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Bazyar M, Kakaei H, Jalilian M, Mirzaei A, Mansournia MA, Pakzad R. Socioeconomic inequality in self-rated health and its determinants: an Oaxaca blinder decomposition in Ilam, West of Iran during 2023. BMC Health Serv Res 2023; 23:1203. [PMID: 37924069 PMCID: PMC10625218 DOI: 10.1186/s12913-023-10242-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023] Open
Abstract
AIM To determine inequality and decompose it's in Self-Rated Health (SRH). METHOD This population-based cross-sectional study was undertaken on the entire population of the city of Ilam, Iran, in 2023. Multi-stage stratified cluster random sampling with proportion-to-size approach was used to select the participants. Oaxaca-Blinder decomposition technique was used to show the amount of inequity in SRH and to decompose of the gap of SRH between the poor and the rich group of participants. RESULTS 1370 persons participated in the study. The 59.38% of participants stated good SRH status and just 8.86% of participants had poor SRH status. The results of the Oaxaca-Blinder decomposition revealed a considerable gap (15.87%) in the poor status of SRH between the rich and the poor. A large proportion (89.66%) of this difference was described by explained portion of the model. The results of decomposition showed that economic status was directly responsible for explaining 27.98% of overall inequality gap between rich and poor people. Moreover, hopelessness to future (32.64%), having an underlying disease (18.34%) and difference in the education level (10.71%) were associated with an increase in inequality disfavoring the poor. CONCLUSION For people suffering from underlying disease, it is suggested to devise policies to improve access to/and remove healthcare utilization barriers. To address hopelessness to future, it is recommended to carry out further studies to reveal factors which affect it in more details. This can help policy makers to formulate more realistic and evidence-informed policies on order to lessen the current socioeconomic inequity in SRH.
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Affiliation(s)
- Mohammad Bazyar
- Department of Health Management and Economics, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Hojatollah Kakaei
- Department of Occupational Health, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Mohsen Jalilian
- Department of Public Health, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Amin Mirzaei
- Department of Public Health, Faculty of Health, Ilam University of Medical Sciences, Ilam, Iran
| | - Mohammad Ali Mansournia
- Department of Epidemiology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Pakzad
- Health and Environment Research Center, Ilam University of Medical Sciences, Ilam, Iran.
- Psychosocial Injuries Research Center, Ilam University of medical Sciences, Ilam, Iran.
- Department of Epidemiology, Faculty of Health, Ilam University of Medical Sciences, Banganjab, Pajouhesh Blvd, Ilam, Iran.
- Student Research Committee, Ilam University Medical Sciences, Ilam, Iran.
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Wang Y, Xu S, Chen Y, Liu H. A decline in perceived social status leads to post-traumatic stress disorder symptoms in adults half a year after the outbreak of the COVID-19 pandemic: consideration of the mediation effect of perceived vulnerability to disease. Front Psychiatry 2023; 14:1217264. [PMID: 37547198 PMCID: PMC10402898 DOI: 10.3389/fpsyt.2023.1217264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 06/12/2023] [Indexed: 08/08/2023] Open
Abstract
Background/purpose In December 2019, Wuhan, Hubei, China firstly reported the existence of the COVID-19 virus. It is crucial to prioritize the psychological well-being of citizens in lockdown cities and make more strides in the academic field of post-traumatic stress disorder (PTSD) to prepare for the post-pandemic era. Methods We took the cognitive-relational theory as our basis and collected Hubei province-level data (N = 3,465) to examine the impact of perceived social status decline on the prevalence of PTSD symptoms, and checked the mediating effect of perceived vulnerability to disease (PVD) during the period of psychological adjustment. Results Using propensity score matching, we estimate the average treatment effect of perceived social status decline on PTSD level, and we robustly regress the two with weight adjustment generated in matching. We found that more decline in perceived social status is associated with a worse degree of PTSD symptoms, and confirmed PVD's buffering role although the mediating effect was not as high as hypothesized. Conclusion and implications Our study confirmed the decisive role of subject social status in health prediction compared to traditional socioeconomic measures, which extends the cognitive-relational in examining socioeconomic status and contributes to the dialog on socioeconomic inequality. We also suggested providing more social support at the community level and enhancing individuals' positive understanding to protect mental health.
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Affiliation(s)
- Yean Wang
- School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Shuge Xu
- School of Sociology, Wuhan University, Wuhan, China
| | - Yue Chen
- School of Social Development and Public Policy, Beijing Normal University, Beijing, China
| | - Haijuan Liu
- School of Sociology, Central China Normal University, Wuhan, China
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Wong ELY, Li J, Yuen S, Lai AHY, Cheung AWL, Yau PSY, Yeoh EK. Vulnerable populations during COVID-19 response: Health-related quality of life among Chinese population and its influence due to socio-demographic factors and loneliness. Front Public Health 2022; 10:857033. [PMID: 36081475 PMCID: PMC9446419 DOI: 10.3389/fpubh.2022.857033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Accepted: 07/06/2022] [Indexed: 01/21/2023] Open
Abstract
Background Infection control policy affected people's wellbeing during the COVID-19 pandemic, especially those vulnerable populations. This study aimed to compare the health-related quality of life (HRQoL) of the Hong Kong (HK) Chinese population under the pandemic with the normative profiles and explore its influencing factors, including socio-demographic characteristics, loneliness, and the interaction between them. Methods A cross-sectional questionnaire survey (301 online and 202 in-person) was conducted between June and December 2020 among the adult Chinese population during the 2nd wave of COVID-19 in HK. HRQoL was measured by a Hong Kong validated EQ-5D-5L instrument (EQ-5D-5L HK). Loneliness was measured by a single-item question regarding the frequency of the participants reporting feeling lonely and their subjective social status was measured by the MacArthur Scale of Subjective Social Status. A series of Tobit regressions was conducted. The interaction terms between socio-demographics and loneliness were also examined to decide their association with HRQoL. Results A total of 503 responses were collected. The level of HRQoL of the respondents was significantly lower than the referred norms profile among the local general population. The findings identified that younger age, single, a higher subjective social status, and a lower level of loneliness were significantly associated with better HRQoL. Moreover, age and marital status were significant moderators in the relationship between loneliness and HRQoL. Conclusion The present study found that some population groups face additional vulnerabilities during the pandemic in terms of declined HRQoL. In addition, reducing loneliness can protect the HRQoL during the pandemic, especially among older people. This article provides useful information for policy-makers to design and promote effective services or provide education to improve the connection of people and recover from the global pandemic.
