Stigma and health inequality experienced by ethnic minorities during the COVID-19 pandemic in a Chinese community: an implication to health policymakers.

Introduction: Ethnic minorities are considered one of the most vulnerable groups during the COVID-19 pandemic. However, the explanatory pathway of how their disadvantaged experiences during epidemics are related to the embedded and longstanding stigmas against them and how these embedded stigmas can affect their resilience in disease outbreaks are not well understood. This study investigated the experiences of ethnic minorities in the COVID-19 pandemic, and how their experiences were related to the embedded stigma toward them. Methods: This study adopted a qualitative approach, interviewed 25 individuals (13 women and 12 men) from ethnic minority groups residing in Hong Kong from August 2021 to February 2022 in a semi-structured format. Thematic analysis was conducted to analyze the data. Results: The participants were isolated and stereotyped as infectious during the COVID-19 pandemic at community and institutional levels. Their experiences did not occur suddenly during the pandemic but were embedded in the longstanding segregation and negative stereotypes toward ethnic minorities in different aspects of life before the pandemic. These negative stereotypes affected their resilience in living and coping with the pandemic. Conclusion: The participants' experiences during the COVID-19 pandemic were mostly disadvantageous and predominantly initiated by the mainstream stigmatization toward them by the local Chinese residents and government. Their disadvantaged experiences in the pandemic should be traced to the embedded social systems, imposing structural disparities for ethnic minorities when accessing social and medical resources during a pandemic. Because of the preexisting stigmatization and social seclusion of ethnic minorities in Hong Kong, the participants experienced health inequality, which stemmed from social inequality and the power differential between them and the Chinese locals. The disadvantaged situation of the participants negatively affected their resilience to the pandemic. To enable ethnic minorities better cope with future epidemics, merely providing assistance to them during an epidemic is barely adequate, but a more supportive and inclusive social system should be established for them in the long run.

Motivations and deterrents of blood donation among blood donors during the COVID-19 pandemic in Hong Kong.

BACKGROUND: The COVID-19 pandemic has resulted in a reduction in blood donations and limited blood supply in many countries. The theory of planned behaviour has been widely used in past studies to understand the factors influencing blood donation. However, this theory limits analyses to the individual level. Furthermore, most research on the determinants of blood donation during the COVID-19 pandemic is quantitative in nature, with relevant qualitative research being rare. OBJECTIVES: To investigate the motivators and demotivators for donating blood among current blood donors during COVID-19 pandemic. DESIGN: Forty in-depth, individual semistructured interviews were conducted with current blood donors from December 2020 to March 2021 in Hong Kong. Thematic content analysis was adopted in the data analysis. RESULTS: The majority of the participants (n = 37) were demotivated from donating blood during the COVID-19 pandemic. Factors at the perceptual, social and institutional levels interacted to cause this reluctance. Only three participants felt more motivated to donate blood. The data revealed that sociocultural forces and government pandemic prevention policies strongly affected the participants' motivations to donate blood during the pandemic. CONCLUSION: This study presents a macro understanding of blood donation behaviour by investigating the institutional, social and perceptual factors influencing current blood donors during the COVID-19 pandemic. This adds a more comprehensive understanding of blood donation where the theory of planned behaviour is widely used in past studies. PUBLIC CONTRIBUTION: The participants shared their experiences in the interviews. Their experiences provide hints for explaining the decreasing blood donation during the pandemic times.

A Community-Based Participatory Research Approach to Developing and Testing Social and Behavioural Interventions to Reduce the Spread of SARS-CoV-2: A Protocol for the 'COPAR for COVID' Programme of Research with Five Interconnected Studies in the Hong Kong Context.

