Background: Rapid economic growth in mainland China has been accompanied in recent years by rising levels of inequality and a growing burden of non-communicable disease (NCD), though little is known at present about the relations between these forces. This thesis makes use of data from a large sample of older men and women in Guangzhou, one of China’s most developed cities, to examine the relations between inequality, inequity and non-communicable disease. Objectives: This thesis addresses two research questions: what is the relationship between inequality/inequity and non-communicable disease in China; and what are the implications of this relationship for health policy in China. These two questions lead to two working hypotheses: first, that inequalities may be both a cause and consequence of NCDs in China, potentially creating a vicious cycle which reinforces inequality and inequity; and second, that reducing dependence on out of pocket payments as a source of healthcare finance may help to prevent the continuation of the inequality-NCD cycle. Methods: I used data from the Guangzhou Biobank Cohort Study (GBCS), including 30,499 men and women aged 50 or over from Guangzhou and multi-variable regression methods to examine associations of socioeconomic position at four life stages (childhood, early adulthood, late adulthood and current) with several health outcomes: self-rated health, chronic obstructive pulmonary disease, metabolic syndrome and markers of immunological inflammation (white blood cells, granulocytes and lymphocytes). These analyses related to the hypothesis that inequalities may be a cause of non-communicable disease in China. I also examined whether inequity may be a consequence of non-communicable disease by measuring whether horizontal inequity (deviation from the principle of equal access to healthcare for equal need) was greater for treatment of NCDs than for general healthcare. I tested this using both concentration index methods and multi-variable regression models. For comparative purposes, I conducted these analyses in data from three settings: Guangzhou, Hong Kong and Scotland (UK). Results: I found that socioeconomic deprivation across the life course was associated with poorer self-rated health, higher risk of COPD, higher white cell and granulocyte cell counts and (in women only) higher risk metabolic syndrome and higher lymphocyte cell counts. I also found evidence of pro-rich inequity in utilisation of treatment for three major non-communicable conditions (hypertension, hyperglycaemia and dyslipidaemia) in Guangzhou, whilst there was no evidence of inequity in general healthcare utilisation (doctor consultations and hospital admissions) or treatment of gastric ulcer. Conclusion: My findings gave qualified support for the idea that socioeconomic inequalities may contribute to some, though not all, non-communicable diseases in China. Moreover, the mechanisms which link socioeconomic inequality to NCDs in China remain unclear. My results also supported the suggestion that a rising burden of non-communicable disease may contribute to greater pro-rich inequity in healthcare utilisation, especially for conditions which are chronic and asymptomatic. As rates of NCDs continue to rise in China and other developing countries, policies to prevent and treat common NCDs may be improved by a clearer understanding of how inequality is related to non-communicable disease. / published_or_final_version / Community Medicine / Doctoral / Doctor of Philosophy

Introduction Self-rated health (SRH) is a widely used indicator of health service utilisation and reflects self-perceived objective health condition. Poorer non-comparative SRH was shown to be related to higher inpatient and outpatient utilisation in Western and elderly populations. Little is known about how healthcare utilisation relates to SRH in non-Western settings, such as Hong Kong and in adult populations. The association of age- and time- comparative SRH with healthcare utilisation is also unclear. This study aimed to assess the association of three types of SRH (non-, age- and time- comparative SRH) with inpatient and outpatient utilisation in Hong Kong‟s general populaion. Methods Data were derived from 2011 Thematic Household Survey (THS), covering 23,892 non-institutional residents aged 20 and above. The