Health issues in Chinese contexts, Volume 2

HEALTH ISSUES IN CHINESE CONTEXTS SERIES

HEALTH ISSUES IN CHINESE CONTEXTS, VOLUME 2 No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in rendering legal, medical or any other professional services.

Health Issues in Chinese Contexts Series Health Issues in Chinese Contexts. Volume 1 Zenobia C.Y. Chan 2009 ISBN: 978-1-60692-690-1

Health Issues in Chinese Contexts, Volume 2 Zenobia C.Y. Chan 2009 ISBN: 978-1-60741-026-3

HEALTH ISSUES IN CHINESE CONTEXTS SERIES

HEALTH ISSUES IN CHINESE CONTEXTS, VOLUME 2

ZENOBIA C.Y.CHAN EDITOR

Nova Science Publishers, Inc. New York

Copyright © 2009 by Nova Science Publishers, Inc. All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers’ use of, or reliance upon, this material. Any parts of this book based on government reports are so indicated and copyright is claimed for those parts to the extent applicable to compilations of such works. Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Available Upon Request ISBN: 978-1-61209-438-0 (E-Book)

Published by Nova Science Publishers, Inc.  New York

CONTENTS About the Editor Zenobia C. Y. Chan

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Introduction

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Fiction

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Chapter 1

The Evaluation of Food Safety Perception in Hong Kong S. F. Chan and Zenobia C. Y. Chan

Chapter 3

Health Promotion Program: Bikesmart for Senior Primary School Students in Tin Shui Wai S. K. Cheng and Zenobia C. Y. Chan

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Good Night’s Sleep Program for the Elderly Living in Wan Hon Estate May M. Y. Li and Zenobia C. Y. Chan

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Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

A Health Promotion Program on Increased Fruit and Vegetable Consumption for Middle-Aged Male Office Workers in Central District, Hong Kong Michelle M. S. Wu and Zenobia C. Y. Chan

1

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Health Promotion Program for Promoting a Healthful Diet to Form 2 Students in Secondary School in Shatin Rosanna K. Y. Lai and Zenobia C. Y. Chan

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The Promotion of a Healthful Diet for Male Nurses in a Government Hospital in Hong Kong Mandy Y. M. Kwan and Zenobia C. Y. Chan

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A Health Promotion Program on Promoting Family Harmony for New Immigrant Housewives in Tin Shui Wai W. Y. Wong and Zenobia C. Y. Chan

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vi Chapter 9

Chapter 10

Chapter 11

Contents ‘Let’s Talk and Listen’: A Two-Day Communication Skills Workshop for Nurses Mandy Y. M. Kwan and Zenobia C. Y. Chan

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Applying Crisis Management Plans to Public Transportation Accidents S. Y. Lee and Zenobia C. Y. Chan

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Crisis Management Plan in an Episode of Infection of H5N1 in Poultry Workers K. L. Hui and Zenobia C. Y. Chan

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Chapter 12

Pre-Marriage Communication: A Case from Hong Kong Queeni T. Y. Ip and Zenobia C. Y. Chan

Chapter 13

Using Role-Playing to Teach Medical Terminology to Social Work Undergraduates Zenobia C. Y. Chan

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Chinese Herbal Medicine in Health Care: What Can Be Learned from the Context of Hong Kong? W. F. Lai and Zenobia C. Y. Chan

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Nutritional Status of the Elderly in Hong Kong: What Do We Know and Where Should We Go? W. F. Lai and Zenobia C. Y. Chan

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The Image of Doctor and Its Signification in Hong Kong Cinema and Television Dr. Sobel K. L. Chan

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Inviting the Brother to Take His Place as “Elder Brother”: Anorexia Nervosa and Family Treatment Zenobia C. Y. Chan and Joyce L. C. Lai

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Chapter 14

Chapter 15

Chapter 16

Chapter 17

Index

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ABOUT THE EDITOR Zenobia C. Y. Chan∗ Assistant Professor, School of Nursing, The Hong Kong Polytechnic University Zenobia Chan is an assistant professor of the School of Nursing, at the Hong Kong Polytechnic University. She received her Bachelor’s Degree in Nursing, and her Master’s Degrees in Primary Health Care and Christian Studies in 1999 and 2008 respectively. She obtained a Doctoral Degree in Social Welfare from The Chinese University of Hong Kong in 2003. Zenobia loves writing for both its therapeutic and communicative uses. She has written for a wide range of academic journals and has contributed five English books (such as Silenced Women Published by the Nova Science Publishers) and two Chinese books. She has published papers related to nursing, family studies, counselling, mental health, medical education, social work, qualitative research and poetry. In hopes of contributing to healthcare research, Zenobia serves as an editorial member and a reviewer of referred journals.

∗

Phone: 852-2766 6426; Email: [email protected]; [email protected]

INTRODUCTION Health Issues in Chinese Contexts, Volume 2 is a collection of health care professionals’ research studies and writings and a film scholar’s analysis of health issues presented in movies in Hong Kong. This book demonstrates the wisdom and innovations of health promotion programs and work experiences of health care providers from diverse health care settings. The selected significant health issues include citizens’ perception of food safety in Hong Kong. A variety of community-based health promotion and primary health care programs are introduced, such as bone health among middle-aged men, the Bikesmart program for primary school students, the good night’s sleep program for the elderly, healthful diet programs and health promotion of family harmony for new immigrant housewives. There are also two chapters on crisis management of public transportation accidents and H5N1 in poultry workers. Regarding health communication topics, this book presents a proposal for a communication skills workshop for nurses and a case study of the need for pre-marriage communication. Some contributors have reviewed health issues and development in Hong Kong, such as the nutritional status of its older people and the development of Chinese medicine. Two contributors have reported clinical observations of a patient suffering from anorexia nervosa and her family members in the course of family treatment. A contributor analyzed doctors’ images in cinema and television to view actual health care services through a mass media lens. This book starts with a fictional piece called “Dr. Medicine Love”, which is a creative work aimed to revisit the values and professional missions of a good doctor. The following is a brief highlight of the 17 chapters. Chapter 1 is a research report on food safety perception in Hong Kong. An upsurge in foodborne disease outbreaks in Hong Kong calls for urgent reform in the conventional official food safety promotion programs. An extensive literature review has failed to find any systematic research study in the application of the public’s food safety perception to the local food safety promotion programs. This paper aimed to evaluate the local public’s perceived knowledge and risk perception of food safety with the goal of formulating more effective food safety promotion programs. The self-administered questionnaires (n=387) were collected by convenience and snowball sampling via email and hand distribution. The results indicated that most of the public was neither knowledgeable enough about local outbreaks nor very concerned about controllable food-related risks. Proper food risk perception through early formal education is suggested. Further studies in risk perception should be conducted so that more tailored food safety promotion programs can meet specific needs of people from different demographic backgrounds.

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Chapter 2 describes the health promotion program on promoting bone health among middle-aged men in Tsuen Wan District. In Hong Kong, osteoporosis has always been regarded as a women’s health issue in society, but men also suffer from it. Fewer health promotion programs were available to promote bone health among men, especially for middle-aged men. This chapter describes a proposal for promoting bone health for middleaged men in Tsuen Wan District. The program duration is one year, and 150 middle-aged men will be invited to join the program. There are three main objectives: to enhance awareness of bone health among middle-aged men, to promote a healthy lifestyle to maintain bone health, and to advocate regular bone mass density screening for the public. Team members will be composed of different professionals, commercial companies and community participants to organize various activities in Tsuen Wan District to promote bone health among middle-aged men. Through this program, public awareness of bone health among middle-aged men and regular bone mass screenings for them will be developed and a healthy lifestyle will be maintained. Chapter 3 presents a health promotion program, called Bikesmart, for senior primary school students in Tin Shui Wai. Bikesmart is recognized as a health promotion program in many countries of the world, but not in Hong Kong (HK). Many people perceive HK as an unsafe city for cycling but, on the contrary, HK is a safe place for bicycles. However, there are limited studies and programs on promoting cycling in HK; therefore, people are not aware of the benefits of cycling to human health and the environment. Accordingly, a Bikesmart program with a Bikesmart team should be implemented in a primary school in Tin Shui Wai during the 2008–2009 academic year, which would reach more than 450 senior primary students. The students should be assessed multidimensionally in order to provide a good Bikesmart program appropriate for the age of the students to increase awareness of and participation in cycling. Qualitative evaluation should be performed from multiple viewpoints. Although the cause-effect relationships from the variables of the students in this pilot glassrod district cannot be distinguished, Bikesmart in HK can be explored, especially corresponding to this particular district. Chapter 4 describes a good night’s sleep program for elderly people living in Wan Hon Estate. Negative outcomes of insomnia in the elderly are associated with poorer self-reported health status, cognitive decline, increased risk of falls and institutionalization. Sleep hygiene education provides a foundation for individuals to learn about effective sleep management. The authors’ health promotion program will be a pioneering community-based program to enhance sleep hygiene for the elderly with sleep problems. It will be an intersectoral program for the marginalized elderly, whereas interactive and client-driven approaches will be focused in my program. Twenty elderly people with sleep problems living in singleton units in Wan Hon Estate in Hong Kong will be recruited. The authors’ health promotion program aims at a partnership approach to improve the sleep hygiene of the elderly, enabling them to become aware of the potential causes of sleeplessness and facilitating these clients to learn relaxation skills to promote sleep. The authors plan to adopt a comprehensive need assessment by interviewing the elderly before the planning and implementation stages. Health talks, workshops, home assessments and social activity will be included. The authors plan to invite one clinical psychologist, one physiotherapist, one part-time nurse, one social worker and volunteers as health team members. Evaluation will be done by group interview, phone survey and questionnaires to weigh the effectiveness of the program.

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Chapter 5 introduces a health promotion program on increasing consumtion of fruits and vegetables among middle-aged male office workers in the Central district of Hong Kong. Health promotion programs that focus on a healthful diet have not been extended to central obesity. “Screen slave” middle-aged male office workers unlikely to seek health care services are particularly vulnerable to many chronic diseases associated with central obesity. This chapter aims to a) increase awareness of eating sufficient fruits and vegetables for the middleaged male office workers in Central, b) create a supportive environment to increase fruit and vegetable consumption, c) increase the frequency of eating foods high in fruit and vegetable content, and d) reduce waist circumference of middle-aged male office workers. Needs assessment will be conducted in 400 interviews and questionnaires to guide development of a four-session program. Health education and “hot tips” on increasing fruit and vegetable consumption will be offered to 200 male office workers. Collaboration with Eat Smart restaurants and the men’s meal preparers to provide foods with high fruit and vegetable content creates a supportive environment and ensures sustainability. Evaluation of change in waist circumference and frequency of fruit and vegetable consumption will be done by interviews and partnership with health care providers in Central. Close intersectoral collaboration and community development is expected in this project. Uncertainty regarding the commitment of the Eat Smart restaurants is the major potential limitation. As pioneers in adopting a comprehensive PHC approach, the authors plan to continue future promotion programs in other districts to strengthen the message of adequate consumption of fruits and vegetables to middle-aged male office workers. Chapter 6 describes a health promotion program for promoting a healthful diet to Form 2 students in a secondary school in Shatin. The prevalence of some chronic diseases throughout the world can be related to diet. In Hong Kong (HK), 57% of registered deaths were due to chronic diseases relating to unhealthful eating habits. ‘Fun in Seven’ and ‘Eat Smart at School’ (ESAS) were launched in HK to focus on primary school pupils. However, these health promotion campaigns made light of adolescents who have more autonomy and independence in choosing their daily foods. Therefore, the authors plan to launch a pilot school-based program to fill the gap and maintain the sustainability of previous campaigns and further develop adolescents’ personal skill in choosing a healthful diet. The program described in this chapter will focus on 100 to 150 Form 2 (F2) students at a secondary school in Shatin. Health education will be provided; the authors also plan to work with adolescents to achieve their behavioural change and further to promote a healthful diet to the people around them. Quantitative and qualitative methods will be used to evaluate the effectiveness of the program. This chapter will raise the public’s recognition of the importance of a healthful diet for adolescents. Chapter 7 presents a pioneer program for promoting a healthful diet among male nurses in a government hospital in Hong Kong. Healthful diet promotion activities can be found globally and locally. However, the majority of them are for the general public, and there is a lack of such a promotion for health care professionals. People believe that because nurses have knowledge of the components of a healthful diet, there is no need for a related promotion program for this group. However, the fact is that nurses, especially male nurses, do not engage in this health practice. The main reason is the limited availability of easilyaccessible healthful foods. The authors’ two-month program, ‘The Promotion of Healthful Diet for Male Nurses in a Government Hospital in Hong Kong’, specific for 30 male nurses, highlights and improves this phenomenon. Document review, interview and field notes are