BACKGROUND: While a number of population preventive measures for COVID-19 exist that help to decrease the spread of the virus in the community, there are still many areas in preventative efforts that need improvement or refinement, particularly as new strains of the virus develop. Some of the key issues currently include incorrect and/or inconsistent use of face masks, low acceptance of early screening or vaccination for COVID-19, vaccine hesitance, and misinformation. This is particularly the case in some vulnerable populations, such as older people with chronic illnesses, ethnic minorities who may not speak the mainstream language well and children. The current protocol introduces a large programme of research through five interrelated studies that all focus on social and behavioural interventions to improve different aspects of community-related preventative indicators. Hence, the specific objectives of the overall programme are to (1) increase early testing for COVID-19 and promote the uptake of COVID-19 vaccines in the community (Study 1); (2) increase COVID-19-related health literacy and vaccine literacy and promote improved preventative measures in minority ethnic groups, chronically ill populations and caregivers (Study 2); (3) strengthen the public's motivation to stay at home and avoid nonessential high-risk activities (Study 3); (4) decrease COVID-19 vaccine hesitancy (Study 4); and (5) enhance the adherence to COVID-19-related hygiene practices and the uptake of early testing in school children (Study 5). METHODS: We will utilise a community-based participatory research (CBPR) approach in the proposed studies. All studies will incorporate an intervention development phase in conjunction with key community stakeholders, a feasibility study and an execution stage. A variety of self-reported and objective-based measures will be used to assess various outcomes, based on the focus of each study, in both the short- and long-term, including, for example, the 8-item self-reported eHealth Literacy Scale (eHEAL) and objective measures such as vaccine uptake. DISCUSSION: Theory-driven interventions will address each study's focus (e.g., social distancing, promotion of vaccine uptake, eHealth education, preventive measures and early detection). Improvements are expected to be seen in the outcomes of vulnerable and high-risk groups. Decreased infection rates are expected due to improved preventative behaviours and increased vaccine uptake. Long-term sustainability of the approach will be achieved through the CBPR model. The publication of this protocol can assist not only in sharing a large-scale and complex community-based design, but will also allow all to learn from this, so that we will have better insight in the future whether sharing of study designs can elicit timely research initiatives.

The Role of Social and Cultural Values in Pandemic Control in a Chinese Community: An Ethnographic Study on the Construction and Stigmatization of "Others" in Severe Acute Respiratory Syndrome (SARS) and COVID-19 in Hong Kong.

BACKGROUND: Studies have widely reported that social and cultural values serve as constraints in controlling the spread of an epidemic. However, I argue that a social and cultural value system is a double-edged sword and can motivate people's preventive health behaviors. Few studies have examined the positive role of social and cultural values in promoting epidemic control. METHODS: Using the severe acute respiratory syndrome outbreak in 2003 and the COVID-19 pandemic that began in 2020 in Hong Kong as examples, the present study performed participant observation in Hong Kong from January to June 2003 and from January 2020 to May 2022; in-depth individual semi-structured interviews were conducted with 70 participants between February 2021 and March 2022. RESULTS: Social and cultural values serve as informal social control mechanisms in manipulating people's adoption of preventive health behaviors that can assist in epidemic control. Specifically, the construction and stigmatization of the "others" groups and the traditional cultural values based on the capitalist ideology were noted to facilitate control measures against the two outbreaks in Hong Kong. CONCLUSION: These two outbreaks reinforced the embedded social and cultural values of the capitalist ideology of Hong Kong, which increased the vulnerability of disadvantaged social groups to stigmatization.

Perceptions of and hesitancy toward COVID-19 vaccination in older Chinese adults in Hong Kong: a qualitative study.

BACKGROUND: COVID-19 vaccination is recommended for older adults by the World Health Organization. However, by July 15, 2021, only 26% of individuals over 60 years old in Hong Kong had received a first dose of the vaccine. The health belief model and the theory of planned behavior have been used to understand the determinants for COVID-19 vaccination in past literature. However, vaccination determinants can be complex and involve social and cultural factors that cannot be explained by micro-individual factors alone; hence, the health belief model and the theory of planned behavior cannot provide a complete understanding of vaccine hesitancy. Few studies on the barriers to, hesitancy toward, and motivations for COVID-19 vaccination among older Chinese adults have been performed. The aim of this study is to fill this gap by conducting a comprehensive analysis of this subject using the critical medical anthropology framework, extending the health belief model and the theory of planned behavior in understanding vaccination determinants among the older adult population. METHODS: Between November 2020 and February 2021, 31 adults (24 women and 7 men) over the age of 65 took part in semi-structured, one-on-one interviews. The data we gathered were then analyzed through a phenomenological approach. RESULTS: Two major themes in the data were examined: barriers to vaccination and motivations for vaccination. The participants' perceptions of and hesitancy toward vaccination demonstrated a confluence of factors at the individual (trust, confidence, and social support networks), microsocial (stigma toward health care workers), intermediate-social (government), and macrosocial (cultural stereotypes, civic and collective responsibility, and economic considerations) levels according to the critical medical anthropology framework. CONCLUSIONS: The decision to receive a COVID-19 vaccination is a complex consideration for older adults of low socioeconomic status in Hong Kong. Using the critical medical anthropology framework, the decision-making experience is a reflection of the interaction of factors at different layers of social levels. The findings of this study extend the health belief model and the theory of planned behavior regarding the understanding of vaccination perceptions and relevant behaviors in an older adult population.

