats and Yi Nao, specific forms of physical violence and their aftermath were measured by a self-designed and verified questionnaire. Multivariable logistic regression models were used to examine the association between perceived organisational encouragement of reporting workplace violence (WPV) and physical violence, threats and Yi Nao after controlling for age, sex, level of facility, professional ranking and type of health worker.ResultsAmong all respondents, 224 (4.6%) were physically attacked and 848 (17.4%) experienced threats in the past year. Respondents in secondary hospitals were more likely to experience physical violence (AOR=3.29, 95% CI 2.21 to 4.89), threats (AOR=1.61, 95% CI 1.32 to 1.98) and Yi Nao (AOR=2.47, 95% CI 2.10 to 2.91), compared with primary care providers. Lack of organisational policies to report WPV was associated with higher likelihood of physical violence (AOR=3.64, 95% CI 2.57 to 5.18) and threats (AOR=2.21, 95% CI 1.76 to 2.78). Among physical violence cases, only 29.1% reported the attack to police mainly because most felt it useless to do so (58.8%). Only 25.7% were investigated and 72.4% of attackers received no punishment. Of all those attacked or threatened, 59.4% wanted to quit current post and 76.0% were fearful of dealing with urgent or severe cases.ConclusionsProper management of the aftermath of violence against health workers is inadequate. Formal guidelines for reporting and managing WPV are urgently needed.

While primary care physicians (PCPs) have opportunities to recognize patients who encounter domestic violence (DV) by intimate partners, warning symptoms such as unexplained physical injury, bruising, anxiety, and depression are often missed during clinic visits. This study investigated the barriers of Hong Kong PCPs toward managing DV, including recognition, management, and referrals of these patients. Four focus group interviews were conducted to explore the in-depth opinions of PCPs on managing DV in Hong Kong. The themes identified were investigated in a questionnaire survey with data from 504 PCPs working in public and private sectors. Factor analysis of the survey data suggested four major barrier factors: (a) worries about the potential harms of intervening in patients’ domestic affairs and DV issues, (b) lack of guidelines and support services, (c) limited skills and time in managing DV, and (d) patients’ reluctance in disclosing DV issues. PCPs with more years of practice had more worries about intervening in domestic issues (Factor 1), while the younger PCPs tended to perceive limited skills and time in managing DV cases as barriers (Factor 3). PCPs working in the public setting were more likely to ask patients about DV ( M = 5.4 vs. 2.9), suspected DV ( M = 3.8 vs. 2.3), and managed DV ( M = 1.7 vs. 1.0) in the past 5 years compared with the private PCPs. Some PCPs in the focus groups expressed the view that DV cases should be handled by social workers instead of doctors. Survey respondents who held such views about doctors’ limited role in DV management also scored higher in all of the barrier factors. The findings suggest that there are boundaries between domestic and medical realms, especially in a Chinese context. Resolving PCPs’ worries by training, provision of DV management guidelines, and referral pathway to social workers may be good starting points to bridge the gaps.

Background: China rolled out the national essential medicines policy (NEMP) in primary care in 2009 and led to some unintended consequences including unavailability of essential medicines. This study examined patients’ coping behaviors to these unintended consequences of NEMP as well as the potential impact on primary care system development in Hangzhou, a developed city of China. Methods: We conducted qualitative interviews and surveys with service users, primary care physicians (PCPs), and specialists in tertiary hospitals. Qualitative findings informed the design of the survey questionnaires. Main outcomes included patients’ coping behaviors after the NEMP implementation, as well as providers’ perceptions of NEMP’s impact on primary care development. Thematic analysis of the qualitative data and descriptive analysis of the survey data were conducted. Results: Unintended effects of NEMP included frequent unavailability of certain essential drugs, leading to patient flow from primary care to hospital outpatient clinics for drug refills, difficulties in the provision of continuing care in primary care, as well as compromised patient trust in PCPs. In total, 1248 service users completed the questionnaires. A total of 132 (10.6%) were aged 60 years or above. Among 153 (57.7%) of the 265 who had some chronic condition(s) and needed long-term medication treatment, 60.1% went to hospitals for refills. Four-hundred sixty PCPs and 651 specialists were recruited. Among 404 PCPs who were aware of the NEMP policy implementation in their facility, 169 (41.8%) reported that there was often a shortage of drugs at their facilities and 44 (10.9%) reported always. Moreover, 68.6% of these PCPs thought that the NEMP could not meet their patients’ needs. Further, 44.2% (220/498) of specialists who were aware of the NEMP policy in primary care reported that they often heard patients complaining about the policy. In total, 53.1% of PCPs and 42.4% of specialists disagreed that NEMP helped direct patient flow to community-based care. Conclusion: NEMP’s unintended effects undermined patients’ utilization of primary care in a developed city in China and led to unnecessary hospital visits. Countermeasures are needed to mitigate the negative impacts of NEMP on the primary care system.

