"The light after the storm": Psychosocial correlates of adversarial growth among nurses in Hong Kong amid the fifth wave of the COVID-19 pandemic.

OBJECTIVE: Healthcare professionals are highly susceptible to adverse psychological outcomes amid the COVID-19 pandemic due to their job duties. As the largest part of the healthcare workforce, growing attention has been paid to nurses' adjustments to the pandemic. Despite the distress, recent studies found that nurses could still experience positive changes (i.e., adversarial growth, AG) during the pandemic. Research on the general populations has indicated that individuals' stress responses, coping resources, and coping strategies are associated with their AG during the pandemic. This study examined how sociodemographic characteristics, secondary traumatic and posttraumatic stress, coping resources, and coping strategies were associated with AG among nurses in Hong Kong amid the fifth wave (i.e., the most disastrous wave) of the COVID-19 pandemic. METHOD: Recruited through local nursing associations between May 24 and June 13, 2022, 209 nurses in Hong Kong completed an online questionnaire measuring the abovementioned variables. RESULTS: Hierarchical regression results found that those affiliating with a religion, having participated in mental health-related workshops, higher levels of secondary traumatic stress (STS), social support, job satisfaction, plus more frequent emotional processing were associated with higher AG (ßs ranging from 0.15 to 0.31, ps < .01). CONCLUSIONS: Nurses did report AG during the fifth wave of the COVID-19 pandemic in Hong Kong. To promote AG among those nurses, future interventions should enhance nurses' understanding about the potential impact of STS on their well-being, solicit their interpersonal and work-related coping resources, plus facilitate their use of effective coping strategies. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Contextualizing evidence-based nurse-led interventions for reducing 30-day hospital readmissions using GRADE evidence to decision framework: A Delphi study.

BACKGROUND: High 30-day readmission rates increase hospital costs and negatively impact patient outcomes in many healthcare systems, including Hong Kong. Evidence-based and local adaptable nurse-led interventions have not been established for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system. AIMS: The aim of this study was to select and refine evidence-based nurse-led interventions for reducing 30-day hospital readmissions among general medical patients in Hong Kong's public healthcare system using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence to Decision (EtD) framework. METHODS: Eighteen local healthcare stakeholders were recruited to carry out a two-step process. In step 1, stakeholders were invited to prioritize nurse-led interventions which were supported by existing evidence and suggest important combinations of different interventions. For all interventions prioritized in step 1, step 2 involved stakeholders performing a two-round Delphi questionnaire aiming to generate consensus-based interventions appropriate to the local context. GRADE EtD framework was applied to guide the decision-making process, taking into account certainty of evidence, benefits and harms, resource use, equity, acceptability, and feasibility. RESULTS: Four out of eight nurse-led interventions reached a positive consensus with percentage agreement ranging from 70.6% to 82.4%. GRADE EtD criteria ratings showed that over 70% of stakeholders agreed these four interventions were probably acceptable and feasible, though the certainty of evidence was low or moderate. Half of stakeholders believed their desirable effects compared to undesirable effects were large. However, the resources required and how these nurse-led interventions might affect health inequities when implemented were uncertain. Preliminary implementation issues included high complexity of delivering multiple nurse-led intervention components, and challenges of coordinating different involved parties in delivering the interventions. Appropriate resource allocation and training should be provided to address these potential problems, as suggested by stakeholders. LINKING EVIDENCE TO ACTION: Using the GRADE EtD framework, four nurse-led interventions were recommended by healthcare stakeholders as possible strategies for reducing 30-day hospital readmissions among general medical patients in Hong Kong. To address preliminary implementation issues, nurses' role as care coordinators should also be strengthened to ensure smooth delivery of nurse-led intervention components, and to facilitate multidisciplinary collaboration during service delivery.

Impact of additional community services provision on dementia caregiver burden: an interrupted time-series analysis of 12-year interRAI assessments in Hong Kong.