COVID-19 one year on: identification of at-risk groups for psychological trauma and poor health-protective behaviour using a telephone survey.

BACKGROUND: This study examined the profiles and correlates of psychological trauma, compliance with preventative measures, vaccine acceptance and participation in voluntary testing during the novel coronavirus disease 2019 (COVID-19) pandemic among the adult population in Hong Kong (n = 3,011). METHODS: Data were collected through a telephone survey between December 2020 and February 2021, using measures of psychological trauma, compliance with preventative measures, reading news reports on COVID-19, vaccine acceptance and willingness to participate in voluntary testing. RESULTS: The prevalence of possible post-traumatic stress disorder was found to be 12.4%. Respondents were generally compliant with routine preventative measures, and approximately half had accepted vaccination and voluntary testing. Participants who had lower levels of education, were unemployed or had no income showed greater psychological trauma symptoms, whereas female, older and more educated participants showed greater compliance with preventative measures. Participants who spent more time watching news reports of COVID-19 had greater psychological trauma, but also greater compliance. Participants who were male, older, had lower education levels or were married showed greater acceptance of vaccination and participation in voluntary testing. CONCLUSIONS: Socio-demographic factors affected both psychological trauma and engagement in health-protective measures at one year after the onset of the pandemic. The theoretical and practical implications of these findings are discussed.

Using knowledge of, attitude toward, and daily preventive practices for COVID-19 to predict the level of post-traumatic stress and vaccine acceptance among adults in Hong Kong.

Introduction: COVID-19 has been perceived as an event triggering a new type of post-traumatic stress (PTSD) that can live during and after the pandemic itself. However, it remains unclear whether such PTSD is partly related to people's knowledge of, attitude toward and daily behavioral practices (KAP) for COVID-19. Methods: Through a telephone survey, we collected responses from 3,011 adult Hong Kong residents. Then using the Catboost machine learning method, we examined whether KAP predicted the participant's PTSD level, vaccine acceptance and participation in voluntary testing. Results: Results suggested that having good preventative practices for, poor knowledge of, and negative attitude toward COVID-19 were associated with greater susceptibility to PTSD. Having a positive attitude and good compliance with preventative practices significantly predicted willingness to get vaccinated and participate in voluntary testing. Good knowledge of COVID-19 predicted engagement in testing but showed little association with vaccine acceptance. Discussion: To maintain good mental health and ongoing vaccine acceptance, it is important to foster people's sense of trust and belief in health professionals' and government's ability to control COVID-19, in addition to strengthening people's knowledge of and compliance with preventative measures.

Effects of Urban Green Space on Cardiovascular and Respiratory Biomarkers in Chinese Adults: Panel Study Using Digital Tracking Devices.