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Affiliation(s)
- Eliza Lai-Yi Wong
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China,*Correspondence: Eliza Lai-Yi Wong
| | - Jia Li
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Shannon Yuen
- Faculty of Social Sciences, Developmental and Educational Psychology, Leiden University, Leiden, Netherlands
| | - Angel Hor-Yan Lai
- Department of Applied Social Sciences, Faculty of Health and Social Sciences, The Hong Kong Polytechnic University, Hong Kong, Hong Kong SAR, China
| | - Annie Wai-Ling Cheung
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Peter Sen-Yung Yau
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Eng-Kiong Yeoh
- Centre for Health Systems and Policy Research, The Jockey Club School of Public Health and Primary Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, Hong Kong SAR, China
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Chen X, Woo J, Yu R, Chung GKK, Yao W, Yeoh EK. Subjective Social Status, Area Deprivation, and Gender Differences in Health among Chinese Older People. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:9857. [PMID: 36011511 PMCID: PMC9408352 DOI: 10.3390/ijerph19169857] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 07/26/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
This study examined the gender differences in the main and interactive effects of subjective social status and area deprivation on health among older adults in Hong Kong. Data for this study came from the baseline of MrOs and MsOs studies, including 4000 Chinese men and women ≥ 65 in Hong Kong. Subjective social status was assessed using the MacArthur Scale of subjective social status scale. Our results reaffirm that subjective social status is an independent indicator of health after adjusting for objective SES measures (e.g., education and income). Perceived rank on the community ladder was more closely related to health among older people than was the society ladder, particularly for women. Although area-level social deprivation was not significantly associated with the health of older people, it may moderate the effect of subjective social status on health. Women with a lower perceived status in the community were more likely to experience depressive symptoms but better grip strength when living in more deprived neighborhoods. The findings suggested that subjective social status provides important information for the physical and mental health of the older population. Policymakers may implement interventions to enhance the subjective social status of older adults. Given the greater contribution of relative status in the community to the health of women, these policies and interventions should target to improve women's perceived status in the community.
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Affiliation(s)
- Xi Chen
- Department of Sociology and Social Policy, Lingnan University, Hong Kong SAR, China
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jean Woo
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Ruby Yu
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Gary Ka-Ki Chung
- CUHK Institute of Health Equity, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Wei Yao
- Department of Sociology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Eng-Kiong Yeoh
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong SAR, China
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong SAR, China
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Sumerlin TS, Kwok TCY, Goggins WB, Yuan J, Kwong EMS, Leung J, Kim JH. The effect of subjective social status on health-related quality of life decline in urban Chinese older adults: a four-year longitudinal study from Hong Kong. BMC Geriatr 2022; 22:619. [PMID: 35883050 PMCID: PMC9316660 DOI: 10.1186/s12877-022-03314-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 07/14/2022] [Indexed: 11/15/2022] Open
Abstract
Background Improving health-related quality of life (HRQOL) is becoming a major focus of old age care and social policy. Researchers have been increasingly examining subjective social status (SSS), one’s self-perceived social position, as a predictor of various health conditions. SSS encompasses not only concrete socio-economic (SES) factors but also intangible aspects of status. This study’s main objective was to examine the association between SSS and long-term change in HRQOL in older Chinese adults. Methods A longitudinal Hong Kong study recruited 2934 community-dwelling adults (age > 65 years). Participants completed SF-12 physical health (PCS) and mental health (MCS) HRQOL scales. This study analyzed baseline SSS-Society (self-perceived social status within Hong Kong) and SSS-Community (self-perceived status within one’s own social network) as predictors of long-term HRQOL decline. After stratifying for sex, multiple-linear-regression was performed on 4-year follow-up SF-12 PCS and MCS scores after adjusting for baseline SF-12 scores, traditional SES indicators, demographic variables, clinical conditions, and lifestyle variables. Results In the multivariable analyses, lower SSS-Society was associated with declines in MCS in males (βstandardized = 0.08, p = 0.001) and declines in PCS (βstandardized = 0.07, p = 0.006) and MCS (βstandardized = 0.12, p < 0.001) in females. SSS-Community was associated with declines in PCS in males (βstandardized = 0.07, p = 0.005) and MCS in females (βstandardized = 0.14, p < 0.001). Conclusions SSS may be a useful supplementary tool for predicting risk of long-term HRQOL decline in older Chinese adults. Strategies to reduce perceived social inequalities may improve HRQOL in older adults.
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Affiliation(s)
- Timothy S Sumerlin
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China
| | - Timothy C Y Kwok
- Faculty of Medicine Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China
| | - William B Goggins
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China
| | - Jinqiu Yuan
- Clinical Research Center, The Seventh Affiliated Hospital Sun Yat-sen University, Shenzhen, Guangdong, China
| | - Elizabeth M S Kwong
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China
| | - Jason Leung
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China
| | - Jean H Kim
- Jockey Club School of Public Health and Primary Care, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, The New Territories, Hong Kong, China.
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Kim JH, Sumerlin TS, Goggins WB, Kwong EMS, Leung J, Yu B, Kwok TCY. Does Low Subjective Social Status Predict Cognitive Decline in Chinese Older Adults? A 4-Year Longitudinal Study From Hong Kong. Am J Geriatr Psychiatry 2021; 29:1140-1151. [PMID: 33563520 PMCID: PMC8298609 DOI: 10.1016/j.jagp.2021.01.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 01/10/2021] [Accepted: 01/13/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Subjective social status (SSS), one's self-perceived social position, encompasses not only concrete socio-economic (SES) factors (e.g., income) but also intangible aspects of status (e.g., social capital). In recent years, there has been increasing research interest in SSS as a predictor of a vast array of health outcomes but very few studies examining effects on cognitive functioning. This study's main objective was to examine the association between SSS and long-term cognitive decline in older Chinese adults. DESIGN A 4-year longitudinal study. SETTING Hong Kong, China. PARTICIPANTS Chinese adults (aged ≥65) (n = 3,153). MEASUREMENTS This study analyzed baseline SSS-Hong Kong (self-perceived social status within Hong Kong) and SSS-Community (self-perceived status within one's own social network) as predictors of long-term cognitive decline. Multiple-linear-regression was performed on 4-year follow-up Mini-Mental-Status-Examination (MMSE) cognitive function score (score range: 0-30) after adjusting for baseline MMSE scores, traditional SES indicators (e.g., education), demographic variables (e.g., sex), clinical conditions (e.g., stroke history, depression), and lifestyle variables (e.g., physical activity levels). RESULTS Lower SSS-Community but not SSS-Hong Kong was associated with greater cognitive decline (unstandardized coefficient (95% CI) = 0.13 (0.07, 0.19) standardized β-coefficient = 0.08, after adjusting for objective SES measures and other background and clinical factors. The standardized β-coefficients for the SSS-Community variable were similar in magnitude to those for depression and diabetes. CONCLUSION Cognitive decline is influenced by self-perceived rank in proximal reference groups rather than socioeconomic comparison with society at-large. SSS-Community is a useful, single-item supplementary instrument to improve prediction of cognitive decline in elderly Chinese.
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Affiliation(s)
- Jean H. Kim
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - Timothy S. Sumerlin
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - William B. Goggins
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - Elizabeth M. S. Kwong
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - Jason Leung
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - Blanche Yu
- The Chinese University of Hong Kong, Jockey Club School of Public Health and Primary Care Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China
| | - Timothy C. Y. Kwok
- The Chinese University of Hong Kong Faculty of Medicine Department of Medicine and Therapeutics, Prince of Wales Hospital Shatin, The New Territories, Hong Kong, China,Corresponding author’s
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Lai ETC, Yu R, Woo J. Social gradient of self-rated health in older people-the moderating/mediating role of sense of community. Age Ageing 2021; 50:1283-1289. [PMID: 33454753 DOI: 10.1093/ageing/afaa277] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Social gradients of self-rated health (SRH) of older people are evident in various settings. However, it is not clear whether improving older people's sense of community (SoC) could mitigate the social gradient. METHODS People aged above 60 in five residential districts of Hong Kong were sampled using multistage sampling (n = 1,793). SoC was measured using the validated eight-item Brief Sense of Community Scale, with each item on a five-point Likert scale, forming a score from 8 to 40. SRH was considered as dichotomous (poor/not poor). Socioeconomic status (SES) was operationalised as monthly income, highest education attainment and self-rated disposable income (defined as whether the older person feel he/she has sufficient income). Causal mediation analysis using four-way decomposition was used to assess whether SoC mediates/moderates the association of SES and poor SRH. RESULTS A social gradient of poor SRH by all measures of SES was observed [adjusted relative risk (RR) per standard deviation income increase = 0.92; 95% confidence interval (95% CI) 0.88-0.97; RR comparing lowest to highest education= 1.77; 95% CI: 1.48-2.11; RR comparing very insufficient to very sufficient disposable income = 1.74; 95% CI: 1.48-2.05]. Causal mediation analysis showed that SoC interacts with the association of education and SRH, with higher the SoC, stronger the education gradient. CONCLUSIONS Our findings showed a social gradient of SRH in the older population in Hong Kong. This relationship was moderated by SoC, for which higher SoC is related to stronger SES-SRH gradient.
