Measuring health-related social deprivation in small areas: development of an index and examination of its association with cancer mortality.

BACKGROUND: The small-area deprivation indices are varied across countries due to different social context and data availability. Due to lack of chronic disease-related social deprivation index (SDI) in Hong Kong, China, this study aimed to develop a new SDI and examine its association with cancer mortality. METHODS: A total of 14 socio-economic variables of 154 large Tertiary Planning Unit groups (LTPUGs) in Hong Kong were obtained from 2016 population by-census. LTPUG-specific all-cause and chronic condition-related mortality and chronic condition inpatient episodes were calculated as health outcomes. Association of socio-economic variables with health outcomes was estimated for variable selection. Candidates for SDI were constructed with selected socio-economic variables and tested for criterion validity using health outcomes. Ecological association between the selected SDI and cancer mortality were examined using zero-inflated negative binomial regression. RESULTS: A chronic disease-related SDI constructed by six area-level socio-economic variables was selected based on its criterion validity with health outcomes in Hong Kong. It was found that social deprivation was associated with higher cancer mortality during 2011-2016 (most deprived areas: incidence relative risk [IRR] = 1.40, 95% confidence interval [CI]: 1.27-1.55; second most deprived areas: IRR = 1.34, 95%CI: 1.21-1.48; least deprived areas as reference), and the cancer mortality gap became larger in more recent years. Excess cancer death related to social deprivation was found to have increased through 2011-2016. CONCLUSIONS: Our newly developed SDI is a valid and routinely available measurement of social deprivation in small areas and is useful in resource allocation and policy-making for public health purpose in communities. There is a potential large improvement in cancer mortality by offering relevant policies and interventions to reduce health-related deprivation. Further studies can be done to design strategies to reduce the expanding health inequalities between more and less deprived areas.

Importance of applying Mixed Generalized Additive Model (MGAM) as a method for assessing the environmental health impacts: Ambient temperature and Acute Myocardial Infarction (AMI), among elderly in Shanghai, China.

Association between acute myocardial infarction (AMI) morbidity and ambient temperature has been examined with generalized linear model (GLM) or generalized additive model (GAM). However, the effect size by these two methods might be biased due to the autocorrelation of time series data and arbitrary selection of degree of freedom of natural cubic splines. The present study analyzed how the climatic factors affected AMI morbidity for older adults in Shanghai with Mixed generalized additive model (MGAM) that addressed these shortcomings mentioned. Autoregressive random effect was used to model the relationship between AMI and temperature, PM10, week days and time. The degree of freedom of time was chosen based on the seasonal pattern of temperature. The performance of MGAM was compared with GAM on autocorrelation function (ACF), partial autocorrelation function (PACF) and goodness of fit. One-year predictions of AMI counts in 2011 were conducted using MGAM with the moving average. Between 2007 and 2011, MGAM adjusted the autocorrelation of AMI time series and captured the seasonal pattern after choosing the degree of freedom of time at 5. Using MGAM, results were well fitted with data in terms of both internal (R2 = 0.86) and external validity (correlation coefficient = 0.85). The risk of AMI was relatively high in low temperature (Risk ratio = 0.988 (95% CI 0.984, 0.993) for under 12°C) and decreased as temperature increased and speeded up within the temperature zone from 12°C to 26°C (Risk ratio = 0.975 (95% CI 0.971, 0.979), but it become increasing again when it is 26°C although not significantly (Risk ratio = 0.999 (95% CI 0.986, 1.012). MGAM is more appropriate than GAM in the scenario of response variable with autocorrelation and predictors with seasonal variation. The risk of AMI was comparatively higher when temperature was lower than 12°C in Shanghai as a typical representative location of subtropical climate.

Adverse life events and late-life cognitive decline in a Chinese cohort: The Shanghai Aging Study.