BACKGROUND: The health benefits of urban green space have been widely reported in the literature; however, the biological mechanisms remain unexplored, and a causal relationship cannot be established between green space exposure and cardiorespiratory health. OBJECTIVE: Our aim was to conduct a panel study using personal tracking devices to continuously collect individual exposure data from healthy Chinese adults aged 50 to 64 years living in Hong Kong. METHODS: A panel of cardiorespiratory biomarkers was tested each week for a period of 5 consecutive weeks. Data on weekly exposure to green space, air pollution, and the physical activities of individual participants were collected by personal tracking devices. The effects of green space exposure measured by the normalized difference vegetation index (NDVI) at buffer zones of 100, 250, and 500 meters on a panel of cardiorespiratory biomarkers were estimated by a generalized linear mixed-effects model, with adjustment for confounding variables of sociodemographic characteristics, exposure to air pollutants and noise, exercise, and nutrient intake. RESULTS: A total of 39 participants (mean age 56.4 years, range 50-63 years) were recruited and followed up for 5 consecutive weeks. After adjustment for sex, income, occupation, physical activities, dietary intake, noise, and air pollution, significant negative associations with the NDVI for the 250-meter buffer zone were found in total cholesterol (-21.6% per IQR increase in NDVI, 95% CI -32.7% to -10.6%), low-density lipoprotein (-14.9%, 95% CI -23.4% to -6.4%), glucose (-11.2%, 95% CI -21.9% to -0.5%), and high-sensitivity C-reactive protein (-41.3%, 95% CI -81.7% to -0.9%). Similar effect estimates were found for the 100-meter and 250-meter buffer zones. After adjustment for multiple testing, the effect estimates of glucose and high-sensitivity C-reactive protein were no longer significant. CONCLUSIONS: The health benefits of green space can be found in some metabolic and inflammatory biomarkers. Further studies are warranted to establish the causal relationship between green space and cardiorespiratory health.

Enhancing the Physical Activity Levels of Frail Older Adults with a Wearable Activity Tracker-Based Exercise Intervention: A Pilot Cluster Randomized Controlled Trial.

A wearable activity tracker (WAT) incorporated with behavioral change techniques (BCTs) increases physical activity in younger adults; however, its effectiveness with frail older adults is unknown. The feasibility and preliminary effects of a WAT-based exercise intervention to increase physical activity levels in frail older adults was investigated in this pilot study involving 40 community-dwelling frail older adults. The experimental group received a 14-week WAT-based group exercise intervention and a 3-month follow-up, while the control group only received similar physical training and all BCTs. The recruitment rate was 93%, and the average attendance rate was 85.2% and 82.2% in the WAT and control groups, respectively, establishing feasibility. Adherence to wearing the WAT was 94.2% and 92% during the intervention and follow-up periods, respectively. A significant interaction effect between time and group was found in all physical assessments, possibly lasting for 3 months post-intervention. However, no significant difference between groups was observed in any daily activity level by the ActiGraph measurement. The majority of the WAT group's ActiGraph measurements reverted to baseline levels at the 1-month follow-up. Thus, the WAT-based exercise program has potential for employment among community-dwelling frail older adults, but sustaining the effects after the intervention remains a major challenge.

Health inequality experienced by the socially disadvantaged populations during the outbreak of COVID-19 in Hong Kong: An interaction with social inequality.

Health inequality creates conditions for the transmission of infectious diseases, and existing health disparities can contribute to unequal burdens of morbidity and mortality. In Hong Kong, low socioeconomic districts were the epicentres of third-wave outbreak of COVID-19 in July and August 2020, suggesting that people from low socioeconomic class are vulnerable groups. Socially disadvantaged people are relatively more vulnerable to the physical, mental, and social impacts of infectious diseases. To achieve more effective infection control, the social determinants of health and existing health inequalities should be identified, and understanding the experiences of socially disadvantaged groups in the COVID-19 outbreak will be beneficial to health authorities in formulating a responsive infection control policy targeting the needs of the socially disadvantaged. This article investigates the experiences of economically disadvantaged groups during the COVID-19 outbreak and examines how they were further disadvantaged in the outbreak by delineating how health inequality intersected with social inequality. In-depth, semistructured interviews were conducted from February to April 2020 with 35 participants from the poverty class in Hong Kong. The high prices of surgical face masks and disinfecting products as well as the economic impacts induced by COVID-19-related social distancing policies imposed severe economic burden on the participants. In addition to economic and housing deprivation, social inequality was closely associated with health inequality, which made the participants more vulnerable to infection. Social inequality is associated with and can worsen health inequality. Here, the participants, who were of low socioeconomic status were more disadvantaged in health and in the attainment of social resources such as employment, education, face masks, disinfection products and right to use public facilities, during the COVID-19 outbreak. All these elements may have interrelated effects and in turn limit accessibility to healthcare and lead to less positive health outcomes and consequently to health inequality.