study adopts Andersen‟s Behavioral Model of Health Service Use for the analytical framework. Healthcare utilisation was measured by inpatient use during the past year and outpatient use (including General Outpatient Clinic (GOPC) and Specialist Outpatient Clinic (SOPC)) during the past month, in terms of ever-use and the amount of use (bed-days and number of outpatient visits). SRH was measured with a 5-point Likert Scale: non-comparative SRH from “Excellent” to “Poor”; age- and time- comparative from “much worse” to “much better”. Logistic regression and zero-truncated negative binomial/ Poisson regression were applied to examine the association of SRH and chronic diseases with healthcare utilisation in the public and private sector separately as per the Andersen behavioral model. Results “Fair/ poor” non-comparative SRH was associated with higher inpatient and outpatient utilisation. The association was not significant for hospital bed-days. Similarly, age-comparative SRH was associated with inpatient (except private bed-days) and outpatient utilisation (except the number of SOPC visits). “Worse/ much worse” time-comparative SRH was associated with higher healthcare utilisation, but the relationship was less clear for private hospitalisation. The presence of cancer, cardiovascular diseases, diabetes, lower respiratory diseases, and musculoskeletal diseases were associated with higher healthcare utilisation, with stronger association observed for ever-use than the amount of use. The relationships between musculoskeletal diseases and inpatient utilisation, between cardiovascular diseases and diabetes and the number of private outpatient visits, and between lower respiratory diseases and GOPC utillisation were not significant. Conclusions The present study suggests SRH to be a useful health indicator of health service utilisation. All three SRH measures were associated with health service utilisation and no marked differences were observed between different measures. Poorer SRH were strongly related to higher public inpatient utilisation, with stronger association observed for ever hospitalisation than bed-days. Poorer SRH measures were also related to higher outpatient uilisation in both sectors during the past month. All the selected chronic conditions were related to increased healthcare use. The associations were less clear for hospital bed-days and the private sector. Future studies should focus on the predictive validity of SRH on future healthcare utilisation. / published_or_final_version / Public Health / Master / Master of Philosophy

published_or_final_version / Medicine / Master / Doctor of Medicine

由於慢性疾病的流行程度有著全球性上升的趨勢，它經已成為一個公共衛生的問題，為醫療系統帶來沉重的負擔。慢性疾病的發病率以老年人為最高，慢性疾病對老年人的生理、心理、社交及經濟等，構成尤其嚴重的後果。由於香港的人口持續老化，所以預計患有慢性疾病的人口數目在將來幾十年會不斷增加。但是，現時對患有慢性疾病的老年人所提供的照顧不足，再加上本地老年人擁有的多種特徵，例如社會經濟地位較低，健康讀寫能力較弱，及同時患有多重疾病，都有可能對醫護人員提供的護理造成障礙。提升慢性病患者掌管健康的能力，例如提供自我管理的支援，增強他們的信心，及協助他們作出有關健康的判斷及決策，有機會能解決慢性疾病所引起的問題。雖然過往的研究已經發現自我管理教育課程能夠改善慢性病患者的生理、心理及社交健康，及提升患者的健康行為，可是這類課程對老年人的成效，依然缺乏足夠科研證據的支持。 / 作者在這論文中進行了兩項研究，去探討自我管理教育課程對患有慢性疾病的長者的健康行為、生理、心理、社交、生活質素及醫療服務的使用的影響。甲項研究是一個半實驗性研究，探討¬「慢性疾病自我管理課程」對患有不同種類慢性疾病的長者的效果。乙項研究是一個隨機控制實驗，研究「糖尿病自我管理課程」對患有非胰島素依賴的長者的效果。 / 甲項研究招募了患有一種或以上慢性疾病，及居住在社區的長者進行研究。三百零二名治療組的參加者接受了一個為期六星期的「慢性疾病自我管理課程」，當中包括六課以小組模式進行的課堂，每堂為兩小時三十分。課程由專業人員或非專業的長者義工組長帶領。二百九十八名對照組的參加者則繼續接受六個月慣常的護理。每位參加者都會在基線及六個月後接受測試，測試包括自我管理行為、自我效能感、健康狀況及醫療服務的使用。 / 利用單向共變數分析法，結果顯示治療組的所有的自我管理行為和自我效能感測試都有顯著改善 (p < .05)。在十項健康狀況測試中，有五項有明顯改善 (p < .05)。另外，醫療服務的使用則沒有明顯改變。 / 乙項研究是利用隨機方法，分別把九十位及八十七位患有非胰島素依賴的長者分配到治療組及對照組。治療組的參加者參與了為期八堂，每星期一堂，每堂兩小時的「糖尿病自我管理課程」。對照組參加者則在八星期內繼續接受慣常的護理。所有參加者都會在基線及八星期後接受測試，測試包括身高體重指數、腰臀比例、血糖及血壓水平、糖尿病相關的認識、糖尿病指定及總稱的生活質素、及營養攝取。 / 利用單向共變數分析法，結果顯示治療組的糖尿病相關的認識 (p < .0005)，糖尿病指定生活質素的滿意分類 (p = .045)，及總稱生活質素的精神健康分類 (p = .003)皆有明顯的改善。治療組的總能量 (p = .018)及飽和脂肪攝取 (p = .03)都有明顯減少。在各生理及人體測量指標及其他生活質素測試，則沒有明顯改變。 / 此研究增加對疾病指定及非疾病指定的自我管理教育課程於社區上患有慢性疾病的長者的成效的認識。研究結果發現針對長者而設計的課程有機會改善長者的行為、心理及社交狀況，長者亦可以通過課程學習自我管理技巧及改變健康行為，從而改善健康。由長者義工組長帶領的課程有可能跟由專業人員帶領的課程的效果相近。研究結果象徵著自我管理課程需要融入醫療系統的慣常服務當中，以達致最大的成效。本論文亦為如何於各個護理層面及本地環境推行自我管理課程作出詳細討論。對於將來的研究發展，本論文建議加長跟進測試的時間及利用更大的實驗樣本探討自我管理課程於長者身上的成效，疾病指定及非疾病指定課程的效果亦需要作出比較，個別自我管理課程的特徵對課程成效的影響亦需要詳盡地探討。 / The global epidemic of chronic disease has become a public health issue and created a huge burden on health care systems and societies. Older population is highly susceptible to chronic disease. The high prevalence of chronic disease among older adults results in a series of physical, psychosocial and financial consequences in this patient group. In Hong Kong, as the population continues to age, the number of people having chronic disease is expected to increase rapidly in next few decades. The care for older adults with chronic disease is yet suboptimal. Local older people are predisposed to a number of characteristics, such as low socioeconomic status, poor health literacy and multiple morbidities, which may hinder professionals to provide effective care. Empowering patients through supporting self-management, increasing confidence and assisting decision-making of people with chronic disease has been found to be a solution to the problem. Although literature has suggested that self-management education programmes may improve physical and psychosocial outcomes, and promote health-related behaviours among people with chronic disease, the evidence of the effects of such programmes in older adults is still lacking. / Two studies have been conducted to examine the effects of self-management education programmes in improving health behaviours, physical and psychological status, quality of life and health care utilization in older people with chronic disease. Study One is a quasi-experimental trial exploring the effects of the Chronic Disease Self-Management Programme (CDSMP) in older adults with a wide range of chronic diseases. Study Two is a randomized controlled trial evaluating the effects of the Diabetes Mellitus Self-Management Programme (DMSMP) in older adults with non-insulin-dependent diabetes mellitus. / In Study One, community-dwelling older people with one or more chronic disease were recruited. The intervention group (n = 302) received the 6-week CDSMP, which consisted of 6 group sessions with each session lasting for 2.5 hours. The programme was facilitated either by professional and older lay leaders. The control group (n = 298) continued their usual care for 6 months. Self-management behaviours, self-efficacy, health status, and health care utilization of participants were assessed at baseline and 6 months. / The one-way analysis of covariance showed that the intervention group has significant improvements in all self-management behaviours and self-efficacy outcomes, and 5 out of 10 health status measures (all p < .05). No significant change was detected in the use of health care services. / In Study Two, older people with non-insulin-dependent diabetes mellitus were randomly assigned to either the intervention (n = 90) or control (n = 87) group. The intervention group attended the DMSMP comprising 8 weekly 2-hour sessions. The control group received usual care for 8 weeks. Body mass index, waist-to-hip ratio, blood glucose and blood pressure levels, diabetes-related knowledge, disease-specific and generic quality of life, and nutritional intakes were measured at baseline and 8 weeks. / Using the one-way analysis of covariance, the intervention group found significant improvements in diabetes-related knowledge (p < .0005), the satisfaction subscale score in the diabetes-specific quality of life measure (p = .045), and the mental health score in the generic quality of life measure (p = .003). Significant reductions of total energy (p = .018) and saturated fat intakes (p = .03) were also demonstrated in the intervention group. No significant change was detected in the physiological outcomes, anthropometric indices and other quality of life and nutritional measures. / The present studies enrich the knowledge of the effects of disease-specific and generic self-management education programmes for older adults with chronic disease living in the community. It demonstrated that the programmes specifically tailored for older adults may improve a wide range of behavioural and psychosocial outcomes. Older adults may be able to learn new skills for self-management and change behaviours to improve their health. The effects of using older lay persons to lead such programmes may be similar with those using professional staff. The findings imply that self-management programmes need to be integrated into the routine service of health care systems and community care in order to have maximal effects. The implementation of self-management support at different levels of care and under the local context was discussed. Further studies should be conducted to explore the effects of self-management programmes on older people using prolonged follow-ups and larger sample size. The comparative effects of disease-specific and generic self-management programme should be evaluated. The individual influences of various essential features of self-management interventions need to be determined explicitly. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Detailed summary in vernacular field only. / Chan, Lap Sun. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2012. / Includes bibliographical references (leaves 265-302). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese; some appendixes also in Chinese. / Chapter CHAPTER ONE --- INTRODUCTION / The epidemiology of chronic disease --- p.1 / Causes of the epidemiology of chronic disease --- p.3 / Risk factors of chronic disease --- p.4 / Self-management approach in managing chronic disease --- p.5 / The research problem --- p.8 / Chapter CHAPTER TWO --- LITERATURE REVIEW / Challenges in managing chronic disease --- p.10 / Specific concerns for older people --- p.12 / Chronic disease management --- p.16 / Introduction --- p.16 / Patient-centred care --- p.18 / Frameworks for improving care of chronic disease --- p.20 / Chronic Care Model --- p.20 / Innovative Care for Chronic Conditions --- p.22 / Service delivery model of chronic disease management --- p.24 / Global strategies in chronic disease management --- p.26 / Empirical evidence of the Chronic Care Model --- p.29 / Self-management --- p.34 / Definitions --- p.34 / Conceptualizing self-management --- p.37 / Patient-professional relationship --- p.37 / The goal of self-management --- p.40 / Self-management tasks and skills --- p.41 / Perspectives and barriers of self-management in older adults with chronic disease --- p.44 / Self-management education and support --- p.50 / Introduction --- p.50 / Comparison with traditional patient education --- p.51 / Characteristics of self-management education --- p.53 / Theoretical basis in self-management education --- p.53 / Self-efficacy theory --- p.56 / Teaching problem-solving skills and making action plans --- p.58 / Individualizing self-management education --- p.59 / Continuity of self-management support --- p.60 / Framework of delivering self-management support services --- p.62 / Global implementation of self-management education --- p.65 / Empirical evidence of the effects of self-management interventions --- p.70 / Effects of self-management interventions in general --- p.71 / Effects of self-management interventions for older adults with chronic disease --- p.77 / Effects of self-management interventions for patients with chronic disease in Hong Kong --- p.85 / Methodological issues in self-management studies --- p.88 / Establishing self-management interventions for older adults --- p.90 / Establishing self-management interventions under the local context --- p.93 / Summary of Literature Review --- p.94 / Chapter CHAPTER THREE --- METHODS (STUDY ONE) / Introduction --- p.97 / Methodology --- p.98 / Research objectives --- p.98 / Null hypotheses --- p.99 / Study design --- p.100 / Participants --- p.101 / Recruitment and procedure --- p.101 / Intervention --- p.103 / Adaptations of programme delivery for local older participants --- p.106 / Sample size calculation --- p.107 / Outcome measures --- p.108 / The questionnaire --- p.108 / The Abbreviated Mental Test, Hong Kong version (AMT) --- p.109 / Frailty Index (FI) --- p.109 / Statistical analysis --- p.112 / Primary analysis --- p.112 / Secondary analysis --- p.112 / Focus group --- p.114 / Chapter CHAPTER FOUR --- RESULTS (STUDY ONE) / Participants --- p.116 / Baseline --- p.118 / Comparing baseline and 6 months outcomes of intervention group --- p.123 / Comparing baseline and 6 months outcomes of control group --- p.125 / Comparing outcomes between intervention and control groups at 6 months --- p.127 / Subgroup analysis --- p.130 / Comparison among age subgroups --- p.132 / Comparison among education level subgroups --- p.133 / Comparison among frailty level subgroups --- p.133 / Comparing professional staff-led and older lay-led programmes at 6 months --- p.140 / Focus group --- p.142 / Chapter CHAPTER FIVE --- DISCUSSION (STUDY ONE) / Introduction --- p.145 / Demographics characteristics --- p.145 / Baseline outcomes --- p.147 / Effects of the CDSMP on older adults with chronic disease --- p.148 / Self-management behaviours and self-efficacy --- p.148 / Health status --- p.148 / Health care utilization --- p.149 / Comparing with existing literature --- p.150 / Effects of age, education level and frailty level on the outcomes --- p.154 / Age --- p.154 / Education level --- p.154 / Frailty level --- p.155 / Effects of leaders on the outcomes --- p.156 / Qualitative findings --- p.157 / Feasibility of training older people to be lay leaders --- p.160 / Summary of the discussion --- p.162 / Chapter CHAPTER SIX --- METHODS (STUDY TWO) / Introduction --- p.164 / Methodology --- p.166 / Research objectives --- p.166 / Null hypothesis --- p.166 / Study design --- p.167 / Pilot study --- p.168 / Participants --- p.169 / Recruitment and procedure --- p.170 / Intervention --- p.172 / Educational talks --- p.174 / Exercise practice --- p.174 / Goal setting and problem-solving --- p.177 / Issues of designing self-management programme for local older adults --- p.177 / Sample size calculation --- p.178 / Outcome measures --- p.179 / Diabetes Knowledge scale (DKN) --- p.179 / 24-hour food recall --- p.180 / Anthropometric measurements --- p.181 / Clinical health indicators --- p.182 / Quality of life --- p.183 / Statistical analysis --- p.185 / Primary analysis --- p.185 / Secondary analysis --- p.186 / Focus group --- p.186 / Chapter CHAPTER SEVEN --- RESULTS (STUDY TWO) / Participants --- p.188 / Baseline --- p.190 / Comparing baseline and 8 weeks outcomes of intervention group --- p.193 / Comparing baseline and 8 weeks outcomes of control group --- p.195 / Comparing outcomes between intervention and control group at 8 weeks --- p.197 / Nutritional intakes --- p.200 / Comparing baseline, 8 weeks and 6 months outcomes of intervention group --- p.203 / Focus group --- p.206 / Chapter CHAPTER EIGHT --- DISCUSSION (STUDY TWO) / Introduction --- p.208 / Demographics characteristics --- p.209 / Baseline outcomes --- p.210 / Effects of the DMSMP on older adults with type 2 DM --- p.213 / Knowledge and nutritional intakes --- p.213 / Anthropometric measures and clinical health indicators --- p.214 / Quality of life --- p.217 / Long-term effects of the DMSMP on intervention group participants --- p.219 / Comparing with existing literature --- p.220 / Comparing with a local study --- p.226 / Qualitative findings --- p.227 / Summary of the discussion --- p.231 / Chapter CHAPTER NINE --- CONCLUSION / Overall effects of self-management interventions for older adults with chronic disease --- p.232 / Strengths of the study --- p.238 / Using a more stringent study design --- p.238 / Incorporated essential features of self-management interventions into current programmes --- p.239 / Demonstrated a collaborative model between health and social sectors --- p.240 / Limitations of the study --- p.241 / The integrity of study sample --- p.241 / Issues in the representativeness of study sample --- p.241 / High attrition rate in the longitudinal follow-up (The DMSMP) --- p.243 / Unknown uptake rate --- p.244 / The study design --- p.244 / Non-randomized allocation of participants (The CDSMP) --- p.244 / The lack of control for attention effect --- p.246 / The implementation of study intervention --- p.247 / Using multiple components --- p.247 / The absence of blinding (The DMSMP) --- p.248 / The evaluation and statistical analysis --- p.248 / Short duration of follow-up --- p.248 / Limitations of post-hoc analyses --- p.249 / Diffusion of self-management interventions for older adults --- p.250 / Considerations to the adoption of current self-management interventions --- p.251 / Relative advantage --- p.251 / Compatibility --- p.251 / Complexity --- p.252 / Trialability --- p.252 / Observability --- p.253 / Experience of implementing self-management interventions in the UK and the US --- p.254 / Considerations to the implementation of current self-management interventions --- p.256 / Strategies applied in promoting the adoption and implementation of current self-management interventions --- p.257 / Recommendations for local implementation of self-management interventions --- p.259 / Recommendations for future research --- p.261 / Conclusion --- p.264