Abstract Background China's comprehensive health-care reform was embarked on in 2009, targeting health-care financing, care delivery, drug supply, and hospital reform. The aim of this study was to ...explore the extent to which being people with multiple long-term disorders who are unemployed and uninsured are prevented from accessing hospital inpatient care. Methods We analysed data from a large community household survey of about 5% of the general resident population with household registry in three prefectures in southern China in 2011. Close-ended questions on demographics, socioeconomics, and lifestyle behaviours were derived from the National Health Services Survey (NHSS) 2008. Open-ended questions on chronic disorders (clinically diagnosed or being treated) and admissions to hospitals at the secondary level or above in the previous 12 months were designed by a research panel. The multistage sample designs and sampling weights were taken into account in the binary logistic regression analysis of the survey response. We cross-validated self-reported chronic disorders with paper-based medical reports obtained from previous health-care visits and annual check-ups. Multimorbidity was defined as having two or more chronic disorders from a validated list of 40 morbidities. Findings 124 829 residents (aged ≥20 years) from 53 760 households participated in the survey. In the previous 12 months, 7211 (5·8%, 95% CI 5·7–5·9) residents had at least one admission to hospital, of whom 3002 (42%, 40·8–42·4) had multimorbidity. Admission to hospital was associated with the number of chronic disorders (≥4 disorders vs none: adjusted odds ratio 17·13 95%CI 16·15–18·16), having social medical insurance (1·41 1·37–1·44), household income per head (highest household income group vs the lowest household income group: 1·80 1·74–1·85), and unemployment (1·61 1·55–1·66). We found a statistically significant interaction between employment status and the presence of medical insurance on hospital admission, meaning that patients who were unemployed and not covered by a social medical insurance were least likely to be admitted to a hospital (0·50, 0·47–0·52). Interpretation The ability to pay a medical bill seems to be significantly predictive of inpatient service use for multimorbidity. A better designed social medical insurance system with more government contribution would be of particular necessity to improve equitable access to health care, particularly for people with less affordability because of unemployment. Funding Department of Health, Guangdong province, China (C2009006/2009–2013), Department of Education, Guangdong province, China (BKZZ2011047/2010–2013), Medical Research Fund, Chinese Medical Association, China (2010-08-05), and Community Health Research Fund, Community Health Association of China, China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong-Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong, and the Scottish Government, UK (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions – General Practice Exploratory Teaching Centre GDJG-2010-N38-35, Guangdong Department of Education, China, and The Ninth Round of Guangdong Key Disciplines – General Practice GDJY-2012-N13-85, Guangdong Department of Education, China, both of which he leads. The Scottish School of Primary Care partly supported SWM's post and the development of the National Research Programme on Multimorbidity, which he leads.
Abstract Background The worldwide trend in population ageing has been met by a concomitant research interest in the effect of environmental factors on the health of elderly people. Green space is an ...important constituent of the living environment, with regard to modifying local air quality and microclimate, and has been qualitatively shown to benefit both physical and psychological aspects of health through several pathways. We aimed to quantitatively and comprehensively evaluate the effect of green space on all-cause mortality in elderly people in Hong Kong. Methods In this retrospective cohort study, we studied the effect of green space on all-cause mortality in participants identified from a community-sourced cohort of Chinese elderly people (aged ≥65 years) who resided in all regions of Hong Kong between 2001 and 2014. The Normalized Difference Vegetation Index was assigned to a 300 m radius buffer around each residential address to identify the qualitative coverage of green space. The proportion of green space was calculated according to counts of pixels with green compared with the total counts of pixels (15 × 15 m). Mortality data were ascertained from the Government Death Registry over a 14-year follow-up. Cox proportional hazard models were used to estimate hazard ratio (HRs) and their corresponding 95% CIs for all-cause mortality, adjusted for demographic and socioeconomic characteristics, lifestyle, housing type, and years of living in Hong Kong. Additional covariates were added to the model to examine underlying mechanisms. The study was approved by the Clinical Research Ethics Committee of the Chinese University of Hong Kong, and all participants gave written informed consent. Findings Of 3556 elderly participants, 795 (22%) died over the 14-year follow-up. A 10% increase in coverage of green space within a 300 m buffer of participants' addresses was associated with a reduction in all-cause mortality during a 1-month period (HR 0·96, 95% CI 0·94–0·98; p=0·03), after adjusting for sex, age, marital and socioeconomic status, current smoking status, housing type, and years of living in Hong Kong. 10·3% of the variation for the effect size of green space on all-cause mortality could be explained by particulate matter 2·5 concentration, physical activity, and cognitive mental status. Interpretation Chinese elderly people living in greener neighbourhoods might have a lower mortality risk than those living in areas with less green space, independent of other confounding factors, although further studies with larger sample sizes recruiting participants from more diverse environments are needed. Our findings suggest that increasing the coverage of green space could be effective at constructing an age-friendly city and could promoting ageing by enhancing physical activity and cognitive mental function in elderly people, lessening the risk of all-cause mortality. Funding None.