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used in the need assessment stage. Participating male nurses are invited to be partners in the planning, implementation and evaluation process. Behavior change and client-centred approaches are adopted. Eight team members, including a dietician, volunteers and coordinators of the male staff canteen, nursing quarters and snack company collaborate together within the program. Evaluation by discussion and interview will be done after the program. Chapter 8 illustrates a health promotion program on promoting family harmony for new immigrant housewives in Tin Shui Wai. There has been a significant growth in the number of immigrants to Hong Kong from mainland China after 1997. Most arriving in Hong Kong face many social problems, such as a communication barrier and unemployment, and experience domestic violence. In recent years, domestic violence has been on a rising trend in Hong Kong. More than 3,700 cases were recorded in the first half of 2007. The majority of victims are new immigrant housewives. They are traditional Chinese women who observe the Confucian decorum of ‘the three obediences and four virtues’. They treat their husband as the core of their family. Several tragedies have occurred and were reported in Tin Shui Wai (TSW). The authors would like to organize a health promotion program to promote family harmony for new immigrant housewives in TSW. This program is under the guidance of primary health care (PHC) and health-promotion principles. Intersectoral collaboration of government departments and non-government organizations (NGO) are crucial in providing health services for the housewives. Needs assessment will be identified by in-depth telephone interviews and questionnaires. Evaluation will be analysed by quantitative and qualitative questionnaires. A potential limitation of this program is lack of funding. The authors plan to try to stimulate the government to allocate more public resources for the implementation of this program in the community, in addition to fund raising via the social welfare department’s assistance. Chapter 9 discusses a two-day communication skills workshop for nurses. Effective communication between nurses and patients and among colleagues is crucial in maintaining and fostering a better quality of health care, as well as a supportive working environment. Many nurses have found difficulty and stress when they need to communicate with either their colleagues, patients, or their patients’ relatives. This phenomenon is especially prevalent among those with less working experience inside the nursing field. Therefore, there is a need to train them in communication skills. Chapter 10 attempts to show how to apply crisis management plans to public transportation accidents. In Hong Kong, public transportation, including subways, franchised buses, public light buses and taxis, plays an important role in a citizen’s daily life. A crisis exists in public transportation that affects all people in Hong Kong. Recalling a fatal traffic disaster in 2003 in Hong Kong, a double-decker bus plunged about 31m off Tuen Mun Road, resulting in 21 fatalities and 20 injuries. Was the rescue conducted in an effective manner? Was the recovery process of the victims facilitated? Did the authorities take any actions to prevent similar traffic accidents from happening again? Crisis management is the answer to these questions. It helps enhance the effectiveness of crisis prevention and the handling procedures. Considering that this is not a common subject in Hong Kong, there is great room for improvement. Chapter 11 presents a crisis management plan in episode of an infection of H5N1 in poultry workers. Avian influenza is widely spread in both human beings and birds all around the world. The possible cradle of this virus is transmitted from mainland China and the Hong

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Kong Special Administrative Region (HKSAR). The World Health Organization (WHO) and most countries are well prepared against the threat if a mass outbreak in humans occurs. Under the traditional practice of the poultry business, poultry workers, however, comprise a high-risk group that can accelerate the spread of avian influenza virus among the community. A crisis management plan is prepared for sudden onset of H5N1 in poultry workers. The focus of this chapter includes two scenarios: Serious Response Level and Emergency Response Level. Chapter 12 discusses a case of pre-marriage communication. Global communication literature indicates the importance of listening in communication and in different settings. However, the importance of “invitation”, which also plays a prominant role in communication, is rarely mentioned. The pre-marriage discussion is a very crucial communication in Chinese society, and the number of marriages is increasing an average of 7% every year in Hong Kong. An example of a real case of negative pre-marriage communication between two families with detailed descriptions and critical analyses should be revisited with the objective to achieve sound and effective communication skills. Moreover, the importance of invitation in communication should be addressed. Chapter 13 demonstrates how to use role-playing to teach medical terminology to social work undergraduates. During the author’s experience in teaching Social Aspects of Health and Illness to five separate classes in Hong Kong, the use of role-playing as a means to teach medical terminology to social work undergraduates was explored. The outline of the mentioned course was shown. Three specific lectures in which role-playing was used to teach medical terminology with four selected role-play scenarios—including the cardiovascular, nervous and urinary systems and ears—for demonstration and discussion were presented and analyzed. More effort should be made to test whether role-playing can be an effective approach in social work undergraduate education. Chapter 14 discusses Chinese herbal medicine (CHM) as a popular form of complementary and alternative medicine (CAM) endorsed by the World Health Organization (WHO). Nowadays, the utilization of CAM is growing dramatically worldwide, albeit within the context of the domination of Western medicine (WM) in global medical systems. Based on the scattershot observations of situations in different places, the authors discern that the establishment of nomothetic control would be one of the necessary initial stages in CHM development. In this chapter, besides explaining why such a legislative framework can function as a potential indicator regarding the growth and modernization of CHM in a region, the authors also focus on the practical aspect of CHM and explore some of its exciting potential in health care sectors. It is worth noting that this is the first publication in the field to use the context of Hong Kong as a reference to comprehend and infer potential challenges and pre-conditions for furtherance of CHM in the direction of integrative Chinese and Western medicine (ICWM) and other practical areas under the ambience of an incompletely sinicized society. Chapter 15 looks into the nutritional status of the older people in Hong Kong. With the rapid extension of life expectancy in both males and females in Hong Kong, the aged population is rising. It is expected that the demand for health care services and nursing care will rapidly increase over the next decade. Nutrition, which plays a pivotal role in health maintenance, is gaining more and more attention in both elderly care institutions and general health settings. In this chapter, apart from offering an overview of the elderly’s nutritional status in Hong Kong, reasons for their general proneness to malnutrition are also discussed.

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Based on the current social, health care and political situations, three practical areas worth prioritizing for nutritional management of elderly people will be highlighted. As the case of Hong Kong illustrates, in order to establish a social environment that could contribute to optimal nutritional health in the aged, the following pre-conditions are required: public awareness of the importance of nutrition for the elderly, coordination of social and political conditions by the local government, and proper recognition of nutritional professions in health care sectors. Chapter 16 revisits the image of doctors and its significance in Hong Kong cinema and television. Hong Kong films about professions such doctor are few in number, but mainly focus on human emotion and relationships. Most doctors face the difficulty that they cannot cure their own pain or their lover’s disease or escape from their past gloomy memories. The final chapter is a clinical observation of the process and outcome of family treatment of a Chinese family with a daughter suffering from anorexia nervosa, which is seldom addressed. The subjective experiences of the family members in family treatment have been inadequately heard. To respond to the above missing links, the authors present a case from Hong Kong for an in-depth qualitative inquiry. The rich narratives of the family’s experiences toward the course of family treatment when struggling through anorexia nervosa are presented. Rose (a pseudonym), 17 years old, received six sessions of family therapy with a remarkable outcome. She weighed 35 kg at a height of 157 cm (BMI =14.2) when she first sought help in 2000. One year later, she weighed 57.5 kg (BMI =23.3). Based on the review of the family sessions, several observations were identified in the process of Rose’s recovery: “Over-involved Mother,” “Inviting the Brother to Take His Place as ‘Elder’ Brother,” “I Like My Job,” and “Goodbye Anorexia Nervosa or Welcome Bulimia?” A health care forum should provide a means for giving patients and their family members a voice, and for allowing health care professionals to hear these families’ voices in their socio-cultural contexts.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-60741-026-3 © 2009 Nova Science Publishers, Inc.

FICTION Medicine Love Zenobia C. Y. Chan Once upon a time, under the Earth near the North Pole, there was a worm community, named Paradise-land, with more than 200,000 residents. Every worm couple gave birth to a single worm baby. Mr. and Mrs. Love had been married for five years and still had no baby. They prayed to God and asked Him to give them a baby girl. They did not really care whether their baby was a boy or a girl, but in their country, 80% of their inhabitants were male and 20% were female. Mr. and Mrs. Love did not want their species to disappear due to reproductive failure. This imbalance was due to the fact that every mother worm, after she gave birth to her first baby, must die, because the mother has to transfer her body fluid to her offspring. Once the offspring takes its first breath, the mother dies, because no worm can live after losing even a drop of body fluid. However, Mrs. Love did not die, because God wanted all creation to know how to love.

AT A FUNERAL Mr. and Mrs. Love’s dear daughter, Medicine, was about eight years old. Medicine stood in front of her parents’ coffin and sobbed soundlessly. Her tearful eyes were full of images of her happy life with her family. She really could not understand why God gave her mother eight more years of life than other mothers, only to have her die of an unknown chest infection. Her father had taken care of his wife, eventually becoming infected himself. None of the doctors were able to cure them, because the disease was unknown and there was no treatment for it. When lovely music began to play at the memorial, a painful memory suddenly came back to Medicine, of a time when her parents were dying in the hospital, both hooked up to various monitors, with tubes running from their bodies to the machines. Medicine: Mother, Father, are you ok? Mrs. Love: My beloved daughter, don’t be afraid. We are not suffering. Mr. Love: Yes. Your mother is right. God will take care of us and will give us eternal life. Medicine: Oh! No! God can’t do that. I need you…

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Zenobia C. Y. Chan Mr. Love: My dear, do you still remember why we gave you the name, Medicine? Medicine: Yes. You want me to be a cure for diseases and save our people’s lives. Mrs. Love: Remember, even though we are not with you physically, we are always with you spiritually and will be very proud of you when you grow up and become a good doctor who loves her patients and practices medicine ethically.

The Loves’ vital signs stopped and they died peacefully. With great regret, the doctor certified the deaths. Two nurses with sincere expressions and a respectful, professional attitude covered the bodies with white sheets. Medicine saw none of this, as she had been blind from birth, but the hospital care assistants hugged her and treated her as if she were their own daughter. A medical social worker comforted Medicine and helped her arrange the funeral. The kindness and care of the hospital team inspired Medicine to work hard to become a good doctor. Medicine felt the soft touch of a warm breeze on her face. She woke from her reverie with a new perspective on her parents’ deaths. She knew she had a mission to fight disease, take good care of her people and be a good doctor. By doing that, her parents would not die in vain. Once soil covered the coffins, Medicine vowed that she would be strong and fulfill her parents’ wish for her.

AT THE HOSPITAL Medicine studied very hard and became a doctor working in an acute care hospital. After the funeral, she never cried and became very tough and committed to her medical profession. She became one of the best-known doctors in Paradise-land. Everyone was amazed that Dr. Love could treat patients as she did, even though she was blind. God’s creatures are designed with great sophistication, and Dr. Love’s other senses developed in ways most people’s don’t, compensating for her lack of sight. In Paradise-land, good doctors were awarded with a green jade lancet to show that they practice medicine with great dedication and take precious good care of every patient. Dr. Love received the jade lancet, too. Nurse Tony: Dr. Love, a middle-aged man named Peter with generalized skin lesions and in a semiconscious state will be sent from the Accident and Emergency Department (AED) to our ward. Dr. Love: I will be there in five minutes.

After a thorough clinical assessment, Peter was diagnosed with Steven-Johnson Syndrome, contracted by treating himself with herbs for the flu. After several days of hospitalization, Peter was still in critical condition, suffering from renal failure, totally bedridden and feverish. His breathing was unclear and sticky sputum in his lungs required suction; physiotherapy was required to loosen the sputum, and limb exercises were being performed to prevent contracture and muscle atrophy. Daisy (Physiotherapist): Peter, I will give you some steam inhalation and then perform chest percussion in order to loosen your sputum; then you can breathe better.

