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1.  Factors associated with difference in prevalence of asthma in children from three cities in China: multicentre epidemiological survey  
BMJ : British Medical Journal  2004;329(7464):486.
Objective To determine the factors associated with difference in prevalence of asthma in children in different regions of China.
Design Multicentre epidemiological survey.
Setting Three cities in China.
Participants 10 902 schoolchildren aged 10 years.
Main outcome measures Asthma and atopic symptoms, atopic sensitisation, and early and current exposure to environmental factors.
Results Children from Hong Kong had a significantly higher prevalence of wheeze in the past year than those from Guangzhou and Beijing (odds ratio 1.64, 95% confidence interval 1.35 to 1.99). Factors during the first year of life and currently that were significantly associated with wheeze were cooking with gas (odds ratio 2.04, 1.34 to 3.13), foam pillows (2.58, 1.66 to 3.99), and damp housing (1.89, 1.26 to 2.83). Factors protecting against wheeze were cotton quilts and the consumption of fruit and raw vegetables.
Conclusion Environmental factors and diet may explain the differences in prevalence of asthma between children living in different regions of China.
PMCID: PMC515199  PMID: 15331473
2.  A Cross-border Comparison of Hepatitis B Testing Among Chinese Residing in Canada and the United States 
Background
The Western Pacific region has the highest level of endemic hepatitis B virus (HBV) infection in the world, with the Chinese representing nearly one-third of infected persons globally. HBV carriers are potentially infectious to others and have an increased risk of chronic active hepatitis, cirrhosis, and hepatocellular carcinoma. Studies from the U.S. and Canada demonstrate that immigrants, particularly from Asia, are disproportionately affected by liver cancer.
Purpose
Given the different health care systems in Seattle and Vancouver, two geographically proximate cities, we examined HBV testing levels and factors associated with testing among Chinese residents of these cities.
Methods
We surveyed Chinese living in areas of Seattle and Vancouver with relatively high proportions of Chinese residents. In-person interviews were conducted in Cantonese, Mandarin, or English. Our bivariate analyses consisted of the chi-square test, with Fisher’s Exact test as necessary. We then performed unconditional logistic regression, first examining only the city effect as the sole explanatory variable of the model, then assessing the adjusted city effect in a final main-effects model that was constructed through backward selection to select statistically significant variables at alpha = 0.05.
Results
Survey cooperation rates for Seattle and Vancouver were 58% and 59%, respectively. In Seattle, 48% reported HBV testing, whereas in Vancouver, 55% reported testing. HBV testing in Seattle was lower than in Vancouver, with a crude odds ratio of 0.73 (95% CI = 0.56, 0.94). However after adjusting for demographic, health care access, knowledge, and social support variables, we found no significant differences in HBV testing between the two cities. In our logistic regression model, the odds of HBV testing were greatest when the doctor recommended the test, followed by when the employer asked for the test.
Discussion
Findings from this study support the need for additional research to examine the effectiveness of clinic-based and workplace interventions to promote HBV testing among immigrants to North America.
PMCID: PMC3856895  PMID: 19640196
Asian and Pacific Islanders; chronic hepatitis B; liver cancer; prevention clinic
3.  Reliability and Validity of Scores of a Chinese Version of the Frenchay Activities Index 
Objective
To develop a Chinese version of the Frenchay Activities Index (FAI-C) and evaluate the reliability and validity of its scores.
Design
A two-week test-retest study.
Setting
Chinese community in Vancouver, BC, Canada.
Participants
Data were collected using a convenience sample of Chinese immigrants living in Vancouver, BC, Canada. Of the 73 participants, data from 66 participants were included in the analysis. The total sample included two subsamples: community dwelling (n = 32), and assisted living (n = 34). Participants were 65 years or older, lived in Canada for more than five years and were able to read Chinese.
Interventions
Not applicable.
Main Outcome Measure
FAI-C scores.
Results
Test-retest reliability of the FAI-C scores assessed using intraclass correlation coefficient (ICC) was 0.86 (95% Confidence interval (CI) = 0.79–0.92) for the total sample, 0.89 (95% CI = 0.78–0.94) for the community dwelling subsample, and 0.71 (95% CI = 0.50–0.85) for the assisted living subsample. The minimal detectable difference (MDD) at 95% CI was 8.64. Correlations between the FAI-C and the Reintegration to Normal Living Index (r = 0.61, p < 0.01), Activities-specific Balance Confidence scale (r = 0.55, p < 0.01), and Timed Up and Go (r = − 0.68, p < 0.01) were in the a priori hypothesized direction and magnitude.
Conclusions
The FAI-C scores are reliable and there is support for validity. This tool enables us to measure social participation level in the Chinese-speaking population.
doi:10.1016/j.apmr.2011.07.197
PMCID: PMC3792087  PMID: 22209474 CAMSID: cams2897
Asian continental ancestry group; Rehabilitation; Reproducibility of results
4.  Cardiovascular risk factors, diet and lifestyle among European, South Asian and Chinese adolescents in Canada 
Paediatrics & Child Health  2012;17(1):e1-e6.
OBJECTIVE:
The authors previously reported that adult South Asian immigrants to Canada have an increased risk of cardiovascular disease (CVD) compared to their European and Chinese counterparts. It is unknown whether these ethnic differences also exist among adolescents, and whether they are related to diet and lifestyle. The objective of the present study was to assess the prevalence of CVD risk factors among apparently healthy adolescents in the three largest ethnic population groups in Canada (European, South Asian and Chinese).
METHODS:
A cross-sectional study among secondary school students in the Greater Toronto Area was undertaken. A total of 203 adolescents from 62 GTA secondary schools were recruited (48% Europeans, 35% Chinese and 18% South Asians) with a mean age of 17.3±1 years; 72% were female.
