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As a result of reading this chapter you will be able to: understand the language of ethics and the role ethics play in public; health practice; understand the principles of priority-setting for health and healthcare; systems within a constrained budget; appreciate how an ethical framework guides choices for population; health and health policy-making, including making choices to reduce health inequalities

Objective To assess public knowledge and expectations of the ways to assess doctors' competence to ensure patient safety. Design setting and participants Telephone survey of a random sample of 1000 non-institutionalized Hong Kong residents. Measures and results Only 5% of public were correct that doctors are not required to periodically be assessed, and 9% were correct that the doctors are not required to update knowledge and skills for renewing their license. These results echo international studies showing a low public knowledge of medical regulation. The public overwhelmingly felt a periodic assessment (92%) and requirements for continuous medical education (91%) were important processes for assuring doctors' competence. A high proportion of the public felt that lay representation in the Medical Council was insufficient. Conclusion There is a significant gap between public expectations and understanding of the existing medical regulation and the actual policies and practices. Despite a lack of public knowledge, the public thought it important to have an ongoing structured monitoring and assessment mechanism to assure doctors' competence. The public also expects a greater involvement in the regulatory processes as members of the Medical Council. There is a need to review and enhance the current regulatory system to meet public expectation and ensure accountability for the privilege and trust granted by the State in professional self-regulation. In the context of our complex health system, a thorough understanding on the dynamic interactions between different institutions and their complementary roles in a meta-regulatory framework is required in assuring patient safety.

Will the new Health Research Authority (HRA) framework go far enough? Dr Emily Phipps, Professor Sian Griffiths of The Chinese University of Hong Kong, and Dr Mark Sheehan of the Nuffield Department of Population Health, Oxford University, consider the challenges facing the new HRA framework in addressing research into public health interventions on both an individual and a population level.IntroductionIn 2013, the public health functions of the National Health Service (NHS) in England moved to local government as part of reforms under the Health and Social Care Act 2012.[1] In this setting, the public health team commissions and manages a broad portfolio of programmes that aim to positively influence the local population's health and wellbeing, reduce inequalities and promote a healthy lifestyle.[2] The very nature of this work requires public health interventions to span the functions of health and politics, bringing together expertise from clinical, nursing, social care and local government backgrounds.Developing a robust evidence base for the delivery of public health interventions is key to ensuring that public health teams can provide the most effective and efficient service possible. Research governance processes regulate the design, implementation and dissemination of studies into public health interventions and are a legal requirement of health research conducted in England. However, there is currently significant variation in the quality and accessibility of research governance processes in local authorities in England to support the study of public health interventions.[1] In a recent nationwide study by Rainey et al.,[3] 35% of research governance leads listed on a national local authority database were no longer in post, and 25% of respondents from local authority public health and social care teams reported not having or not being aware of research governance arrangements in their local authority.Where such processes are available, a lack of familiarity with the relatively recently introduced public health functions to local authority can make it difficult for research projects to be assessed in a robust and appropriate manner. Research governance leads unfamiliar with governance issues pertinent to the study of public health interventions may be reluctant to pass review and approval. This risk may mean that projects are altered at the point of design to 'fit' the model most familiar to the research governance lead, rather than being of a methodology best suited to the hypothesis in question, in order to increase the likelihood of approval.Ethical review processes are a fundamental part of research governance, protecting the safety, dignity, rights and wellbeing of study participants. Researchers wishing to study public health interventions in local authorities rely on there being robust and appropriate ethical review services available in that organisation. As the nature of this research is unlikely to involve conventional methodology or typically medical interventions, local NHS research governance teams will likely not feel appropriately equipped to provide approval. In addition, academic research ethics committees often will not review the ethics of applications for research that is being conducted without university involvement, and vary widely in their approval processes and remit.[4] National guidance on the provision of research governance services, such as ethical review processes within local authority settings in England, may be one way to ensure standardised and appropriate services are available.In January 2015, the Health Research Authority (HRA) took over the responsibilities of the National Research Ethics Service and National Social Care Research Ethics Committee, so that all research involving health and social care in England is now governed by the same authority. The HRA are currently developing a high-level framework to guide the revision of local research governance policy which should recognise the changes to health and social care functions introduced in 2012. …