OBJECTIVES: To evaluate the impact of providing additional dementia caregiver support services on caregiver burden. DESIGN: Interrupted time-series analysis using territory-wide panel data. SETTINGS: All public-funded district elderly community centres in Hong Kong (HK). PARTICIPANTS: Primary caregivers for older adults (age over 65 years) living with dementia assessed through International Residential Assessment in HK between 1 October 2004 and 31 September 2016. Paid caregivers were excluded. INTERVENTIONS: In April 2014, US$280 million was allocated to provide additional psychological support, education and respite care for dementia caregivers in HK. MAIN OUTCOME MEASURES: Caregiver burden was measured by two age-standardised rates: (1) caregivers in emotional distress; and (2) caregivers with long care time in a week (more than 20 hours a week). We fitted the two time-series into Autoregressive Integrated Moving Average models to evaluate intervention impacts, with follow-up analyses to consider a 6-month transition period of policy implementation. Segmented linear regressions and Holt-Winter exponential smoothening models were used as sensitivity analyses. RESULTS: 36 689 dementia caregivers were included in this study, of which 14.4% caregivers were distress and 31.9% were long-hours caregivers after the policy intervention in April 2014. Providing additional caregiver service significantly reduced standardised rates of caregivers in distress (ß (95% CI)=-3.93 (-7.85 to -0.01), p<0.05), but the effect was not sustained (p=0.183). There was no significant impact on the level of age-standardised rates of caregiver with long care time (ß (95 CI)=-4.25 (-9.61 to 1.10), p=0.120). Also, there was no significant delay of intervention impacts. CONCLUSION: Our study finds that strengthening caregiver services provision could reduce distress rates among primary caregivers for older adults living with dementia. Expanding community services for caregiver could be a solution to the escalating burden of informal care for people living with dementia.

Enabling Factors, Barriers, and Perceptions of Pneumococcal Vaccination Strategy Implementation: A Qualitative Study.

Invasive pneumococcal disease (IPD) is a leading cause of disability and mortality worldwide, particularly in the elderly population. With the implementation of the Government Vaccination Programme (GVP) and the Vaccination Subsidy Scheme (VSS), enabling factors and barriers in service provider scheme participation and vaccination uptake were examined in 32 interviews with doctors and 16 interviews with vaccine recipients. Interview data were analysed in NVivo 11.0 with reference to the Consolidated Framework for Implementation Research (CFIR) and the REAIM Framework to develop codes and themes. Barriers to pneumococcal vaccination uptake included concerns on vaccine efficacy and poor understanding of the disease and vaccine schemes, whilst service provider participation was hindered by ill-defined parameters for patient eligibility and time, location, and logistical constraints. Enabling factors to improve intervention implementation were involvement of the government and physicians to encourage participation, clarifying eligibility criteria, and improving individual knowledge of IPD and vaccination schemes. As participation rates in the GVP and VSS remains low in Hong Kong, efforts concentrating on health promotion strategies encouraging pneumococcal vaccination amongst the elderly population are recommended.

The Efficacy of Herbal Supplement Danggui Buxue Tang for Relieving Menopausal Symptoms.

OBJECTIVES: This study aimed to further explore the efficacy and safety of Danggui Buxue Tang (DBT), a simple herbal formula, for improving the quality of life of women suffering from menopausal symptoms. METHODS: A third clinical trial to determine the clinical efficacy of high-dose DBT for a period of 12 weeks was carried out. The standard Menopause-Specific Quality of Life (MENQOL) assessment chart was used for the evaluation. Safety was defined as an absence of direct estrogenic effects, serum inflammatory cytokines. Notably, interleukin IL-6, IL-8 and tumor necrosis factor TNF-α, known to be directly related to estrogenic reactions in menopause studies, were monitored. RESULTS: The third clinical trial indicated an overall improvement in the four domains of MENQOL, offering further proof of the efficacy of DBT demonstrated in the two previous trials. The serial checks of the three cytokines related to estrogen activities did not show either upward or downward trends. The haphazard behavior reactions of the three cytokines offered indirect indications that DBT improved the MENQOL independently from estrogen activities. CONCLUSIONS: The three clinical trials using DBT to relieve menopausal syndrome have offered solid evidence for its efficacy. The uncertainty regarding whether the "phytoestrogen" contained in DBT had bioactivities similar to estrogen was alleviated through the confirmation that no strict estrogenic bioactivities were observed. The issue of safety was further clarified via laboratory platform studies on DBT, which not only showed the lack of similarity with estrogen actions but also confirmed the value of combining the two herbs in the classic formula.