OBJECTIVE: This study aimed to demonstrate the association between adverse life events (ALEs) and the risk of late-life cognitive decline in older community-dwelling individuals in China. METHODS: We prospectively followed up 1657 dementia-free participants with ALE data at baseline in the Shanghai Aging Study. The cohort was categorized into four subgroups (depression with ALEs, depression without ALEs, no depression with ALEs, and no depression without ALEs). Cox regressions were conducted to estimate the hazard ratio (HR) for incident dementia stratified by all participants and depressed and nondepressed participants. RESULTS: We identified 168 incident dementia cases over a mean period of 5.2 years. The cumulative dementia incidence in nondepressed participants with ALEs was the lowest among the four subgroups. Nondepressed participants with ALEs had a lower risk of incident dementia (HR [95% CI]: 0.50 [0.27-0.92], P = .0267) than those without ALEs, adjusted for age, sex, education, apolipoprotein E ε4 (APOE ε4), body mass index, cigarette smoking, heart disease, hypertension, diabetes, stroke, Mini-Mental State Examination (MMSE) at baseline, and anxiety. CONCLUSIONS: This study explored a significant inverse association between ALEs and the risk of incident cognitive decline among older adults without depression in China. Interventions for depression prevention immediately after ALEs may reduce the risk of cognitive decline later in life.

A Projection of Future Hospitalisation Needs in a Rapidly Ageing Society: A Hong Kong Experience.

To assess the impact of ageing on hospitalisation in a rapidly ageing society. A study using retrospective and prospective data was conducted using hospitalisation data with age-specific admission rates in the period from 2001⁻2010 and demographic data from the period of 2001⁻2066 by the United Nations. The Hong Kong Special Administrative Region (SAR) with a 7 million population experiences extreme low fertility (1.1 children per woman) and long life expectancy (84 years old). Days of hospitalisation: For the period 2010⁻2066, the length of stay (LOS) in the age group 85+ is projected to increase by 555.3% while the LOS for the whole population is expected to increase by only 134.4% and by ageing only. In 2010, the proportion in the LOS contributed to by the oldest age group (85+) was 15%. In 2066, this proportion is projected to nearly triple (42%). Around 70% of the projected days of hospitalisation would be taken by people aged 75 years and above. It is projected that this phenomenon would be converted to a more balanced structure when the demographic transition changes into a more stable distribution. Apparently, the impact of ageing on the public hospital system has not been well understood and prepared. The determined result provides insight into monitoring the capacity of the hospital system to cope with a rapidly changing demographic society. It provides empirical evidence of the impact of ageing on the public hospitalisation system. It gives a long term projection up to the year 2066 while the situation would be different from the transient period of 2016⁻2030. The analysis adopts a fixed rate approach, which assumes the LOS to be only driven by demographic factors, while any improvements in health technologies and health awareness are not accounted for. Only inpatient data from the Hospital Authority were used, nonetheless, they are the best available for the study. Due to the limitation of data, proximity to death is not controlled in conducting this analysis.

Revisiting knowledge, attitudes and practice (KAP) on human papillomavirus (HPV) vaccination among female university students in Hong Kong.

Despite cervical cancer can be preventable by HPV vaccination, little is known on its associated factors among young females in Hong Kong. This study aimed to investigate the present situation regarding the self-reported knowledge, attitudes and practice (KAP) of Human Papillomavirus (HPV) vaccination and to examine their associated factors among female university students in Hong Kong. 195 respondents were recruited to complete a self-administered questionnaire from two local universities through convenience sampling. 8.2% respondents indicated that family doctors as sources of knowledge of HPV and HPV vaccination. 59.0% of the sample identified more than four knowledge items, 82.6% thought that HPV vaccines can effectively prevent cervical cancer and 47.2% received HPV vaccination. Regression analyses found those at older age, thought that they might be infected by HPV and received HPV would have a higher level of knowledge. Those who knew HPV is sexually transmitted, thought may be infected by HPV and received HPV vaccination would have positive attitude on HPV vaccination. Those at older ages, knew their university provided discounted vaccination for female students, and were not afraid of the side effects were associated with HPV vaccination. Family doctors should take a more prominent role in disseminating accurate and precise information. Advocacies should be emphasised on the risk of HPV as a sexually transmitted disease and the availability of discounted and safe HPV vaccines in tertiary educational institutions to increase the uptake rate of HPV vaccines for first-year and non-health major university students.

The incomparability of cause of death statistics under "one country, two systems": Shanghai versus Hong Kong.