RESULTS:
Similar to adults, South Asian adolescents have increased rates of CVD risk factors compared with their European and Chinese peers, including higher prevalence of low high-density lipoprotein levels (P=0.001), high triglycerides (P=0.006) and high triglyceride/high-density lipoprotein levels (P<0.001), despite no significant differences in dietary intake among the ethnic groups. European adolescents had higher rates of self-reported intensity of physical activity (P=0.002) than their Chinese or South Asian peers.
CONCLUSIONS:
Similar to adult data, South Asian adolescents have comparably higher rates of CVD risk factors compared with their European or Chinese peers, which could partly be attributed to lower physical activity in South Asian adolescents. Whether the findings in these selected samples of healthy adolescents can be generalized to their respective populations requires further validation.
PMCID: PMC3276533  PMID: 23277758
Adolescents; Cardiovascular disease; Ethnicity; Risk factors
5.  Chinese immigrant parents’ vaccination decision making for children: a qualitative analysis 
BMC Public Health  2014;14:133.
Background
While immunization coverage rates for childhood routine vaccines in Hong Kong are almost 100%, the uptake rates of optional vaccines remain suboptimal. Understanding parental decision-making for children’s vaccination is important, particularly among minority groups who are most vulnerable and underserved. This study explored how a subsample of new immigrant mothers from mainland China, a rapidly-growing subpopulation in Hong Kong, made decisions on various childhood and adolescent vaccines for their offspring, and identified key influences affecting their decision making.
Methods
Semi-structured in-depth interviews were conducted with 23 Chinese new immigrant mothers recruited by purposive sampling. All interviews were audio-taped, transcribed and analyzed using a Grounded Theory approach.
Results
Participants’ conversation revealed five underlying themes which influenced parents’ vaccination decision-making: (1) Institutional factors, (2) Insufficient vaccination knowledge and advice, (3) Affective impacts on motivation, (4) Vaccination barriers, and (5) Social influences. The role of social norms appeared overwhelmingly salient influencing parents’ vaccination decision making. Institutional factors shaped parent’s perceptions of vaccination necessity. Fear of vaccine-targeted diseases was a key motivating factor for parents adopting vaccination. Insufficient knowledge about vaccines and targeted diseases, lack of advice from health professionals and, if provided, suspicions regarding the motivations for such advice were common issues. Vaccination cost was a major barrier for many new immigrant parents.
Conclusions
Social norms play a key role influencing parental vaccination decision-making. Insight gained from this study will help inform healthcare providers in vaccination communication and policymakers in future vaccination programme.
doi:10.1186/1471-2458-14-133
PMCID: PMC3937074  PMID: 24507384
Vaccination decision making; Social norm; Immigrants; Qualitative analysis; Grounded theory
6.  Self-reported prevalence of childhood allergic diseases in three cities of China: a multicenter study 
BMC Public Health  2010;10:551.
Background
Several studies conducted during the 1990s indicated that childhood allergic diseases were increasing worldwide, but more recent investigations in some Western countries have suggested that the trend is stabilizing or may even be reversing. However, few data are available on the current status of allergic disease prevalence in Chinese children. The aim of the present study was to investigate the prevalence rates of asthma, allergic rhinitis, and eczema in children of three major cities of China, to determine the status of allergic diseases among Chinese children generally, and to evaluate the prevalence of allergic diseases in children of different ages.
Methods
We conducted a cross-sectional survey between October 2008 and May 2009 in three major cities of China (Beijing, Chongqing, and Guangzhou) to evaluate the prevalence rates of childhood allergic diseases including asthma, allergic rhinitis, and eczema, using a questionnaire of the International Study of Asthma and Allergies in Childhood (ISAAC) group. A total of 24,290 children aged 0-14 years were interviewed, using a multi-stage sampling method. To acquire data on children aged 3-14 years, we visited schools and kindergartens. To access children too young to attend school or kindergarten, we extended our survey to community health service centers. Each questionnaire was completed by a parent or guardian of a child after an informed consent form was signed.
Results
Of the 24,290 children in our study, 12,908 (53.14%) were males and 11,382 (46.86%) females; 10,372 (42.70%) were from Beijing, 9,846 (40.53%) from Chongqing, and 4,072 (16.77%) from Guangzhou. Our survey indicated that in Beijing, Chongqing, and Guangzhou, the prevalence rates of asthma were 3.15%, 7.45%, and 2.09%, respectively; the rates of allergic rhinitis were 14.46%, 20.42%, and 7.83%; and the rates of eczema were 20.64%, 10.02%, and 7.22%. The prevalence of allergic diseases varied with age. Asthma was relatively less common both in children aged under 2 years, and in those aged 9 years or more, in each of the three cities. The prevalence of allergic rhinitis was also lower in children younger than 2 years. The prevalence of eczema fell with age.
Conclusions
A marked increase in the prevalence rates of allergic diseases in China (compared with earlier data) was evident. Further studies exploring the precise causes of this increase are warranted.
doi:10.1186/1471-2458-10-551
PMCID: PMC2944377  PMID: 20836838
7.  Lack of awareness of heart disease and stroke among Chinese Canadians: Results of a pilot study of the Chinese Canadian Cardiovascular Health Project 
BACKGROUND:
According to Statistics Canada’s 2001 census, the Chinese make up the largest (27.5%) visible minority population in Canada. The cardiovascular health information for this population is therefore important for the allocation of health care and promotion resources.
OBJECTIVES:
In the present pilot study, the authors sought to define the degree of awareness and knowledge of cardiovascular disease, as well as their risk factors, among the Chinese Canadian population.
METHODS:
A 16-item telephone survey was conducted among 1004 ethnic Chinese subjects (18 years of age and older) in the greater Toronto area of Ontario (n=503) and the greater Vancouver area of British Columbia (n=501) in February 2004.