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Affiliation(s)
- Eric T C Lai
- Jockey Club Institute of Ageing, Chinese University of Hong Kong, Hong Kong SAR
- Institute of Health Equity, Chinese University of Hong Kong, Hong Kong SAR
| | - Ruby Yu
- Jockey Club Institute of Ageing, Chinese University of Hong Kong, Hong Kong SAR
| | - Jean Woo
- Jockey Club Institute of Ageing, Chinese University of Hong Kong, Hong Kong SAR
- Institute of Health Equity, Chinese University of Hong Kong, Hong Kong SAR
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Yu R, Leung G, Chan J, Yip BHK, Wong S, Kwok T, Woo J. Neighborhood Social Cohesion Associates with Loneliness Differently among Older People According to Subjective Social Status. J Nutr Health Aging 2021; 25:41-47. [PMID: 33367461 DOI: 10.1007/s12603-020-1496-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To examine whether neighborhood social cohesion can alleviate the negative impact of low subjective social status on feelings of loneliness. DESIGN Cross-sectional study. SETTING Community, Hong Kong. PARTICIPANTS Older people who participated in a cohort study on osteoporosis and general health in Hong Kong (MrOs study). METHODS Data were sourced from the 14-year follow-up data of the MrOs study. Loneliness was measured using the 6-item De Jong Gierveld Loneliness Scale. Neighborhood social cohesion was measured by the Hong Kong version of Neighborhood Cohesion Instrument. Linear regression models were used to examine the associations between neighborhood social cohesion and loneliness, controlled for age, sex, marital status, educational level, lifestyle, number of diseases, and maximum lifetime income. The analyses were stratified by subjective social status as measured by a 10-rung self-anchoring scale. RESULTS 1,037 participants with a mean age of 83 years were included in the study, of whom 72%, 83%, and 64% were classified as at risk of overall loneliness, emotional loneliness, and social loneliness, respectively. Those who were classified as at risk of overall loneliness reported lower subjective social status and had lower levels of neighborhood social cohesion. Linear regression models showed that higher levels of neighborhood social cohesion were associated with lower levels of overall and social loneliness. Stratified analyses showed that the associations between neighborhood social cohesion and loneliness vary across subjective social status groups. Among those with low/middle social status ranking, higher levels of neighborhood social cohesion were associated with lower overall (low-ranking B=-0.111, p=0.001; middle-ranking B=-0.057, p=0.026) and social (low-ranking B=-0.093, p<0.001; middle-ranking B=-0.073, p<0.001) loneliness scores. Among those with high ranking, higher levels of neighborhood social cohesion were associated with lower overall (B=-0.099, p=0.041) and emotional (B=-0.056, p=0.017) loneliness scores, but the associations became insignificant when controlling for maximum lifetime income. CONCLUSIONS AND IMPLICATIONS Neighborhood social cohesion may operate differently in different social ranking groups. Interventions to alleviate feelings of loneliness should be subjective social status specific.
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Affiliation(s)
- R Yu
- Ruby Yu, Department of Medicine and Therapeutics, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China., Tel: (852) 3943 5142, Fax: (852) 2637 9215 E-mail:
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Malnutrition According to GLIM Criteria and Adverse Outcomes in Community-Dwelling Chinese Older Adults: A Prospective Analysis. J Am Med Dir Assoc 2020; 22:1953-1959.e4. [PMID: 33153909 DOI: 10.1016/j.jamda.2020.09.029] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2020] [Revised: 09/18/2020] [Accepted: 09/22/2020] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The Global Leadership Initiative on Malnutrition (GLIM) has proposed a consensus scheme for classifying malnutrition. This study examined the prevalence of malnutrition according to GLIM criteria and evaluated if these criteria were associated with adverse outcomes in community-dwelling older adults. DESIGN This was a prospective cohort study. SETTING AND PARTICIPANTS Community-dwelling Chinese men and women aged ≥65 years in Hong Kong. METHODS A health check including questionnaire interviews and physical measurements was conducted at baseline and 14-year follow-up. Participants were classified as malnourished at baseline according to the GLIM criteria based on 2 phenotypic components (low body mass index and reduced muscle mass) and 1 etiologic component (inflammation). Adverse outcomes including sarcopenia, frailty, falls, mobility limitation, hospitalization, and mortality were assessed at 14-year follow-up. Adjusted multiple logistic regression and Cox proportional hazards model were performed to examine the associations between malnutrition and adverse outcomes and presented as odds ratio (OR) or hazard ratio (HR) and 95% confidence interval (CI). RESULTS Data of 3702 participants [median age: 72 years (IQR 68-76)] were available at baseline. Malnutrition was present in 397 participants (10.7%). Malnutrition was significantly associated with higher risk of sarcopenia (n = 898, OR 2.25; 95% CI 1.04-4.86), frailty (Fried (n = 971, OR 2.83; 95% CI 1.47-5.43), FRAIL scale (n = 985, OR 2.30; 95% CI 1.06-4.98)) and all-cause mortality (n = 3702, HR: 1.62; 95% CI 1.39-1.89). There was no significant association between malnutrition and falls (n = 987, OR 1.09; 95% CI 0.52-2.31), mobility limitation (n = 989, OR 0.98; 95% CI 0.36-2.67), and hospitalization (n = 989, OR 1.37; 95% CI 0.67-2.77). CONCLUSIONS AND IMPLICATIONS Among community-dwelling Chinese older adults, malnutrition according to selected GLIM criteria was a predictor of sarcopenia, frailty, and mortality at 14-year follow-up; whereas no association was found for falls, mobility limitation, and hospitalization. Clinicians may consider applying the GLIM criteria to identify malnourished community-dwelling older adults.