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Daisy performed her professional duties skillfully, informing Peter about every step and comforting him with great mercy. Peter thanked her. He was indeed very weak. He had an intravenous infusion and a urinary tube insertion and, from his skull to his toes, all of his skin was ulcerated with countless red blisters. Nurse Tony was now finished with his morning shift. He had worked all week without a day off, due to a staff shortage, and needed a rest, but he asked to work overtime. He wanted to help with Peter’s care, so he asked his senior Nursing Officer, Ms. Au, for permission. Ms. Au acknowledged Tony’s initiative and commitment to offering quality care despite limited resources. Due to the heavy workload of the morning shift, when there were only six nurses to tend to more than forty patients, Nurse Tony felt guilty that he could not provide Peter with the best care. After his shift, he checked the research to learn about the care of patients with Steven-Johnson Syndrome. He found out that a saline bath might improve Peter’s skin condition, reduce the chance of infection and offer him some relief. He went to Dr. Love. Tony: Dr. Love, I just read about a traditional treatment that might help Peter: a saline bath. What do you think? Dr. Love: Tony, the senior doctors told me that Peter’s prognosis is not good. He has severe renal failure and his urinal output is diminishing. Over 95% of his skin has lesions and seems to be worsening. Anything that would help him, we should try. I appreciate your advice. Let me consult with my seniors.

A meeting was held to discuss Peter’s case management. In attendance were Dr. Love, her seniors, Ms. Au, Tony, Daisy and Peter’s wife. They all agreed to try the saline bath once, and evaluate its effectiveness and Peter’s response to it, before any other decisions were made. A warm saline bath was prepared for Peter, and he sat in it for about 20 minutes while his vital signs were carefully monitored. Amazingly, the next morning, Peter’s skin was improved and he felt less pain and itchiness. He felt cleaner and had an improved self-image, as he could now leave his bed and the lesions had stopped weeping. Ms. Au played a pivotal role in arranging family care for Peter. She is an empathetic nurse with more than twenty years of experience, and received an award for Best Patient Care in 2008 because of her sensitivity to patients’ needs and uniqueness. Ms. Au watched for any psychological distress on the part of Peter’s wife, Betty, who also had to care for their two children, aged three and five. Ms. Au approached Betty in an attentive and supportive manner. Betty shared her fear, hopelessness and sense of helplessness. She loved Peter very much and worried he would not recover. She was exhausted from caring for the children and traveling to the hospital daily. Ms. Au showed her understanding and did not give so-called expert-driven strategies to Betty to ease her emotional distress; instead, she asked Betty about her experience and worked with her to find solutions that suited her best. After a thorough needs assessment, Ms. Au shared her observations with Dr. Love, offering four suggestions: (1) a medical social worker should be consulted to determine if any allowances were available to ease Betty’s financial constraints; (2) volunteer organizations could be contacted to find help with the care of the children and the housework; (3) Betty could see the clinical psychologist on staff, David, for counseling and screening for any emotional problems; and

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(4) the childrens’ teachers should be informed about their father’s condition so they could be given a little extra attention and compassion. Dr. Love took Ms. Au’s advice. Dr. Love talked to Betty, hoping to discover if she had any family or social support networks that could empower her and help her realize she was never alone. Besides her husband’s health care providers, she had relatives, neighbors and friends standing by her. Eventually, Betty’s church members visited Peter and prayed for Betty’s family. This gave Betty a strong feeling of powerful, faithful support. In order to facilitate the skin regeneration and build up Peter’s tissue mass, Dr. Love brought a dietitian, Lucy, onto his care team. Lucy prescribed a high-protein, high-fiber diet with some vitamin supplementation. At this treatment stage, Dr. Love made plans for followup care and rehabilitation with all of the valuable team members introduced above. She also consulted the occupational therapist, Ken, to help Peter modify his self-care. Long-term bed rest and the severity of the disease had resulted in mild muscle atrophy, and Peter could not yet fully resume the normal activities of daily living. In order to ensure that Peter could adapt to life after hospitalization and that the home environment was safe for him, Ken paid a home visit and suggested some modifications, such as installing rails on the walls, adjusting the height of the toilet seat and keeping pathways free of obstacles to help prevent falls. With the coordinated work of his health care team and Betty’s active involvement in the decision making and implementation of Peter’s care plan, four months later he had recovered enough to walk with the aid of a walker. Learning from Peter’s case, Dr. Love realized that a teamwork approach that includes all health disciplines is the best approach, that family members’ concerns must be addressed, and that family participation is crucial. “Help! Help!” “The water is over my head!” “I can’t breathe!!” A catastrophic flood was drowning Paradise-land. This flood was unpredictable, and its rapidly changing nature left the Weather Centre unable to forecast its progress. Some residents ran away; some drowned; many panicked and all struggled for survival. The police, fire fighters and ambulance drivers rescued the victims. They resuscitated some victims at the scene and sent others to the hospital for emergency treatment. Paramedic Mark: Ambulance calling! Ambulance calling! We are sending over 100 drowning victims to the Accident and Emergency Department (AED) within 10 minutes! AED Nurse Mathews: Message received.

Mathews informed the AED consultant, Dr. Hawkins, about the massive number of victims on the way, then quickly prepared the staff both psychologically and by ensuring that adequate equipment was at the ready, including thermo-blankets, suction, oxygen, resuscitators and other items. Some of the ward staff were asked to join the AED to help with the victims. Dr. Love went to the AED and reported to Dr. Hawkins. Dr. Hawkins: The only way to save our victims is by infusing our body fluid into them. Dr. Love: I heard this is our traditional healing regimen for drowned people, but we never had people donate their own body fluid. None of us can live if we lose even one drop of our body fluid.

Fiction

xix

Dr. Hawkins, in a low tone full of disappointment: Yes. All of the victims will die because there is never a donor. How could there be? No one can donate body fluid; they would die. Dr. Love dissolved into tears. This was the first time she had cried since her parents’ funeral. She had stayed strong in order to save others, but now, she could not hold in all the sorrow she felt for the flood victims. Suddenly, Dr. Love heard the voices of her parents. “Our beloved daughter, you are a good doctor passionate about helping your patients. We are very proud of you.” Dr. Love stepped forward and asked Dr. Hawkins to let her donate her body fluid to save the victims. A normal worm has about 100 drops of body fluid, enough to share among, and save, all of the victims. Dr. Hawkins strongly disagreed with this proposal, but Dr. Love asked again. “Dr. Hawkins,” she said, “I remember your course on medical ethics and the doctorpatient relationship. You said we have to love our patients and be strongly committed to our profession. The length of a life doesn’t matter; it’s the meaning and quality that do. I am sure about this decision. The loss of my life will cause no regret if it means that all of the victims will be saved.”

Dr. Hawkins held back his tears and arranged for the removal of Dr. Love’s body fluid. Dr. Love lay peacefully on a bed with a smile, mentally rehearsing her meeting with her parents. After the anaesthetic took effect, Dr. Hawkins used Dr. Love’s own lancet to lightly cut her neck, and inserted a catheter to suck out her fluid. Five minutes later, Dr. Love was dead and Dr. Hawkins led his AED team to transfuse Dr. Love’s body fluid to the victims, all of whom were saved.

AROUND THE GIANT SCULPTURE To show their great respect and appreciation for Dr. Love’s sacrifice, the Paradise-land worms built a memorial park with a giant sculpture in the shape of Dr. Love at its center. “Mum, Dad, why there is a giant sculpture in the center of this park?” a little girl asked. And her parents answered, “Once upon a time, there was a special doctor named Dr. Love, who. . .”

IN HEAVEN Mrs. Love, Mr. Love and Medicine live happily with God. Here there are no more tears, diseases and disasters, only love. God praised Medicine, saying “I will give you a chapter in worm history—Dr. Medicine Love.” Then God mused, “I must figure out a plan to tell your story to human health care professionals, as it embodies my primary intentions in creating medicine and heath care providers.” How can God let people know Dr. Medicine Love’s story? Certainly God can find a way.

xx

Zenobia C. Y. Chan

CURTAIN Remarks: I hope Dr. Medicine Love’s story will become a reference for every first-year medical student about what a good doctor should be, and for everyone to consider what the most important qualities of health care professionals are.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 1

THE EVALUATION OF FOOD SAFETY PERCEPTION IN HONG KONG S. F. Chan and Zenobia C. Y. Chan ABSTRACT An upsurge in foodborne disease outbreaks in Hong Kong calls for an urgent review of the conventional official food safety promotion programs. An extensive literature review has failed to find any systematic research study in the application of the public’s food safety perception to the local food safety promotion programs. This study aimed to evaluate the local public’s perceived knowledge and risk perception of food safety with the goal of formulating more effective food safety promotion programs. The selfadministered questionnaires (n=387) were collected by convenience and snowball sampling via email and hand distribution. The results indicated that most of the public was neither knowledgeable enough about local outbreaks nor very concerned about controllable food-related risks. Proper food risk perception through early formal education is suggested. Further studies in risk perception should be conducted so that more tailored food safety promotion programs can meet specific needs of people from different demographic backgrounds.

Keywords: food safety, foodborne disease, Hong Kong, risk perception

INTRODUCTION Hong Kong has long been regarded as a gourmet paradise and is renowned for its exotic fusion of Eastern and Western cuisines. However, how many would think of food safety when they are dining? Most of the local public, including consumers and food business stakeholders, are trapped in panic by the recent uncontrollable health-threatening food safety problems such as malachite green in fish (FEHD, 2006a; ISD, 2006; Cheung, 2006), pesticide residues in vegetables (FEHD, 2006b), Streptococcus suis and clenbuterol in pork (DH, 2006a and FEHD, 2005a), Norovirus in live oysters (FEHD, 2006c), E. coli in US spinach

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S. F. Chan and Zenobia C. Y. Chan

(FEHD, 2006d), Salmonella in US tomatoes (USFDA, 2006), Clostridium botulinum in US carrot juice (FEHD, 2006e), and Sudan red dyes in preserved and fresh eggs (FEHD, 2006f). Meanwhile, how many would notice that most risk factors are personally controllable? From the official figures, it appears that the number of local foodborne disease outbreaks and persons affected during the last ten years has been generally on an upward trend (DH, 2007a). This may imply that the conventional official food safety promotion programs that have been focused on general cognitive information are not effective in controlling local foodborne disease outbreaks. In view of growing concern in the application of the public’s risk perception to food safety policies (De Boer, Mccarthy, Brennan, Kelly and Ritson, 2005 and EC, 2006), it is suggested that the public’s food safety perception should be integrated into the local food safety promotion plans.

RESEARCH RATIONALES A lack of research into the public’s risk perception of food safety in Hong Kong (FEHD, 2001 and Kivela, Lam and Inbakaran, 2002) and the rising concerns over food safety from the local public formed the impetus for undertaking this study. This study aimed to evaluate the public’s perceived knowledge and risk perception of food safety through a self-administered questionnaire survey. The identified improper perceived knowledge of food safety and the misconception of risk perception of food safety from the results should be taken into consideration so that more tailored and effective food safety promotion programs can be formulated for the local general public. There are four sections in this research paper: materials and methods, results, discussion and references.

MATERIALS AND METHODS Since this study aimed to evaluate the food safety perception of the general local public, only Hong Kong citizens who have been living in Hong Kong for at least seven years were eligible to participate in the questionnaire survey. This requirement is intended to ensure that all of the participants are representatives of Hong Kong people in that they share similar culture, norms and behaviour typical of Hong Kong. It also complies with the permanent local resident status in Hong Kong as stipulated by the Immigration Department (ID, 2007).

Self-Completed Questionnaire Survey This questionnaire survey (Appendix A) contained 29 questions written in Chinese and English. There were two parts in the questionnaire. Part I contained 10 questions to evaluate the perceived knowledge of food safety from the local public, while Part II contained another 19 questions to study their risk perception of food safety.