Differential associations among social support, health promoting behaviors, health-related quality of life and subjective well-being in older and younger persons: a structural equation modelling approach.

BACKGROUND: Extensive studies have confirmed social support as a critical protective factor of people's health-related quality of life (HRQoL) and subjective well-being (SWB). However, health promoting behaviors as a potential mechanism and age differences in this mechanism has received fewer attention. This study aims to examine the associations among social support, health promoting behaviors, HRQoL and SWB in older and younger persons in Hong Kong. METHOD: A convenience sample of both younger (12-35 years old) and older persons (55 years old and above) were recruited from three non-government organizations to complete a survey. Structural Equation Model (SEM) was conducted to test both the measurement model and structural models to examine the relationship between social support, health promoting behaviors, HRQoL and SWB. Multi-group SEM was also performed and compared to test whether there were significant age differences in the pathways between the key variables. RESULTS: A final sample of 408 participants (older-persons: N = 200 (mean age: 71.63 (8.16); 180/200 female), younger-persons: N = 208 (mean age: 18.10 (5.04); 155/208 female) were included in the final analysis. Results showed that social support was positively associated with SWB directly and indirectly through health promoting behaviors for the whole sample (CFI = .95, IFI = .94, RMSEA = .07, SRMR = 0.056). Results suggested that the association between the variables differed across age samples. While social support showed a positive association with health promoting behaviors for both younger and older persons, how each of them associated with HRQoL and SWB was different. CONCLUSION: Findings suggest that the pathway which social support linked with HRQoL and SWB might differ across age groups. Age-specific strategies should be considered when promoting HRQoL and SWB among the younger and older population.

Effectiveness of Peri-Discharge Complex Interventions for Reducing 30-Day Readmissions among COPD Patients: Overview of Systematic Reviews and Network Meta-Analysis.

BACKGROUND: An overview of systematic reviews(SRs) and network meta-analysis(NMA) were conducted to evaluate the comparative effectiveness of peri-discharge complex interventions for reducing 30-day readmissions among chronic obstructive pulmonary disease(COPD) patients. METHODS: Five databases were searched for SRs of randomized controlled trials(RCTs). An additional search was conducted for updated RCTs from database inception until Jun 2020. Pooled effect of peri-discharge complex interventions was assessed using random-effect pairwise meta-analyses. Comparative effectiveness across different peri-discharge complex interventions was evaluated using NMA. RESULTS: Nine SRs and 11 eligible RCTs(n = 1,422) assessing eight different peri-discharge complex interventions were included. For reducing 30-day all-cause readmissions, pairwise meta-analysis showed no significant difference between peri-discharge complex interventions and usual care, while NMA indicated no significant differences among different peri-discharge complex interventions as well as usual care. For reducing 30-day COPD-related readmissions, peri-discharge complex interventions were significantly more effective than usual care (pooled RR = 0.45, 95% CI:0.24-0.84). CONCLUSIONS: Peri-discharge complex interventions may not differ from usual care in reducing 30-day all-cause readmissions among COPD patients but some are more effective for lowering 30-day COPD-related readmission. Thus, complex intervention comprising core components of patient education, self-management, patient-centred discharge instructions, and telephone follow up may be considered for implementation, but further evaluation is warranted.

Sociodemographic moderation of the association between depression and stroke incidence in a retrospective cohort of 0.4 million primary care recipients with hypertension.