Background Vouchers are increasingly used as a demand-side subsidy to reduce financial hardship and improve quality of services. Elderly Healthcare Voucher Scheme has been introduced by the Hong Kong Government since 2009 to provide subsidy to elderly aged 65 and above to visit ten different types of private primary care providers for curative, preventive and chronic disease management. Several enhancements have been made over the past few years. This paper (as part of an evaluation study of this unique healthcare voucher scheme) aims to assess the long term impact of the voucher scheme in encouraging the use of primary care services. Methods Two rounds of cross-sectional survey among elderly in Hong Kong were conducted in 2010 and 2016. Propensity score matching and analysis were used to compare changes in perception and usage of vouchers over time. Results 61.5% of respondents in 2016 agreed “the scheme encourages me to use more private primary care services”, a significant increase from 36.2% in 2010. Among those who agreed in 2016, the majority thought the voucher scheme would encourage them to use acute services (90.3%) in the private sector, rather than preventive care (40.3%) and chronic disease management (12.2%). Respondents also reported that their current usual choice of care was visiting “both public and private doctors” (61.9%), representing a significant increase (up from 48.4%) prior to their use of voucher. Conclusions The voucher scheme has encouraged the use of more private care services, particularly acute services rather than disease prevention or management of chronic disease. However, there needs to be caution that the untargeted and open-ended nature of voucher scheme could result in supply-induced demand which would affect long term financial sustainability. The dual utilization of health services in both the public and private sector may also compromise continuity and quality of care. The design of the voucher needs to be more specific, targeting prevention and chronic disease management rather than unspecified care which is mainly acute and episodic in order to maximize service delivery capacity as a whole for equitable access in universal health coverage and to contribute to a sustainable financing system.

To incentivize private primary care utilization and reduce reliance on public healthcare services, Elderly Healthcare Voucher Scheme has been implemented to provide a voucher entitlement to entire older resident population for subsidising their purchase of unspecified primary healthcare services in the private sector. Our study assessed whether voucher usage is associated with reduced utilization of public healthcare services. We retrieved the public healthcare services utilization and voucher transaction data of a survey cohort of 551 participants, who were age eligible for the scheme since 2009, over the period 2009-2015. Our results showed that voucher usage was not associated with reduced utilization of public healthcare services and has encouraged dual utilization of public and private healthcare. It may be due to a generated supply-induced demand and price inflation. The finding suggests the voucher is specifically designed to address the health systems issues to achieve the effective policy objectives. Defining the specific services to be provided and the prices at which they should be offered based on the needs of specified populations is a fundamental design parameter which needs to be incorporated. The alternatives of whether primary care services should be expanded and provided in the public sector or purchased using supply/demand side instruments should be considered taking the context and goals of the health system into account.

BackgroundResearch suggests that an 8-week mindfulness-based cognitive therapy (MBCT) course may be effective for generalised anxiety disorder (GAD).AimsTo compare changes in anxiety levels among participants with GAD randomly assigned to MBCT, cognitive–behavioural therapy-based psychoeducation and usual care.MethodIn total, 182 participants with GAD were recruited (trial registration number: CUHK_CCT00267) and assigned to the three groups and followed for 5 months after baseline assessment with the two intervention groups followed for an additional 6 months. Primary outcomes were anxiety and worry levels.ResultsLinear mixed models demonstrated significant group × time interaction (F(4,148) = 5.10, P = 0.001) effects for decreased anxiety for both the intervention groups relative to usual care. Significant group × time interaction effects were observed for worry and depressive symptoms and mental health-related quality of life for the psychoeducation group only.ConclusionsThese results suggest that both of the interventions appear to be superior to usual care for the reduction of anxiety symptoms.

• Exploration of internet addiction in the largest population of internet users: Chinese adolescents.

The licensing and regulation of physicians is an important topic worldwide and is often tied to discussions in various countries of health care system reform. We conducted a review of current practices for regulating physicians as a key group of health care professionals in eight jurisdictions in Asia and other parts of the world in order to draw implications for the development of future regulatory policies in Hong Kong. Jurisdictions studied included Australia, Canada, China, Malaysia, New Zealand, Singapore, the United Kingdom and the United States. A literature search, supplemented by interviews, was conducted. In analyzing information gathered about global regulatory systems, we used a framework for comparing regulatory typology, developed by the RAND Europe research institute. Our review found that the jurisdictions studied exhibited both similarities and differences in terms of how physicians are regulated and by whom. As a result of our search, we were able to identify 10 key trends in international medical regulation of importance to Hong Kong as it considers reforms to its health care system overall:Changes in medical regulation are seen as a way of improving the quality of patient care.Reform of medical regulation often requires government legislation.The creation of common principles for policies, structures and the organization of regulation between professions is an emerging practice.The involvement of lay people on boards and in inquiries is increasingly common.Medical regulation is moving away from models of self-regulation and toward regulatory models that emphasize partnership between professions and the public, physicians and patients.Health care providers and institutional regulators play complementary roles in medical regulation.Regulation impacts the quality of care — not just the detection and remediation of poor performance.Investigatory and disciplinary functions are increasingly separated and organized independently of each other.Continuous Professional Development (CPD) is compulsory for physicians in many jurisdictions.Overseas medical graduates are admitted into practice in different ways from country to country. These trends are important for regulators in all countries to note as they assess the basic structure and effectiveness of their own medical regulatory systems.

During August 2009–July 2010, we conducted 7 longitudinal telephone surveys among 503 adults in Hong Kong, China, to explore changes in their behavioral and psychological responses to the influenza A(H1N1)pdm09 virus epidemic. Trends were examined using generalized estimating equations models. Findings showed that responses varied with the course of the pandemic.

