1. Health Determinants and Inequalities
Richard Lee
Institute of Ageing and Institute of Health Equity
The Chinese University of Hong Kong
2. Outline
• Is health a matter of choice of individual lifestyle only?
• Why is there health inequalities in Hong Kong?
• For ageing society in Hong Kong, what is the situation of
older people?
3. “Why treat people and send them back to the
conditions that made them sick?”
5. According to the World Health
Organization, 30-55% of the differences
in health outcomes within and across
countries are down to a collective of
wider social factors
5
6. Dahlgren G, Whitehead M. 1991. Policies and Strategies to Promote Social Equity in Health.
Stockholm, Sweden: Institute for Futures Studies.
6
12. The context of Hong Kong
• Longest life expectancy
• 83.2 years (males) and 87.9 years (females) in 2021
• Rapidly ageing society with increasing dependency ratio
• Highest income inequality
• Gini coefficients (0.539 (pre-intervention); 0.473 (post-intervention))
• Public-private dual-track healthcare system
• Primary care largely provided by the private sector
16. Life Course approach on Health Inequality
Source: Marmot M, Allen J, Goldblatt P, Boyce T, McNeish D, Grady M (2010) Fair Society, Healthy Lives: The Marmot Review. s.l. : Institute of Health Equity.
17. Inequalities in Early Childhood Development
Source: Ip P, Rao N, Bacon-Shone J et al (2016) Socioeconomic gradients in school readiness of Chinese preschool children: The mediating role of family processes
and kindergarten quality.
Association between SES and school readiness in children aged 5–6 years, Early Development
Instrument scores in five developmental domains, Hong Kong, 2016
The Early Development
Instrument (EDI) assesses
children’s readiness for
school through teacher
ratings of five
developmental domains:
• physical health and
wellbeing
• social competence
• emotional maturity
• language and cognitive
development
• communication and
general knowledge
18. Inequalities in Educational Attainment
Source: OECDiLibrary (2018). PISA Results. Volume II: Where All Students Can Succeed. Annex B1. Results for countries and economies
Mean performance in reading, by socioeconomic status (ESCS), Hong Kong and selected countries, 2018
• ESCS: comprises students’ reports
on parental occupation, highest
level of parental education, an
index of home possessions
related to family wealth, home
educational resources, and
possessions related to ‘classical’
culture in the family home.
• students with high ESCS
outperformed low ESCS peers by
59 points in reading, indicating
clear inequalities in educational
attainment
• Analysis of previous PISA cycles
suggested certain degree of
socioeconomic and academic
segregation in Hong Kong
• During 2002–2012, social
segregation (based on the
student’s SEP) was higher in HK’s
schools than in Macau, Taiwan
and Shanghai, which could be
related to the policies of Direct
Subsidy Scheme and English as
Medium of Instruction.
19. Inequalities in Self-rated Health of Students
Source: Hong Kong survey results of the Health Behaviour in School-aged Children (HBSC) 2020 Main Study, Hong Kong Centre for International Student Assessment
Self-rated health of students, Hong Kong and Health Behaviour in School-aged Children (HBSC) survey,
average of 45 countries, 2020
• Only about 18 percent of students
were very satisfied with their
current life, a much lower figure
than the HBSC average
percentage of 36 percent.
• Hong Kong students’ life
satisfaction and self-rated health
decreased with age among the
surveyed adolescents (who were
aged 11, 13 and 15), while
physical and psychological
symptoms of ill-health increased.
• The higher the family’s SES, the
higher the student’s life
satisfaction and self-rated health
20. Inequalities in Income, Education and Occupation
Source: C&SD
Median hourly wages by educational attainment, Hong Kong, 2009-21
• Difference in earnings between
workers with tertiary education
and those with only primary level
education remained largely
constant over this period, with
the former earning around twice
as much as the latter
• The earnings ratio by education
between the highest and lowest
earners was highest in the years
immediately after the global
financial crisis, reaching a
threefold difference between
both groups in 2010
21. Inequalities in Income, Education and Occupation
Source: C&SD
Unemployment rate by previous occupation
• Vulnerability to unemployment is
unevenly distributed among
different occupational groups
• Craft and related workers are the
most vulnerable in times of crisis
• During COVID, low-skilled service
and sales workers experienced a
big rise in unemployment, in
particular in retail,
accommodation and food services
and construction industry
22. Source: C&SD
Percent of workers working 40 and over and workers in Low Paying Sectors (LPS), by hours worked
• LPS comprise: i) retail, ii) food and
beverage services, iii) estate
management, security and
cleaning services and iv)
miscellaneous activities (e.g.,
elderly homes, local courier
services, food processing and
production)
• Workers in LPS are more exposed
to long working hours than
workers in general
• In 2021, 80% of LPS sector
workers worked 40 hours a week
or more (75% for all workers) ,
17.6% working 60 hours+ (7%)
and 4.9% working 72+ hours
Inequalities in Income, Education and Occupation
23. Inequalities and impact on wellbeing of older people
Source: Primary Healthcare Blueprint. Health Bureau
• People from lower
socioeconomic position
experience less access and
worse care over time than
those from more privileged
backgrounds, although they
experience a higher burden of
multimorbidity
• It will widen the already
existing inequalities in people
living with chronic diseases
24. Psychosocial well-being of older people
Results based on four cross-sectional population-wide surveys
on older people aged 60+ in Hong Kong from 2017 to 2020:-
❖ Regression analyses suggested:
❖ Increases in psychological distress from 2017 to
2020
❖ Decreases in life satisfaction from 2017 to 2020
❖ Unclear changes in loneliness (p = .235)
❖ Moderation analyses suggested that across the years,
more prominent increases in psychological distress
among those with higher education attainment (p for
interaction = .048)
❖ Tertiary education vs no formal education: +22%
❖ Senior secondary vs no formal education: +23%
25. Source: Hong Kong Jockey Club Centre for Suicide Research and Prevention
Suicide rate and rate ratio by area quantiles
Source: Hsu C-Y, Chang S-S, Lee EST (2015) Geography of suicide in Hong Kong: Spatial
patterning, and socioeconomic correlates and inequalities. Social Science & Medicine
(130):190-203
Rate ratios measure the relative likelihood of suicide for different income levels compared
to quintile 1 ( the least deprived quintile). The higher the rate, the higher the likelihood of
suicide.