The Evaluation of Food Safety Perception in Hong Kong

3

Perceived Knowledge of Food Safety (Part I) By using the five categories of the local official statistics (Appendix B) (DH, 2006b), 10 questions presented in multiple-choice format were generated by the author with the aim of studying the public’s perceived knowledge of food safety (Appendix A). Model answers were provided (Appendix C). The results were presented in percentage and then compared with the official statistics (Appendix B). The disparities between health professionals’ point of view regarding food safety and the public’s perception of food safety were described and studied. Any identified improper perceived knowledge of food safety was regarded as the targeted area in future local food safety promotion programs. Risk Perception of Food Safety (Part II) There were 19 questions in this part, 10 out of which were copied from a survey conducted by the European Commission (EC, 2006). The original paper aimed to assess how people in the European Union perceive risks of food safety (EC, 2006). The survey was conducted in the 25 Member States of the European Union in 2005 by face-to-face interviews in the participants’ homes in their national language (EC, 2006). There were 44 questions from the reference questionnaires; after screening, 10 questions suitable to this local study were selected. Questions such as country code, postal code, interview number, questions about the European Union, the living place, the place of birth, the number of people living in the household, telephone number and other irrelevant questions were not selected (EC, 2006). Some questions were modified to fit local needs: “How long have you lived in The HKSAR” and “What is your highest education level?” (Appendix A). Another nine questions in this part were related to the respondent’s personal background, such as gender, educational background, occupation, and marital status. No model answer was provided, since the questions in the second part referred to questions on risk perception and personal background. The answers were therefore arbitrary. Any identified improper risk perception of food safety was also regarded as an area to target in future local food safety promotion programs.

Sampling and Data Collection A total of 624 self-administered questionnaires were initially distributed within our network (i.e., our families, relatives, colleagues and classmates) by hand and email through convenience sampling method for reasons of convenience (i.e., easy to recruit, near at hand and likely to respond). To encourage the response rate, the purposes of the study were explained and telephone calls, SMS messages and emails were sent to remind participants to return their questionnaires. Simultaneously, the respondents were then asked to further distribute the questionnaires within their network by hand or email or both through snowball sampling. This was especially useful for email distribution of questionnaires, since it would reduce the danger of it being rejected as junk mail by unknown receivers and therefore decrease the non-response rate. Since two of our friends were teachers in secondary schools, they were asked to distribute the questionnaires to the students by convenience sampling with verbal consent from the school principals (Appendix D). Although a more generalized result could have been obtained if a Web site had been set up for respondents to fill in the questionnaires, or a large-scale questionnaire survey had been

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S. F. Chan and Zenobia C. Y. Chan

conducted on the whole population in each district in the territory, or more students from different schools at each level had been invited to the questionnaires, convenience sampling and snowball sampling were used in this study due to limited resources. Since risk perception of food safety has been an under-researched topic in Hong Kong, the results from the convenience sampling and snowball sampling in this study allowed a foundation for further studies. Many attempts were used to reduce bias of such limited samples. The questionnaires were distributed to various local residents in different gender, age, occupation and educational background via email. To reduce the bias for generating samples using internet only, the questionnaires were also distributed by hand to colleagues, friends and relatives in different gender, age, occupation and educational background. By snowball sampling, the questionnaires were further distributed to the people they knew in their network from assorted backgrounds. Under limited constricts, only two secondary schools were available to join the study, however, the questionnaires were distributed to students at secondary four to seven levels to increase the generalizability.

Sample Size In questionnaire studies using convenience sampling, the larger the sample the better. However, due to inevitable restrictions imposed by limited time, manpower and money, the sample size is often arbitrary. Based on a local renowned popularity poll (HKU POP SITE, 2007), the sample size was 500 before the year 2000 and has been increased to 1,000 since then. In a research study investigating the underlying factors for consumer’s implementation of specific food safety practices, a small sample size of 140 respondents were invited (Clayton, Griffith and Price, 2003). For a small-scale of research study like this one, a sample size of around 300 should be reasonable. In fact, the 387 questionnaires collected were in excess of this number.

Reliability and Validity in Measurement Since there is little previous study on the perception of food safety in Hong Kong, more local studies are encouraged to improve the face validity, content validity, criterion validity, internal validity and external validity to the questions in Part I of the questionnaires (Neuman, 1977). To improve reliability, a pilot study was conducted before formal distribution of the questionnaires. In future studies, the reliability can be increased by allowing multiple indicators (e.g., face-to-face interview and telephone interview) or increased level of measurement by designing more in-depth relevant questions on perception of food safety or repeated filling the questionnaires by the same participant across time (Neuman, 1997). As the European Food Safety Authority, and the Directorate-General Health and Consumer Protection (EC, 2006) are such large-scale and renowned organizations that the validity and reliability of the 10 questions in Part II can be ascertained. The questionnaire were translated to Chinese by me and counter-checked by peer groups. A pilot test was conducted before the formal distribution of the questionnaires. Professional translation, more tests on validity and reproducibility are advised in further studies.

The Evaluation of Food Safety Perception in Hong Kong

5

Ethical Considerations Ethical approval was granted from the Survey and Behavioural Research Committee of The Chinese University of Hong Kong for conducting this research study. As the questionnaires survey in this research study involved only food safety related questions and answers, it would not give any physical, mentally or biological harm to the participants. High anonymity and confidentiality remained since no personal information was asked, and all the questionnaires were destroyed after the analysis had been finished (Nardi, 2003). The purpose for data collection was clearly stated in the consent form (Appendix E). The rights of voluntary participation and withdrawal were also mentioned (Appendix E). A declaration that the contact information (i.e., email address) would not be transmitted for the commercial purposes and the document had been virus-scanned was also attached (Appendix E). Those who complete and return the questionnaires via email would imply voluntary consent to participate in this research study. Since the questions in Part II were originated from a survey conducted by the European Commission (EC, 2006), permission was sought and granted from the European Commission of adopting its questionnaires before distributing the questionnaires (Appendix F).

RESULTS AND DISCUSSION Response Rate A total of 624 questionnaires were distributed and 387 questionnaires were returned and collected (table 1). This gave an overall response rate of 62.02%. The response rate by email was 37.91% and that by hand distribution was 81.27%. From the 387 questionnaires returned and collected, 6 questionnaires were excluded because the respondents had lived in Hong Kong for less than seven years. As a result, only 381 questionnaires were included in the calculation. 234 questionnaires were collected from local students at primary, secondary and higher diploma educational levels while 147 were from local non-students with academic background varied from primary school to doctorate degree. Out of the 381 respondents, about 50% were female while about 45% were male. It should be noted that all the calculation in percentage was based on 147 respondents in the non-student group and 234 in the student group respectively from the questionnaire survey. Table 1. Response rate of the questionnaire survey Overall response rate

62.02%

Email response rate

37.91%

Hand distribution response rate

81.27%

Questionnaires distributed Questionnaires collected Questionnaires distributed Questionnaires collected Questionnaires distributed Questionnaires collected

624 387 277 105 347 282

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S. F. Chan and Zenobia C. Y. Chan

Questionnaire of Perceived Knowledge of Food Safety (Part I) As figure 1 shows, in the non-student group, over 70% of the respondents scored correct answers to Question 1 and 2. This implied that the majority in this group noticed the number of the local reported food poisoning outbreaks and the victims involved from 1996 to 2005 were increasing. For the rest of the questions in the non-student group and all the questions in the student group, less than 50% of the respondents scored correct answers. These indicated that the majority of the respondents were not knowledgeable enough about the details of the local foodborne disease outbreaks. Percentage of respondents scoring correct answers to Question 1 to 9

1 2

70.75%

45.73% 16.33% 10.26%

3 Question number

74.15%

48.29%

4

25.85%

5.56%

23.13% 29.91%

5 6

43.54%

24.36%

7

42.18%

18.80% 19.73%

8

42.74% 29.93% 31.62%

9 0%

10%

20%

30%

40%

50%

60%

70%

80%

Percentage % Students scoring correct answers

% Non-students scoring correct answers

Figure 1. The percentage of respondents scoring correct answers to Question 1 to 9. 1 The no. of the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 is increasing. 2 The no. of victims affected from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 is increasing. 3 The no. of victims affected (both confirmed and suspected cases) from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 was between 20,001 to 30,000. 4 Vibrio parahaemolyticus was the major causative agent among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005. 5 Staphylococcus aureus was the second major causative agent among all reported food poisoning outbreaks in Hong Kong from 1996 to 2005. 6 The no. of hospitalization (both confirmed and suspected cases) from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 was less than or equal to 5,000. 7 There was no death among all reported food poisoning outbreaks in Hong Kong from 1996 to 2005. 8 Inadequate cooking was the major contributing factor among all the reported food poisoning outbreaks in Hong Kong form 1996 to 2005. 9 Contamination by raw food was the second major contributing factor among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005.

The Evaluation of Food Safety Perception in Hong Kong

7

As figure 2 illustrates, it was found that the proportion of students (26.50%) participated in official health education program on food safety in Hong Kong was almost twice as much as the non-student group (13.61%). Q. 10. Have you ever participated in any official health education program on food safety in Hong Kong?

Non-students 13,61% Students

86,39%

26,50% 0%

20%

72,22% 40%

60%

80%

100%

120%

Percentage Participated

Never participated

Figure 2. The percentage of respondents in participating official health education program on food safety in Hong Kong.

Questionnaire of Risk Perception of Food Safety (Part II) When the respondents were asked a list of possible health-related risks, the majority (over 70% in the student group and over 80% in the non-student group) declared that “environmental pollution” was on top of the list and they felt it would most likely happen personally to them. Food related risk came only the second. The proportion of respondents who thought that their health could be damaged by the food they ate was almost the same in both groups (i.e., 56% in the student group and about 57% in the non-student group) (figure 3). As can be seen from figure 4, the distribution of the thought of food from the student group dispersed more than that of the non-student group. Both groups associated it first with taste and pleasure (these 2 factors accounted for almost 49% in each group respectively) while the conjunction of food with the basic needs such as necessity and hunger accounted for about 18% and 21% in the student group and the non-student group respectively. The association of food with health was less than 5% in the student group while that in the nonstudent group was about 16%. From the results, none of them linked food with diseases. Pursuant to figure 5, taste, price and quality were found to be the key factors influencing their choice when purchasing food in both groups. For the student group, taste (27%) and price (22%) were more important than quality (13%). The non-student group shared a similar pattern in which the importance of quality (22%) was rated above the factors of price (16%) and taste (16%). The factor “Health” (8% in the non-student group and 3% in the student group) was not the principal factor in relation to their food choices despite the fact that a greater proportion of non-students considered that factor than that of students. Although more than half of the respondents in both groups considered it likely that the food they ate would damage their health (figure 3), the survey results showed that when

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S. F. Chan and Zenobia C. Y. Chan

people were asked the things that come to their mind when thinking about possible problems or risks associated with food (figure 6 and 7), the answers were divergent. Neither of the groups gave consistent answers. Q. 19

The food you eat damaging your health

Non-students

57.14%

40.14%

Students

55.98%

43.59%

0%

20%

40%

60%

80%

100%

120%

Percentage Likely

Not likely

Figure 3. The percentage of respondent thought the food they eat damaged their health.

In the student group, diseases or health problems came to mind most often (16%), followed by food poisoning (14%), death (11%) and gastrointestinal infection (9%), while about 1% of respondents did not identify any problems at all. In the non-student group, diseases or health problems (16%), food poisoning (12%) and gastrointestinal infection (6%) shared the same sequence to that in the student group while food safety and hygiene (7%) was at the third position. About 1% of respondents did not identify any problems at all. As figure 6 and 7 shows, the answers were not in conformity when the respondents were asked the possible problems or risks associated with food. Moreover, there was also a wide range of the intensity of “worry” when the respondents were asked from the designated list of potential issues as shown in figure 8 and 9. The four different points on the “worry” scale (i.e., “very worried”, “fairly worried”, “not very worried” and “not at all worried”) were transformed into numerical values as an “average index” for easy comparison (EC, 2006, p.8).