BACKGROUND: Valid and comparable cause of death (COD) statistics are crucial for health policy analyses. Variations in COD assignment across geographical areas are well-documented while socio-institutional factors may affect the process of COD and underlying cause of death (UCD) determination. This study examines the comparability of UCD statistics in Hong Kong and Shanghai, having two political systems within one country, and assesses how socio-institutional factors influence UCD comparability. METHODS: A mixed method was used. Quantitative analyses involved anonymized official mortality records. Mortality rates were analyzed by location of death. To analyze the odds ratio of being assigned to a particular UCD, logistic regressions were performed. Qualitative analyses involved literature reviews and semi-structural interviews with key stakeholders in death registration practices. Thematic analysis was used. RESULTS: Age-standardized death rates from certain immediate conditions (e.g., septicemia, pneumonia, and renal failure) were higher in Hong Kong. Variations in UCD determination may be attributed to preference of location of death, procedures of registering deaths outside hospital, perceptions on the causal chain of COD, implications of the selected UCD for doctors' professional performance, and governance and processes of data quality review. CONCLUSIONS: Variations in socio-institutional factors were related to the process of certifying and registering COD in Hong Kong and Shanghai. To improve regional data comparability, health authorities should develop standard procedures for registering deaths outside hospital, provide guidelines and regular training for doctors, develop a unified automated coding system, consolidate a standard procedure for data review and validity checks, and disseminate information concerning both UCD and multiple causes of death.

Influences of population-level factors on suicides in older adults: a national ecological study from Australia.

OBJECTIVE: The relationship between older adult suicide rates and population-level variables has been examined in a few studies. Therefore, the objective of the present study is to analyse the extent to which population-level factors are associated with suicide by older persons in Australia, from an ecological perspective. METHODS: Suicide rates for older adults aged 65 years and over were calculated for 68 observation units at Statistical Areas Level 4 in Australia for 2002-2011. The 2011 Census of Population and Housing was used for population-level variables. Analysis on standardised suicide mortality ratios and Poisson regression were performed to examine geographical and gender differences. RESULTS: Between 2002 and 2011, a total of 3133 suicides of persons aged 65 years and above (men: n = 2418, 77.1%) was identified with an average annual rate of 10.1 per 100,000 persons. Suicide rates in older adults vary widely between different geographical regions in Australia. The multivariate estimates of contextual factors showed that the risk of suicide was positively associated with the sex ratio (incidence risk ratio (IRR) = 1.053, 95%CI = 1.016-1.092), the proportion of those in tenant household (IRR = 1.120, 95%CI = 1.081-1.160) and Australian residents born in North-West Europe (IRR = 1.058, 95%CI = 1.022-1.095). Significant gender variations were found. CONCLUSIONS: Specific factors increasing risk of suicide for older adults on SA4 level in Australia were living in areas with a higher proportion of male population, a higher proportion of tenant household dwellers and a higher proportion of immigrants from North-West Europe. The different influences of population-level factor on suicide between older men and women indicate the need for targeted suicide prevention activities.

The influence of deprivation on suicide mortality in urban and rural Queensland: an ecological analysis.

PURPOSE: A trend of higher suicide rates in rural and remote areas as well as areas with low socioeconomic status has been shown in previous research. Little is known whether the influence of social deprivation on suicide differs between urban and rural areas. This investigation aims to examine how social deprivation influences suicide mortality and to identify which related factors of deprivation have a higher potential to reduce suicide risk in urban and rural Queensland, Australia. METHODS: Suicide data from 2004 to 2008 were obtained from the Queensland Suicide Register. Age-standardized suicide rates (15+ years) and rate ratios, with a 95% confidence interval, for 38 Statistical Subdivisions (SSDs) in Queensland were calculated. The influence of deprivation-related variables on suicide and their rural-urban difference were modelled by log-linear regression analyses through backward elimination. RESULTS: Among the 38 SSDs in Queensland, eight had a higher suicide risk while eleven had a lower rate. Working-age males (15-59 years) had the most pronounced geographic variation in suicide rate. In urban areas, suicide rates were positively associated with tenant households in public housing, Aboriginal and Torres Strait Islander people, the unemployment rate and median individual income, but inversely correlated with younger age and households with no internet access. In rural areas, only tenant households in public housing and households with no internet access heightened the risk of suicide, while a negative association was found for younger and older persons, low-skilled workers or labourers, and families with low income and no cars. CONCLUSIONS: The extent to which social deprivation contributes to suicide mortality varies considerably between rural and urban areas.

Restricting access to a suicide hotspot does not shift the problem to another location. An experiment of two river bridges in Brisbane, Australia.