RESULTS:
Among the respondents, 73% spoke Cantonese at home and 21% spoke Mandarin. Ninety-seven per cent were immigrants, and 53% had been in Canada for less than 10 years. A history of hypertension was reported in 9.2% of respondents, diabetes in 3.2% and high cholesterol in 14.5%. Thirty-two per cent and 40% of respondents were unable to name at least one symptom of heart attack or stroke, respectively, unaided. Thirty-two per cent and 35% of respondents named at least one incorrect symptom of heart attack and stroke, respectively. When asked about their immediate response in a hypothetical case of a heart attack or stroke, only 20% would have called 911.
CONCLUSIONS:
The present study is the first to address the awareness of cardiovascular health and disease among Chinese Canadians. These data suggest that Chinese Canadians have a relatively low awareness of the warning symptoms for common cardiovascular emergency situations. The findings presented here have important implications for the development of future health promotion and research initiatives targeted to visible minority populations in Canada.
PMCID: PMC2644359  PMID: 18685742
Chinese; Ethnicity; Myocardial infarction; Population health; Stroke
8.  Determinants of changes in dietary patterns among Chinese immigrants: a cross-sectional analysis 
Background
Chinese individuals who have immigrated to a Western country initially tend to have a lower risk of cardiovascular disease (CVD) compared to people who are already living there. Some studies have found, however, that CVD risk increases over time in immigrants and that immigration to a western country is associated with changes in dietary patterns. This could have unfavourable effects on the risk of CVD. There is limited knowledge on the food patterns, awareness and knowledge about healthy nutrition among Chinese immigrants. The objective for this study is to explore changes in food patterns, and levels of awareness and knowledge of healthy nutrition by length of residence among Chinese immigrants to Canada.
Methods
120 Chinese individuals born in China but currently living in Canada completed an assessment on socio-demographic characteristics, changes in dietary patterns and variables of awareness and knowledge about healthy foods. With ordinal logistic regression the associations between the quartiles of length of residence and dietary patterns, variables of awareness and knowledge about healthy foods were explored, adjusting for age, sex, education and body mass index.
Results
More than 50% of the participants reported increasing consumption of fruits and vegetables, decreasing the use of deep-frying after immigration. Increased awareness and knowledge about healthy foods was reported by more than 50% of the participants. Ordinal regression indicated that Chinese immigrants who lived in Canada the longest, compared to Chinese immigrants who lived in Canada the shortest, consumed significant greater portion sizes (OR: 9.9; 95% CI: 3.11 - 31.15), dined out more frequently (OR: 15.8; 95% CI: 5.0 - 49.85), and consumed convenience foods more often (OR: 3.5; 95% CI: 1.23 - 10.01).
Conclusions
Chinese immigrants reported some favourable changes in their dietary intake and greater awareness and more knowledge about healthy foods after immigration. However, an increase in portion size, an increased frequency of dining out and an increased consumption of convenience foods could indicate some unfavourable changes. These results suggest that health promotion strategies should build on the observed benefits of improved nutritional knowledge and target areas of portion size and convenience eating.
doi:10.1186/1479-5868-8-42
PMCID: PMC3118129  PMID: 21592378
9.  Screening for asthma in Cantonese-speaking immigrant children 
BMC Public Health  2005;5:48.
Background
Asthma prevalence among Chinese immigrant children is poorly understood and attempts to screen these children have produced varied outcomes. We sought to learn how to improve screening for asthma in Chinese immigrant children.
Methods
Children (n = 152) were administered the Brief Pediatric Asthma Screen in either Cantonese or English, they then viewed and reacted to a video showing people wheezing and subsequently took a pulmonary function test.
Results
The diagnosed asthma prevalence for our study population was 27.0%, with another 5.3% having possible undiagnosed asthma. Very few children had spirometry findings below normal. In multivariate analysis, being native born (p = 0.002) and having a family history of asthma (p = 0.003) were statistically associated with diagnosis of asthma. After viewing the video, 35.6% of respondents indicated that the images differed from their conception of wheezing. Of four translations of the word "wheeze" no single word was chosen by a majority.
Conclusion
Our findings suggest that asthma diagnoses are higher for Chinese children who were born in the US suggesting that desegregation of data might reveal at risk subpopulations. Care needs to be taken when diagnosing asthma for Cantonese speakers because of the centrality of the word wheeze and the challenges of translation.
doi:10.1186/1471-2458-5-48
PMCID: PMC1168903  PMID: 15904513
10.  Overweight, family history of diabetes and attending schools of lower academic grading are independent predictors for metabolic syndrome in Hong Kong Chinese adolescents 
Archives of Disease in Childhood  2006;92(3):224-228.
Background
Overweight and metabolic syndrome (MES) are emerging in both adult and paediatric populations.
Aims
To study the prevalence of and associated risk factors for the MES, using the National Cholesterol Education Program definition, among Hong Kong Chinese adolescents studying in secondary schools.
Methods
This was a cross‐sectional, population‐based study. A sample of 2115 Chinese adolescents was randomly selected from 14 secondary schools throughout Hong Kong. Data on anthropometric parameters, fasting blood and urine samples were collected in the school setting. Information regarding the adolescent's family history of diabetes, perinatal history, socioeconomic status and school grading was evaluated.
Results
The prevalence of MES was 2.4% (95% confidence interval (CI) 1.8 to 3.1), with no significant difference between boys (2.9%) and girls (2%). The prevalence of various components of MES was 32.2% (30.2 to 34.2) for hypertension, 10.9% (9.6 to 12.2) for increased triglyceride, 9.0% (7.8 to 10.2) for central adiposity, 2.4% (1.7 to 3) for low high‐density lipoprotein cholesterol and 0.3% (0.1 to 0.6) for impaired fasting glucose. On multivariate analysis, overweight (odds ratio 32.2; 95% CI 13.2 to 78.4), positive family history of diabetes (4.3; 1.3 to 14.1) and studying at schools of lower academic grading (5.5; 2.2 to 13.7) were found to be independent risk factors for MES.