The Evaluation of Food Safety Perception in Hong Kong

9

Q. 18 When thinking about food,what words first come to mind? (Max. 1 answer)

Pleasure

16.24%

21.77%

0.68% 2.14%

Conviviality

27.21%

Taste Guilt

32.48%

1.28% 0.68%

Greed

10.88% 8.12%

Necessity Health

15.65%

4.70% 10.88% 10.26%

Hunger Obesity

1.36% 2.14%

Diet or balanced diet

2.04% 0.85%

Calories

2.56%

Chemicals

0.43%

Local or national culture

0.85%

Diseases 0%

5%

10%

15% Students

20%

25%

30%

Non-students

Figure 4. The words first come to mind to the respondents when thinking about food.

35%

10

S. F. Chan and Zenobia C. Y. Chan Q. 21 When you go shopping for food, what would you say are the most important factors that influence your choice? (Max. 2 answers)

Price

16.33%

Taste

16.33%

Quality 3.40% 3.63%

Family preference

3.74% 1.28%

You and your family's health

26.71% 22.45%

12.61%

Habit

22.01%

7.82%

3.21% 0.34% 0.85%

Production methods Appearance or freshness

7.48%

3.42% 1.36% 2.78%

Brand name

9.86% 8.55%

Food safety 0.34% 0.64%

Convenience or availability

2.38% 0.85%

Country of origin

0.68% 0.85%

Avoiding food allergies 0%

5%

10%

15%

20%

25%

30%

Percentage Students

Non-students

Figure 5. The important factors influencing choice when the respondents go shopping for food. Q. 20 What are all the things that come to you mind when thinking about possible problems or risk associated with food (student groups in %)? (Multiple answes possible) Diseases/Health problems

15.57%

Food poisoning

13.52%

Death

10.66%

G.I. infection

9.43%

Doctor/Hospitalization

6.56%

Toxin/Poison

3.69%

Food safety and hygiene

1.64%

Horrible

1.64%

No problem

1.23%

Food shortage

1.23% 1.23%

Heart diseases Money

0.82% 0.82%

Virus GMF

0.41%

Cancer

0.41%

Fatness

0.41% 0.41%

Food additives 0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Percentage Students

Figure 6. The things that come to the mind in student group when thinking about possible problems or risks associated with food (in %).

The Evaluation of Food Safety Perception in Hong Kong

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Q. 20 What are all the things that come to your mind when thinking about possible problems or risks associated with food (non-student group in %)? (Multiple answers possible) 15.56%

Diseases/Health problems 11.67%

Food poisoning 7.22%

Food safety & hygiene

6.11%

G.I. infection 3.89%

Other illness

3.33%

Doctor/Hospital

2.78%

Fatness

2.78%

Contamination Cancer

2.22%

GMF

2.22% 2.22%

Chemicals Imative food

1.67%

Food additives

1.67% 1.67%

Virus

1.11%

No problem

1.11%

Food shortage

0.56%

Death 0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

Percentage Non-students

Figure 7. The things that come to the mind in non-student group when thinking about possible problems or risks associated with food (in %). Q. 23 For each of the following issues, please tell if you are very worried, fairly worried, not very worried or not at all worried by it (student group)? (Average index)

69.06 67.88 65.72 64.31 58.90 56.29 54.03 53.68 53.24 52.16 43.40 43.22 39.74 38.26

New viruses Pollutants Bacteria Unhygienic conditions outside home Pesticides residues Residues in meat Chemical formed during food processing Uhygienic conditions at home Additives Weight GMF Animal welfare Allergy BSE 0

10

20 30 40 50

60 70 80

Percentage Students

Figure 8. The intensity of worry in the student group when they were asked for fourteen potential risks related to food.

12

S. F. Chan and Zenobia C. Y. Chan Q. 23 For each of the following issues, please tell if you are very worried, fairly worried, not very worried or not at all worried by it (non-student group)? (Average index) Pollutants Residues in meat New viruses Unhygienic conditions outside home Weight Bacteria Pesticides residues Additives Chemical formed during food processing GMF Allergy Unhygienic conditions at home BSE Animal welfare

69.55 65.36 64.90 63.07 63.02 62.58 60.76 58.41 54.73 52.89 44.80 43.60 41.40 40.83 0

10

20

30

40

50

60

70

80

Percentage Non-students

Figure 9. The intensity of worry in the non-student group when they were asked for fourteen potential risks related to food.

From the findings, the students under research were most worried about some uncontrollable potential risks caused by external factors. Some controllable risk factors linked to personal behaviour were only at or below the mid range of “worry” scale. At the top of the “worry” scale (i.e., average index greater than 60), the student group expressed more concern in some external factors (i.e., new viruses such as avian influenza, environmental pollutants, contamination by bacteria and unhygienic conditions outside home). In the mid-range of the “worry” scale (i.e., average index between 50 to 59), it was found that they were more likely to worry about other external risk factors (i.e., pesticides residues, residues in meat and food additives) and the factors linked to their own behaviour (i.e., food preparation, food hygiene at home and putting on weight). The students were less concerned about personal factors (e.g., individual allergies to food) and some other external factors (e.g., genetically modified products in food or drinks, welfare of farmed animals and BSE (Bovine Spongiform Encephalopathy). The non-student group was most worried about uncontrollable potential risks caused by external factors. The controllable personal factor of “putting on weight” was also in the range of “most worried”, however, it was little to do with food safety. Some other controllable risk factors linked to personal behaviour were only at or below the mid range of the “worry” scale. At the top of the “worry” scale (i.e., average index greater than 60), the non-student group expressed more concern in some external factors (i.e., environmental pollutants, residues in meat, new viruses such as avian influenza, unhygienic conditions outside home, contamination by bacteria and pesticides residues) and the personal factor of “putting on weight”. In the mid-range of the “worry” scale (i.e., average index between 50 to 59), it was found that they were more likely to worry about other external risk factors (i.e., food additives and genetically modified products in food and drinks) and the factor linked to their own behaviour (i.e., food preparation). The non-students were less concerned about some other

The Evaluation of Food Safety Perception in Hong Kong

13

personal factors (i.e., individual allergies to food and unhygienic conditions at home) and some other external factors (i.e., BSE (Bovine Spongiform Encephalopathy) and welfare of farmed animals). During the data analysis to Question 23, it was shown that there was a profile of worriers. Over 60% population in both groups were classified as “a bit worried”, “very worried” accounted for less than one-fifth of the respondents in each group while “not very worried” came to only single digits in percentage in both groups (figure 10). In the non-student group, female (figure 11) and respondents with a tertiary educational level or above appeared to be over-presented in the group “worried”. In the student group, more than half of the respondents were found to be female (figure 12) in the group “worried”. In both groups, males tended to be over-presented in the group “not very worried”. Since female is in general more prudential to take care of herself and her families, this discrepancy in the results between sexes may explain why the females reacted more cautiously to food safety problems. In response to the perspectives on food safety over the last ten years, a higher proportion of students (47%) considered that it has improved than did the non-students (46%). On the other hand, a higher percentage of non-students (almost one fifth of the respondents) indicated that the food safety has worsened than did the students (almost one tenth of the respondents) (figure 13). When the respondents were asked how they reacted to the last story about a food safety problem, both groups responded in similar pattern (figure 14 and 15). A majority in the student group (44%) and the non-student group (65%) revealed they temporarily avoided the food in problem, followed by “worried but no action taken” in the student group (24%) and the non-student group (17%). About 11% of respondents in the student group and 7% in the non-student group just ignored the information. Only a minority of 3% in the non-student group and 8% in the student group had permanently changed their eating habits. Classification of "worriers"

15.38% 17.01%

Very worried

61.11% 68.03%

A bit worried

5.98% 4.08%

Not very worried

0%

10%

20%

30%

40%

50%

Percentage Students

Figure 10. Classification of “worriers”.

Non-students

60%

70%

80%

14

S. F. Chan and Zenobia C. Y. Chan

Classification of "worriers" in non-student group

Very worried

76.92%

A bit worried

23.08%

54.90%

45.10%

Not very worried 14.29% 0%

85.71% 20%

40%

60%

80%

100%

120%

Percentage Female

Male

Figure 11. Classification of “worriers” by gender in non-student group.

Classification of "worriers" in student group

Very worried

55.26%

44.74%

A bit worried

52.60%

47.40%

Not very worried

31.25% 0%

20%

68.75% 40%

60%

80%

Percentage Female

Male

Figure 12. Classification of “worriers” by gender in student group.

100%

120%

The Evaluation of Food Safety Perception in Hong Kong

15

Q. 22 Compared to ten years ago, would you say that, overall, food safety has improved, stayed about the same or has gotten worse?

Non-students

45.58%

Students

27.21%

47.44%

0%

24.49%

39.32%

20%

40%

60%

9.83%

80%

100%

Percentage Has improved

Stayed about the same

Has worsened

Figure 13. The opinion on food safety over the last ten years. Q. 25 Please tell me how you reacted to the last story you heard about a type of food being unsafe or bad for your health (Non-student group) 1.36% 6.80%

3.40%

Permanet change of habits Temporary avoidance of food

17.01%

Worried but no action taken Ignored information Others 64.63%

Figure 14. The response to the last story about a food safety problem in non-student group. Q. 25 Please tell me how you reacted to the last story you heard about a type of food being unsafe or bad for your health (Student group)

11.11%

2.99%

8.12%

Permanent change of habits Temporary avoidance of food Worried but no action taken Ignored information

24.36% 44.44%

Others

Figure 15. The response to the last story about a food safety problem in student group.

16

S. F. Chan and Zenobia C. Y. Chan Table 2. The distribution of the intensity of “worry” in response to the last story about a food safety problem in student group Student group Permanent change of habits Temporary avoidance of food Worried but no action taken Ignored information

Very worried 2.56% 7.69% 5.56% 0.85%

A bit worried 5.56% 33.33% 17.52% 8.12%

Not very worried 0.00% 3.42% 1.28% 2.14%

In the student group, respondents who tended to worry (“very worried” and “a bit worried”) about the food safety problems were likely to either temporarily avoid the food in problem or just to take no action (table 2). Although only about 8% of respondents considered permanently changing their eating habits, all these came from the “worry” category (“very worried” and “a bit worried”). For those who claimed to have ignored the information, about 2% came from the “not very worried” category while almost 9% were from the “worry” category. Those who took no action or just ignored the information may present important implications for food safety promotion. In the non-student group, respondents who tended to worry (“very worried” and “a bit worried”) about the food safety problems were also likely to either temporarily avoid the food concerned or just to take no action (table 3). Although only about 3% of respondents considered permanently changing their eating habits, they all came from “worry” category (“very worried” and “a bit worried”). For those who claimed to have ignored the information, about 1% came from the category “not very worried” while almost 5% were from the “worry” category. Those who took no action or just ignored the information may present important implications for food safety promotion. The research results presented in figure 16 showed that the public authorities, scientists, food manufacturers and media were the most trusted sources of information about food risks in the student group while that in the non-student group were the public authorities, media, scientists and consumer groups in that order. Table 3. The distribution of the intensity of “worry” in response to the last story about a food safety problem in non-student group Non-student Permanent change of habits Temporary avoidance of food Worried but no action taken Ignored information

Very worried 0.68% 12.93% 2.72% 0.68%

A bit worried 2.72% 48.98% 12.93% 4.76%

Not very worried 0.00% 2.72% 1.36% 1.36%

The Evaluation of Food Safety Perception in Hong Kong

Q. 24

17

Suppose a serious food risk were found in fish or chicken. Who would you trust the most to inform you about the risk?

14.63%

Scientists

18.80% 28.23% 27.99%

Public authorities 7.44%

Food manufacturers

18.18% 17.35% 16.03%

Media

Consumer groups

7.48%

Your physician or doctor Supermarkets or shops

Farmers

11.56%

7.14% 8.33% 0.34% 1.71% 0.00% 0.85%

None

1.36% 1.07%

Other

1.02% 2.35% 0%

5%

10%

15%

20%

25%

30%

Percentage Students

Non-students

Figure 16. The sources of information about food risks that the respondents most trusted.