BACKGROUND: Previous research has suggested an association between depression and subsequent acute stroke incidence, but few studies have examined any effect modification by sociodemographic factors. In addition, no studies have investigated this association among primary care recipients with hypertension. METHODS: We examined the anonymized records of all public general outpatient visits by patients aged 45+ during January 2007-December 2010 in Hong Kong to extract primary care patients with hypertension for analysis. We took the last consultation date as the baseline and followed them up for 4 years (until 2011-2014) to observe any subsequent acute hospitalization due to stroke. Mixed-effects Cox models (random intercept across 74 included clinics) were implemented to examine the association between depression (ICPC diagnosis or anti-depressant prescription) at baseline and the hazard of acute stroke (ICD-9: 430-437.9). Effect modification by age, sex, and recipient status of social security assistance was examined in extended models with respective interaction terms specified. RESULTS: In total, 396 858 eligible patients were included, with 9099 (2.3%) having depression, and 10 851 (2.7%) eventually hospitalized for stroke. From the adjusted analysis, baseline depression was associated with a 17% increased hazard of acute stroke hospitalization [95% confidence interval (CI) 1.03-1.32]. This association was suggested to be even stronger among men than among women (hazard ratio = 1.29, 95% CI 1.00-1.67). CONCLUSION: Depression is more strongly associated with acute stroke incidence among male than female primary care patients with hypertension. More integrated services are warranted to address their needs.

COVID-19 Vaccine Hesitancy in a City with Free Choice and Sufficient Doses.

BACKGROUND: Vaccine hesitancy represents one of the major global health issues around the world. We examined the perception, attitude, perceived barriers and facilitation measures of receiving the COVID-19 vaccine in a Chinese population with free vaccine choices (Sinovac [Coronavac] vs. BioNTech/Fosun [Comirnaty]) and adequate doses. METHOD: We conducted a random telephone survey of the general population in 1195 subjects aged 18 years or above from 23 April 2021 to 8 May 2021 after two months of vaccine rollout. A descriptive analysis of the levels of enabling factors, obstacles and perception of COVID-19 vaccination was conducted using ANOVA and Chi-square tests for trend. RESULTS: Only 10.1% and 13.5% had received one and two COVID-19 vaccine doses, respectively. Among those who had not received any COVID-19 vaccine (75.4%), only 25.1% expressed their intention to receive in the coming 6 months. The barriers with the highest scores included "having heard of cases with serious adverse events or death after vaccination" (score: 8.17 out 10, 95% C.I. 7.99, 8.35), "lack of confidence on governmental recommendations" (7.69, 95% C.I. 7.47, 7.91), and "waiting for a better vaccine" (7.29, 95% C.I. 7.07, 7.52). The highest score for the impact of various incentives for vaccination was for "vaccine passports for overseas travel" (4.44, 95% C.I. 4.18, 4.71). CONCLUSIONS: Vaccine hesitancy is commonly observed in this Chinese population despite adequate provision of vaccine doses and choices. No single incentive is strong enough to promote vaccination, and multiple facilitation measures for different groups of population are needed to encourage vaccine uptake. Active clarification and promotion by medical professionals together with a variety of incentives are needed to drive vaccine uptake.

Acceptance of pneumococcal vaccination in older adults: A general population-based survey.

BACKGROUND: Pneumococcal infection is a leading cause of disability and death globally. The Hong Kong Government has launched two programmes for pneumococcal vaccination - The Vaccination Subsidy Scheme (VSS) and the Government Vaccination Programme (GVP). This study aimed to examine the enabling factors, obstacles and perception of pneumococcal vaccination, and their association with its uptake in a general Chinese population. METHODS: We performed a population-based, telephone survey in the general public aged 65 or above via simple random sampling. A validated survey based on the Health Belief Model (HBM) was used. Their socio-demographic information; history of previous participation in the GVP or VSS; and self-perceived health status were captured. Binary logistic regression models were constructed to examine the factors independently associated with vaccination. RESULTS: A total of 1,000 respondents were enrolled in the study, with 402 (40.2%) respondents having intention to join the GVP/VSS in 12 months. Respondents with long-term medical consultant and medication (adjusted odds ratios [aOR] = 1.541, 95% confidence interval (CI): 1.008-2.356, p = 0.046); high levels of perceived susceptibility of infections (aOR = 3.624, 95 %CI: 2.318-5.665, p < 0.001); high levels of perceived benefits of vaccine (aOR = 1.699, 95 %CI: 1.153-2.504, p < 0.001); recommendations from government (aOR = 8.025, 95 %CI: 4.771-13.497, p < 0.001) or physicians (aOR = 7.399, 95 %CI: 3.472-15.764, p = 0.008); and high levels of self-efficacy (aOR = 3.045, 95 %CI: 1.458-6.362, p = 0.003) were more likely to have intention to participate in the vaccination programme. CONCLUSIONS: The acceptance rate of pneumococcal vaccination programme remained suboptimal in the population. The government and physicians should be involved in the promotion of pneumococcal vaccination and GVP/VSS by increasing perceived benefits and self-efficacy, and reducing barriers towards vaccination among the target population. More studies are required to confirm our findings in other settings.