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Kwong E, Kwok TTY, Sumerlin TS, Goggins WB, Leung J, Kim JH. Does subjective social status predict depressive symptoms in Chinese elderly? A longitudinal study from Hong Kong. J Epidemiol Community Health 2020; 74:882-891. [PMID: 32631845 DOI: 10.1136/jech-2019-212451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 10/28/2019] [Accepted: 06/11/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Subjective social status (SSS), one's self-perceived social status, has been gaining interest among researchers as a risk/protective factor of many health outcomes. SSS encompasses both socio-economic factors (eg, income) and intangible aspects of status (eg, esteem from peers). This study's main objective was to examine the association between SSS and future risk of depression in elderly Chinese. METHODS Using data from the ongoing Mr/Mrs Os study, a longitudinal study of Hong Kong Chinese elderly, this study analysed baseline SSS-Hong Kong (self-perceived social status within Hong Kong) and SSS-Community (self-perceived status within one's own social network) as predictors of Geriatric Depression Scale (GDS) score at year 4 (n=3153). The models adjusted for baseline depression scores, socio-economic status indicators, demographic variables, clinical conditions and functional status variables. RESULTS Higher depression scores at follow-up were independently associated with lower SSS-Hong Kong (standardised β-coefficient= -0.040, p=0.017), lower SSS-Community (standardised β-coefficient= -0.057, p=0.001), in addition to older age, female gender and stroke history. After stratifying by dementia status, higher baseline SSS was associated with less depressive symptoms only in the non-dementia group. In the multivariable models that included both SSS variables, only SSS-Community was significantly associated with year 4 GDS score. However, both SSS variables were independently associated with year 4 depression status in the logistic regression analysis. CONCLUSION In Chinese elderly, SSS captures aspects of social status that are not captured by traditional socio-economic indicators. SSS can be a useful supplementary tool for assessing future risk of developing mental health conditions.
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Affiliation(s)
- Elizabeth Kwong
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Timothy T Y Kwok
- Faculty of Medicine Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Timothy S Sumerlin
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - William B Goggins
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Jason Leung
- Faculty of Medicine Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
| | - Jean H Kim
- Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Shatin, New Territories, Hong Kong
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Yu R, Tong C, Leung J, Woo J. Socioeconomic Inequalities in Frailty in Hong Kong, China: A 14-Year Longitudinal Cohort Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041301. [PMID: 32085541 PMCID: PMC7068288 DOI: 10.3390/ijerph17041301] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 12/29/2022]
Abstract
The prevalence of frailty varies among socioeconomic groups. However, longitudinal data for the association between subjective social status and frailty is limited. In this study, we examined whether subjective social status was associated with incident frailty. Data were obtained from a 14-year cohort of Chinese men and women (n = 694) aged 65 years and older who participated in the MrOs study—a longitudinal study on osteoporosis and general health in Hong Kong. Subjective social status at baseline (2001–2003) was assessed using a 10-rung self-anchoring scale. Incident frailty at the 14-year follow-up (2015–2017) was defined as proposed by Fried and colleagues. Ordinal logistic regressions were used to examine the association between subjective social status (high, middle, or low) and incident frailty. After adjustment for age, sex, marital status, objective socioeconomic status, medical history, lifestyle, mental health, and cognitive function, subjective social status at baseline was negatively associated with risk of developing frailty over time (OR 2.3, 95% CI 1.2–4.6). In sex-stratified analysis, the social gradient in frailty was only found in men. Social inequality in frailty in men but not in women supports interventions specific to gender inequality and frailty.
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Affiliation(s)
- Ruby Yu
- Department of Medicine and Therapeutics/Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Cecilia Tong
- Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jason Leung
- Jockey Club Centre for Osteoporosis Care and Control, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Jean Woo
- Department of Medicine and Therapeutics/Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Shatin, Hong Kong
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The Associations of Income, Education and Income Inequality and Subjective Well-Being among Elderly in Hong Kong-A Multilevel Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041271. [PMID: 32079186 PMCID: PMC7068358 DOI: 10.3390/ijerph17041271] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 02/12/2020] [Accepted: 02/13/2020] [Indexed: 12/02/2022]
Abstract
Background: Higher income and education and lower income inequality in a neighbourhood have been shown to be related to better mental health outcome in developed countries. However, it is not clear whether these factors would affect the subjective well-being of the elderly, especially in a setting with recent rapid economic development. Methods: This study was conducted in 80 community centres with a total of 7552 community-dwelling elderly (mean age 75.9 years (SD = 7.79), 79% female) in Hong Kong. Income at individual level was measured as perceived disposable income. Education level was also collected. At district level, income was measured by district median household income and education was measured as the proportion of the population with no formal schooling. Income inequality was quantified using Gini coefficients. Low subjective well-being was defined as any one or a combination of the following: not satisfied with life, no meaning of life and being unhappy (Likert scale ≤ 2). Multilevel logistic regression was used to assess the association of income, education and income inequality and low subjective well-being. Results: We found that 15.3% (95% confidence interval (CI): 14.5 to 16.1) of the elderly have low subjective well-being. Compared with elderly who reported a very adequate disposable income, those who reported a very inadequate disposable income are at increased risk of low subjective well-being (OR=5.08, 95%CI: 2.44 to 10.59). Compared with elderly with tertiary education, those with no formal schooling were at higher risk (OR=1.60, 95%CI 1.22 to 2.09). Income inequality was not related to subjective well-being. Conclusions: Elderly with inadequate disposable income and lower education level are more likely to suffer from low subjective well-being. At the neighbourhood level, income inequality was not related to subjective well-being. However, the relationships between neighbourhood income and education level and individuals’ subjective well-being are not clear.
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Yoshany N, Seyed khameshi SS, Rezaei M, Baghin N, Karimian kakolaki Z. Relationship between Quality of Life and Using Smart Phones in the Elderly. JOURNAL OF EDUCATION AND COMMUNITY HEALTH 2019. [DOI: 10.29252/jech.6.4.247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Yu R, Wang D, Leung J, Lau K, Kwok T, Woo J. Is Neighborhood Green Space Associated With Less Frailty? Evidence From the Mr. and Ms. Os (Hong Kong) Study. J Am Med Dir Assoc 2018; 19:528-534. [DOI: 10.1016/j.jamda.2017.12.015] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 12/15/2017] [Accepted: 12/15/2017] [Indexed: 10/17/2022]
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Chung RYN, Chung GKK, Gordon D, Wong SYS, Chan D, Lau MKW, Tang VMY, Wong H. Deprivation is associated with worse physical and mental health beyond income poverty: a population-based household survey among Chinese adults. Qual Life Res 2018; 27:2127-2135. [PMID: 29761348 DOI: 10.1007/s11136-018-1863-y] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2018] [Indexed: 11/30/2022]
Abstract
PURPOSE In studying health inequality, poverty as measured by income is frequently used; however, this omits the aspects of non-monetary resources and social barriers to achieving improved living standard. Therefore, our study aimed to examine the associations of individual-level deprivation of material and social necessities with general physical and mental health beyond that of income poverty. METHODS A territory-wide two-stage stratified random sample of 2282 community-dwelling Hong Kong adults was surveyed between 2014 and 2015. Income poverty and a Deprivation Index were used as the main independent variables. General health was assessed using the validated 12-item Short-Form Health Survey version 2, from which physical component summary and mental component summary were derived. RESULTS Our results in multivariable ordinal logistic regressions consistently showed that, after adjusting for income poverty, socio-demographic and lifestyle factors, being deprived was significantly associated with worse physical (OR 1.66; CI 1.25-2.20) and mental health (OR 1.83; CI 1.43-2.35). Being income poor was also significantly associated with worse mental health (OR 1.63; CI 1.28-2.09) but only marginally with physical health (OR 1.34; CI 1.00-1.80) after adjustments. CONCLUSIONS Income does not capture all aspects of poverty that are associated with adverse health outcomes. Deprivation of non-monetary resources has an independent effect on general health above and beyond the effect of income poverty. Policies should move beyond endowment and take into account the multidimensionality of poverty, in order to address the problem of health inequality.