BACKGROUND: Restricting access to lethal means is a well-established strategy for suicide prevention. However, the hypothesis of subsequent method substitution remains difficult to verify. In the case of jumping from high places ('hotspots'), most studies have been unable to control for a potential shift in suicide locations. This investigation aims to evaluate the short- and long-term effect of safety barriers on Brisbane's Gateway Bridge and to examine whether there was substitution of suicide location. METHODS: Data on suicide by jumping - between 1990 and 2012, in Brisbane, Australia - were obtained from the Queensland Suicide Register. The effects of barrier installation at the Gateway Bridge were assessed through a natural experiment setting. Descriptive and Poisson regression analyses were used. RESULTS: Of the 277 suicides by jumping in Brisbane that were identified, almost half (n=126) occurred from the Gateway or Story Bridges. After the installation of barriers on the Gateway Bridge, in 1993, the number of suicides from this site dropped 53.0% in the period 1994-1997 (p=0.041) and a further reduction was found in subsequent years. Analyses confirmed that there was no evidence of displacement to a neighbouring suicide hotspot (Story Bridge) or other locations. CONCLUSIONS: The safety barriers were effective in preventing suicide from the Gateway Bridge, and no evidence of substitution of location was found.

Suicide mortality in second-generation migrants, Australia, 2001­2008.

PURPOSE: Generally, due to limited availability of official statistics on the topic, little is known about suicide mortality in second-generation migrants. A recent study from Sweden showed that these people could be at a high suicide risk. In a generalised phenomenon, this aspect would represent an important issue in suicide prevention. This paper aims to report the profile of second-generation migrants who died by suicide and the suicide risk differentials of second-generation migrants with other Australians. METHODS: Official suicide data from 2001 to 2008 were linked with State/Territory registries to collect information about the birthplace of the deceased's parents to differentiate migration status (first, second or third-plus generation). The profile and suicide risk of second-generation migrants were compared with other generations by logistic and Poisson regression. RESULTS: Suicide in second-generation migrants accounted for 811 cases (14.6%). These tended to be represented by younger subjects, more often never married, as compared to the other cases. Second-generation males aged 25­39 years tended to have a higher suicide risk than first generation migrants, but the risk was lower when compared with the third-plus generation. Second-generation migrants aged 60? tended to have a lower suicide risk than first generation migrants. CONCLUSION: In Australia, second-generation migrants are not at a higher suicide risk as compared to first-generation migrants or locals (third-plus-generation). In males aged 25­39, a lower suicide risk was found in second-generations as compared to Australian-born third generation,which may be explained by their more advantageous socioeconomic status and the flexibility and resources rendered by having grown up in a bicultural environment.The higher suicide rates found amongst older first-generation migrants require further examination.

Seasonal differences in the day-of-the-week pattern of suicide in Queensland, Australia.

Various temporal patterns of suicide events, according to time of day, day of week, month and season, have been identified. However, whether different dimensions of time interact has not been investigated. Using suicide data from Queensland, Australia, this study aims to verify if there is an interaction effect between seasonal and day-of-the-week distribution. Computerized suicide data from the Queensland Suicide Register for those aged 15+ years were analyzed according to date of death, age, sex and geographic location for the period 1996-2007. To examine seasonal differences in day-of-the-week pattern of suicide, Poisson regressions were used. A total of 6,555 suicides were recorded over the whole study period. Regardless of the season, male residents of Brisbane had a significantly marked day-of-the-week pattern of suicide, with higher rates between Mondays and Thursdays. When seasonal differences were considered, male residents in Brisbane showed a Monday peak in summer and a wave-shape pattern with a peak on Thursday and a nadir on Saturdays in winter. Whilst males have distinctive peaks in terms of days of the week for summer and winter, females do not show similar patterns.

Temporal patterns of charcoal burning suicides among the working age population in Hong Kong SAR: the influence of economic activity status and sex.

