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1.  Interpersonal Trust across Six Asia-Pacific Countries: Testing and Extending the ‘High Trust Society’ and ‘Low Trust Society’ Theory 
PLoS ONE  2014;9(4):e95555.
Trust is regarded as a necessary component for the smooth running of society, although societal and political modernising processes have been linked to an increase in mistrust, potentially signalling social and economic problems. Fukuyama developed the notion of ‘high trust’ and ‘low trust’ societies, as a way of understanding trust within different societies. The purpose of this paper is to empirically test and extend Fukuyama’s theory utilising data on interpersonal trust in Taiwan, Hong Kong, South Korea, Japan, Australia and Thailand. This paper focuses on trust in family, neighbours, strangers, foreigners and people with a different religion.
Cross-sectional surveys were undertaken in 2009–10, with an overall sample of 6331. Analyses of differences in overall levels of trust between countries were undertaken using Chi square analyses. Multivariate binomial logistic regression analysis was undertaken to identify socio-demographic predictors of trust in each country.
Our data indicate a tripartite trust model: ‘high trust’ in Australia and Hong Kong; ‘medium trust’ in Japan and Taiwan; and ‘low trust’ in South Korea and Thailand. Trust in family and neighbours were very high across all countries, although trust in people with a different religion, trust in strangers and trust in foreigners varied considerably between countries. The regression models found a consistent group of subpopulations with low trust across the countries: people on low incomes, younger people and people with poor self-rated health. The results were conflicting for gender: females had lower trust in Thailand and Hong Kong, although in Australia, males had lower trust in strangers, whereas females had lower trust in foreigners.
This paper identifies high, medium and low trust societies, in addition to high and low trusting population subgroups. Our analyses extend the seminal work of Fukuyama, providing both corroboration and refutation for his theory.
PMCID: PMC3997396  PMID: 24760052
2.  Does prognosis and socioeconomic status impact on trust in physicians? Interviews with patients with coronary disease in South Australia 
BMJ Open  2012;2(5):e001389.
There is concern across a range of healthcare settings worldwide that trust in physicians is declining. Decreased trust may lead to lesser tolerance of prognosis uncertainty and an increased demand for tests, referrals and second opinions. Literature suggests that there has been a recent cultural shift towards decreased trust in, and increased questioning of, medical advice. We investigated the impact of varying prognosis and socioeconomic status (SES) on trust in physicians, and patient questioning of medical advice.
Semistructured, audio-recorded transcribed interviews were conducted. The interview schedule was developed with reference to the Health Belief Model. Interviews were conducted between October 2008 and September 2009.
Participants were recruited via general practitioner clinics and hospital cardiac rehabilitation programmes.
Participants consisted of patients either receiving preventive treatment or active treatment for established cardiovascular disease.
Outcome measures
A coding structure was developed based on the aim of the research, to investigate the impact of varying prognosis and SES on trust in physicians.
Older participants are more likely than their younger counterparts to be unquestioning of medical advice. Higher SES participants are more likely to question medical advice than lower SES participants. Also, unlike primary prevention participants, established pathology increased participants’ trust, or decreased questioning behaviour. Participants who perceived themselves at risk of a poor or uncertain outcome were unlikely to doubt medical advice.
Blind trust in physicians remains strong in older participants, participants who perceive their prognosis to be uncertain and a proportion of lower SES participants. This is important for practitioners in terms of patient agency and points to the importance of moral and ethical practice. However, physicians also need to be aware that there are a growing proportion of patients for whom trust needs to be developed, and cannot be assumed.
PMCID: PMC3488703  PMID: 23035015
Preventive Medicine; Medical Education & Training
3.  A qualitative study of CVD management and dietary changes: problems of ‘too much’ and ‘contradictory’ information 
BMC Family Practice  2014;15:25.
Nutrition education for cardiovascular disease (CVD) management is not effective for all population groups. There is little understanding of the factors that hinder patients from adhering to dietary recommendations.
37 interviews were conducted with people living with CVD in Adelaide, Australia. Recruitment occurred via General Practitioner (GP) clinics and hospital cardiac rehabilitation programs. Participants were either receiving preventive treatment or active treatment for established CVD.
The volume and contradictory nature of dietary information were the most prominent barriers to making changes identified in interviews, especially by order participants.
Patients will seek out, or come into contact with information which contradicts advice from their GPs. The volume of information may lead them to resort to old and familiar habits. GPs play a valuable role in highlighting key take-home messages and reliable external sources of information. The findings have implications for GP practice given that lifestyle changes are a cost- and clinically-effective means of managing CVD.