BackgroundLicensure and registration are the traditional approaches to ensure minimally acceptable standards of care for practice. However, due to advances in medical technology and changes in clinical practice, the knowledge and skills obtained from basic education and training may rapidly become out of date. There is no mandated, structured and ongoing mechanism to assess all doctors' competence in Hong Kong. This paper assessed doctors' perceived needs for continuous professional development, and to identify facilitators and barriers that are likely to influence the implementation of compulsory continuous professional development for maintaining professional competence and ensuring patient safety.MethodsAn explanatory sequential mixed method design with two distinct interactive phases was adopted comprising a postal self-administered questionnaire survey among a random sample of 2,459 of doctors (Phase 1), followed by individual interviews of a stratified sample of 30 questionnaire respondents for the subsequent qualitative analysis (Phase 2).ResultsThe majority of doctors (over 90%) agreed the importance of continuous professional development to update knowledge and skills. However, just 30.7% of non-specialists compared with 65.4% of specialists agreed it would be desirable for continuous professional development to be a requirement for renewal of licenses. A relatively higher percentage of non-specialists compared with specialists reported barriers to participation such as accessibility, availability and relevance of the content of the programmes. Facilitators for uptake included more convenient schedule and location, relevant content, and incentives for participation such as making this a pre-condition for enrolling in government-funded services.ConclusionsTo address the needs of individual doctors, the spheres of practice, personal preferences and learning styles should be considered in deciding the content and processes of continuous professional development. Flexibility is also an important principle. A learning model, incentives for participation and a compliance strategy (instead of deterrence) could be effective strategy for continuous professional development.

Introduction This study investigated the associations between the variables of the theory of planned behavior (TPB), influence of significant others, and smoking intentions and behaviors among adolescents living in rural southern China. Methods A cross-sectional study was conducted among 2609 students in two junior high schools in rural Shantou, Guangdong province, using a self-administered questionnaire. Logistic regression models were fitted to estimate univariate and adjusted odds ratios and corresponding 95% confidence intervals. Results Multivariate analyses showed that having favorable attitudes towards smoking on psychological and social aspects, perceived behavioral control, and having most friends who were current smokers were significantly associated with smoking intentions in the next six months and in the next five years. Having most family members who were current smokers was also significantly related to smoking intention in the next five years. Having favorable attitudes towards smoking on psychological aspect and negative attitudes on physical aspect, perceived support from friends on smoking, and having most friends and senior relatives being current smokers were significantly associated with increased likelihood of ever smoking. Perceived behavioral control and having most friends being current smokers were also significantly associated with regular smoking and smoking in the past 30 days. Conclusions Our results suggest that the key constructs of the TPB model and friends' smoking behaviors play important roles in accounting for smoking intentions and behaviors among a sample of rural Chinese adolescents.

Lisinopril and perindopril are two commonly used first-line antihypertensive agents. Few studies compared their effectiveness in reducing the incidence of renal diseases and diabetes.Adult patients who received new prescriptions of lisinopril or perindopril from 2001 to 2005 in all public hospitals and clinics in Hong Kong were included, and followed up for at least 2 years. Patients prescribed the angiotensin converting enzyme inhibitors (ACEIs) for1 month were excluded. The incidence of admissions due to renal diseases and diabetes was evaluated. We used Cox proportional hazard regression models to assess hospital admissions as the outcome measures, adjusting for age, sex, socioeconomic status, service types, and the proportion of days covered as a measure of medication adherence. The regression models were constructed with propensity score matching to minimize indication biases.20,252 eligible patients with an average age of 64.5 years (SD 15.0) were included. The admission rates 24 months within the date of index prescription due to renal diseases were 3.1% (lisinopril) and 2.3% (perindopril); and 9.6% (lisinopril) and 7.2% (perindopril) for diabetes. Except for admissions due to diabetes at 6 months, lisinopril users were significantly more likely to be admitted due to renal diseases (adjusted hazard ratios: 1.304 to 1.378) and diabetes (1.146 to 1.231) than perindopril users at all time points.Patients prescribed different ACEIs might have a different incidence of hospital admissions. Future studies should be conducted to evaluate the comparative effectiveness of different ACEIs on various patient-centered outcomes by head-to-head randomized controlled trials.

Objectives Community health centres are the main form of provision of primary care in China. There are three models: government managed, hospital managed and private. Our aim was to describe and compare primary care under the three ownership models. Methods Four aspects of primary care were studied: services, organization, financing and human resources. Interviews were undertaken with 60 managerial and professional staff in 13 community health centres in the Pearl River Delta region in 2010. Three community health centres were selected in the capital city and two were selected from each of the other five cities. Thematic framework analysis was conducted. Results Government-managed community health centres received the largest public funding, followed by hospital-managed community health centres, while private community health centres received the least. Private community health centres were the smallest in scale and provided lower quality public health services compared with the other two models. Patient out-of-pocket costs accounted for the majority of the revenue in all models of community health centres despite improved government funding for preventive services. General challenges such as the shortage of public funding, the exclusion of migrants in the funding for preventive services, low capacity in human resources and the separation of clinical and preventive care in community health centres were identified in all three models of community health centres. Conclusions The ownership and management of a community health centre greatly influence the service it provides. Private community health centres are in a disadvantaged position to deliver high quality clinical and preventive care.