A Bayesian method for synthesizing multiple diagnostic outcomes of COVID-19 tests.

The novel coronavirus disease 2019 (COVID-19) has spread worldwide and threatened human life. Diagnosis is crucial to contain the spread of SARS-CoV-2 infections and save lives. Diagnostic tests for COVID-19 have varying sensitivity and specificity, and the false-negative results would have substantial consequences to patient treatment and pandemic control. To detect all suspected infections, multiple testing is widely used. However, it may be challenging to build an assertion when the testing results are inconsistent. Considering the situation where there is more than one diagnostic outcome for each subject, we proposed a Bayesian probabilistic framework based on the sensitivity and specificity of each diagnostic method to synthesize a posterior probability of being infected by SARS-CoV-2. We demonstrated that the synthesized posterior outcome outperformed each individual testing outcome. A user-friendly web application was developed to implement our analytic framework with free access via http://www2.ccrb.cuhk.edu.hk/statgene/COVID_19/. The web application enables the real-time display of the integrated outcome incorporating two or more tests and calculated based on Bayesian posterior probability. A simulation-based assessment demonstrated higher accuracy and precision of the Bayesian probabilistic model compared with a single-test outcome. The online tool developed in this study can assist physicians in making clinical evaluations by effectively integrating multiple COVID-19 tests.

Comparing Multimorbidity Patterns Among Discharged Middle-Aged and Older Inpatients Between Hong Kong and Zurich: A Hierarchical Agglomerative Clustering Analysis of Routine Hospital Records.

Background: Multimorbidity, defined as the co-occurrence of ≥2 chronic conditions, is clinically diverse. Such complexity hinders the development of integrated/collaborative care for multimorbid patients. In addition, the universality of multimorbidity patterns is unclear given scarce research comparing multimorbidity profiles across populations. This study aims to derive and compare multimorbidity profiles in Hong Kong (HK, PRC) and Zurich (ZH, Switzerland). Methods: Stratified by sites, hierarchical agglomerative clustering analysis (dissimilarity measured by Jaccard index) was conducted with the objective of grouping inpatients into clinically meaningful clusters based on age, sex, and 30 chronic conditions among 20,000 randomly selected discharged multimorbid inpatients (10,000 from each site) aged ≥ 45 years. The elbow point method based on average within-cluster dissimilarity, complemented with a qualitative clinical examination of disease prevalence, was used to determine the number of clusters. Results: Nine clusters were derived for each site. Both similarities and dissimilarities of multimorbidity patterns were observed. There was one stroke-oriented cluster (3.9% in HK; 6.5% in ZH) and one chronic kidney disease-oriented cluster (13.1% in HK; 11.5% ZH) in each site. Examples of site-specific multimorbidity patterns, on the other hand, included a myocardial infarction-oriented cluster in ZH (2.3%) and several clusters in HK with high prevalence of heart failure (>65%) and chronic pain (>20%). Conclusion: This is the first study using hierarchical agglomerative clustering analysis to profile multimorbid inpatients from two different populations to identify universalities and differences of multimorbidity patterns. Our findings may inform the coordination of integrated/collaborative healthcare services.