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Affiliation(s)
- Roger Yat-Nork Chung
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China.
| | - Gary Ka-Ki Chung
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - David Gordon
- School for Policy Studies, University of Bristol, Bristol, UK
| | - Samuel Yeung-Shan Wong
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Dicken Chan
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
| | - Maggie Ka-Wai Lau
- Asia-Pacific Institute of Ageing Studies, Lingnan University, Hong Kong, China
| | - Vera Mun-Yu Tang
- Asia-Pacific Institute of Ageing Studies, Lingnan University, Hong Kong, China
| | - Hung Wong
- Department of Social Work, The Chinese University of Hong Kong, Hong Kong, China
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Tang KL, Pilote L, Behlouli H, Godley J, Ghali WA. An exploration of the subjective social status construct in patients with acute coronary syndrome. BMC Cardiovasc Disord 2018; 18:22. [PMID: 29409448 PMCID: PMC5801903 DOI: 10.1186/s12872-018-0759-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 01/26/2018] [Indexed: 03/21/2023] Open
Abstract
Background Perception of low subjective social status (SSS) relative to others in society or in the community has been associated with increased risk of cardiovascular disease. Our objectives were to determine whether low SSS in society was associated with barriers to access to care or hospital readmission in patients with established cardiovascular disease, and whether perceptions of discordantly high SSS in the community modified this association. Methods We conducted a prospective cohort study from 2009 to 2013 in Canada, United States, and Switzerland in patients admitted to hospital with acute coronary syndrome (ACS). Data on access to care and SSS variables were obtained at baseline. Readmission data were obtained 12 months post-discharge. We conducted multivariable logistic regression to model the odds of access to care and readmission outcomes in those with low versus high societal SSS. Results One thousand ninety patients admitted with ACS provided both societal and community SSS rankings. The low societal SSS cohort had greater odds of reporting that their health was affected by lack of health care access (OR 1.48, 95% CI 1.11, 1.97) and of experiencing cardiac readmissions (1.88, 95% CI 1.15, 3.06). Within the low societal SSS cohort, there was a trend toward fewer access to care barriers for those with discordantly high community SSS though findings varied based on the outcome variable. There were no statistically significant differences in readmissions based on community SSS rankings. Conclusion Low societal SSS is associated with increased barriers to access to care and cardiac readmissions. Though attenuated, these trends remained even when adjusting for clinical and sociodemographic factors, suggesting that perceived low societal SSS has health effects above and beyond objective socioeconomic factors. Furthermore, high community SSS may potentially mitigate the risk of experiencing barriers to access to health care in those with low societal SSS, though these associations were not statistically significant. Subjective social status relative to society versus relative to the community seem to represent distinct concepts. Insight into the differences between these two SSS constructs is imperative in the understanding of cardiovascular health and future development of public health policies. Electronic supplementary material The online version of this article (10.1186/s12872-018-0759-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen L Tang
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Louise Pilote
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada.,Division of General Internal Medicine, McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada
| | - Hassan Behlouli
- Division of Clinical Epidemiology, Research Institute of McGill University Health Centre, 687 Pine Ave West, Montreal, Quebec, H3A 1A1, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4, Canada.,O' Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - William A Ghali
- Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.,O' Brien Institute for Public Health, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.,Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
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Wang D, Lau KKL, Yu R, Wong SYS, Kwok TTY, Woo J. Neighbouring green space and mortality in community-dwelling elderly Hong Kong Chinese: a cohort study. BMJ Open 2017; 7:e015794. [PMID: 28765127 PMCID: PMC5642810 DOI: 10.1136/bmjopen-2016-015794] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 06/07/2017] [Accepted: 06/13/2017] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Green space has been shown to be beneficial for human wellness through multiple pathways. This study aimed to explore the contributions of neighbouring green space to cause-specific mortality. METHODS Data from 3544 Chinese men and women (aged ≥65 years at baseline) in a community-based cohort study were analysed. Outcome measures, identified from the death registry, were death from all-cause, respiratory system disease, circulatory system disease. The quantity of green space (%) within a 300 m radius buffer was calculated for each subject from a map created based on the Normalised Difference Vegetation Index. Cox proportional hazard models adjusted for demographics, socioeconomics, lifestyle, health conditions and housing type were used to estimate the HRs and 95% CIs. RESULTS During a mean of 10.3 years of follow-up, 795 deaths were identified. Our findings showed that a 10% increase in coverage of green space was significantly associated with a reduction in all-cause mortality (HR 0.963, 95% CI 0.930 to 0.998), circulatory system-caused mortality (HR 0.887, 95% CI 0.817 to 0.963) and stroke-caused mortality (HR 0.661, 95% CI 0.524 to 0.835), independent of age, sex, marital status, years lived in Hong Kong, education level, socioeconomic ladder, smoking, alcohol intake, diet quality, self-rated health and housing type. The inverse associations between coverage of green space with all-cause mortality (HR 0.964, 95% CI 0.931 to 0.999) and circulatory system disease-caused mortality (HR 0.888, 95% CI 0.817 to 0.964) were attenuated when the models were further adjusted for physical activity and cognitive function. The effects of green space on all-cause and circulatory system-caused mortality tended to be stronger in females than in males. CONCLUSION Higher coverage of green space was associated with reduced risks of all-cause mortality, circulatory system-caused mortality and stroke-caused mortality in Chinese older people living in a highly urbanised city.
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Affiliation(s)
- Dan Wang
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China
| | - Kevin Ka-Lun Lau
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Future Cities, The Chinese University of Hong Kong, Hong Kong, China
- Institute of Environment, Energy and Sustainability, The Chinese University of Hong Kong, Hong Kong, China
| | - Ruby Yu
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Samuel Y S Wong
- The Jockey Club School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, China
- Hong Kong Institute of Intergrative Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Timothy T Y Kwok
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jean Woo
- CUHK Jockey Club Institute of Ageing, The Chinese University of Hong Kong, Hong Kong, China
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Woo J, Leung J, Zhang T. Successful Aging and Frailty: Opposite Sides of the Same Coin? J Am Med Dir Assoc 2016; 17:797-801. [DOI: 10.1016/j.jamda.2016.04.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 04/15/2016] [Indexed: 12/25/2022]
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Tang KL, Rashid R, Godley J, Ghali WA. Association between subjective social status and cardiovascular disease and cardiovascular risk factors: a systematic review and meta-analysis. BMJ Open 2016; 6:e010137. [PMID: 26993622 PMCID: PMC4800117 DOI: 10.1136/bmjopen-2015-010137] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 02/18/2016] [Accepted: 02/23/2016] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE To determine the association between subjective social status (SSS), or the individual's perception of his or her position in the social hierarchy, and the odds of coronary artery disease (CAD), hypertension, diabetes, obesity and dyslipidaemia. STUDY DESIGN Systematic review and meta-analysis. METHODS We searched PubMed, MEDLINE, EMBASE, CINAHL, PsycINFO, SocINDEX, Web of Science and reference lists of all included studies up to October 2014, with a verification search in July 2015. Inclusion criteria were original studies in adults that reported odds, risk or hazard ratios of at least one outcome of interest (CAD, hypertension, diabetes, obesity or dyslipidaemia), comparing 'lower' versus 'higher' SSS groups, where SSS is measured on a self-anchoring ladder. ORs were pooled using a random-effects model. RESULTS 10 studies were included in the systematic review; 9 of these were included in the meta-analysis. In analyses unadjusted for objective socioeconomic status (SES) measures such as income, education or occupation, the pooled OR comparing the bottom versus the top of the SSS ladder was 1.82 (95% CI 1.10 to 2.99) for CAD, 1.88 (95% CI 1.27 to 2.79) for hypertension, 1.90 (95% CI 1.25 to 2.87) for diabetes, 3.68 (95% CI 2.03 to 6.64) for dyslipidaemia and 1.57 (95% CI 0.95 to 2.59) for obesity. These associations were attenuated when adjusting for objective SES measures, with the only statistically significant association remaining for dyslipidaemia (OR 2.10, 95% CI 1.09 to 4.06), though all ORs remained greater than 1. CONCLUSIONS Lower SSS is associated with significantly increased odds of CAD, hypertension, diabetes and dyslipidaemia, with a trend towards increased odds of obesity. These trends are consistently present, though the effects attenuated when adjusting for SES, suggesting that perception of one's own status on a social hierarchy has health effects above and beyond one's actual income, occupation and education.