Objective To assess changes in the quality of primary care in two megacities following the introduction of health system reforms in China. Methods We conducted multistage stratified random face-to-face surveys of patients visiting community health centres in Shanghai in 2011 and 2013, and Shenzhen in 2012 and 2013. Quality of primary care was measured using an assessment tool. Difference-in-difference analyses based on multiple linear regressions were used to compare the changes over time, after controlling for potential confounders. Findings Most (2721) of the 3214 participants used a community health centre as their regular source of care and were included in our analyses. The mean total scores for quality of primary care were similar for Shanghai and Shenzhen at baseline. In Shenzhen, the mean total scores for all participants and those on low incomes had worsened by 0.922 (95% CI: 0.629 to 1.215) and 1.203 (95% CI: 0.397 to 2.009), respectively. In Shanghai, however, there were improvements in the mean total scores which included increases in the scores for first-contact utilization, continuity, coordination of information and comprehensiveness. Conclusion The quality of primary care improved in Shanghai but not in Shenzhen. This may be because, in Shanghai, beneficial long-term relationships between patients and general practitioners were supported by capitation payments and the provision of services tailored to the local health priorities.

Despite effective treatments, suboptimal medication adherence substantially hinders blood pressure (BP) control among hypertensive patients. This study aimed to evaluate the determinants of medication adherence and BP control among hypertensive patients in Hong Kong.A cross-sectional study was conducted. Adult patients aged18years taking at least one type of antihypertensive drugs were recruited from four clinics in Hong Kong. Each patient completed a self-administered questionnaire, including socio-demographic variables and items related to knowledge, illness perception and medication adherence. Medication adherence was measured by the eight-item Morisky Medication Adherence Scale (MMAS-8), with a score6 defined as "good adherence". BP was measured, and optimal control was defined as systolic BP140mmHg and diastolic BP90mmHg.Among 2445 patients, 55.1% and 52.5% had optimal medication adherence and BP control, respectively. Binary logistic regression analyses were conducted with optimal medication adherence and BP control, respectively, as the outcome variables. Advanced age (adjusted odds ratio [aOR] 1.012, 95% CI 1.002-1.022, p=0.014), unemployment (aOR for employed 0.782, 95% CI 0.628-0.975, p=0.029), and good self-perceived health status (aOR 2.155, 95% CI 1.711-2.714, p0.001) were associated with good adherence; whereas being married (aOR 1.265, 95% CI 1.038-1.542, p=0.020) and having no co-morbidity (aOR for morbidity count 0.713, 95% CI 0.639-0.796, p0.001) were associated with optimal BP control.Evidence-based, adherence-enhancing interventions should be targeted on younger subjects; employed patients; and those with poor self-perceived health status. Patients who are single and those with comorbidities should be closely monitored for their BP control.

Optimal adherence with antihypertensive medications is crucial to prevent hypertension-related complications. This study evaluated whether the duration of initial antihypertensive prescription is associated with better medication adherence in a large sample of Chinese hypertensive patients.From a validated clinical database which consists of all patients in the public healthcare sector in Hong Kong, all patients on their first-ever antihypertensive agent from 2001 to 2005 (N=203,259) were included and followed-up for 12 months (and up to 5 years in separate analyses). The average age was 58.7 years (SD 17.3), and the overall rate of optimal adherence (as measured by having the Proportion of Days Covered≥0.80) was 32.4%. The proportion of patients whose initial prescriptions lasted for ≤6 days; 7-14 days; 15-28 days and ≥29 days was 23.7%, 24.3%, 15.1% and 37.0%, respectively. The corresponding proportion of optimal adherence was 18.1%, 20.1%, 31.0% and 50.3%. The binary logistic regression analysis showed that after controlling for age, sex, socioeconomic status, service type, drug class, and district of residence, those whose initial prescription was 7-14 days (adjusted odds ratio [AOR]=1.17, 95% C.I. 1.12-1.22); 15-28 days (AOR=1.90, 95% C.I. 1.82-1.99) and ≥29 days (AOR=4.13, 95% C.I. 3.96-4.31) were significantly more likely to be adherent than those who were prescribed for ≤6 days (all p0.001). These findings remained significant in separate analyses where the period of follow-up was extended to 5 years.Shorter duration of first antihypertensive prescriptions was associated with poorer medication adherence, and this practice should be avoided if possible.

Background: Cell-free fetal DNA-sequencing-based noninvasive prenatal testing (NIPT) for fetal aneuploidy was introduced in late 2011 in Hong Kong. While the clinical benefits of NIPT as an easy, accurate, and procedurally risk-free test at an early gestational stage are recognized, little is known about its ethical implications in antenatal care. This study aimed to assess obstetric professionals’ views of NIPT. Methods: Surveys containing closed-ended questions about knowledge and attitudes toward NIPT and views on selected ethical issues associated with it were distributed to obstetricians, nurses, and midwives practicing in both the public and private sectors in Hong Kong between October 2013 and January 2014. Results: Of the 327 respondents, 123 (38%) were NIPT providers, 138 (42%) were knowledgeable about the test but did not provide it (“nonproviders”), and 20% (66/327) had no knowledge of NIPT (“NIPT unaware”). Forty-three percent of NIPT providers and nonproviders (111/261) regarded NIPT as a pri...