The Impact of the Environment on the Quality of Life and the Mediating Effects of Sleep and Stress.

(1) Background: Environment is an independent factor that affects one's quality of life (QoL), where studies suggest that health behaviours also affect one's quality of life. The purpose of the present study was to examine the association between environmental conditions and QoL and how individual health behaviours affect this association. (2) Methods: Participants aged 20 or above were recruited from 11 tertiary planning units in the central part of Kowloon. These tertiary planning units were selected as they represented the overall living environment in Hong Kong, with a mix of the poorer urban areas alongside relatively affluent districts. A mediation analysis was implemented using multiple linear regressions to examine the effects of environmental conditions on QoL. (3) Results: Of the 607 eligible participants included for analysis, 390 were female and 217 were male, with a mean age of 47.4 years. Living within 500 m of a green space area had benefits on the physical aspect of QoL and physical activity but no effect on the psychological aspect of QoL. Moderate satisfaction with public spaces affected QoL positively. In contrast, less satisfaction with public spaces affected QoL negatively in both physical and psychological aspects through the mediating effect of stress. Poor environmental quality affected all domains of QoL negatively through the mediating effects of increased stress and poor sleep. (4) Conclusions: Environment is an important factor that affects individuals' overall well-being. The interaction between environmental conditions and individual variables, especially perceived stress and sleep, is extremely important when assessing its impact on QoL. The findings of this study support the importance of individual stress and sleep in mediating the relationship between the environment and QoL for health. Further studies should be conducted to include objective measurements, such as those of cortisol levels for stress and physical fitness tests.

Knowledge level and motivation of Hong Kong young adults towards blood donation: a cross-sectional survey.

OBJECTIVES: This study aimed to (1) determine the knowledge level of young adults towards blood donation, and (2) to understand their donor identity and the meanings of blood donation to them. DESIGN: A questionnaire-based cross-sectional survey. SETTING AND PARTICIPANTS: Undergraduate students of a university in Hong Kong recruited by convenience sampling, at public facilities in campus such as student canteens and the Campus Blood Donor Centre of the university. OUTCOME MEASURES: The questionnaire which consisted of three parts was used for data collection. Part 1 collected sociodemographic information and items associated with blood donation; part 2 related to knowledge on blood donation and part 3 focused on blood donor identity. Univariate and multivariate logistic regression analyses were conducted to determine the OR and identify the predictors for blood donation. RESULTS: Among the 542 respondents, 274 were non-blood donors and 268 were blood donors. Blood donors generally have a better knowledge towards blood donation than non-blood donors. The results of univariate analyses indicated that being a female (OR=1.99, p<0.001), aged 22 years or above (OR=234, p<0.001), studying at year 4 or 5 (OR=2.12, p=0.003), studying health-related programmes (OR=1.96, p<0.001), being registered as an organ donor (OR=6.59, p<0.001), had prior experience of receiving blood (OR=7.60, p<0.001) or prior experience of being refused for blood donation (OR=5.14, p<0.001) were significantly associated with being a blood donor. Having prior experience of receiving blood was the strongest predictor for being a blood donor, followed by being registered as an organ donor, after controlling for all other factors in the logistic regression model. CONCLUSIONS: The findings are consistent with self-determination theory, which hypothesises that people are more likely to abide with blood donation behaviours that are internally rather than externally motivated.

Schoolteachers' experiences of implementing school-based vaccination programs against human papillomavirus in a Chinese community: a qualitative study.