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Affiliation(s)
- Karen L Tang
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ruksana Rashid
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Jenny Godley
- Department of Sociology, University of Calgary, Calgary, Alberta, Canada
- O’ Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
| | - William A Ghali
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- O’ Brien Institute for Public Health, University of Calgary, Calgary, Alberta, Canada
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Telomere length is not associated with frailty in older Chinese elderly: Cross-sectional and longitudinal analysis. Mech Ageing Dev 2015; 152:74-9. [PMID: 26483096 DOI: 10.1016/j.mad.2015.10.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/30/2015] [Accepted: 10/09/2015] [Indexed: 11/23/2022]
Abstract
Telomere shortening has been associated with biological age and several chronic degenerative diseases. However, less is known about telomere length and frailty, which is an indicator of biological age. This study examines the association between telomere length and frailty in a prospective study over five years of 2006 men and women aged 65 years and older living in the community. The frailty status was determined by the Fried's criteria. Telomere length in leukocytes was measured using the quantitative polymerase chain reaction. Logistic regression was used to examine the association between telomere length and incidence of frailty. Among 2006 subjects (mean age 72.4±5.1 years, 51.3% women), the mean telomere length at baseline was 9.1±2.0kb and the frailty phenotype was detected in 127 subjects (6.3%). Male gender was related to shorter telomere length, with increased years of age related to a shortened telomere length (P<0.05). In both men and women, no statistically significant difference of telomere length and the frailty phenotype was observed at baseline. After 4 years of follow-up, 116 cases of frailty were identified. There was no association between telomere length and incident frailty. In conclusion, telomere length was not associated with frailty in this study population.
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Yu R, Leung J, Woo J. Incremental Predictive Value of Sarcopenia for Incident Fracture in an Elderly Chinese Cohort: Results From the Osteoporotic Fractures in Men (MrOs) Study. J Am Med Dir Assoc 2014; 15:551-8. [DOI: 10.1016/j.jamda.2014.02.005] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Accepted: 02/14/2014] [Indexed: 12/29/2022]
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Woo J, Leung J. Multi-morbidity, dependency, and frailty singly or in combination have different impact on health outcomes. AGE (DORDRECHT, NETHERLANDS) 2014; 36:923-931. [PMID: 24091565 PMCID: PMC4039270 DOI: 10.1007/s11357-013-9590-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 09/23/2013] [Indexed: 06/01/2023]
Abstract
Multi-morbidity, dependency, and frailty were studied simultaneously in a community-living cohort of 4,000 men and women aged 65 years and over to examine the independent and combined effects on four health outcomes (mortality, decline in physical function, depression, and polypharmacy). The influence of socioeconomic status on these relationships is also examined. Mortality data was documented after a mean follow-up period of 9 years, while other health outcomes were documented after 4 years of follow-up. Fifteen percent of the cohort did not have any of these syndromes. Of the remaining participants, nearly one third had multi-morbidity and frailty (pre-frail and frail), while all three syndromes were present in 11 %. All syndromes as well as socioeconomic status were significantly associated with all health outcomes. Mortality was only increased for age, being male, frailty status, and combinations of syndromes that included frailty. Both multi-morbidity and frailtymale was protective. Only a combination of all three syndromes, and age per se, increased the risk of depressive symptoms at 4 years while being male conferred reduced risk. Multi-morbidity, but not frailty status or dependency, and all syndrome combinations that included multi-morbidity were associated with use of ≥ four medications. Decline in homeostatic function with age may thus be quantified and taken into account in prediction of various health outcomes, with a view to prevention, management, formulation of guidelines, service planning, and the conduct of randomized controlled trials of interventions or treatment.
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Affiliation(s)
- Jean Woo
- Department of Medicine & Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, N.T, Hong Kong,
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Yu R, Wong M, Leung J, Lee J, Auyeung TW, Woo J. Incidence, reversibility, risk factors and the protective effect of high body mass index against sarcopenia in community-dwelling older Chinese adults. Geriatr Gerontol Int 2014; 14 Suppl 1:15-28. [DOI: 10.1111/ggi.12220] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2013] [Indexed: 12/25/2022]
Affiliation(s)
- Ruby Yu
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; New Territories Hong Kong
| | - Moses Wong
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; New Territories Hong Kong
| | - Jason Leung
- Jockey Club Center for Osteoporosis Care and Control; The Chinese University of Hong Kong; New Territories Hong Kong
| | - Jenny Lee
- The S. H. Ho Center for Gerontology and Geriatrics; The Chinese University of Hong Kong; New Territories Hong Kong
- Department of Medicine and Geriatrics; Shatin Hospital; New Territories Hong Kong
| | - Tung Wai Auyeung
- The S. H. Ho Center for Gerontology and Geriatrics; The Chinese University of Hong Kong; New Territories Hong Kong
- Department of Medicine and Geriatrics; Pok Oi Hospital; New Territories Hong Kong
| | - Jean Woo
- Department of Medicine and Therapeutics; The Chinese University of Hong Kong; New Territories Hong Kong
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Chan R, Chan D, Woo J. A cross sectional study to examine the association between dietary patterns and cognitive impairment in older Chinese people in Hong Kong. J Nutr Health Aging 2013; 17:757-65. [PMID: 24154648 DOI: 10.1007/s12603-013-0348-5] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Dietary patterns can be identified using a priori and a posterior approaches. Few studies have related dietary patterns with cognitive impairment in Chinese population. This study examined the risk of cognitive impairment associated with dietary patterns identified by both approaches. METHODS Baseline data on 1,926 Chinese men and 1,744 Chinese women aged > 65 years participating in a cohort study examining the risk factors for osteoporosis in Hong Kong were analyzed. Dietary data were collected using a validated food frequency questionnaire. Adherence to a priori dietary patterns, namely the Mediterranean Diet Score (MDS) was assessed. Factor analysis (FA) identified three a posterior dietary patterns: "vegetables-fruits" pattern which was rich in vegetables, fruits, soy products and legumes, "snacks-drinks-milk products" pattern which was a mixture of healthy and unhealthy food groups including fast food, sweets and desserts, nuts, milk products and whole grains, and "meat-fish" pattern which included frequent intake of meat, fish and seafood. Cognitive function was assessed by the Community Screening Instrument for Dementia (CSI-D). Multivariate logistic regression examined the risk of cognitive impairment with adjustment for potential confounders. RESULTS A total of 221 men and 656 women was classified as cognitive impaired. Neither the MDS nor the dietary patterns identified by FA were associated with risk of cognitive impairment in men. In women, higher "vegetables-fruits" pattern score was associated with reduced risk of cognitive impairment [Adjusted OR=0.73 (95% CI: 0.54-1.00) of the highest quartile of "vegetables-fruits" pattern score compared with the lowest quartile, ptrend=0.018]. Similar inverse trend was observed for "snacks-drinks-milk products" pattern score [Adjusted OR=0.65 (95% CI: 0.47-0.90) of the highest quartile of "snacks-drinks-milk products" pattern score compared with the lowest quartile, ptrend=0.003]. There was no association of "meat-fish" pattern or the MDS with risk of cognitive impairment in women. CONCLUSION Higher "vegetables-fruits" and "snacks-drinks-milk products" pattern scores were associated with reduced risk of cognitive impairment in Chinese older women in Hong Kong.