Conclusion
A comparable prevalence of MES (2%) is observed in our study group Chinese adolescent girls and in US girls (2.1%), but a lower prevalence in Chinese boys (2.9%) than in US boys (6.1%). In our study, 41.8% harbour at least one component of the syndrome. Both families and schools should be alerted to this growing epidemic.
doi:10.1136/adc.2006.100453
PMCID: PMC2083404  PMID: 17088339
11.  The problem of obesity among adolescents in Hong Kong: a comparison using various diagnostic criteria 
BMC Pediatrics  2008;8:10.
Background
Obesity is now a global epidemic. In this study, we aimed to assess the rates of obesity using several major diagnostic criteria in Chinese school adolescents in Hong Kong.
Methods
This is a cross-sectional study. Using a computer-generated coding system, we randomly selected schools from different geographical regions in Hong Kong to obtain a representative sample. Subjects aged 11–18 years of age were randomly selected from different class of the schools. Their rates of obesity according to four different international and local criteria were compared [International Obesity Task Force (IOTF) 2000 criterion; the Group of China Obesity Task Force (COTF) 2004 criterion; Centers for Disease Control and Prevention (CDC) 2000 Growth Charts and the Hong Kong Growth Survey (HKGS) charts in 1993].
Results
Of the 2098 adolescents [982 (46.8%) boys and 1116 (53.2%) girls], the mean age (± SD) was 15.1 ± 1.8 years (range: 11–18 years; median: 15.0 years). The crude rates of obesity were similar based on IOTF, COTF or CDC criteria (boys: 3.9–6.0%, girls: 1.8–3.7%), however, the rate increased to 11–27% if the HKGS charts were used. Obesity rate varied markedly according to age. It decreased from 8–10% among those aged 12–13 years to 2–4% among those aged 17–18 years.
Conclusion
The prevalence of obesity in Hong Kong adolescents using various diagnostic criteria were similar except for the 1993 HKGS criteria, which gave an exceeding high figure. Using the IOTF, COTF or CDC criteria, the adolescent obesity in Hong Kong varied from 1.8% to 6.0%.
doi:10.1186/1471-2431-8-10
PMCID: PMC2276189  PMID: 18315886
12.  A single nucleotide polymorphism in APOA5 determines triglyceride levels in Hong Kong and Guangzhou Chinese 
European Journal of Human Genetics  2010;18(11):1255-1260.
Single nucleotide polymorphisms (SNPs) in the apolipoprotein A5 (APOA5) gene have been associated with hypertriglyceridaemia. We investigated which SNPs in the APOA5 gene were associated with triglyceride levels in two independent Chinese populations. In all, 1375 subjects in the Hong Kong Cardiovascular Risk Factor Prevalence Study were genotyped for five tagging SNPs chosen from HapMap. Replication was sought in 1996 subjects from the Guangzhou Biobank Cohort Study. Among the five SNPs, rs662799 (-1131T>C) was strongly related to log-transformed triglyceride levels among Hong Kong subjects (β=0.192, P=2.6 × 10−13). Plasma triglyceride level was 36.1% higher in CC compared to TT genotype. This association was confirmed in Guangzhou subjects (β=0.159, P=1.3 × 10−12), and was significantly irrespective of sex, age group, obesity, metabolic syndrome, hypertension, diabetes, smoking and alcohol drinking. The odds ratios and 95% confidence interval for plasma triglycerides ≥1.7 mmol/l associated with TC and CC genotypes were, respectively, 1.81 (1.37–2.39) and 2.22 (1.44–3.43) in Hong Kong and 1.27 (1.05–1.54) and 1.97 (1.42–2.73) in Guangzhou. Haplotype analysis suggested the association was due to rs662799 only. The corroborative findings in two independent populations indicate that the APOA5-1131T>C polymorphism is an important and clinically relevant determinant of plasma triglyceride levels in the Chinese population.
doi:10.1038/ejhg.2010.93
PMCID: PMC2987477  PMID: 20571505
apolipoproteins; triglycerides; hypertriglyceridaemia; single nucleotide polymorphisms
13.  Infodemiology of Alcohol Use in Hong Kong Mentioned on Blogs: Infoveillance Study 
Background
In 2007 and 2008, the beer and wine tax in Hong Kong was halved and then abolished, resulting in an increase of alcohol consumption. The prevalence of the Internet and a high blogging rate by adolescents and adults present a unique opportunity to study drinking patterns by infodemiology.
Objective
To assess and explain the online use of alcohol-related Chinese keywords and to validate blog searching as an infoveillance method for surveying changes in drinking patterns (eg, alcohol type) in Hong Kong people (represented by bloggers on a Hong Kong–based Chinese blogging site) in 2005-2010.
Methods
Blog searching was done using a blog search engine, Google Blog Search, in the archives of a Hong Kong–based blog service provider, MySinaBlog from 2005-2010. Three groups of Chinese keywords, each representing a specific alcohol-related concept, were used: (1) “alcohol” (ie, the control concept), (2) “beer or wine”, and (3) “spirit”. The resulting blog posts were analyzed quantitatively using infodemiological metrics and correlation coefficients, and qualitatively by manual effort. The infodemiological metrics were (1) apparent prevalence, (2) actual prevalence, (3) prevalence rate, and (4) prevalence ratio. Pearson and Spearman correlations were calculated for prevalence rates and ratios with respect to per capita alcohol consumption. Manual analysis focused on (1) blog author characteristics (ie, authorship, sex, and age), and (2) blog content (ie, frequency of keywords, description of a discrete episode of alcohol drinking, drinking amount, and genres).