Background Most of the previous studies on help seeking for psychological distress were derived from Western countries. This study investigated the barriers to help-seeking for psychological distress among Chinese primary care attenders in Hong Kong. Methods Nine focus groups and 6 individual interviews were conducted among Chinese primary care attenders with/without known distress, patients' significant others and the general public. The identified barriers were investigated in a questionnaire survey with data from 1626 primary care attenders recruited from 13 private clinics and 6 public clinics. Results Worries about side effects of drugs (79.9%, 95% CI:(77.9%, 81.8%)) and drug dependency (74.7%, 95% CI:(72.5%, 76.8%)) were rated as the top barriers in the survey. Qualitative interviews found both worries and actual experience of the side effects of drugs, which weakened patients' trust in the treatment. Factor analysis on all barrier items suggested three factors: 1) worries of treatment, 2) uncertainties on primary care physicians' capacity, 3) public’s limited knowledge on distress and sources of help. Distress level, education level and age were associated with factor 1, whereas distress level and healthcare setting were associated with the other two factors. Qualitative interviews revealed that not having a regular primary care physician in the public setting discouraged disclosure of psychological problems. Limitations The findings were based on self-reported data from the respondents. Hong Kong is influenced by a mixed Chinese and Western culture. Conclusions Relevant public education in a Chinese context should target at reducing patients' worries of drug treatment and strengthening the image of primary care physicians as a feasible source of help.

Background and objectiveAnorexia nervosa (AN) is one of the most difficult-to-treat psychiatric disorders. AN is associated with individual vulnerability, societal and family factors. There has been limited research in Asia regarding the patients or their families' perceptions on its treatment. This study explored the perceived treatment outcomes among Chinese families having adolescents with AN.MethodsQualitative interviews were conducted on parents of adolescents with AN recruited through an eating disorder association in Hong Kong to understand their views and experiences regarding the help-seeking and treatment process.ResultsThe parents expressed dissatisfaction towards help-seeking and treatment outcomes, including relationships with health professionals, hospitalization, health professionals' knowledge of AN, understanding of the treatment model and parents' role, amount of psychological support, and coordination among health professionals. The parents were unclear about the treatment plan as they received little explanation from the health professionals. The parents perceived that the AN treatment only focused on weight restoration with limited psychological support. Home diet monitoring was seen as a harsh task which worsened the relationship with their children. The parents often needed to take up the coordinator role and search around for different health professionals and integrate their advices by themselves.ConclusionsThe study shows that limited psychoeducation, communication and coordination in the treatment for AN are major problems in a Chinese context. Open communication between the health professionals and the parents about the expected treatment outcomes and limitations is needed to enhance their mutual trust. Besides, treatment should emphasize not only family involvement but also empower them to fight against AN.

Background Most of the previous studies of help seeking for psychological distress were conducted in Western countries. Chinese studies have had a stronger emphasis on psychosis. Objective This study aims to understand how Hong Kong Chinese primary care attenders see psychological distress, including its causes, management approaches and recovery, and whether their views are different from Western views. Method Nine focus groups and six individual interviews were conducted in Hong Kong among Chinese primary care attenders with/without known distress, patients' significant others and the general public, and a questionnaire survey was conducted with 1626 primary care attenders recruited from 13 private clinics and 6 public clinics. Results More survey respondents agreed with psychological counselling (95.3%) than drugs (69.0%) to relieve psychological distress. Despite the belief in self-resilience (77.7%), only 34.8% respondents agreed that psychological distress could get better without professional help. Respondents with younger ages, better education and higher incomes tended to have stronger trust in counselling and self-resilience than drugs. Qualitative interviews revealed that although participants regarded psychological distress as a common problem in modern societies, distressed patients might be seen as being weak and troublesome. Some distressed patients found their recovery process painful because of discouragement from family and personnel at their workplace. Conclusions Hong Kong Chinese patients' views of the causes and management approaches of psychological distress are similar to Western findings. However, help seeking and recovery are of greater concern in a Chinese context where patients may receive limited empathy for their conditions of psychological distress.