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Affiliation(s)
- R Chan
- Dr Ruth Chan, Research assistant professor, Rm 124021, 10/F Clinical Sciences Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, Telephone number: (852) 2632 2190, Fax number: (852) 2637 9215,
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Housework reduces all-cause and cancer mortality in Chinese men. PLoS One 2013; 8:e61529. [PMID: 23667441 PMCID: PMC3647044 DOI: 10.1371/journal.pone.0061529] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 03/11/2013] [Indexed: 12/11/2022] Open
Abstract
Background Leisure time physical activity has been extensively studied. However, the health benefits of non-leisure time physical activity, particular those undertaken at home on all-cause and cancer mortality are limited, particularly among the elderly. Methods We studied physical activity in relation to all-cause and cancer mortality in a cohort of 4,000 community-dwelling elderly aged 65 and older. Leisure time physical activity (sport/recreational activity and lawn work/yard care/gardening) and non-leisure time physical activity (housework, home repairs and caring for another person) were self-reported on the Physical Activity Scale for the Elderly. Subjects with heart diseases, stroke, cancer or diabetes at baseline were excluded (n = 1,133). Results Among the 2,867 subjects with a mean age of 72 years at baseline, 452 died from all-cause and 185 died from cancer during the follow-up period (2001–2012). With the adjustment for age, education level and lifestyle factors, we found an inverse association between risk of all-cause mortality and heavy housework among men, with the adjusted hazard ratio (HR) of 0.72 (95%CI = 0.57–0.92). Further adjustment for BMI, frailty index, living arrangement, and leisure time activity did not change the result (HR = 0.71, 95%CI = 0.56–0.91). Among women, however, heavy housework was not associated with all-cause mortality. The risk of cancer mortality was significantly lower among men who participated in heavy housework (HR = 0.52, 95%CI = 0.35–0.78), whereas among women the risk was not significant. Men participated in light housework also were at lower risk of cancer mortality than were their counterparts, however, the association was not significant. Leisure time physical activity was not related to all-cause or cancer mortality in either men or women. Conclusion Heavy housework is associated with reduced mortality and cancer deaths over a 9-year period. The underlying mechanism needs further study.
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Chan R, Chan D, Woo J. The association of a priori and a posterior dietary patterns with the risk of incident stroke in Chinese older people in Hong Kong. J Nutr Health Aging 2013; 17:866-74. [PMID: 24257570 DOI: 10.1007/s12603-013-0334-y] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Dietary patterns can be identified by a priori and a posterior approaches. Limited data have related dietary patterns with stroke risk in Chinese population. This study examined stroke risk associated with patterns identified by both approaches. METHODS Data on 1,338 Chinese men and 1,397 Chinese women aged >= 65 years participating in a cohort study examining the risk factors for osteoporosis in Hong Kong were analyzed. Baseline dietary data were collected between 2001 and 2003 using a validated food frequency questionnaire. Adherence to a priori dietary patterns including the Mediterranean Diet Score (MDS) and the Dietary Approaches to Stop Hypertension (DASH) was assessed. Factor analysis (FA) identified three a posterior dietary patterns: "vegetables-fruits", "snacks-drinks-milk products", and "meat-fish". Data on incidence of stroke were retrieved from an official database in 2008. Cox regression was used to estimate hazard ratios (HRs) for stroke risk adjusted for potential confounders. RESULTS There were 156 incident stroke events during a median follow up of 5.7 years. A posterior dietary patterns derived by FA were not associated with risk of incident stroke in either men or women. MDS was inversely associated with risk of incident stroke [Adjusted HR=0.55 (95% CI: 0.31-0.99) of the highest level of MDS compared with the lowest level, ptrend=0.008] in men but not in women. Similar non-significant inverse association was observed between DASH accordance and stroke risk in men [Multivariate HR (95% CI) of the DASH score of >=4.5 = 0.62 (0.38-1.04) compared with the DASH score of <=4, ptrend = 0.068] but not in women. CONCLUSION Our findings suggest that higher MDS and possibly higher DASH scores were associated with lower stroke risk in Chinese older people in Hong Kong.
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Affiliation(s)
- R Chan
- Dr Ruth Chan, Research assistant professor, Rm 124021, 10/F Clinical Sciences Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong SAR, Telephone number: (852) 2632 2190, Fax number: (852) 2637 9215,
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Associations between dietary patterns and demographics, lifestyle, anthropometry and blood pressure in Chinese community-dwelling older men and women. J Nutr Sci 2012; 1:e20. [PMID: 25191550 PMCID: PMC4153085 DOI: 10.1017/jns.2012.19] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2011] [Revised: 09/05/2012] [Accepted: 09/28/2012] [Indexed: 02/07/2023] Open
Abstract
This cross-sectional study examined dietary patterns, and the associations of these patterns with demographics, lifestyle, anthropometry and blood pressure in 3707 Chinese people aged 65 years and above taking part in a population-based cohort study investigating the risk factors for osteoporosis. Baseline dietary data were collected using a validated FFQ. Dietary patterns were identified using factor analysis. Scores were calculated for each pattern. Demographics, lifestyle factors and self-reported hypertension history were collected through a questionnaire. BMI, waist circumference (WC), hip circumference (HC), waist-to-hip ratio, systolic blood pressure and diastolic blood pressure (DBP) were measured. Three dietary patterns were identified, namely 'vegetables-fruit', 'snacks-drinks-milk products' and 'meat-fish'. Participants who were more physically active, more educated, non-smokers and non-drinkers were more likely to have higher 'vegetables-fruit' dietary pattern scores. Current smoking habit and alcohol use were associated with higher 'snacks-drinks-milk products' dietary pattern scores and 'meat-fish' dietary pattern scores. 'Vegetables-fruit' dietary pattern scores were inversely (unstandardised regression coefficient B = -0·60 mmHg, 95 % CI -1·04, -0·16) and 'snacks-drinks-milk products' dietary pattern scores were positively (B = 0·50 mmHg, 95 % CI 0·08, 0·92) associated with DBP in men in multiple regressions. Higher 'meat-fish' dietary pattern scores were associated with higher BMI (B = 0·19 kg/m(2), 95 % CI 0·06, 0·33), waist-to-hip ratio (B = 0·004, 95 % CI 0·002, 0·007) and WC (B = 0·57 cm, 95 % CI 0·18, 0·97) in men, and higher BMI (B = 0·40 kg/m(2), 95 % CI 0·22, 0·57), WC (B = 0·87 cm, 95 % CI 0·39, 1·36) and HC (B = 0·61 cm, 95 % CI 0·26, 0·96) in women in multiple regressions. The influence of demographic and lifestyle characteristics on dietary patterns and the health risks associated with dietary patterns provides insights for the provision of tangible dietary advice to this population.