Results
The online use of alcohol-related concepts increased noticeably for “alcohol” in 2008 and “spirit” in 2008-2009 but declined for “beer or wine” over the years. Correlation between infodemiological and epidemiological data was only significant for the “alcohol” prevalence rate. Most blogs were managed by single authors. Their sex distribution was even, and the majority were aged 18 and above. Not all Chinese keywords were found. Many of the blog posts did not describe a discrete episode of alcohol drinking and were classified as personal diary, opinion, or emotional outlets. The rest lacked information on drinking amount, which hindered assessment of binge drinking.
Conclusions
The prevalence of alcohol-related Chinese keywords online was attributed to many different factors, including spam, and hence not a specific reflection of local drinking patterns. Correlation between infodemiological data (represented by prevalence rates and ratios of alcohol-related concepts) and epidemiological data (represented by per capita alcohol consumption) was poor. Many blog posts were affective rather than informative in nature. Semantic analysis of blog content was recommended given enough expertise and resources.
doi:10.2196/jmir.2180
PMCID: PMC3785983  PMID: 23999327
alcohol drinking; blogging; blog search; Chinese; Hong Kong; infodemiology; infoveillance; Internet
14.  Correlates of Quality of Life in New Migrants to Hong Kong from Mainland China 
Social Indicators Research  2011;107(2):373-391.
The concept of Quality of life (QOL) has received considerable attention from different disciplines. The aim of this study was to identify what are the correlates of QOL among Chinese new immigrants in Hong Kong. Data were collected through a cross-sectional survey among 449 Hong Kong new immigrants from Mainland China. Bivariate and multiple regression analyses were performed to examine the association between immigrants’ QOL and their demographic characteristics, socio-economic factors, optimism, sense of control, perceived social support, perceived neighborhood disorder, collective efficacy, pre-migration planning, depressive symptoms and acculturation stress. Our findings demonstrated that depressive symptom is the most prominent factor in reducing immigrants’ level of QOL, perceived social support and optimism are the two important factors that enhance the QOL of these depressed immigrants. Our results indicate that preventive measures must be developed, and professional counseling and psychological support services must be provided to new immigrants in Hong Kong, especially those who have depressive symptoms.
doi:10.1007/s11205-011-9853-2
PMCID: PMC3342488  PMID: 22611300
Quality of life; Depression; Immigrants; China; Hong Kong; Social Sciences, general; Human Geography; Public Health/Gesundheitswesen; Quality of Life Research; Quality of Life Research; Microeconomics; Sociology, general
15.  Perceptions of tobacco health warnings in China compared with picture and text-only health warnings from other countries: an experimental study 
Tobacco Control  2010;19(Suppl_2):i69-i77.
Objective
To assess the perceived effectiveness of cigarette health warnings in China, compared with picture and text-only warnings from other countries.
Method
1169 individuals (adult smokers, adult nonsmokers and youth) from four Chinese cities (Beijing, Shanghai, Kunming and Yinchuan) viewed 10 health warnings on cigarette packages, which included (a) the current Chinese text warnings covering 30% of the front/back of the pack (introduced October 2008); (b) the former Chinese text warning located on the side of the pack; (c) four picture warnings covering 50% of the front/back of the pack from Canada (lung cancer), Singapore (mouth disease), Hong Kong (gangrene) and European Union (clogged arteries); and (d) the same four warnings without the picture. Participants rated and ranked the 10 warnings on dimensions including how effective each would be in motivating smokers to quit and in convincing youth not to start smoking.
Results
Both Chinese warnings were consistently rated as least effective, with the new Chinese warning rated only slightly higher than the old warning. The picture warnings were consistently ranked or rated as most effective, with the text-only versions in the middle. Results were consistent across subject group, city and sex.
Conclusions
(1) Picture warnings are rated as much more effective than the same warnings without pictures. (2) The revised health warnings in China, introduced in October 2008, are only marginally more effective than the previous warning and far less effective than even text warnings from other countries. These results, coupled with population-based evaluation studies, suggest that pictorial warnings would significantly increase the impact of health warnings in China.
doi:10.1136/tc.2010.036483
PMCID: PMC2976466  PMID: 20935200
Health warnings; china; tobacco control; cigarette packaging; ITC Project; packaging and labelling; public policy
16.  The Chinese Translations of Alcohol Use Disorders Identification Test (AUDIT) in China: A Systematic Review 
Aims: To systematically review the literature on the Chinese translations of the Alcohol Use Disorders Identification Test (AUDIT) and their cross-cultural applicability in Chinese language populations. Methods: We identified peer-reviewed articles published in English (n = 10) and in Chinese (n = 11) from 1980 to September 2009, with key words China, Chinese and AUDIT among PubMed, EBSCO, PsycInfo, FirstSearch electronic databases and two Chinese databases. Results: Five teams from Beijing, Tibet, Taiwan and Hong Kong reported their region-specific translation procedures, cultural adaptations, validity (0.93–0.95 in two versions) and reliability (0.63–0.99). These Chinese translations and short versions demonstrated relatively high sensitivity (0.880–0.997) and moderate specificity (0.709–0.934) for hazardous/harmful drinking and alcohol dependence, but low specificity for alcohol dependence among Min-Nan Taiwanese (0.58). The AUDIT and its adaptations were most utilized in workplace- and hospital-settings for screening and brief intervention. However, they were under-utilized in population-based surveys, primary care settings, and among women, adolescents, rural-to-urban migrants, the elderly and minorities. Among 12 studies from mainland China, four included both women and men, and only one in Tibet was published in English. Conclusion: There is a growing amount of psychometric, epidemiologic and treatment research using Chinese translations of the AUDIT, much of it still unavailable in the English-language literature. Given the increase in burden of disease and injury attributable to alcohol use in the Western Pacific region, the use of an internationally comparable instrument (such as the AUDIT) in research with Chinese populations presents a unique opportunity to expand clinical and epidemiologic knowledge about alcohol problem epidemics.
doi:10.1093/alcalc/agr012
PMCID: PMC3119458  PMID: 21467046
17.  Mortality and smoking in Hong Kong: case-control study of all adult deaths in 1998 
BMJ : British Medical Journal  2001;323(7309):361.