This study investigated the differences in attitudes towards mental health patients between primary care physicians (PCPs) who have received postgraduate training in community mental health and those who have not. A questionnaire regarding the PCPs' attitudes towards mental health care in general, and specifically on depression and schizophrenia, was designed to compare the attitudes between the PCPs with postgraduate training in community mental health (CMH group) and those without (non-CMH group). Besides having greater confidence in management, PCPs in the CMH group had less stigmatizing opinions towards the mental health patients than those in the non-CMH group. Differences between the two groups were mostly shown in the case for depression but not for schizophrenia. The proportion of PCPs who liked to have depressed patients on their practice list was significantly higher in the CMH group (94 vs 71 %), and their satisfaction rate in looking after depressed patients was also significantly higher than the non-CMH group (87 vs 59 %).

ObjectiveChina is engaged in promoting community health services (CHS) nationwide. This study examines the public’s views towards CHS and their utilisation of community-based and hospital-based outpatient services.DesignA mixed methods study using qualitative interviews and a cross-sectional survey.Study setting and participantsThe study was conducted among the public between September 2014 and September 2015 in Zhejiang province, China. Six focus groups and 13 individuals were interviewed. The questionnaire was completed by 1248 respondents (response rate: 83%).Primary outcome measuresUtilisation of community-based and hospital-based outpatient services.ResultsFunctions of CHS perceived by the public included provision of minor illness management, coordination, drug dispensing, follow-up care and patient education. However, many also showed a distrust in primary care providers’ (PCPs) competence for confirming the initial diagnosis and management plan. As coordinators, PCPs’ integrity was challenged, and PCPs were thought to be potential ‘tuo er’ (cunning agents who tried to lead patients to some notorious hospitals to make money). Survey results showed that 800 (64.1%) respondents visited hospital-based clinics and 688 (55.1%) visited CHS at least once in the past year. Compared with the uninsured group, those covered by Urban Resident Medical Insurance (adjusted OR (AOR)=1.95, 95% CI 1.24 to 3.07) and Urban Employee Medical Insurance (AOR=2.59, 95% CI 1.59 to 4.24) were more likely to use hospital-based services. Respondents who had a chronic condition were more likely than their counterparts to use both hospital-based services (AOR=1.72, 95% CI 1.18 to 2.49) and CHS (AOR=1.66, 95% CI 1.19 to 2.32). Income levels were positively associated with the likelihood of visiting hospital-based clinics (AOR=1.67, 95% CI 1.15 to 2.42) but negatively associated with the likelihood of using CHS (AOR=0.68, 95% CI 0.48 to 0.96).ConclusionsDemand of hospital-based outpatient services is much higher than the community-based outpatient services. Policy reformers need to take further actions to address the public distrust in PCPs to facilitate their gatekeeping role.

This study investigated enablers to seeking professional help for psychological distress among Chinese primary care attenders in Hong Kong. Nine focus groups and six individual interviews were conducted among adult patients with/without known distress, significant others of the distressed, and the general public. The identified potential enablers were further investigated in a questionnaire survey with data from 1626 patients. Survey respondents who had sought professional help for distress (n = 231) and those without this experience (n = 1395) showed similar attitudes to the enabler items. However, the first group had more “strongly agree” responses and their top five enablers were: crisis caused by distress, distress affecting daily life, wanting to treat associated physical symptoms, having trust in doctor, and encouragement by family/friends to seek help. Qualitative interviews found that the patients often somatised distress and they felt comfortable to consult for somatic symptoms. There was strong family involvement in help-seeking whereas the doctors were the authoritative figures to convince the patients for treatment. The findings, in line with Western literature, indicate that crisis and interference in daily life due to distress are the top enablers to seeking professional help. The other three key enablers are likely to be influenced by Chinese culture.

Objective: There is a lack of in-depth studies on the stigmatization of mental health patients in China. This study aimed to investigate the stigmatizing opinions of Chinese toward different types of mental illnesses by a qualitative approach. Method: Nine focus group interviews with 5 to 12 participants each were conducted in areas of different social classes in Hong Kong. Opinions on different types of mental illnesses, including anxiety, depression, schizophrenia, dementia, mania, bipolar disorder, and alcohol/drug abuse, were discussed by the focus group participants. Results: The participants tended to share very negative examples about the potential violent and annoying behaviors of patients with psychosis, including schizophrenia, mania, and bipolar disorders. However, the stigmatizing opinions did not generalize across different mental illnesses. Patients with anxiety or dementia were much better accepted than those with psychosis. The views on depression were diverse, depending on whether the patients had violent behaviors. Alcohol and drug abuse were seldom related to mental illnesses by the participants. Conclusions: While there are different stereotypes for different mental illnesses, the perceived risks of aggressive behaviors determine the public's acceptance. Future interventions among Chinese should aim to reduce the public's exaggeration of the aggressive image of psychotic patients.