Current evidence is mixed regarding the association between antihypertensive prescriptions and cancer mortality. We evaluated this association in a large Chinese hypertensive population. We followed for five years all patients who were prescribed their first-ever antihypertensive agents between 2001 and 2005 in a public healthcare sector of Hong Kong. The association between antihypertensive drug class and cancer mortality was evaluated by Cox proportional hazard models with propensity score matching. Age, gender, socioeconomic status, service settings, district of residence, proportion of days covered reflecting medication adherence, and the number of comorbidities were adjusted. From 217,910 eligible patients, 9500 (4.4%) died from cancer within five years after their first-ever antihypertensive prescription. Most cancer deaths occurred in the digestive (38.9%) and respiratory system (30.4%); the breast (6.2%); and the lympho-hematopoietic tissues (5.3%). The proportion of patients who died from cancer was the highest in the calcium channel blocker (CCB) group (6.5%), followed by thiazide diuretics (4.4%), angiotensin converting enzyme inhibitors (4.2%) and β-blockers (2.6%). When compared with β-blockers, patients prescribed CCBs (Adjusted Hazard Ratio [AHR] = 1.406, 95% C.I. 1.334–1.482, p < 0.001) were more likely to die from cancer. Thiazide users were also more likely to suffer from cancer deaths (AHR = 1.364, 95% C.I. 1.255–1.483, p < 0.001), but became insignificant in stratified analysis. The association between cancer mortality and use of CCB, and perhaps thaizide, may alert physicians to the need for more meticulous and comprehensive care of these patients in clinical practice. We recommend prospective studies to evaluate cause-and-effect relationships of these associations.

Background Despite empirical evidence demonstrating the effectiveness of collaborative stepped care program (SCP) in Western countries, such programs have not been evaluated in the east, which has a different services system structure and cultural nuances in seeking help for mental illness. Furthermore, only a few studies have used SCP for depression and anxiety prevention. We conducted a trial to test its effectiveness in preventing major depressive disorder and generalized anxiety disorder among primary care patients with subthreshold depression and/or anxiety in Hong Kong. Methods Subthreshold depression and/or anxiety patients were randomized into the SCP group (n=121) or care as usual (CAU) group (n=119). The SCP included watchful waiting, telephone counseling, problem solving therapy, and family doctor treatment within one year. The primary outcome was the onset of major depressive disorder or generalized anxiety disorder in 15 months. The secondary outcomes were depressive and anxiety symptoms, quality of life and time absent from work due to any illness. Results Survival analysis showed no differences between the SCP and CAU groups (the cumulative probability of onset at 15 month was 23.1% in the SCP group and 20.5% in the CAU group; Hazard Ratio=1.62; 95% Confidence Interval: 0.82–3.18; p=0.16). No significant differences were found in secondary outcomes. Limitations Sample size might not have been large enough. Conclusions SCP did not show beneficial effect on depression/anxiety prevention compared with CAU in Hong Kong primary care. As a large majority of patients improved overtime without any intervention, we are not able to exclude the possibility that the intervention might be effective. Future studies would need to have a larger sample size and conduct on patients with more severe symptoms or perform a second screening.

Aims To examine the patterns of alcohol consumption in Hong Kong Chinese women before and after a period of major alcohol policy amendments. Short summary This study compared alcohol consumption patterns in Hong Kong Chinese women before and after a period of major alcohol policy amendments and found increased drinking among certain subgroups, particularly middle-aged women. These increases are likely due to personal factors (e.g. changing perceptions) as well as environmental influences (e.g. greater marketing). Methods Cross-sectional telephone surveys were conducted on adult Chinese women prior to the 2007-2008 beer and wine tax eliminations in 2006 (n = 4946) and in 2011 (n = 2439). Results Over the study period, only women in the 36-45 year age stratum reported significant increases in all three drinking patterns: past-year drinking (38.1-45.2%), past-month binge drinking (2.3-5.2%) and weekly drinking (4.0-7.3%) (P < 0.05); middle-aged women, unemployed or retired women and those ascribing to alcohol's health benefits emerged as new binge drinking risk groups. In 2011, 3.5% of all drinking-aged women (8.8% of past-year drinkers, 20.7% of binge drinkers and 23.1% of weekly drinkers) reported an increased drinking frequency after the tax policy changes. The main contexts of increased drinking were social events and with restaurant meals; moreover, beliefs of alcohol's health benefits were common to all contexts of increased drinking. Of women who increased their drinking frequency, the largest proportion attributed it to peer effects/social environment conducive to drinking, and brand marketing/advertising influences. Conclusions Increased drinking among certain subgroups of Hong Kong Chinese women may be due to combined influences of: increased societal acceptance of social drinking, aggressive marketing promotions and personal beliefs in the health benefits of drinking that have recently emerged in the region. Hence, multi-prong strategies are required to combat potential drinking harms in these women.