Area quintiles are based on a deprivation index based on 14 socioeconomic characteristics
of 1639 large street blocks (LSB) in Hong Kong using data from 2006 Census
Inequalities and impact on wellbeing of older people
27. Who will more likely be your clients?
• There are inequalities of different social groups using
healthcare services, e.g., ethnicity, gender, patients on
certain diseases
• However, older adults are major users of public hospital
services.
28. 2
• Average annual increase
rate of the population
aged 65 and over – 4.0%
from 2021 to 2030
• Population aged 65 +
increase from 1.5 million
(20% of total
population) in 2021 to
2.52 million (31%) in
2039
• Proportion of old-old
(aged 80 and over)
increase from 0.4 million
(5%) in 2021 to 0.93
million (11.5%) in 2039
Features of Ageing Population in Hong Kong
29. Who will more likely be your clients?
• Older adults aged 65+ account for 62% of general outpatients
attendance, 56% of specialist outpatients attendance, 50% of
patient bed days, and 89% of community nursing service.
• However, we should also note that part of the driver of the use of
hospital in patient services is proximity to death rather than age per
se.
Yeoh, E. K., & Lai, H. Y. A. (2016). An Investment for the Celebration of Aging. Our Hong Kong Foundation Report.
Woo, J., Goggins, W., Zhang, X., Griffiths, S., & Wong, V. (2010). Aging and utilization of hospital services in Hong Kong: retrospective cohort
study. Int J Public Health, 55(3), 201-207
30. Who will more likely be your clients?
Average number of A&E visits during the last year of life, by CSSA status (2004-2014)
With increase in life expectancy to
90 years, the number of people in
hospital around 80+ years old will
also increase.
There is no inequality in access to
hospital services since these are
free for those who are receiving
CSSA. In fact those who are on CSSA
use services slightly more
frequently.
Chung, R. Y., Lai, D. C. K., Hui, A. Y., Chau, P. Y., Wong, E. L., Yeoh, E. K., & Woo, J. (2021). Healthcare inequalities in emergency visits and
hospitalisation at the end of life: a study of 395 019 public hospital records. BMJ Support Palliat Care.
32. Apart from disease, what else?
Chewing difficulties
Poor hearing
Poor vision
Frailty
Sarcopenia
Memory complaints
Poor self-rated health
No meaning in life
Problems with IADL
Problems with finance
Polypharmacy
Incontinence
34. Fried L, et al. J Gerontol Medical Sciences 2001;56A(3):M146-M156
Kelaiditi E, et al. J Nutr Health Aging 2013;17(9):726-34
What is frailty?
• Clinically recognized state of increased vulnerability
• Results from ageing associated with a decline in the body’s
physical and psychological reserves
• Subdivided into physical and cognitive frailty
• Sarcopenia
• Cognitive impairment (dementia / mild cognitive impairment)
35. How is frailty distributed in HK?
•One study of 816 people aged 65 or over living in the
community in Hong Kong found that:
•prevalence of frailty: 52.4%
•prevalence of pre-frailty: 12.5%
•Prevalence of frailty increased with age
•5.1% for those aged 65–69 years
•16.8% for those 75 and over
•higher for women than men (13.9% vs 4.2%)
36. People will live longer but could
be more dependent
Source:
Yu et al. Age and Ageing 2018; 47(2): 254-261
37. Is frailty treatable?
• Yes!
• Frailty is not an inevitable part of ageing
• Physical frailty (sarcopenia) is reversible
Recognition of
Frailty
(Screening)
辨認衰老狀況
(篩查)
Comprehensive
Geriatric
Assessment
全面性
老年健康評估
Individualized
care and
training /
intervention
個人化的介入治療
、訓練及護理服務
Yu R et al. Geriatr Gerontol Int 2014;14(suppl1):15-28
Lee J et al. J Am Med Dir Assoc 2014;15(4):281-6
What can we do?