Background Patients who usually attend Traditional Chinese Medicine (TCM) need to go to western medicine (WM) doctors for antibiotics in Hong Kong. They might have different knowledge, attitude and practice (KAP) with antibiotics from the WM-attenders. Objective This study compares TCM attenders with the WM-attenders in Hong Kong about their KAP with antibiotics. The comparison could help future campaigns/education on appropriate antibiotic use. Design and setting A questionnaire on KAP with antibiotics was designed after eight focus groups of purposively selected participants. A territory-wide telephone survey then interviewed randomly selected residents who were aged 18 years or above and spoke the local dialect. Result Of 2471 respondents, 270 and 2092 usually attended TCM and WM, respectively. Majority of both the TCM- and WM-attenders preferred doctors who were judicious in prescribing antibiotics and seldom asked for them. The TCM-attenders were significantly more likely to be female and with lower household income. They were also more likely to agree that antibiotics were not useful for upper respiratory tract infections and that antibiotic resistance was a serious local problem. They were less likely to accept or be treated with antibiotics. The TCM-attenders were also more concerned about the side-effects of antibiotics. However, they were also less likely than the WM-attenders to always finish a full course of antibiotic. Conclusion Apart from non-compliance, the TCM-attenders’ KAP with antibiotics favour the appropriate use of antibiotics.

Summary Objectives This study aimed to explore the in-depth views of the Traditional Chinese Medicine (TCM) practitioners towards Western and Chinese medicine, and the possible ways of integration under a predominant Western medical setting. Design and setting Purposive, qualitative design based on focus group interviews of TCM practitioners in Hong Kong. Participants Information-rich participants were recruited from a Western medicine training course for TCM practitioners. Two focus groups comprising 13 TCM practitioners were held before the course, and two others with 10 TCM practitioners after the course. Results The TCM practitioners were adapted to act in a supportive role to Western doctors although they recognized their own strengths. They highlighted the prejudice from the Western doctors on their diagnostic approach. The TCM practitioners felt that they were actually more open-minded than the Western doctors, who often discouraged the patients to see them. Regarding integration with Western medicine, they considered it as a complicated issue due to the different concepts and forms of integration, as well as the balance between the two types of medicine. While there was a concern that learning Western medicine might overshadow their TCM mindset, they thought that TCM had always welcomed new elements to be added into it over the centuries, Western medicine being no exception. Conclusions The TCM practitioners are adapted to a supportive role to Western doctors under a predominant Western medical setting. Despite the uncertainties for collaboration, the TCM practitioners tend to support the trend of integration.

Background About 15–20% of the general public in Hong Kong consult TCM practitioners. This study explored the decision making process involved in Hong Kong Chinese's choice between TCM and western medicine. Methods Eight focus group interviews (six to eight participants per group) and four individual interviews were conducted. Results The participants kept an “old fashioned” concept of TCM. Many saw TCM as a non-scientific practice and had stronger trust on the credibility of western medicine. Some participants, however, preferred the more personalized treatment approach of TCM. While western medicine was usually the initial choice, the participants were pragmatic to adopt TCM when they felt western medicine was not working, or to supplement the treatment. They were often referred by members of their social networks. Conclusion The public' perception of TCM lagged behind its actual development. Many TCM users are pragmatic users who learn through trial and error.

Objective Physicians' prescribing patterns may be influenced by how they perceive their patients' expectations of medical care. This study explored doctors' perceptions of patient expectations of medical care. Design Qualitative interviews and a cross-sectional survey (September 2014-September 2015). Setting Primary- and tertiary-care facilities in Zhejiang province, China. Participants Primary care practitioners (PCPs) and hospital specialists. Main outcomes Perceived patients' expectations. Results Seven focus groups and 21 individuals were interviewed. Questionnaires were completed by 460 PCPs and 651 specialists (response rate: 78%). About 36.8% of doctors reported generating profit for the facility at which they practiced as a foremost consideration. Participants perceived patients as holding high expectations of clinical performance and use of medical products. Respondents perceived that their patients expected either drug prescriptions (48.2%) or intravenous (IV) therapy (45.2%). Perceived patient expectations of an arrangement of tests and consultation fee refunds if no prescriptions were made were reported by 29.7 and 22.7%, respectively. Doctors reported feeling undervalued and disrespected when patients requested consultation fee refunds. Compared to those who did not report a need for profit-making, doctors who did were significantly more likely to perceive that their patients expected medication-based treatments (AOR = 1.62, P < 0.001), IV therapy (AOR = 1.32, P = 0.037), the arrangement of tests (AOR = 2.06, P < 0.001), and consultation fee refunds when no prescriptions were made (AOR = 1.92, P < 0.001). Conclusions Most doctors believed that patients had high expectations. Workplace profit-orientation demonstrated a strong association with doctors' perceptions.