BACKGROUND: Charcoal burning in a sealed room has recently emerged as the second most common suicide means in Hong Kong, causing approximately 200 deaths each year. As charcoal burning suicide victims have a unique sociodemographic profile (i.e., predominantly economically active men), they may commit suicide at specific times. However, little is known about the temporal patterns of charcoal burning suicides. METHODS: Suicide data from 2001 to 2008 on victims of usual working age (20-59) were obtained from the registered death files of the Census and Statistics Department of Hong Kong. A total of 1649 cases of charcoal burning suicide were analyzed using a two-step procedure, which first examined the temporal asymmetries in the incidence of suicide, and second investigated whether these asymmetries were influenced by sex and/or economic activity status. Poisson regression analyses were employed to model the monthly and daily patterns of suicide by economic activity status and sex. RESULTS: Our findings revealed pronounced monthly and daily temporal variations in the pattern of charcoal burning suicides in Hong Kong. Consistent with previous findings on overall suicide deaths, there was an overall spring peak in April, and Monday was the common high risk day for all groups. Although sex determined the pattern of variation in charcoal burning suicides, the magnitude of the variation was influenced by the economic activity status of the victims. CONCLUSION: The traditional classification of suicide methods as either violent or nonviolent tends to elide the temporal variations of specific methods. The interaction between sex and economic activity status observed in the present study indicates that sex should be taken into consideration when investigating the influence of economic activity status on temporal variations of suicide. This finding also suggests that suicide prevention efforts should be both time- and subgroup-specific.

The economic and potential years of life lost from suicide in Taiwan, 1997-2007.

BACKGROUND: Taiwan has experienced a marked increase in the suicide rate in the last decade. However, the socioeconomic burden and impact to the community has not been adequately assessed. AIMS: This study aimed to estimate the social and economic burden of premature mortality from suicide in Taiwan in 1997-2007. METHODS: The suicide rate, potential years of life lost (PYLL), and present value of lifetime earnings (PVLE) by sex and age groups in 1997-2007 were calculated. The contribution of each suicide method to PYLL for each age group was also assessed. RESULTS: Using the PYLL calculations, suicide had become the third leading cause of death in Taiwan in 2007, compared to its ninth position in terms of absolute numbers. Furthermore, the PYLL was associated with an estimated NTD (New Taiwan Dollars) 32.5 billion of lost earnings in 2007. The increase in PYLL and PVLE from suicide was highest in middle-aged men (aged 25-59 years). Charcoal burning suicide accounted for most of the increase in PYLL in the middle-aged group in the past decade. CONCLUSIONS: The loss of life in middle-aged males contributes disproportionately to the social and economic burden of suicide in Taiwan. Suicide intervention effort should target this high-risk population.

Assessing the quantitative impact of suicide on life expectancy in Hong Kong: 1986-2006.

It is important to have a more complete understanding of the social and economic burden associated with suicide mortality. Apart from the usual year of life lost (YLL), we propose an alternative method, a life table approach to assess the impact of suicide and compare with the YLL approach from 1986 to 2006 in Hong Kong. The life-table approach is to assess the impact at a population level. It shows that the impact of suicides increased from 0.52% (0.30 years) to 0.62% (0.38 years) of life span for males aged 18 while the same figure for females kept at 0.4% (0.30 years) of lifespan over the period. A comparison with the YLL and some discussion are also given.

Charcoal burning suicides in Hong Kong and urban Taiwan: an illustration of the impact of a novel suicide method on overall regional rates.

OBJECTIVES: Following the first case in Hong Kong in 1998, the method of committing suicide by charcoal burning has spread to other communities. This aim of this study was to examine the impact of charcoal burning suicides on both overall suicide rates and older-method suicide rates in Hong Kong and urban Taiwan. DESIGN: Trend analysis of the overall and method-specific suicide rates between 1997 and 2002. Comparison of age and gender profiles of those who committed suicide by charcoal burning and other methods of suicide. SETTING: Hong Kong and Urban Taiwan. MAIN RESULTS: Suicides by charcoal burning increased rapidly within five years in both Hong Kong and urban Taiwan. This increase was not paralleled by decreases in suicides by older methods and led to an increase of more than 20% in the overall suicide rates. Those in the 24-39 age range were more likely to choose charcoal burning than other methods. CONCLUSIONS: The lack of parallel decreases in the suicides rates of older methods with the rise of charcoal burning suicides suggests limited substitution between the methods. The preponderance of the rise in suicide deaths associated with charcoal burning suggests that its invention, followed by wide media dissemination, may have specifically contributed to the increase in suicides in both regions. As a similar increase was found in urban Taiwan as in Hong Kong, charcoal burning suicide should not be viewed as merely a local health problem and has the potential to become a major public health threat in other countries.