Objective
To assess the mortality currently associated with smoking in Hong Kong, and, since cigarette consumption reached its peak 20 years earlier in Hong Kong than in mainland China, to predict mortality in China 20 years hence.
Design
Case-control study. Past smoking habits of all Chinese adults in Hong Kong who died in 1998 (cases) were sought from those registering the death.
Setting
All the death registries in Hong Kong.
Participants
27 507 dead cases (81% of all registered deaths) and 13 054 live controls aged ⩾35 years.
Main outcome measures
Mortality from all causes and from specific causes.
Results
In men aged 35-69 the adjusted risk ratios (and 95% confidence intervals) comparing smokers with non-smokers were 1.92 (1.70 to 2.16) for all deaths, 2.22 (1.94 to 2.55) for neoplastic deaths, 2.60 (2.10 to 3.21) for respiratory deaths (including tuberculosis, risk ratio 2.54), and 1.68 (1.43 to 1.97) for vascular deaths (each P<0.0001). In women aged 35-69 the corresponding risk ratios were 1.62 (1.40 to 1.88) for all deaths, 1.60 (1.33 to 1.93) for neoplastic deaths, 3.13 (2.21 to 4.44) for respiratory deaths, and 1.55 (1.20 to 1.99) for vascular deaths (each P<0.001). If these associations with smoking are largely or wholly causal then, among all registered deaths at ages 35-69 in 1998, tobacco caused about 33% (2534/7588) of all male deaths and 5% (169/3341) of all female deaths (hence 25% of all deaths at these ages). At older ages tobacco seemed to be the cause of 15% (3017/20 420) of all deaths.
Conclusions
Among middle aged men the proportion of deaths caused by smoking is more than twice as big in Hong Kong now (33%) as in mainland China 10 years earlier. This supports predictions of a large increase in tobacco attributable mortality in China as a whole.
What is already known on this topicChina, with 20% of the world's population, smokes 30% of the world's cigarettes. Men smoke most, and the proportion of male deaths at ages 35-69 attributable to tobacco has been predicted to rise over the next few decades from 13% (in 1988) to about 33%In Hong Kong cigarette consumption reached its peak 20 years earlier than in mainland China, so the epidemic of male deaths from tobacco should now be at a more advanced stageWhat this study addsIn the general population of Hong Kong in 1998 tobacco caused about 33% of all male deaths at ages 35-69 plus 5% of all female deaths, and hence 25% of all deaths at these agesIn the male smokers tobacco caused about half of all deaths at ages 35-69The hazards now seen in Hong Kong foreshadow a substantial increase in tobacco deaths among middle aged men in mainland China over the next few decades if current smoking patterns persist
PMCID: PMC37393  PMID: 11509422
18.  Prevalence Studies of Dementia in Mainland China, Hong Kong and Taiwan: A Systematic Review and Meta-Analysis 
PLoS ONE  2013;8(6):e66252.
Background
Many studies have considered the prevalence of dementia in mainland China, Hong Kong and Taiwan. However, area level estimates have not been produced. This study examines area differences across mainland China, Hong Kong and Taiwan adjusting for the effect of methodological factors with the aim of producing estimates of the numbers of people with dementia in these areas.
Method and Findings
A search of Chinese and English databases identified 76 dementia prevalence studies based on samples drawn from mainland China, Hong Kong and Taiwan between 1980 and 2012. A pattern of significantly decreasing prevalence was observed from northern, central, southern areas of mainland China, Hong Kong and Taiwan. Area variations in dementia prevalence were not explained by differences in methodological factors (diagnostic criteria, age range, study sample size and sampling method), socioeconomic level or life expectancy between areas. The results of meta-analysis were applied to current population data to provide best estimate. Based on the DSM-IV diagnostic criteria, the total number of people aged 60 and over with dementia in mainland China, Hong Kong and Taiwan is 8.4 million (4.6%, 95% CI: 3.4, 5.8) and in northern, central and southern areas are 3.8 (5.1%, 95% CI: 4.1, 6.1), 3.2 (4.4%, 95% CI: 3.2, 5.6) and 1.2 (3.9%, 95% CI: 2.3, 5.4) million respectively. These estimates were mainly based on the studies existing in highly developed areas and potentially affected by incomplete and insufficient data.
Conclusions
The findings of this review provide a robust estimate of area differences in dementia prevalence. Application of the estimated prevalence to population data reveals the number of people with dementia is expected to double every 20 years, areas in mainland China will be facing the greatest dementia challenge.
doi:10.1371/journal.pone.0066252
PMCID: PMC3679068  PMID: 23776645
19.  Individual-level factors associated with intentions to quit smoking among adult smokers in six cities of China: findings from the ITC China Survey 
Tobacco Control  2010;19(Suppl_2):i6-i11.
Background
Over 350 million smokers live in China, and this represents nearly one-third of the smoking population of the world. Smoking cessation is critically needed to help reduce the harms and burden caused by smoking-related diseases. It is therefore important to identify the determinants of quitting and of quit intentions among smokers in China. Such knowledge would have potential to guide future tobacco control policies and programs that could increase quit rates in China.