Comparison of adaptive versions of the Hong Kong-specific criteria and 2015 Beers criteria for assessing potentially inappropriate medication use in Hong Kong older patients.

BACKGROUND: The Hong Kong-specific criteria have been established in 2019 to assess potentially inappropriate medication (PIM) use in older adults and improve the local prescribing quality. The aim of this study was to compare the adaptive versions of the Hong Kong-specific criteria and 2015 Beers criteria for assessing the prevalence and correlates of PIM use in Hong Kong older patients. METHODS: A cross-sectional study was performed from January 1, 2014 to December 31, 2014 using the Hospital Authority (HA) database. A total of 489,301 older patients aged 65 years and older visiting general outpatient clinics (GOPCs) during the study period were included in the study. Two categories of PIM use included in the Hong Kong-specific criteria and 2015 Beers criteria, i.e. PIMs independent of diagnoses and PIMs considering specific medical conditions, were adapted to assess the prevalence of PIM use among the study sample. Characteristics of PIM users and the most frequently prescribed PIMs were investigated for each set of the criteria. Factors associated with PIM use were identified using the stepwise multivariable logistic regression analysis. RESULTS: The adaptive Hong Kong-specific criteria could detect a higher prevalence of patients exposed to at least one PIM than that assessed by the adaptive Beers criteria (49.5% vs 47.5%). Meanwhile, the adaptive Hong Kong-specific criteria could identify a higher rate of patients exposed to PIMs independent of diagnoses (48.1% vs 46.8%) and PIMs considering specific medical conditions (7.3% vs 4.9%) compared with that of the adaptive Beers criteria. The most frequently prescribed PIMs detected by the adaptive Beers criteria were all included in the adaptive Hong Kong-specific criteria. The strongest factor associated with PIM use was number of different medications prescribed. Patients with female gender, aged 65 ~ 74 years, a larger number of GOPC visits, and more than six diagnoses were associated with greater risk of PIM use, whereas advancing age was associated with lower risk of PIM use. CONCLUSIONS: The adaptive Hong Kong-specific criteria could detect a higher prevalence of PIM use than the adaptive Beers criteria in older adults visiting GOPCs in Hong Kong. It is necessary to update the prevalence and correlates of PIM use regularly in older adults to monitor the burden of PIM use and identify vulnerable patients who need further interventions.

Caregiving burnout of community-dwelling people with dementia in Hong Kong and New Zealand: a cross-sectional study.

BACKGROUND: Informal caregiving for people with dementia can negatively impact caregivers' health. In Asia-Pacific regions, growing dementia incidence has made caregiver burnout a pressing public health issue. A cross-sectional study with a representative sample helps to understand how caregivers experience burnout throughout this region. We explored the prevalence and contributing factors of burnout of caregivers of community-dwelling older people with dementia in Hong Kong (HK), China, and New Zealand (NZ) in this study. METHODS: Analysis of interRAI Home Care Assessment data for care-recipients (aged ≥65 with Alzheimer's disease/other dementia) who had applied for government-funded community services and their caregivers was conducted. The sample comprised 9976 predominately Chinese in HK and 16,725 predominantly European in NZ from 2013 to 2016. Caregiver burnout rates for HK and NZ were calculated. Logistic regression was used to determine the adjusted odds ratio (AOR) of the significant factors associated with caregiver burnout in both regions. RESULTS: Caregiver burnout was present in 15.5 and 13.9% of the sample in HK and NZ respectively. Cross-regional differences in contributing factors to burnout were found. Care-recipients' ADL dependency, fall history, and cohabitation with primary caregiver were significant contributing factors in NZ, while primary caregiver being child was found to be significant in HK. Some common contributing factors were observed in both regions, including care-recipients having behavioural problem, primary caregiver being spouse, providing activities-of-daily-living (ADL) care, and delivering more than 21 h of care every week. In HK, allied-health services (physiotherapy, occupational therapy and speech therapy) protected caregiver from burnout. Interaction analysis showed that allied-health service attenuates the risk of burnout contributed by care-recipient's older age (85+), cohabitation with child, ADL dependency, mood problem, and ADL care provision by caregivers. CONCLUSIONS: This study highlights differences in service delivery models, family structures and cultural values that may explain the cross-regional differences in dementia caregiving experience in NZ and HK. Characteristics of caregiving dyads and their allied-health service utilization are important contributing factors to caregiver burnout. A standardized needs assessment for caregivers could help policymakers and healthcare practitioners to identify caregiving dyads who are at risk of burnout and provide early intervention.