Supplemental Digital Content is available in the text, Ownership of primary care providers varies in different cities in China. Shanghai represented the full public ownership model of primary providers; Shenzhen had public-owned but private-operated providers; and Hong Kong represented the full private ownership. The study aims to assess the association of primary care ownership and patient perceived quality of care in 3 Chinese megacities. We conducted multistage stratified random surveys in 2013 in the 3 cities. Quality scores of primary care were measured using the validated primary care assessment tools. Multivariate linear regression models were used to compare quality scores after controlling potential confounders of patient demographic, socioeconomic, and healthcare utilization factors. Overall, 797 primary care users in Shanghai, 802 in Shenzhen, and 1325 in Hong Kong participated in the study. The mean total quality scores were reported the highest in Shanghai (28.39), followed by Shenzhen (25.82) and then Hong Kong (25.21) (P

Multimorbidity has become the norm worldwide as populations age. It remains, however, infrequently researched. This study evaluated factors associated with multimorbidity in a predominantly Chinese hypertensive population. We included all adult patients prescribed their first antihypertensive agents in the entire public sector in Hong Kong from a validated database. Multimorbidity was defined as having one or more medical conditions (cardiovascular diseases; respiratory diseases; diabetes or impaired fasting glucose; renal disease) in addition to hypertension. We studied the prevalence of multimorbidity and performed multinomial regression analyses to evaluate factors independently associated with multimorbidity. 223,286 hypertensive patients (average age of 59.9 years, SD 17.6) were included. The prevalence of having 0, 1 and ≥ 2 additional conditions was 59.6%, 32.8% and 7.5%, respectively. The most common conditions were cardiovascular disease (24.2%) and diabetes (23.0%), followed by respiratory disorders (14.6%) and renal disease (10.9%). Older age (>50 years), male sex, lower household income, receipt of social security allowance and suboptimal blood pressure control (>140 mmHg or >90 mmHg; >130 mmHg or >80 mmHg for diabetes patients; AOR = 3.38-4.49) were significantly associated with multimorbidity. There exists a synergistic effect among these variables as older (≥ 70 years), male patients receiving security allowance had substantially higher prevalence of multimorbidity (19.9% vs 7.5% among all patients). Multimorbidity is very common in hypertensive patients and its prevalence increased markedly with the presence of risk factors identified in this study. Hypertensive patients with multimorbidities should receive more meticulous clinical care as their blood pressure control tends to be poorer.

Non-communicable diseases dominate the public health arena in China, yet neglected tropical diseases (NTDs) are still widespread and create a substantial burden. We review the geographical distribution, prevalence, and epidemic characteristics of NTDs identifi ed in China caused by helminths, protozoa, bacteria, and viruses. Lymphatic fi lariasis was eliminated in 2007, but schistosomiasis still aff ects up to 5% of local village residents in some endemic counties with around 300 000 people infected. China harbours more than 90% of the world’s burden of alveolar echinococcosis and food-borne zoonoses are emerging. In 2010, the overall prevalence of soil-transmitted helminth infections caused by Ascaris lumbricoides, Trichuris trichiura, and hookworm was 11·4%, with 6·8% of these infections caused by A lumbricoides. Corresponding fi gures for food-borne trematodiasis, echinococcosis, and cysticercosis are more than 5%. Dengue, leishmaniasis, leprosy, rabies, and trachoma exist in many areas and should not be overlooked. Transmission of vector-borne diseases can be interrupted; nevertheless, epidemics occur in remote areas, creating a challenge for surveillance and control. Rigorous surveillance, followed by immediate and integrated response packages tailored to specifi c social and ecological systems, is essential for progress towards the elimination of NTDs in China.

To simultaneously examine the impact of self-reported and newly-identified hypertension upon subsequent risk of developing type 2 diabetes. Data were pooled from two community-based urban adult cohort studies, which were separately conducted during 2004–2007 and 2007–2010 in Nanjing, China. Type 2 diabetes was identified using the 1999 World Health Organization diagnosis criteria and hypertension was diagnosed using the 2004 Chinese guidelines for the management of hypertension. Based on blood pressure status, participants were categorized as: (1) people with normal blood pressure at baseline and during the follow-up period (normotension), (2) subjects with self-reported or newly-diagnosed hypertension at baseline (self-reported hypertension) and (3) those with normal blood pressure at baseline but diagnosed having hypertension during the follow-up period (newly-identified hypertension). All covariates were assessed at baseline and study end. Among 4,550 participants, the 3-year cumulative incidence of type 2 diabetes was 14.1 %, 6.5 % and 3.2 % for participants with newly-identified hypertension, self-reported hypertension and normtension, respectively. After adjustment for potential confounders, compared to people with normotension, participants with newly-identified (OR = 4.25; 95%CI = 3.04, 5.93) or self-reported (OR = 1.76; 95 %CI = 1.25, 2.48) hypertension were more likely to develop type 2 diabetes. Furthermore, subjects with newly-identified hypertension (OR = 2.53; 95 %CI = 1.71, 3.73) were at elevated risk of developing type 2 diabetes relative to their counterparts with self-reported hypertension. The similar associations of hypertension with type 2 diabetes were also found in men and women, separately. Newly-identified hypertensive people were at the particularly high risk of developing type 2 diabetes compared to those with self-reported hypertension.