Objective
To identify the correlates of intentions to quit smoking among a representative sample of adult smokers in six cities in China.
Methods
Data from wave 1 (2006) of the International Tobacco Control (ITC) Policy Evaluation Project China Survey, a face-to-face survey of adult Chinese smokers in six cities: Beijing, Shenyang, Shanghai, Changsha, Guangzhou and Yinchuan, was analysed. Households were sampled using a stratified multistage design. About 800 smokers were surveyed in each selected city (total n=4815).
Results
Past quit attempts, duration of past attempts, Heaviness of Smoking Index (HSI), outcome expectancy of quitting, worry about future health and overall opinion of smoking were found to be independently associated with intentions to quit smoking, but demographic characteristics were not.
Conclusions
The determinants of quit intentions among smokers in China are fairly similar to those found among smokers in Western countries, despite the fact that interest in quitting is considerably lower among Chinese smokers. Identifying the determinants of quit intentions provides possibilities for shaping effective policies and programs for increasing quitting among smokers in China.
doi:10.1136/tc.2010.037093
PMCID: PMC2976002  PMID: 20935198
Smoking cessation; surveillance and monitoring; China; addiction; cessation; surveillance and monitoring
20.  A descriptive phenomenology study of newcomers’ experience of maternity care services: Chinese women’s perspectives 
Background
Maternity health care available in Canada is based on the needs of women born in Canada and often lacks the flexibility to meet the needs of immigrant women. The purpose of this study was to explore immigrant Chinese women’s experiences in accessing maternity care, the utilization of maternity health services, and the obstacles they perceived in Canada.
Methods
This descriptive phenomenology study used in-depth semi-structured interviews to examine immigrant Chinese women’s experiences. Fifteen participants were recruited from the Chinese community in Toronto, Canada by using purposive sampling. The interviews were digitally recorded and transcribed verbatim into written Chinese. The transcripts were analyzed using Colaizzi’s (1978) phenomenological method.
Results
Six themes were extracted from the interviews: (1) preference for linguistically and culturally competent healthcare providers, with obstetricians over midwives, (2) strategies to deal with the inconvenience of the Canadian healthcare system (3) multiple resources to obtain pregnancy information, (4) the merits of the Canadian healthcare system, (5) the need for culturally sensitive care, and (6) the emergence of alternative supports and the use of private services.
Conclusions
The findings provide new knowledge and understanding of immigrant Chinese women’s experiences in accessing maternity health services within a large metropolitan Canadian city. Participants described two unique experiences within the themes: preference for linguistically and culturally competent healthcare providers, with obstetricians over midwives, and the emergence of alternative supports and the use of private services. Few studies of immigrant maternity service access have identified these experiences which may be linked to cultural difference. Further investigation with women from different cultural backgrounds is needed to develop a comprehensive understanding of immigrant women’s experiences with maternity care.
doi:10.1186/1472-6963-14-114
PMCID: PMC3975855  PMID: 24602231
Access to maternity health services; Chinese; Women; Immigrants
21.  Asthma, atopy and tuberculin responses in Chinese schoolchildren in Hong Kong 
Thorax  2001;56(10):770-773.
BACKGROUND—The prevalence rates of asthma and other atopic disorders have increased steadily in many developed countries over the past few decades. Recent epidemiological and animal studies have suggested that BCG vaccination might be beneficial in reducing the subsequent development of atopy. This study investigates the relationship between asthma, allergic symptoms, atopy, and tuberculin response in Chinese schoolchildren who received BCG vaccination at birth.
METHODS—A total of 3110 schoolchildren aged 10 years were recruited for the Hong Kong arm of the phase II International Study of Asthma and Allergies in Childhood. Of the 2599 children born in Hong Kong and vaccinated with BCG after birth, 2201 had tuberculin testing performed at a mean (SD) age of 8.4 (1.4) years. A random subsample of 980 children was also recruited for skin prick testing.
RESULTS—The prevalence rates of asthma ever, wheeze ever, current wheeze, current rhinoconjunctivitis, and current flexural eczema were not significantly different between tuberculin positive and negative subjects. The mean (SE) tuberculin response was 3.4 (0.2) mm in atopic subjects and 3.3 (0.2) mm in non-atopic subjects (difference not significant). Logistic regression analyses did not reveal any significant relationship between asthma ever, current wheeze, atopy, and positive tuberculin responses.
CONCLUSIONS—This study did not find any relationship between asthma, allergic symptoms, atopy, and positive tuberculin reactivity in Chinese schoolchildren vaccinated with BCG at birth.


doi:10.1136/thorax.56.10.770
PMCID: PMC1745922  PMID: 11562515
22.  Evaluation of a Hepatitis B Educational ESL Curriculum for Chinese Immigrants 
Objectives
According to recent census data, 1,216,600 Canadians are of Chinese descent, and over 80% of Chinese Canadians are foreign born. Approximately 10% of Chinese immigrants are chronic carriers of hepatitis B, compared with less than 0.5% of the general population. English as a second language (ESL) classes provide ready access for individuals with limited English proficiency who are not reached by English language health education materials and media campaigns. We conducted a group-randomized trial to evaluate the effectiveness of a hepatitis B ESL educational curriculum for Chinese immigrants.
Methods
Five community-based organizations that provide ESL education in the greater Vancouver area participated in the study. Forty-one ESL classes (which included 325 Chinese students) were randomly assigned to experimental or control status. A follow-up survey, conducted six months after randomization, assessed knowledge about hepatitis B. Generalized estimating equations were used to analyze the data.