PMCID: PMC3916316  PMID: 24495674
General practice; Cardiovascular disease; Lifestyle; Diet; Australia
4.  Identifying Vulnerable Populations Using a Social Determinants of Health Framework: Analysis of National Survey Data across Six Asia-Pacific Countries 
PLoS ONE  2013;8(12):e83000.
In order to improve the health of the most vulnerable groups in society, the WHO called for research on the multiple and inter-linking factors shaping the social determinants of health (SDH). This paper analyses four key SDH (social cohesion, social inclusion, social empowerment and socioeconomic security) across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
Population surveys were undertaken using a validated instrument in 2009-10, with sample sizes around 1000 in each country. The four SDH were analysed using multivariate binomial logistic regression to identify socio-demographic predictors in each country.
Low socio-economic security was associated with low income in all six study countries and with poor subjective health in Japan, South Korea and Thailand and with being married or cohabiting in Australia and Hong Kong. Low social cohesion was associated with low income in all countries and with undertaking household duties in South Korea, Thailand and Taiwan. Low social inclusion was associated with low income in Australia, South Korea and Taiwan and with poor subjective health in Australia, Japan and South Korea. Older people had lower social inclusion in Taiwan (50-59 years) and Hong Kong (retired), younger people in Japan and South Korea (20-29 years in both countries) and younger and middle-aged people in Australia. Low social empowerment was associated with low income in Australia, Thailand and Taiwan, with being aged 60 years or over in Australia, Hong Kong and South Korea, and over 50 years in Thailand.
This paper provides baseline measures for identifying where and how policy should be altered to improve the SDH. Furthermore, these data can be used for future policy evaluation to identify whether changes in policy have indeed improved the SDH, particularly for marginalised and vulnerable populations.
PMCID: PMC3857316  PMID: 24349417
5.  Inequities in access to healthcare: analysis of national survey data across six Asia-Pacific countries 
Evidence suggests that there is a link between inequitable access to healthcare and inequitable distribution of illness. A recent World Health Organization report stated that there is a need for research and policy to address the critical role of health services in reducing inequities and preventing future inequities. The aim of this manuscript is to highlight disparities and differences in terms of the factors that distinguish between poor and good access to healthcare across six Asia-Pacific countries: Australia, Hong Kong, Japan, South Korea, Taiwan, and Thailand.
A population survey was undertaken in each country. This paper is a secondary analysis of these existing data. Data were collected in each country between 2009 and 2010. Four variables related to difficulties in access to healthcare (distance, appointment, waiting time, and cost) were analysed using binomial logistic regression to identify socio- and demographic predictors of inequity.
Consistent across the findings, poor health and low income were identified as difficulties in access. Country specific indicators were also identified. For Thailand, the poorest level of access appears to be for respondents who work within the household whereas in Taiwan, part-time work is associated with difficulties in access. Within Hong Kong, results suggest that older (above 60) and retired individuals have the poorest access and within Australia, females and married individuals are the worst off.
Recognition of these inequities, from a policy perspective, is essential for health sector policy decision-making. Despite the differences in political and economic climate in the countries under analysis, our findings highlight patterns of inequity which require policy responses. Our data should be used as a means of deciding the most appropriate policy response for each country which includes, rather than excludes, socially marginalised population groups. These findings should be of interest to those involved in health policy, but also in policy more generally because as we have identified, access to health care is influenced by determinants outside of the health system.
PMCID: PMC3734194  PMID: 23816181
Equity; Access; Healthcare; Asia; Pacific; Social determinants; Policy
6.  Elevated HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam: a systematic review 
BMJ Open  2012;2(5):e001511.
To review and analyse original studies on HIV prevalence and risk behaviours among men who have sex with men (MSM) in Vietnam.
Systematic literature review. Comprehensive identification of material was conducted by systematic electronic searches of selected databases. Inclusion criteria included studies conducted from 2002 onwards, following a systematic review concluding in 2001 conducted by Colby, Nghia Huu and Doussantousse. Data analysis was undertaken through the application of both the Cochrane Collaboration and ePPI Centre approaches to the synthesis of qualitative and quantitative studies.
Sixteen studies, undertaken during 2005–2011, were identified that met the inclusion criteria. The analysis showed that HIV prevalence among MSM in Vietnam has increased significantly (eg, from 9.4% in 2006 to 20% in 2010 in Hanoi) and that protective behaviours, such as condom use and HIV testing and counselling, continue at inadequately low levels.
Increasing HIV prevalence and the lack of effective protective behaviours such as consistent condom use during anal sex among MSM in Vietnam indicate a potential for a more severe HIV epidemic in the future unless targeted and segmented comprehensive HIV prevention strategies for MSM in Vietnam are designed and programmes implemented.
PMCID: PMC3467604  PMID: 23015604
HIV; AIDS; Homosexuality; Gay men; Sexual behaviour

Results 1-6 (6)