Public health concerns have moved up global and national agendas as the challenges of ageing populations, the epidemic of lifestyle-related disease and the recognition of the importance of the environment, including climate change, gain prominence in the public consciousness. Concerns about affordability of health care, provision of integrated services and creating sustainable environments occupy more media space and policy discussion, putting public health leaders under pressure. Questions about how they can respond effectively and what strategies they need to use take up pages of eminent text and the leadership pressures become more acute. Take, for example, the challenge of obesity. Across the world the rates of overweight and obesity continue to shock. The IASO/IOTF analysis estimates that approximately 1.0 billion adults are currently overweight (BMI 25–29.9 kg/m), and a further 475 million are obese. When Asian-specific cut-off points for the definition of obesity (body mass index >28 kg/m) are taken into account, the number of adults considered obese globally is over 600 million (International Obesity Taskforce). Globally, IASO/IOTF estimate that up to 200 million school-aged children are either overweight or obese; of those, 40–50 million are classified as obese. The consequence of obesity is reflected in the growing incidence of non-communicable diseases (NCD) which are now the commonest cause not only of mortality but also of morbidity – a growing burden in lowand middle-income countries – not just in affluent societies. Salty, sugary, low-fibre foods are consumed in large quantities, and at the same time, populations are becoming less physically active, more cars are polluting the atmosphere and work becomes more stressful. Whilst the burden on health services grows with escalating numbers of people diagnosed with diabetes, hypertension or heart disease, economies start to suffer from loss of productivity and higher numbers of days off work. The problem is now so apparent that it is recognised not only by the World Health Organisation but also by the secular United Nations. At a summit in 2012, called as only the second specific health summit, the first being on HIV/AIDS, national leaders committed

Timely and appropriate care for children with autism spectrum conditions is affected by the interaction between healthcare professionals and parents. Despite the importance of the parent–professional partnership, there is a dearth of cultural-specific data on parent–professional partnership in the Chinese context. We conducted 10 in-depth life-history interviews with parents of children with autism spectrum conditions in Hong Kong who were diagnosed during preschool years. Using an interpretative phenomenological analytic method, five themes were constructed to represent the context of parent–professional partnership in Hong Kong along the pathway of seeking a diagnosis: (a) access to the assessment and diagnosis of autism spectrum conditions, (b) multiple procedures of assessment, (c) consultation prior to diagnosis and assessment, (d) communication of diagnosis and assessment result and (e) post-assessment isolation. Parental narratives highlight the important domains of parent–professional partnership and reflect the complexity of diagnosis and the lack of a cohesive system. For many parents, the assessment procedure was marred by a series of obstacles, which were further exacerbated by a poorly developed parent–professional partnership. Suggestions for parent–professional partnership development include establishing an evidence-based best practice guideline for Hong Kong, creating pre-assessment information workshops for parents to attend and equipping professionals with knowledge about autism spectrum conditions and enhanced communication skills.

Aim : In an effort to promote Hong Kong as a global wine hub, the government eliminated duties on wine and beer in 2008. The changes in alcohol consumption patterns are examined. Methods : Anonymous, cross-sectional telephone surveys on a random sample of Chinese male and female residents aged 18–70 were carried out in 2011 ( n = 4800) and 2012 ( n = 1001). These data were compared with those of a 2006 ( n = 9896) baseline survey conducted before the excise tax elimination. Results : Prevalence of those ever drinking alcohol significantly increased from the 2006 baseline level of 66.6% to 82.0% in 2011 and to 85.2% in 2012. Of note, 10.2% of ever drinkers within the 2012 sample reported consuming alcohol for the first time in or after 2008. Younger, more educated or more affluent parts of the population are more likely to be ever drinkers. Unexpectedly, prevalence of binge drinking in the population decreased slightly from the 2006 baseline of 9.0% to 7.1% in 2011 and to 7.3% in 2012. Quantity of alcohol reportedly consumed by individuals did not change, while alcohol abuse and alcohol dependence levels decreased. However, binge drinking prevalence among the unemployed has increased. Logistic regression showed that those with lower educational achievement and the unemployed have higher likelihood of binge drinking. Conclusion : The government appears to have achieved its objective of making Hong Kong a world center for alcohol trade. However, the resulting access locally to cheaper alcohol has been associated with an increase in the numbers of those drinking alcohol. There has been a trend toward more adults drinking alcohol and greater risk of harm to some disadvantaged groups.