Results
Follow-up surveys were completed by 298 (92%) of the students. At follow-up, experimental group students were significantly (p<0.05) more likely than control group students to know that immigrants have higher hepatitis B infection rates than people who were born in Canada; hepatitis B can be spread during childbirth, during sexual intercourse and by sharing razors; hepatitis B is not spread by sharing eating utensils; and hepatitis B infection can cause cirrhosis and liver cancer.
Conclusion
Our findings indicate that ESL curricula can have a positive impact on health knowledge among Chinese immigrants with limited English. Future research should evaluate the effectiveness of ESL curricula for other immigrant groups, as well as other health topics.
PMCID: PMC2836807  PMID: 20209742
Chinese; health education; hepatitis B
23.  Chinese herbal medicine and acupuncture. How do patients who consult family physicians use these therapies? 
Canadian Family Physician  1998;44:1009-1015.
OBJECTIVE: To determine how a population of Chinese patients consulting family physicians in Vancouver use traditional Chinese medicine (TCM), specifically Chinese herbal medicine and acupuncture. DESIGN: Bilingual survey (English and Chinese). SETTING: Four family practices with predominantly Chinese patients in metropolitan Vancouver. PARTICIPANTS: The 932 patients or family members who visited one of the practices. MAIN OUTCOME MEASURES: Demographic characteristics; frequency and reason for visiting a family physician, Chinese herbalist, or acupuncturist; choice of practitioner if affected by one of 16 common conditions. RESULTS: The study population was mostly Chinese and immigrant to Canada. Chinese herbal medicine was currently used by 28% (262/930) of respondents (more than one visit in the last year), and another 18% (172/930) were past users. Acupuncture was currently used by 7% (64/927) and had been used in the past by another 8% (71/927). Use of Chinese herbal medicine varied significantly (P < .01) according to age, sex, immigrant status, and ethnicity. Acupuncture use varied significantly only by age. The main reasons for consulting Chinese herbalists were infection (41%, 157/382), respiratory problems (11%, 42/382), and rheumatologic problems (10%, 38/382), whereas acupuncturists were consulted almost exclusively for rheumatologic problems (80%, 45/56). CONCLUSIONS: Using TCM in conjunction with visiting family physicians was very popular among this predominantly Chinese study population. Patients with acute conditions, such as influenza, consulted both their family physicians and Chinese herbalists in quick succession. On the other hand, those suffering from more chronic conditions, such as rheumatologic diseases, were more likely to start using TCM after repeated visits to their family physicians.
Images
PMCID: PMC2277654  PMID: 9612586
24.  Indoor allergens, asthma, and asthma-related symptoms among adolescents in Wuhan, China 
Annals of epidemiology  2004;14(8):543-550.
Purpose
Information on indoor allergen exposures among non-Western populations, which have lower prevalence of atopic illness, is scant. We examined whether exposures to common indoor allergens were associated with doctor-diagnosed asthma and asthma-related symptoms among Chinese adolescents.
Methods
A cross-sectional study of 4185 ninth grade students was conducted at 22 randomly selected schools in Wuhan, China. Information on respiratory health and exposures to indoor allergens was obtained by a self-administered questionnaire completed in class.
Results
Having animals currently was associated with persistent cough (prevalence odds ratio [POR] = 1.54, 95% confidence interval [CI ] 1.21–2.11) and wheeze (POR = 1.41, 95% CI 1.03–1.94). Early-life exposure to animals was also associated with doctor-diagnosed asthma (POR = 1.95, 95% CI 1.35–2.82). Associations with respiratory symptoms strengthened with higher levels of exposure and for exposure in both early childhood and in adolescence. Exposure to cockroaches and having mold/water damage in the home contributed especially to wheezing (POR=2.03, 95% CI 1.41–2.90 for cockroaches; POR = 2.49, 95% CI 1.82–3.40 for mold/water damage).
Conclusions
Indoor allergen exposures were positively associated with asthma diagnosis and persistent respiratory symptoms among Chinese adolescents. Neither early-life nor current exposure to animals was protective for asthma or asthma-related symptoms.
doi:10.1016/j.annepidem.2003.09.015
PMCID: PMC1626161  PMID: 15350953
Asthma; Allergens; Children; China; Indoor; POR = prevalence odds ratio; CI = confidence interval; SD = standard deviation; EU = endotoxin unit
25.  Disease burden of chronic hepatitis B among immigrants in Canada 
BACKGROUND:
The prevalence of chronic hepatitis B (CHB) infection among immigrants to North America ranges from 2% to 15%, 40% of whom develop advanced liver disease. Screening for hepatitis B surface antigen is not recommended for immigrants.
OBJECTIVE:
To estimate the disease burden of CHB among immigrants in Canada using Markov cohort models comparing a cohort of immigrants with CHB versus a control cohort of immigrants without CHB.
METHODS:
Markov cohort models were used to estimate life years, quality-adjusted life years and lifetime direct medical costs (adjusted to 2008 Canadian dollars) for a cohort of immigrants with CHB living in Canada in 2006, and an age-matched control cohort of immigrants without CHB living in Canada in 2006. Parameter values were derived from the published literature.
RESULTS:
At the baseline estimate, the model suggested that the cohort of immigrants with CHB lost an average of 4.6 life years (corresponding to 1.5 quality-adjusted life years), had an increased average of $24,249 for lifetime direct medical costs, and had a higher lifetime risk for decompensated cirrhosis (12%), hepatocellular carcinoma (16%) and need for liver transplant (5%) when compared with the control cohort.
DISCUSSION:
Results of the present study showed that the socio-economic burden of CHB among immigrants living in Canada is sub-stantial. Governments and health systems need to develop policies that promote early recognition of CHB and raise public awareness regarding hepatitis B to extend the lives of infected immigrants.
PMCID: PMC3732151  PMID: 23516678
Chronic hepatitis B; Disease burden; Immigrants

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