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Abstract
Previous research shows that socioeconomic status (SES) identity, also referred to as perceived or subjective social status, is shaped by objective measures of status, socio-cultural influences and psychological attributes and predicts current and future well-being. Prior studies, however, have not examined whether older adults reassess their SES identity over time. In this study, we use two assessments of subjective social status measured six years apart in a sample of older Taiwanese adults to: 1) determine the degree to which respondents adjust their perceptions of social rank; and 2) identify the characteristics of individuals who are most likely to revise their assessments. We find that many older Taiwanese adults reassess their SES identity, but most respondents show small to moderate levels of change. Females, more highly educated respondents, and those who have a positive economic outlook tend to revise their subjective social status upward relative to their respective counterparts; those who become widowed during the period adjust their rankings downward compared with those who do not become widowed. These findings suggest that SES identity may be dynamic, highlighting the importance of collecting information on socioeconomic status identity at multiple points in the life course.
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Abstract
BACKGROUND This study explored the relationship between "worthlessness" and all cause non-suicide mortality in Chinese elderly men. METHODS Data from interviews of 1999 men aged 65 years and over were collected. Clinically significant depressive symptoms were measured using the validated Chinese version of Geriatric Depression Scale. "Worthlessness" was defined by one of the 15 questions from the Geriatric Depression Scale with a yes/no response. All-cause mortality over six years was collected using data from the National Death Registry with adjudication by 4-monthly telephone interviews. Two men were excluded after suicide death. RESULTS Age-adjusted mortality rates at five years were 44.3 and 23.9 per 1,000 person years for those who felt "worthless" and those did not, respectively. The adjusted relative risk for all-cause mortality associated with feeling worthless was 1.34 (95% CI: 1.02-1.76) after adjusting for potential confounders that included age, marital status, education, smoking, alcohol consumption, number of chronic diseases, self-rated health, body mass index, cognitive status, physical activity, occupation and maximum lifetime income. There was no statistically significant association between other depressive symptoms or overall depression and mortality. CONCLUSION Worthlessness may be independently associated with all-cause mortality in Chinese elderly men.
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Relative contributions of geographic, socioeconomic, and lifestyle factors to quality of life, frailty, and mortality in elderly. PLoS One 2010. [PMID: 20098745 DOI: 10.1371/journal.pone.0008775.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND To date, few studies address disparities in older populations specifically using frailty as one of the health outcomes and examining the relative contributions of individual and environmental factors to health outcomes. METHODOLOGY/PRINCIPAL FINDINGS Using a data set from a health survey of 4,000 people aged 65 years and over living in all regions of Hong Kong, we examined regional variations in self-rated health, frailty, and four-year mortality, and analyzed the relative contributions of lifestyle, socioeconomic status, and geographical location of residence to these outcomes using path analysis. We hypothesize that lifestyle, socioeconomic status, and regional characteristics directly and indirectly through interactions contribute to self-rated physical and psychological health, frailty, and four-year mortality. District variations directly affect self-rated physical health, and also exert an effect through socioeconomic position as well as lifestyle factors. Socioeconomic position in turn directly affects self-rated physical health, as well as indirectly through lifestyle factors. A similar pattern of interaction is observed for self-rated mental health, frailty, and mortality, although there are differences in different lifestyle factors and district associations. Lifestyle factors also directly affect physical and mental components of health, frailty, and mortality. The magnitude of direct district effect is comparable to those of lifestyle and socioeconomic position. CONCLUSIONS/SIGNIFICANCE We conclude that district variations in health outcomes exist in the Hong Kong elderly population, and these variations result directly from district factors, and are also indirectly mediated through socioeconomic position as well as lifestyle. Provision and accessibility to health services are unlikely to play a significant role. Future studies on these district factors would be important in reducing health disparities in the older population.
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Woo J, Chan R, Leung J, Wong M. Relative contributions of geographic, socioeconomic, and lifestyle factors to quality of life, frailty, and mortality in elderly. PLoS One 2010; 5:e8775. [PMID: 20098745 PMCID: PMC2808254 DOI: 10.1371/journal.pone.0008775] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 12/18/2009] [Indexed: 11/25/2022] Open
Abstract
Background To date, few studies address disparities in older populations specifically using frailty as one of the health outcomes and examining the relative contributions of individual and environmental factors to health outcomes. Methodology/Principal Findings Using a data set from a health survey of 4,000 people aged 65 years and over living in all regions of Hong Kong, we examined regional variations in self-rated health, frailty, and four-year mortality, and analyzed the relative contributions of lifestyle, socioeconomic status, and geographical location of residence to these outcomes using path analysis. We hypothesize that lifestyle, socioeconomic status, and regional characteristics directly and indirectly through interactions contribute to self-rated physical and psychological health, frailty, and four-year mortality. District variations directly affect self-rated physical health, and also exert an effect through socioeconomic position as well as lifestyle factors. Socioeconomic position in turn directly affects self-rated physical health, as well as indirectly through lifestyle factors. A similar pattern of interaction is observed for self-rated mental health, frailty, and mortality, although there are differences in different lifestyle factors and district associations. Lifestyle factors also directly affect physical and mental components of health, frailty, and mortality. The magnitude of direct district effect is comparable to those of lifestyle and socioeconomic position. Conclusions/Significance We conclude that district variations in health outcomes exist in the Hong Kong elderly population, and these variations result directly from district factors, and are also indirectly mediated through socioeconomic position as well as lifestyle. Provision and accessibility to health services are unlikely to play a significant role. Future studies on these district factors would be important in reducing health disparities in the older population.
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Affiliation(s)
- Jean Woo
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Hong Kong, China.
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Woo J, Suen EWC, Leung JCS, Tang NLS, Ebrahim S. Older men with higher self-rated socioeconomic status have shorter telomeres. Age Ageing 2009; 38:553-8. [PMID: 19556325 DOI: 10.1093/ageing/afp098] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND previous studies examining the relationship between socioeconomic status and telomere length showed conflicting results, one study finding shorter telomere length in subjects with lower socioeconomic status and one showing no relationship. DESIGN cross-sectional study. SETTING community-living elderly Chinese in Hong Kong. OBJECTIVE this study examines the relationship between self-rated social economic status and telomere length in Hong Kong Chinese men and women aged 65 years and over living in the community. SUBJECTS AND METHOD information was collected from 958 men and 978 women regarding possible confounding factors such as the presence of chronic diseases, smoking, physical activity level, dietary intake and body mass index. Telomere length was measured by quantitative PCR. RESULT in men only, after adjustment for age and other confounding factors, a higher ranking in community standing was associated with shorter telomere length. CONCLUSION men with higher self-rated socioeconomic status have shorter telomeres, possibly mediated through psychosocial rather than lifestyle factors or the presence of chronic disease. There may be cultural ethnic and age-related differences in social determinants of health.
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Affiliation(s)
- Jean Woo
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, 9/F, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
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Prevalence and correlates of musculoskeletal pain in Chinese elderly and the impact on 4-year physical function and quality of life. Public Health 2009; 123:549-56. [DOI: 10.1016/j.puhe.2009.07.006] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 06/25/2009] [Accepted: 07/15/2009] [Indexed: 11/23/2022]
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