Abstract Background China is reshaping its health-care system to orient towards primary care. We developed a short instrument on the basis of the Primary Care Assessment Tool-Adult Edition (PCAT-AE) ...to assess patients' experiences of primary-care delivery in community health centres, the major primary-care provider in urban areas. Methods A multistage cluster sampling method was used to select seven geographical regions in southern China where the population's ageing and gender structure is similar to that of China's overall population. A validated PCAT-AE (Mandarin Chinese short version) with 33 PCAT items on a four-point Likert-type scale was used, with higher scores representing better primary-care experiences. This study was approved by the Ethics Committee of Guangzhou Medical University, Guangzhou, China, and the Survey and Behaviour Research Ethics Committee of The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China (TB106179/MD10606). All study participants provided written consent. Findings The overall response rate of adult subjects interviewed at community health centres was 85·8% (3360 of 3916). Both frequent (2237) and less-frequent service users (1123) were surveyed, among which 1122 (33%) patients had an optimum PCAT score (higher than the third quantile of the score range—ie, above 99 of 132). The proportion of subjects with optimum scores in individual primary-care domains ranged from 62·1% (95%CI 59·8–64·3) in the comprehensiveness of service attribute to only 16·6% (14·7–18·7) in the community orientation attribute. Among all subjects, those with social medical insurance were more likely to report optimum primary care experience (adjusted odds ratio 2·30, 95% CI 1·92–2·75) than those uninsured. In the stratified analysis among subjects who were uninsured, those attending community health centres owned and managed by the government as their usual source of primary care had the highest PCAT scores compared with other models of community health centres owned and managed by secondary or tertiary hospitals (95·16 vs 90·18; p=0·0001) or by private investors (95·16 vs 87·80; p<0·0001), as a result of better first-contact care and coordination of care. Interpretation The study suggests an urgent need to understand and address how social medical insurance coverage could affect patients' experiences. The community health centre model with a government-dominant top-down approach seems to be most effective in solving conundrums for China's health-care reform. Funding This study was funded by the Bauhinia Foundation Research Centre; Department of Health, Guangdong province (C2009006/2009–2013); Department of Education, Guangdong province (BKZZ2011047/2010–2013); Medical Research Fund, Chinese Medical Association (2010-08-05); and Community Health Research Fund, Community Health Association of China (2012-2-91). HHXW was supported by a postdoctoral research fellowship in the Hong Kong–Scotland Partners in Post Doctoral Research programme, Research Grants Council of Hong Kong and the Scottish Government (S-CUHK402/12). JJW is supported by Guangdong Exemplary Centres for Exploratory Teaching in Higher Education Institutions—General Practice Exploratory Teaching Centre (GDJG-2010-N38-35, Guangdong Department of Education) and The Ninth Round of Guangdong Key Disciplines—General Practice (GDJY-2012-N13-85, Guangdong Department of Education), both of which he leads.
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