Limitations of the Study Further studies should be conducted so as to create questions on risk perception that are more applicable to the local population. Based on the reasons that food safety programs should be tailored to meet the specific needs of various targeted groups, therefore more surveys in larger sample size should be continued to the local public from different demographic backgrounds in the discipline of perception of food safety. In future, the reliability and generalizability can be improved by applying professional translation, random sampling and face-to-face interviews. Nevertheless, the convenience samples in this study were worthwhile because of a lack of research in this topic. It provided a starting point for scholarship, public health workers in the government or policy-makers. It should be remembered that the survey results should be regarded as estimations; the accuracy of the results depends upon the sample size and the observed percentages.

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S. F. Chan and Zenobia C. Y. Chan

Furthermore, some of the survey questions are fixed, therefore the respondents are restricted to response from the designated options given. The overall response rate was 62.02%. It was found that a higher response rate (i.e., more than double) was given by hand distribution of questionnaires than email distribution. In further studies when resources are allowed, it was suggested that a face-to face interview should be conducted in order to increase the response rate and to reduce the missing answers.

Implications for Food Safety According to the research results in Part I, except Question number 1 and 2 where there were over 70% respondents scored correct answers in the non-student group, less than half of the respondents in both groups scored correct answers to all questions (figure 1). This implies that the majority of the respondents were not concerned about the prevalence of the local foodborne disease outbreaks. Most of them underestimated the true number of victims involved in the total local foodborne disease outbreaks. Furthermore, they may not be knowledgeable enough to notice that Vibrio parahaemolyticus and Staphylococcus aureus were the major and second major causative agents, and that inadequate cooking and contamination by raw food were the top two major contributing factors in all total outbreaks, but overestimated the seriousness of the number of the hospitalization and death reports. All these results from the general public did not coincide with those of the professional’s statistics (DH, 2006b). Even though the local government departments (i.e., DH and FEHD) (DH, 2007b and FEHD, 2007) provide many food safety education programs to the public (DH, 2007c; DH, 2007d; DH, 2007e; FEHD, 2002; FEHD, 2003; FEHD, 2004; FEHD, 2005c; FEHD, 2006g; FEHD, 2006h; FEHD, 2006i and FEHD, 2006j), more than 80% and 70% of respondents in the non-student group and the student group respectively had never participated in the official programs (figure 2). Under limited resources, instead of providing general foodborne disease related information in the local official food safety education programmes, it is suggested that these programmes should be targeted on these dominant factors. This may greatly reduce the number of outbreaks and victims affected. If this were done, not only the economic burden in this health sector could be reduced, but also the public health campaigns could be conducted more efficiently and more resources could be released to prepare for combating other newly emerging diseases (for further details, please refer to “A review of foodborne disease outbreaks from 1996 to 2005 in The HKSAR and its implications on food safety promotion” under the same series published in The Journal of Food Safety issues 28(2008), 276-299). In response to the low participation rate to the local official food safety education programs, more resources should be invested into “school food safety education” to ensure that the official group visits and talks on food safety (FEHD, 2006h and FEHD, 2006j) can cover all the school age people at least once a year. Food hygiene and food safety should be approved to become one of the formal curricula in school subjects. Under this proposal, some proper food safety messages not only can consolidate in the early life of the young generation, but can also be disseminated among friends and families within the youngsters’ network. The participation rate can also be increased by launching more out-reaching activities at community levels such as elderly centers, community centers, MTR (i.e., Mass Transit Railway) stations, RoadShow (i.e., the free TV programs and advertisements shown on the

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19

bus), large shopping malls, food premises, markets and supermarkets. While more publicity should be launched to increase the attendance rate of the official food safety programs, further studies should be conducted to investigate the reasons behind for the public never joining the official food safety promotion programs. However, why do most respondents seem to be indifferent to the local foodborne disease outbreaks? The following discussion in Part II may help to explore the reasons. The results indicated that most local public associated food risks with their health and food safety. However, how many would put the idea into action? It was found that most associated food with taste, pleasure and quality rather than the health of themselves and their families, and food safety when purchasing food (figure 5). Despite their concerns about health and food safety, they were more driven by taste, price and quality than by health and food safety concerns when purchasing food. Why did most respondents put taste, price and quality over the food safety and health problems? When the respondents were asked a list of possible health related risks, most found that the top potential risk that was likely to happen personally to them belonged to the uncontrollable external risk factor (i.e., environmental pollution) but not the controllable personal risk factor (i.e., food safety) (figure 3). These results were similar to the study conducted by the European Commission (EC, 2006, p.3). Furthermore, based on the results shown in figure 13, almost half of the proportion of respondents in each group considered that the local food safety has improved for the last ten years. It may be anticipated that their confidence in the monitoring of food safety by the local authorities and the “NOT ME” concept may explain most of them believed food risks were less likely to affect them personally. It is certain that further research studies are needed to investigate the underlying reasons for the lower risk perception of food safety in local population. In fact, we are all exposed to various sorts of health-related risks in our daily lives, such as car accidents, environmental pollution, illnesses, food risks, crime or terrorism (Question 19). However, it is not difficult to conclude that only the food we consume can be under personal control. As we must keep consuming food to maintain our lives, the probability of getting foodborne diseases should be much greater than any kind of risks, as mentioned in Question 19, if we are not concerned about food safety and food hygiene. We are all susceptible to foodborne diseases, therefore the “NOT ME” concept should never apply to foodborne diseases. Meanwhile, the local public authorities have an advantage over the media, scientists, consumer groups and doctors because they are the most trusted sources when it comes to providing information about food risks (figure 16). The faith shown by the local public in the local authorities was shown to be much greater than that in European countries (EC, 2006, p.15). The local food authorities should therefore treasure this trust and design some effective food safety strategies in the long term so as to safeguard public health. For example, the local food authorities should highlight the concept that everyone is susceptible to foodborne diseases at any moment. Contrary to the results shown in figure 13 in which most respondents believed that food safety has improved during the last 10 years, the local food authorities should expose the truth to the public, i.e., that the number of local foodborne disease outbreaks is on an upward trend (DH, 2007a), and prompt the public not to be over-confident in local food safety. All of the parties—from the food authorities, food business stakeholders to the local public—should share the responsibility in the food and personal hygiene in the domestic and commercial sectors.

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S. F. Chan and Zenobia C. Y. Chan

When the respondents were requested to focus on food safety and reminded of the designated possible risks associated with food (figures 8 and 9), the majority were more likely to worry about uncontrollable external risk factors. It was noticed that most respondents tended to neglect some personal controllable risk factors in food safety but rely heavily on the external uncontrollable risk factors to safeguard their own food safety. The official food safety promotion program should pinpoint the fact that the major contributing factors in local foodborne disease outbreaks were inadequate cooking and contamination by raw food (DH, 2006b) which could be under personal control. Empowerment and self-efficacy should be advocated in the way that every individual is capable of eliminating of foodborne diseases and contributing to his or her own health. Hotpot dining is one of the sources of foodborne disease outbreaks, in which cross contamination between raw and cooked food and undercooked food items can be avoided under personal control (FEHD, 2005b). The analysis also manifested that there was a profile of worriers. As women were dominant in the category of “worriers” (both “very worried and “a bit worried”) while males tended to be over-represented in the group “not very worried” in both groups (figures 11 and 12), further studies should be performed to study the causes of those who were “worried” or “not worried” before some tailored food safety promotion strategy could be made to meet the specific needs of each gender. Furthermore, respondents with tertiary educational level or above were over-represented in the category of “worriers” in the non-student group. Therefore, special food safety promotion strategies aimed at elevating the risk perception of food safety should be applied to people of lower education attainments. It is explicit that the goal of a food safety promotion program is the implementation of food safety practices (e.g., behavioral change) in response to a food risk. Those who temporarily avoided the food problem or permanently changed habit were believed to be more likely to benefit from any intervention of food safety promotion programs (tables 2 and 3). However, it was found that there were more than 20% and 30% respondents, respectively, in the non-student group and the student group who did not take any action or even just ignored the information in response to a food risk or problem, regardless of whether or not they were worried (tables 2 and 3). Since they deviated from the overall population, some further research studies are called for to explore the reasons. Possible reasons are that they are not knowledgeable enough to make a decision; or they intentionally put themselves at the risk for foodborne diseases because they put their organoleptic pleasures above health concerns; or because of inequalities of health. Reasons such as these need to be examined before a food safety promotion program can be tailored effectively to this special population group.

CONCLUSION Although knowledge is a prerequisite to food safety practices, it does not in itself guarantee the implementation of safe food preparation and handling practices. More sweeping official research should therefore be conducted to examine the underlying causes of the public’s food safety practices and behaviour, and a balance struck between cost and benefits during implementing food safety practices. Determining this balance could be aided by studying which fundamental factors in the public’s attitudes, beliefs, norms and knowledge would influence their implementation of food safety practices.

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ABOUT THE AUTHOR The first author holds a master’s degree in health education and health promotion granted by the Chinese University of Hong Kong, and has been working as a health inspector in a local food and health authority for almost ten years.

REFERENCES Chan, S.F. and Chan, Z.C.Y. (2008). A review of foodborne disease outbreaks from 1996 to 2005 in The HKSAR and its implications on food safety promotion. Journal of Food Safety, 28, 276-299. Cheung, K. B. (2006, November 28). Loopholes in food safety system. Ming Pao Daily News, F04. Clayton, D. A., Griffith, C. J. and Price, P. (2003). An investigation of the factors underlying consumers’ implementation of specific food safety practices. British Food Journal, 105(7), 434-453. De Boer, M., Mccarthy, M., Brennan, M., Kelly, A. L. and Ritson, C. (2005). Public understanding of food risk issues and food risk messages on the island of Ireland: the views of food safety experts. Journal of Food Safety, 25(4), 241-265. Department of Health (DH). About us. Retrieved Mar 22, 2007b, from http://www.dh.gov.hk/english/aboutus/aboutus.html Department of Health (DH). Central Health Education Unit. Retrieved May 17, 2007c, from http://www.cheu.gov.hk/eng/aboutus/index.htm Department of Health (DH). Central Health Education Unit. Education resources. Retrieved May 17, 2007d, from http://www.cheu.gov.hk/eng/resources/communicable_Boards.htm Department of Health (DH). Central Health Education Unit. Promotion activities. Retrieved May 17, 2007e, from http://www.cheu.gov.hk/eng/activities/index.asp?page=3 Department of Health (DH). Centre for Health Protection (CHP). A case of Streptococcus suis infection under investigation. Retrieved August 14, 2006a from http://www.chp. gov.hk/content.asp?lang=en and id=116 and info_id=7343 and pid=14 Department of Health (DH). Centre for Health Protection. Statistics on communicable diseases. Retrieved April 27, 2007a, from http://www.chp.gov.hk/notifiable1.asp? lang=en and id=43 and pid=26 and ppid=10 Department of Health (DH). Statistics on food poisoning issues from 1996 to 2005 (Appendix B). Dr Manny LAM (2006b). European Commission (EC). Risk Issues. Executive summary on food safety. Retrieved February 2006, from http://www.efsa.eu.int/about_efsa/communicating_risk/risk_ perception/1339/comm_summary_eurobarometer_en1.pdf Food and Environmental Hygiene Department (FEHD). About us. Retrieved February 17, 2007, from http://www.fehd.gov.hk/index2/aboutus-index.html Food and Environmental Hygiene Department (FEHD). Annual Reports 2001. Retrieved August 9, 2002, from http://www.fehd.gov.hk/publications/text/annualrpt/ 2001/ annual2001.html