BACKGROUND: Cervical cancer was the fourth most common cancer among women worldwide in 2012 and was the eighth most common cancer in 2014 and the eighth greatest cause of female cancer deaths in Hong Kong in 2015. Human papillomavirus (HPV) vaccination has been clinically documented to have a high efficacy in reducing HPV-related cervical intraepithelial neoplasia incidence. Therefore, receiving vaccination is a crucial public health measure to reduce disease burden. Significant others, such as schools and schoolteachers, have prominent influence in shaping adolescents' health perceptions and behavior. Therefore, the perspective of schools and schoolteachers regarding vaccination can significantly influence students' acceptance and accessibility of the vaccine. However, few studies have analyzed the perceptions of schoolteachers toward HPV vaccination, and even fewer have concerned how schoolteachers' perceptions influence their schools' motivation in implementing school-based HPV vaccination programs. This study was thus conducted to fill this literature gap. METHODS: With a Chinese community as the field site of this study, a qualitative approach of five focus group interviews was conducted with 35 schoolteachers from five primary and eight secondary schools in Hong Kong between July 2014 and January 2015. Thematic content analysis was used for data analysis. RESULTS: Perceptual, institutional, student and parental, and collaborator barriers interacted to discourage the sampled schoolteachers from organizing school-based HPV vaccination programs. Lack of knowledge regarding HPV vaccination, perception of HPV vaccination as inappropriate given the students' age, violation of traditional cultural values, lack of perceived needs and perceived risk, opposition from schools, low priority of HPV vaccination over other health education topics, lack of government support, lack of interest from parents and students, and lack of confidence in implementing organizations, all were the mentioned barriers. CONCLUSIONS: The sampled schoolteachers were demotivated to organize school-based HPV vaccination programs because of their perceptions and various social and cultural factors. As significant influencers of adolescent students, schoolteachers and schools should receive more support and information on organizing school-based HPV vaccination programs in the future.

Social and cultural construction processes involved in HPV vaccine hesitancy among Chinese women: a qualitative study.

BACKGROUND: HPV vaccine is a prophylactic vaccine to prevent HPV infections. Recommended by the World Health Organization, this vaccine is clinically proven to be one of the most effective preventive measures against the prevalence of cervical cancer and other HPV-associated cancers and chronic genital conditions. However, its uptake rate among women in Hong Kong is insignificant-only approximately 2.9% adolescent girls and 9.7% female university students received HPV vaccination in 2014. With the notion of Critical Medical Anthropology, we aimed to identify if different influential factors, ranging from individual, societal, and cultural, are involved in the decision-making process of whether to receive HPV vaccination. METHODS: We adopted a qualitative approach and conducted in-depth individual semistructured interviews with 40 women in Hong Kong between May and August 2017. RESULTS: We noted that the following factors intertwined to influence the decision-making process: perceptions of HPV and HPV vaccine; perceived worthiness of HPV vaccines, which was in turn influenced by vaccine cost, marriage plans, and experiences of sexual activities; history of experiencing gynecological conditions, stigma associated with HPV vaccination, acquisition of information on HPV vaccines, distrust on HPV vaccines, and absence of preventive care in the healthcare practice. CONCLUSIONS: HPV vaccination is promoted in a manner that is "feminized" and "moralized" under the patriarchal value system, further imposing the burden of disease on women, and leading to health inequality of women in pursuing the vaccination as a preventive health behaviour as a result. We believe that this ultimately results in an incomplete understanding of HPV, consequently influencing the decision-making process. The "mixed-economy" medical system adopting capitalist logic also molds a weak doctor-patient relationship, leading to distrust in private practice medical system, which affects the accessibility of information regarding HPV vaccination for participants to make the decision.

Barriers to Receiving HPV Vaccination Among Men in a Chinese Community: A Qualitative Study in Hong Kong.

Human papillomavirus (HPV) can cause various diseases; low-risk strains can cause genital warts, whereas high-risk strains can cause cervical cancer and cancer of the vulva in women and cancers of the penis, anus, and oropharynx in men. Although HPV affects men, literature has reported that the prevalence of HPV vaccination is far lower among men than among women. Few studies have examined perceptions and acceptability of the HPV vaccine among men, particularly in Chinese communities. In this study, the acceptability of the HPV vaccine to men was investigated using Hong Kong men as a case group. A qualitative research approach was adopted. Thirty-nine men were purposively sampled for the in-depth individual semistructured interviews from June to October 2017 to investigate their perceptions of the HPV vaccine and the barriers for them to receive the vaccination. Limited knowledge and awareness of HPV-related issues, low perceived risk of HPV infection, perceived association between HPV vaccine and promiscuity, and lack of accessible official information on HPV-related topics were identified as the key barriers. These barriers intermingled with the sociocultural environment, cultural values of sexuality, and patriarchal gender values. HPV vaccine is shown to be socially constructed as a vaccine for women exclusively and for promiscuity. The participants were discouraged from receiving HPV vaccination because of its signaling of socially deviant promiscuity. Cultural taboo on sex served as a social oppression of open discussion about HPV vaccine and affected the participants' perceived need of vaccination. Perceived insignificance of reproductive organs also influenced the participants' perceived need of vaccination.