SUMMARYCase report data and a matched case-control study were used to investigate the epidemiological characteristics of hand, foot and mouth disease (HFMD) in children in Shenzhen, China between 2008 and 2011. Multivariate analyses were used to evaluate factors associated with severity of infection. Laboratory tests were performed to determine aetiological identification for samples from 163 severe and fatal cases as well as an outpatient-based HFMD sentinel surveillance system (n = 446). All identified EV71 belonged to sub-genotype C4a. No major changes in the CA16 and EV71 viruses were found until the end of 2011. Annual attack rates and the case-severity ratios (CSRs) rose from 0·82/1000 and 0·56/1000, respectively, in 2008 to 2·12/1000 and 6·13/1000 in 2011. The CSR was higher in migrants than in local residents. The adjusted odds ratio (OR) of having a severe attack for being a migrant was 2·45, having a fever >39°C (OR 5·77), visiting a private clinic (OR 2·65), longer time from symptom onset to diagnosis (OR 1·49), visiting a doctor (OR 1·51), early use of intramuscular pyrazolone (OR 3·36), early use of intravenous glucocorticoids (OR 2·28), or the combination of both (OR 3·75). The mortality and increasing case severity appears to be associated with socioeconomic factors including migration and is of worldwide concern.

Socioeconomic transformation in China at the beginning of the twenty-first century has led to rapid urbanization and accelerated rural-urban migration. As a result, the concerns about public health problems triggered by increasing internal population mobility have been more widely studied in recent years.Published data in Chinese and English on health of migrants and their families in mainland China from 2000 to 2012.The shifting patterns of disease distribution due to rural-urban migration, health equity and health reform strategies that cater for this specific yet substantial subpopulation are outstanding concerns. Infectious diseases, mental health, occupational health and women's health are emerging public health priorities related to migration.The high mobility and large numbers of Chinese rural-urban migrants pose challenges to research methods and the reliability of evidence gained.While the theme of working migrants is common in the literature, there have also been some studies of health of those left behind but who often remain unregistered. Migration within China is not a single entity and understanding the dynamics of new and emerging societies will need further study.Social, economic, emotional, environmental and behavioural risk factors that impact on health of migrants and their families call for more attention from health policy-makers and researchers in contemporary China.

Adherence to antihypertensive medications represents a crucial success factor for optimal blood pressure (BP) control in clinical practice. This study evaluated whether an additional pharmacist-led medication counseling could achieve better optimal BP control and enhance compliance. In a designated family clinic in a region with similar resident characteristics to Hong Kong, patients takingone antihypertensive agent with suboptimal compliance were randomly allocated to a brief 3-minute drug advice (control; n ¼ 161) or pharmacist counseling (intervention; n ¼ 113). The two groups were comparedbyrepeatedmeasureANOVAat3-monthsand6-monthswithBPcontrolandmedicationcomplianceasoutcomevariables,respectively.The proportions of patients having optimal compliance increased from 0% to 41.1% at 3 months and 61.9% at 6 months (P < 0.001). The proportion of patients having optimalBP control improvedfrom 64.1% at baselineto 74.0% at 3 months and 74.5% at 6 months(P ¼ 0.023). There were no significant differences between the two groups in the changes of BP control and compliance levels. This study implied that even a brief 3-minute drug advice might lead to improvedBP levels among patients on antihypertensive medications in general practice, but did not demonstrate additional effects by pharmacist counseling.

AIMS: To investigate the competing effects of increased anti-drink driving legislation and the recent elimination of excise taxes on wine and beer. DESIGN: Serial cross-sectional telephone surveys were conducted in 2006 (n=9860) and 2011 (n=4800). SETTING: Hong Kong, China. PARTICIPANTS: Chinese adults (>18 years of age). MEASUREMENTS: Respondents were asked about their drinking patterns, past-year experience of driving within 2 hours of drinking, drinking-related attitudes and reported deterrents to drink driving. FINDINGS: Following the legislative changes, the age-standardized past-year prevalence of drink driving significantly decreased from 5.2% to 2.8% (p Language: en

Objective The recent population census showed China had officially become a graying society. In the meantime, China also faces a growing burden of non-communicable diseases. Since 2009, a series of policies have been implemented to enhance primary care at the community level. This study describes the elderly care services provided in the differently organized community health centers (CHCs). Methods It covered 13 CHCs of six cities located within the Pearl River Delta (PRD) region. In-depth interviews were conducted with a total of 59 health administrators, CHC managers, and CHC doctors regarding elderly care. Results The study found that accessibility of healthcare for elders has been improved due to the development of health insurance schemes as well as preferential policy to encourage the CHC utilization by the elderly. All the CHCs provide health examinations and chronic disease management to the permanent elderly within their catchment district. However, some preventative care such as fall prevention, immunization and mental health management are not provided. Conclusion Key barriers include low capacity of health service providers in the CHCs, and a lack of government investment in CHCs. Our report provides an empirical evidence for the health care reform in China.

• This is the first Chinese study to show that parental alcohol dependence is a risk factor for practicing child maltreatment.