Acceptance of the COVID-19 vaccine based on the health belief model: A population-based survey in Hong Kong.

BACKGROUND: Vaccines for COVID-19 are anticipated to be available by 2021. Vaccine uptake rate is a crucial determinant for herd immunity. We examined factors associated with acceptance of vaccine based on (1). constructs of the Health Belief Model (HBM), (2). trust in the healthcare system, new vaccine platforms and manufacturers, and (3). self-reported health outcomes. METHODS: A population-based, random telephone survey was performed during the peak of the third wave of COVID-19 outbreak (27/07/2020 to 27/08/2020) in Hong Kong. All adults aged ≥ 18 years were eligible. The survey included sociodemographic details; self-report health conditions; trust scales; and self-reported health outcomes. Multivariable regression analyses were applied to examine independent associations. The primary outcome is the acceptance of the COVID-19 vaccine. RESULTS: We conducted 1200 successful telephone interviews (response rate 55%). The overall vaccine acceptance rate after adjustment for population distribution was 37.2% (95% C.I. 34.5-39.9%). The projected acceptance rates exhibited a "J-shaped" pattern with age, with higher rates among young adults (18-24 years), then increased linearly with age. Multivariable regression analyses revealed that perceived severity, perceived benefits of the vaccine, cues to action, self-reported health outcomes, and trust in healthcare system or vaccine manufacturers were positive correlates of acceptance; whilst perceived access barriers and harm were negative correlates. Remarkably, perceived susceptibility to infection carried no significant association, whereas recommendation from Government (aOR = 10.2, 95% C.I. 6.54 to 15.9, p < 0.001) was as the strongest driving factor for acceptance. Other key obstacles of acceptance included lack of confidence on newer vaccine platforms (43.4%) and manufacturers without track record (52.2%), which are of particular relevance to the current context. CONCLUSIONS: Governmental recommendation is an important driver, whereas perceived susceptibility is not associated with acceptance of COVID-19 vaccine. These HBM constructs and independent predictors inform evidence-based formulation and implementation of vaccination strategies.

Effectiveness of routine measurement of health-related quality of life in improving the outcomes of patients with musculoskeletal problems-a cluster randomised controlled trial: protocol paper.

INTRODUCTION: Managing chronic musculoskeletal problems usually focuses on pain control using medications, but outcomes are often unsatisfactory and sometimes harmful. Information on a patient's health-related quality of life (HRQOL) may trigger a doctor to tailor management improving quality of life. The aim of this trial is to find out whether routine measurement and reporting of a patient's EuroQoL 5-Dimension 5-Level (EQ-5D-5L) HRQOL data using an electronic platform can improve HRQOL and pain in patients with chronic knee or back problems in primary care. We will also assess the acceptability of routine electronic measurements and reporting of the EQ-5D-5L in primary care settings. METHODS: This is a multicentre, prospective, cluster randomised controlled trial set in six public primary care clinics in Hong Kong. At the intervention clinics, subjects will complete an electronic EQ-5D-5L form at recruitment and at each clinic follow-up over 12 months. A report of the patient's longitudinal EQ-5D-5L data will be provided to the doctor. Subjects in the control clinics will receive care as usual. All subjects will complete the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), a 10-point Pain Rating Scale and a structured questionnaire to collect sociodemographic information and data on morbidity and service utilisation at recruitment at baseline, 3, 6 and 12 months. Primary outcome is the change in WOMAC total score. Secondary outcomes are change in pain, other patient-reported outcome scores and doctor-rated severity of disease. Group differences in the changes in WOMAC and other outcome scores over time will be analysed using generalised estimating equation model with an intention-to-treat principle. ETHICS AND DISSEMINATION: Ethics approval has been obtained from The University of Hong Kong/Hospital Authority Hong Kong West Cluster (IRB reference number: UW 18-270). The results of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: NCT03609762.