Adolescents from low-income families in Hong Kong and unhealthy eating behaviours: Implications for health and social care practitioners.

The development of dietary preferences of adolescents involves a complex interplay of individual behaviours and environmental factors. Interpersonal factors-such as peer influences and unpleasant school experiences-and institutional factors-such as school rules and policies-are closely associated with unhealthy eating of adolescents. Family support and guidance are also crucial in influencing adolescents' eating habits. However, the low social status, low educational levels, and low household incomes of disadvantaged parents can markedly prevent their children from establishing healthy eating habits. Therefore, adolescents from low-income families are more likely to engage in unhealthy dietary behaviours and hence to be more susceptible to diet-related health problems. However, few studies have addressed the difficulties associated with inculcating healthy eating habits among adolescents from low-income families. Therefore, to investigate the barriers to adopting healthy eating habits, this study adopted a qualitative research approach and conducted five focus-group semistructured interviews with 30 junior- and senior-form students of a secondary school in Hong Kong, all of whom were from low-income families. The results revealed skipping meals because of poverty, following irregular meal patterns on school holidays, receiving poor guidance from family and peers, perceiving healthy eating as expensive and unappealing, and geographical inaccessibility to healthy food all prevented these students from healthy eating. These mutually reinforcing factors were interlocking with the economic strain that was experienced by the participants and their families. In particular, the stereotype of "healthful food is expensive" was strong. Therefore, we suggest students from low-income families should be enabled to understand that healthy eating is not necessarily expensive. The participants' stereotypes about healthy food was handed down by their parents. Such stereotypes, together with the low health literacy, influence the food preparation habits of the parents. Therefore, parents should be made to aware that healthful food can also be affordable.

Perceptions of Seasonal Influenza and Pneumococcal Vaccines Among Older Chinese Adults.

BACKGROUND AND OBJECTIVES: Seasonal influenza can lead to pneumonia. In Hong Kong, deaths from pneumonia increased steadily from 2001 to 2015, and pneumonia was the second most common cause of death between 2012 and 2015. The seasonal influenza vaccine and pneumococcal vaccine have been clinically proven as effective measures against these two diseases among older adults, who are at particularly high risk. Despite the availability of vaccine subsidies, however, more than 60% of older adults in Hong Kong remain unvaccinated against pneumococcal diseases and seasonal influenza. The objective of this study was to investigate the perceptions and barriers associated with the seasonal influenza and pneumococcal vaccinations among older adults in Hong Kong. RESEARCH DESIGN AND METHODS: A qualitative approach of individual semistructured interviews was adopted; 40 adults aged 65 years and older were interviewed between September and November 2016. RESULTS: The intersecting influences of belief of vaccines as harmful, low perceived risk of contracting the diseases, negative rumors about the vaccines, lack of promotion by health care providers, the perceived risk posed by the vaccinating locations, and the preference of using traditional Chinese medicine were discovered to prevent the participants from receiving the two vaccinations. DISCUSSION AND IMPLICATIONS: Perceptions and cultural factors should be considered in future vaccination promotion among older adults. This study found that, in particular, the participants' cultural associations and stereotypes of hospitals and clinics and health care providers' lack of perceived need to vaccinate older adults contributed to low vaccine acceptance among the participants.

Coping with patients suffering from overactive bladder: experiences of family caregivers in Hong Kong.