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Food and Environmental Hygiene Department (FEHD). Annual Reports 2002. Retrieved August 20, 2003, from http://www.fehd.gov.hk/publications/annualrpt/2002/content.html Food and Environmental Hygiene Department (FEHD). Annual Reports 2003. Retrieved September 24, 2004, from http://www.fehd.gov.hk/publications/annualrpt/2003/content. html Food and Environmental Hygiene Department (FEHD). Annual Reports 2004. Retrieved July 18, 2005c, from http://www.fehd.gov.hk/publications/annualrpt/2004/content.html Food and Environmental Hygiene Department (FEHD). Annual Reports 2005. Retrieved July 19, 2006g, from http://www.fehd.gov.hk/publications/annualrpt/2005/content.html Food and Environmental Hygiene Department (FEHD) (2006, October 20). CFS explains food poisoning investigations. [Press Release]. Retrieved October 20, 2006c, from http://www.fehd.gov.hk/news/details/20-10-2006-1485.html Food and Environmental Hygiene Department (FEHD) (2006, November 20). CFS follows up problem eggs on the Mainland. [Press Release]. Retrieved November 20, 2006f, from http://www.fehd.gov.hk/news/details/20-11-2006-1508.html Food and Environmental Hygiene Department (FEHD) (2006, April 18). FEHD response on pesticides in vegetables survey. [Press Release]. Retrieved April 18, 2006b, from http://www.fehd.gov.hk/news/details/18-04-2006-1392.html Food and Environmental Hygiene Department (FEHD). Food Safety Survey. Retrieved July, 2001, from http://www.fehd.gov.hk/publications/foodsurvey/foodsurvey.PDF Food and Environmental Hygiene Department (FEHD). Health Education Exhibition and Resource Centre. Retrieved March 22, 2006h, from http://www.fehd.gov.hk/ research_ education/heerc/index.html Food and Environmental Hygiene Department (FEHD) (2005, August 21). HWFB studies malachite green test results. [Press Release]. Retrieved April 3, 2006a, from http://www. info.gov.hk/gia/general/200508/21/08210236.htm Food and Environmental Hygiene Department (FEHD). Public Education. Communication Resource Unit. Retrieved March, 21, 2006j, from http://www.fehd.gov.hk/research_ education/cr_unit/index.htm Food and Environmental Hygiene Department (FEHD) (2006, October 3). Public warned not to drink Bolthouse Farms carrot juice. [Press Release]. Retrieved October 3, 2006e, from http://www.fehd.gov.hk/news/details/03-10-2006-1474.html Food and Environmental Hygiene Department (FEHD). Risk in brief issue no. 2. Retrieved Jan 19, 2005a, from http://www.fehd.gov.hk/safefood/report/rib/clenbuterol.html Food and Environmental Hygiene Department (FEHD). Safe food and public health. Retrieved May 2, 2006i, from http://www.fehd.gov.hk/safefood/index.html Food and Environmental Hygiene Department (FEHD) (2006, October 25). Updates on US spinach products. [Press Release]. Retrieved October 25, 2006d, from http://www. fehd.gov.hk/news/details/25-10-2006-1489.html Food and Environmental Hygiene Department (FEHD). Ways to enjoy hotpot safely. Retrieved Dec 15, 2005b, from http://www.fehd.gov.hk/safefood/food-safety-express/ safefood_tips/hotpot.html HKU POP SITE (2007). Survey method on rating of Chief Executive Donald Tsang Yamkuen - per poll (3/4/2007). Retrieved April 17, 2007, from http://hkupop.hku.hk/

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Immigration Department (ID). Rights of abode in HKSAR. Retrieved May 17, 2007, from http://www.immd.gov.hk/ehtml/faq_roaihksar.htm Information Services Department (ISD) (2006, November 23). Results of tests on eggs and fish. [Press Release]. Retrieved November 23, 2006, from http://www.info.gov.hk/gia/ general/200611/23/P200611230297.htm Kivela, J., Lam, M. L. and Inbakaran, R. (2002). Food safety in school catering in the People’s Republic of China. International Journal of Contemporary Hospitality Management, 14(6), 301-312. Nardi, P. M. (2003). Doing survey research: a guide to quantitative methods. Boston: Allyn and Bacon. Neuman, W. L. (1997). Social research methods: qualitative and quantitative approaches. (3rd Ed.). Boston: Allyn and Bacon. U.S. Food and Drug Administration (USFDA). FDA News. FDA notifies consumers that tomatoes in restaurant linked to Salmonella Typhimurium outbreak. Retrieved November 3, 2006 from http://www.fda.gov/bbs/topics/NEWS/2006/NEW01504.html

APPENDIX A Questionnaire Survey Title: A review of foodborne disease outbreaks from 1996–2005 in Hong Kong and the evaluation of the perception on food safety from the local general public There are two parts to this questionnaire. Please click your mouse (add a ╳) or fill your answers in the box provided or in the space provided. Please answer all the questions.

Part I – Public Perceived Knowledge of Food Safety 1. What do you think about the number of the reported food poisoning outbreaks in Hong Kong from 1996 to 2005? Please cross one option from the list below. A B C D

Increasing Decreasing More or less the same No idea

2. What do you think about the number of persons affected from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005?

24

S. F. Chan and Zenobia C. Y. Chan Please cross one option from the list below. A B C D

Increasing Decreasing More or less the same No idea

3. What was the number of persons affected (both confirmed cases and suspected cases) from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 (10-year period)? Please cross one option from the list below. A B C D

Less than or equal to 5,000 Between 5,001 to 10,000 Between 10,001 to 20,000 Between 20,001 to 30,000

4. What was the major causative agent among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005? Please cross one option from the list below. A B C D

Ciguartoxin Salmonella Vibrio parahaemolyticus Norwalk-like viruses

5. What was the second major causative agent among all reported food poisoning outbreaks in Hong Kong from 1996 to 2005? Please cross one option from the list below. A B C D

Ciguartoxin Salmonella Vibrio parahaemolyticus Staphylococcus aureus

6. What was the number of people admitted to the hospitals (both confirmed cases and suspected cases) from the reported food poisoning outbreaks in Hong Kong from 1996 to 2005 (10-year period)? Please cross one option from the list below. A B C D

Less than or equal to 5,000 Between 5,001 to 10,000 Between 10,001 to 20,000 Between 20,001 to 30,000

7. Do you think there were there any deaths among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005?

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Please cross one option from the list below. A B

Yes No

8. What was the major contributing factor among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005? Please cross one option from the list below. A B C D

Toxin in food Inadequate cooking Poor personal hygiene of food handler Contamination by raw food

9. What was the second major contributing factor among all the reported food poisoning outbreaks in Hong Kong from 1996 to 2005? Please cross one option from the list below. A B C D

Toxin in food Inadequate cooking Poor personal hygiene of food handler Contamination by raw food

10. Have you ever participated in any official health education program on food safety in Hong Kong? Please cross one option from the list below. A B

Yes No

Part II – Risk Perception of Food Safety From questions 11 – 16, please write your answer on the line. 11. Date 12. What is your nationality? 13. How long have you lived in Hong Kong?

Yrs

14. What is your current occupation? (Answer questions 15 and 16 only if you are not doing any paid work currently. Please continue to questions 17 to 29.) 15. Did you do any paid work in the past?

26

S. F. Chan and Zenobia C. Y. Chan 16. What was your last occupation? 17. QB1 When thinking about food, what words first come to mind? Please cross one option from the list below. Pleasure Conviviality Taste Guilt Greed Necessity Health Hunger Obesity Diet/ Balanced diet Calories Chemicals Local or national culture Diseases Others

18. BQ2 Potential risks: for each of them please tell how likely you think they are happen to you personally. (Please cross your options in the appropriate box below. You can only cross one option in each question.) No

Questions

1 2 3 4

Being the victim of a crime Being the victim of terrorism A serious illness The food you eat damaging your health Being injured in a car accident Consumer goods (other than food) damaging your health Environmental pollution damaging your health

5 6 7

Very likely

Fairly Likely

Not very likely

No at all likely

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19. QB3 What are all the things that come to your mind when thinking about possible problems or risks associated with food? Please write your answer on the line. 20. QB4a When you go shopping for food, what would you say are the most important factors that influence your choice? (You may cross two options in a maximum from the list below.) Price Taste Quality Habit Family preference You and your family’s health Production methods (organic, free range, eco-friendly, etc.) Appearance/ freshness Brand name Food safety Convenience/ availability Country of origin Avoiding food allergies None

21. QB4b Compared to ten years ago, would you say that, overall, food safety has improved, stayed about the same or has gotten worse? Please cross one option from the list below Has improved Stayed about the same Has worsened

22. QB5 For each of the following issues, please tell if you are very worried, fairly worried, not very worried or not at all worried by it? (Please cross your options in the appropriate box below. You can only cross one option in each question.) No.

Questions

1

The so called mad cow disease (BSE) Genetically modified products in food or drinks To put on weight Having an allergic reaction to food or drinks

2 3 4

Very Worried

Fairly Worried

Not very worried

Not at all Worried

28

S. F. Chan and Zenobia C. Y. Chan No.

Questions

5

Additives like colours, preservatives or flavourings used Contamination by bacteria like salmonella in eggs or listeria in cheese Chemical substances that are formed during heating, baking, barbecuing or frying foods Pollutants like mercury or dioxins Residues in meats like antibiotics or hormones Pesticide residues in fruit, vegetables or cereals New viruses like avian influenza Unhygienic conditions in food handling at home Unhygienic conditions in food handling outside home like in food processing plants, shops or restaurants The welfare of farmed animals

6

7

8 9 10 11 12 13

14

Very Worried

Fairly Worried

Not very worried

Not at all Worried

23. QB6 Suppose a serious food risk were found in fish or chicken. Who would you trust the most to inform you about this risk? (You may cross two answers in a maximum from the list below.) Scientists Public authorities Food manufacturers Media Consumer groups Your physician/ doctor Supermarkets or shops Farmers None Other

24. QB11 Please tell how you reacted to the last story you heard about a type of food being unsafe or bad for your health? Please cross one option from the list below. You have permanently changed your eating habits You avoided the food mentioned in the story only for a while You got worried about the problem but finally you did nothing at all Your have ignored the story Other

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25. D7 Could you give the letter which corresponds best to your own current situation? Please cross one option from the list below. Married Remarried Unmarried, currently living with partner Unmarried, having never lived with a partner Unmarried, having previously lived with a partner, but now on my own Divorced Separated Widowed Other Refusal

26. D8 How old were you when you stopped full-time education? If you are “still having full-time education”, please enter “S” Please write your answer on the line. 27. What is your highest educational level? Please write your answer on the line. 28. Gender? Please write your answer on the line. 29. How old are you ? Please write your answer on the line. (Thank you for your cooperation.)

APPENDIX B Statistics Provided by Department of Health, HKSAR Total no. of food poisoning outbreaks reported to the DH Year Confirmed Suspected Total

1996 93 221 314

1997 107 257 364

1998 129 448 577

1999 194 344 538

2000 234 384 618

2001 214 457 671

2002 283 387 670

2003 158 264 422

2004 165 656 821

2005 252 720 972

2004 831 2300 3131

2005 1241 2301 3542

Total no. of persons affected in food poisoning outbreaks reported to DH Year Confirmed Suspected Total

1996 980 849 1829

1997 998 902 1900

1998 1421 1590 3011

1999 1570 1248 2818

2000 1177 1275 2452

2001 1292 1415 2707

2002 1137 1503 2640

2003 995 1235 2230

Total no. of deaths and hospitalizations in food poisoning outbreaks reported to DH Year Confirmed outbreaks Suspected outbreaks

Deaths Hospitalization Deaths hospitalization

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

0 151 0 169

0 163 0 107

0 86 0 232

0 120 0 91

0 105 0 74

0 79 0 70

0 73 0 32

0 53 0 27

0 48 0 89

0 51 0 34

S. F. Chan and Zenobia C. Y. Chan

31

Causative agents of food poisoning outbreaks reported to DH from 1996 to 2005 Causative agents Vibrio parahaemolyticus Salmonella spp. Staphylococcus aureus Norwalk-like viruses Clenbuterol Ciguartoxin Clostridium perfringens Others Total

No. of outbreaks (confirmed) 857 455 141 123 70 68 14 94 1822

No. of outbreaks (suspected) 1453 488 845 244 0 308 104 704 4146

Main contributing factors of all food poisoning outbreaks reported to DH from 1996 to 2005 Primary contributing factor Inadequate cooking Contamination by raw food Toxin in food Poor personal hygiene of food handler Contaminated raw food Others

Percentage of outbreaks 26.71 18.95 9.80 6.47 6.30 31.77

APPENDIX C Model answers to the questions from Part I of the questionnaire at Appendix A. With reference to the Appendix B, the model answers to the questions from Part I of the questionnaire at Appendix A are listed as follows: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

A A D C D A B B D Arbitrary

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S. F. Chan and Zenobia C. Y. Chan