Can voucher scheme enhance primary care provision for older adults: cross-sectional study in Hong Kong.

BACKGROUND: The Hong Kong government has launched the Elderly Health Care Voucher (EHCV) scheme to facilitate primary care in the private sector for older adults. This study aimed to examine whether voucher use was associated with a shift of healthcare burden from the public to the private sector, vaccine uptake and continuity of care. METHODS: This cross-sectional survey recruited older adults with ≥3 chronic diseases through convenience sampling from seven general outpatient clinics, seven geriatric day hospitals, and five specialist outpatient clinics of the public healthcare sector in Hong Kong. We used multiple logistic regression to address the study objective. RESULTS: A total of 1032 patients participated in the survey. We included 714 participants aged 70 or above in the analysis. EHCV use was associated with higher utilization of private primary care services, including general practitioner and family doctor (Adjusted Odds Ratio (AOR) 2.67, 95% Confidence Interval (95%CI) 1.51-4.72) and Chinese medicine clinic (AOR 3.53, 95%CI 1.47-8.49). There were no significant associations of EHCV use with public general outpatient clinic attendance, Accident & Emergency attendance, and hospitalization. Furthermore, EHCV users were more likely to receive pneumococcal vaccination (AOR 2.17, 95%CI 1.22-3.85) and were less likely to visit the same doctors for chronic disease management (AOR 0.10, 95%CI 0.01-0.73). CONCLUSIONS: While the EHCV may promote private primary care utilization and preventive care, older patients continue to rely on public services and the EHCV may worsen continuity of care. Policy-makers should designate voucher usage for chronic disease management and continuity of care.

Association between antipsychotic use and acute ischemic heart disease in women but not in men: a retrospective cohort study of over one million primary care patients.

BACKGROUND: Research comparing sex differences in the effects of antipsychotic medications on acute ischemic heart disease (IHD) is limited and the findings ambiguous. This study aimed to investigate these associations within a primary care setting. METHODS: Hong Kong public general outpatient electronic records of patients aged 45+ during 2007-2010 were extracted, with the last consultation date as the baseline for a 4-year follow-up period to observe acute IHD hospitalizations (2011-2014). Antipsychotic use was defined as any prescription over the previous 12 months from a list of 16 antipsychotics, while acute IHD was defined by ICD-9: 410.00-411.89. Both sex-specific and sex-combined (both sexes) mixed-effects Cox models (random intercept across 74 clinics) were implemented to examine the association and test the interaction between antipsychotics and sex. RESULTS: Among 1,043,236 included patients, 17,780 (1.7%) were prescribed antipsychotics, and 8342 (0.8%) developed IHD. In sex-specific analyses, antipsychotic prescription was associated with a 32% increased hazard rate of acute IHD among women (95% CI 1.05-1.67) but not among men. A likelihood ratio test comparing sex-combined models with and without the interaction between antipsychotic use and sex suggested significant interaction (χ2 = 4.72, P = 0.030). The association between antipsychotic use and IHD among women attenuated and became non-significant when haloperidol was omitted from the operationalization of antipsychotic use (HR = 1.23, 95% CI 0.95-1.60). CONCLUSION: Our results suggest that antipsychotic prescription is moderately associated with an increased risk of acute IHD among women in primary care and this relationship may be explained by specific antipsychotics. Further research should observe and capture the potential intermediary mechanisms and the dose-response relationship of this association to provide more rigorous evidence to establish causality and inform clinical practices.

An evaluation of universal vouchers as a demand-side subsidy to change primary care utilization: A retrospective analysis of longitudinal services utilisation and voucher claims data from a survey cohort in Hong Kong.

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.

What is the long term impact of voucher scheme on primary care? Findings from a repeated cross sectional study using propensity score matching.

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.