This article examines the experiences of family caregivers working with patients affected by overactive bladder (OAB) in Hong Kong. Chronic diseases create physical and emotional burdens not only for patients but also for family caregivers, who often experience physical and emotional burnout and social impairment. Extensive literature has pertained to caregiver experiences in western and non-western settings; however, few studies have addressed the livelihoods and experiences of family caregivers of patients with OAB in ethnic Chinese communities. Because of the increasing prevalence of OAB worldwide, this study investigated the experiences of such caregivers in Hong Kong, examining their emotional and social needs. A qualitative research design with individual semistructured interviews was adopted, and snowball sampling was used to recruit 35 family caregivers who were referred by patients with OAB. The participants were interviewed individually from May to August 2013. A phenomenological approach was adopted in the data analysis. The data revealed that all participants had unpleasant experiences in caring for family members with OAB. A sense of powerlessness, helplessness, confusion and guilt, as well as grievances and social withdrawal, was prevalent, causing great physical and emotional suffering and subsequent physical and emotional burnout. These negative experiences were often caused by confusion regarding caretaking duties. The negative emotions of the participants and their family members also caused a lack of communication and mutual understanding about the disease, causing care-giving to be even more confusing and difficult. Furthermore, because of traditional Chinese cultural values and gender expectations, male participants experienced the triple burden of employment, domestic duties and care-giving. More holistic social and healthcare support services should be provided for care-giving family members of patients with OAB patients, empowering such caregivers to attend to family members and care for their own emotional well-being.

Imprisoned in the Cultural Stereotypes of Overactive Bladder: Cultural Meanings of Disease and Sick Role Adaptation in Hong Kong.

BACKGROUND: Diseases often carry cultural meanings and metaphors, and these meanings can influence illness experiences and behavioral responses. OBJECTIVES: This research investigated how old cultural stereotypes and new social understandings of overactive bladder (OAB) intertwined to influence sick role adaptation and behavioral responses among those with OAB. METHODS: A qualitative approach using in-depth individual, semistructured interviews was adopted. Thirty patients having OAB were purposively sampled from a patient self-help group for people with OAB. RESULTS: The cultural stereotypes about OAB-as an "old people" disease, as a hopeless disease without cure, as a sexually related disease, and as a disease of substance use-had significant impact on the social and illness experiences of participants, leading to difficulty in adapting to their sick role, indicated by behavioral responses of denial, concealment, resignation, and self-seclusion. DISCUSSION: Cultural stereotypes of OAB significantly influenced sick role adaptation, which affected illness experiences of persons with OAB. These cultural stereotypes were associated with behavioral responses that led to difficulties in coping with OAB.

Qualitative study on the shifting sociocultural meanings of the facemask in Hong Kong since the severe acute respiratory syndrome (SARS) outbreak: implications for infection control in the post-SARS era.

BACKGROUND: The clinical importance and efficacy of facemasks in infection prevention have been documented in the international literature. Past studies have shown that the perceived susceptibility, the perceived severity of being afflicted with life-threatening diseases, and the perceived benefits of using a facemask are predictors of a person's use of a facemask. However, I argue that people wear a facemask not merely for infection prevention, and various sociocultural reasons have been motivating people to wear (and not wear) a facemask. Facemasks thus have sociocultural implications for people. Research on the sociocultural meanings of facemasks is scant, and even less is known on how the shifting sociocultural meanings of facemasks are related to the changing social environment, which, I argue, serve as remarkable underlying factors for people using (and not using) facemasks. As new infectious diseases such as avian influenza and Middle East Respiratory Syndrome have been emerging, threatening people's health worldwide, and because facemasks have been documented to have substantial efficacy in the prevention of infection transmission, understanding the sociocultural meanings of facemasks has significant implications for public health policymakers and health care providers in designing a socially and culturally responsive public health and infection control policy for the community. METHODS: A qualitative research design involving the use of 40 individual, in-depth semistructured interviews and a phenomenological analysis approach were adopted. RESULTS: The sociocultural meanings of the facemask have been undergoing constant change, from positive to negative, which resulted in the participants displaying hesitation in using a facemask in the post-SARS era. Because it represents a violation of societal ideologies and traditional Chinese cultural beliefs, the meanings of the facemask that had developed during the SARS outbreak failed to be sustained in the post-SARS era. CONCLUSION: The changes in meaning not only influenced the participants' perceptions of the facemask but also influenced their perceptions of people who use facemasks, which ultimately influenced their health behavior, preventing them from using facemasks in the post-SARS era. These findings have critical implications for designing a culturally responsive infection prevention and facemask usage policy in the future.