APPENDIX D To: School Principals A review of foodborne disease outbreaks from 1996–2005 in Hong Kong and the evaluation of the perception on food safety from the local general public I am a Health Inspector working for the Food and Environmental Hygiene Department, and a part-time student studying for a Master of Science degree in Health Education and Health Promotion in the Chinese University of Hong Kong. I am going to carry out a research study as stated in the captioned title. This is a quantitative research in which a questionnaire survey will be used to collect data. About three hundred questionnaires will be distributed to the general public of Hong Kong by convenience sampling and snowballing technique via email and hand distribution. There were two parts in the designed questionnaire (as attached) that gave a total of twenty nine questions. The first part contained ten questions to evaluate the perceived knowledge on food safety from the public while the second part was composed of nineteen questions to study the risk perception on food safety from the public. It takes about 10 minutes to finish the questionnaire. The results in this study may identify what preventive measures can be targeted in future food safety related health education programs in Hong Kong. I would be grateful if you would grant permission to me to distribute 100 questionnaires to your students. Thank you very much for your attention and assistance. I am looking forward to receiving your reply very soon. Yours faithfully, S.F. CHAN, Catherine

APPENDIX E Consent Form A review of foodborne disease outbreaks from 1996 - 2005 in Hong Kong and the evaluation of the perception on food safety from the local general public I am a Health Inspector working for the Food and Environmental Hygiene Department, and a part-time student studying for a Master of Science in Health Education and Health Promotion of The Chinese University of Hong Kong. I am going to carry out a research study as stated in the captioned title. In order to study the perception on food safety from the general public in Hong Kong, you are invited to voluntary participate in this self-completed questionnaire. Your responses may contribute to the later policy related to food safety, so your participation is very important. Since this is a questionnaire about the situation of food poisoning outbreaks in Hong Kong, no physical, chemical or biological harmful effect will be received by you. The questionnaire is anonymous and the collected data will be used for research purpose only, so the confidentiality will be remained. This is a research for academic

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purposes, so I declare that your email address will not be saved or used for any commercial purposes. The document is free of viruses so it is safe to your computer. It is certain that you are free to withdraw at any time if you do not want to continue answering the questions. There are 29 questions in this questionnaire. I would be grateful if you would complete all the questions and email to me at [email protected] within 3 weeks from date of this email. Please feel free to contact me at the given email address if there is any enquiry. Thank you very much for your cooperation. Return of this questionnaire will indicate your voluntary consent to participate in this research study. Yours faithfully, S.F. CHAN, Catherine

APPENDIX F Permission Granted by EC in Applying Their Questionnaire

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In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 3

HEALTH PROMOTION PROGRAM: BIKESMART FOR SENIOR PRIMARY SCHOOL STUDENTS IN TIN SHUI WAI S. K. Cheng and Zenobia C. Y. Chan ABSTRACT Bikesmart is recognized as a health promotion program in many countries of the world, but not in Hong Kong (HK). Many people perceive HK as an unsafe city for bicycling but, on the contrary, HK is a safe place for bicycles. However, there are limited studies and programs on promoting bicycling in HK; therefore, people are not aware of the benefits of bicycling to our health and the environment. Accordingly, a Bikesmart program with a Bikesmart team should be implemented in a primary school in Tin Shui Wai during the 2008–2009 academic year, which would reach more than 450 senior primary students. The students should be assessed multidimensionally in order to provide a good Bikesmart program appropriate for the age of the students to increase awareness of and participation in bicycling. Qualitative evaluation should be performed from multiple viewpoints. Although the cause-effect relationships from the variables of the students in this pilot glassrod district cannot be distinguished, Bikesmart in HK can be explored, especially corresponding to this particular district.

BACKGROUND OF BIKESMART Bikesmart is being recognized as a health promotion program in many countries of the world (Toronto Public Health Bicycle Safety Workgroup, 2005; Portland Office of Transportation, 2007; San Francisco Municipal Transportation Agency, 2007; Tarallo-Falk, 2007; Santa Clara Valley Transportation Authority, 2008). It not only refers to the promotion of bike safety, but also refers to the benefits of bicycling. As a matter of fact, bicycling is an exercise that is good for the heart, kind to joints, shapes leg muscles, balances gait, provides relief from daily stress (Ramirez, 2007) and also saves the air from vehicular emissions of carbon dioxide (Transport Department, 2004). These bike-related benefits enable people to

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optimize control over and improve their healthy well-being, which fits in with the concept of health promotion announced by the World Health Organization (WHO) (World Health Organization, 1986). Many people perceive Hong Kong (HK) as an unsafe city for cycling because of the crowed environment (Hong Kong Childhood Injury Prevention Research Group, 1998); on the contrary, HK is a safe place for bicycling (TD, 2004). In the United States (US), of a total of 85 million bicyclists, ~540,000 bicyclists were involved in accidents and more than 700 bicyclists died in 2006 (Bicycle Helmet Safety Institute, 2007). However, in HK, there are ~62,000 cycle trips a day (TD, 2004) with ~1,666 bicyclists involved in accidents (TD, 2008a) and 13 bicyclists died in 2007 (TD, 2008b). Approximately 21% of the accident victims are the children below 14 years of age (TD, 2008b). This implies that US cyclists have a three times higher chance of being involved in an accident than the cyclists in HK. Tin Shui Wai (TSW) is a new town in the New Territories (NT) of HK, where more than 97% of bicyclists ride every day (TD, 2004). As the residential developments in TSW are relatively scattered and relatively remote from the railway stations, bicycling is a popular and less expensive way to get to the railway station or other destinations, rather than short vehicular trips and shuttle services (TD, 2007). According to the Hong Kong Police Force (2008), school students are the largest group of bicyclists in TSW. In view of this, a Bikesmart health promotion program should be developed for a school year in collaboration with governmental and non-governmental organizations (NGOs). The students involved should not only be the recipients of the program, but should also be empowered to share the responsibility of being Bikesmart. The Bikesmart program advocates positive evolutionary cognitive behavioral changes for the senior primary students on the safety and promotion of bicycling proactively (Macdonald, 1993; Kenny, 1999). It will be achieved by raising the self-awareness of the students, teachers, parents and the community; by educating on the safety and benefits of bicycling with written and graphic information; by empowering the students with regard to their individual environment of daily livings; by collaborating with different sectors; and by enhancing the mutual support between the participants and the community. The benefits from the physical activity involved in bicycling will be maximized, on the contrary, the injuries caused by bicycling will be minimized. In the long term, healthy well-being will be maintained by safe cycling.

TARGET POPULATION Tin Shui Wai Methodist Primary School (TSWMPS) is an ideal school. It facilitates the students through empowerment, active participation and teamwork with the teachers and parents (TSWMPS, 2008) and is therefore a suitable school in which to implement a health promotion program. Approximately 450 senior primary students (primary grades 4–6) in TSWMPS can be recruited in the school year 2008–2009, as there are approximate 35 students in each of four classes in grades 4 and 6, and in each of five classes in grade 5. This target group is relatively independent from their parents; rather, they have more interactions with their parents (Committee on Home-school Cooperation, 2007).

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HEALTH PROMOTION CONCEPTUAL FRAMEWORK The Declaration of Alma-Ata for Primary Health Care (WHO, 1978) and the Ottawa Charter for Health Promotion (WHO, 1986) are the worldwide blueprint documents to achieve Health for All (HFA), which emphasizes community participation and empowerment with equity (Wass, 2000b). Even though our world is undergoing an increasing urbanization and socio-economic changes, health promotion is still recognized as a worldwide fundamental element of development and investment in health (WHO, 1997; Wass, 2000b; WHO, 2005). Everyone can be enabled to improve their own health by using some global strategies, so as to augment controls over individual determinants of health and to advocate personal choice and social responsibility for creating a healthier future (WHO, 1986).

Build Healthy Policy The standpoint of the stakeholder can identify any obstacles to the health-promoting issues and its subsequent adoption (Catford, 2004), and can establish some diverse but complementary policies, including legislation, taxations, and re-structuring of organizations (Department of Health, 2008). The outcomes should be monitored and revised whenever necessary, with emphasis on equity and social justice in the community (WHO, 1978; Wass, 2000b). In HK, the present legislation includes some bicycling safety measures (TD, 2001), but these are rarely enforced (HKCIPRG, 1998), e.g., children below 11 years of age must ride accompanied by an adult. Meanwhile, the HK police tries to raise the public awareness of safe bicycling through prosecuting punishments: there were 772 traffic summonses and 3,616 warning letters for violations of cycling traffic regulations in NT in 2007 (Hong Kong Police Force, 2008). Therefore, the HK government should further enforce the present policies by establishing a ‘Child Safety Council’ (HKCIPRG, 1998) to promote healthful daily activities with a focus on the safety of children by drawing the attention of the community and its participation as a multidisciplinary approach.

Create Supportive Environment The reciprocal maintenance of various supportive environments, including the natural environment, the living environment, socio-economic conditions, and the political environment can affect health as well as daily living, work and leisure (WHO, 1986; DH, 2008). They are fundamental to sustain the fulfillment of other strategies at all levels (Jackson, Perkins, Khandor. Cordwell, Hamann, and Buasai, 2007). A ‘bottom-up’ approach for health promotion is a definitive approach in which people and their communities can manage their own health collaboratively with active mutual support (Ewles and Simnett, 2003; McMurray, 2003). TSWMPS is a motivational creative school, and its policies are open to the public (TSWMPS, 2008). It provides a safe and supportive environment for the students to learn and

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play. Interpersonal interaction is emphasized among the students, teachers, parents and the community so that some safe paths can be planned with them for the bike training program. Different governmental organizations, including the police, Transportation Department (TD), and NGOs, such as the Hong Kong Cycling Association (HKCA), can be invited to participate for various purposes: for example, maintaining road safety, facilitating road arrangements for outreach activities, providing education on road safety guidelines and bicycling knowledge.

Strengthen Community Action Community participation with empowerment is the principal proposition to enhance selfhelp ability and social support within the existing community resources to enrich people’s health (Liamputtong and Gardner, 2003; Catford, 2004; Bandesha and Litva, 2005). People can determine their own needs and can choose the ways to fulfill own needs (Wass, 2000b). Community awareness and participation can be increased by the accessibility of information, learning opportunities for health and funding support (WHO, 1986). The TD and HKCA are trying to raise awareness on the benefits and safety of bicycling throughout the year by a proactive advertising approach (TD, 2001; Hong Kong Cycling Association, 2008). They can empower the public to maintain cycling safety and promote the physical activities of bicycling. Therefore, they will be the main supporters of the Bikesmart program. TSW has one of the longest cycle routes in HK (TD, 2004), but it is still not enough for the daily demands for the residents. Inadequate bike parking areas is another issue. So, the relevant governmental departments should sort out solutions for these issues.

Develop Personal Skills Personal and social development are acting as the structural level in health promotion (WHO, 1986; Catford, 2004; Jackson et al., 2007) through ‘providing information, education for health and enhancing life skills’ (WHO, 1986; Catford, 2004). People can learn at all stages of life for facilitating voluntary actions conducive to their own wellness and good quality of life (Wass, 2000a). Individual responsibility is emphasized for protecting one’s own health and that of the environment (WHO, 1997; Catford, 2004; DH, 2008) in order to achieve equity in the community (Baum, 2007). Skills on bicycling safety and knowledge on the benefits of bicycling can be taught to the students in a simple and concise way with lots of pictures and games. The students can learn through some interesting initiatives, which can leave an imprint on their minds, such as ‘egg drop activities’ on the importance of wearing a helmet during bicycling. Their parents can be involved in the program to act as a support team, enhancing parent-child interactions and inter-relationships (Clements, 2005).

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Reorient Health Services The clinical treatment of diseases is not the unique focus of the health care system (Hong Kong Government, 2007), whereas disease prevention and health promotion are emphasized to a greater extent than ever before (Wass, 2000b). All levels of the community should share the responsibility for health promotion (DH, 2008) through mediating their mutual needs to support their overall needs by negotiation and collaboration (WHO, 1986). Currently, riding a bicycle is regarded as a recreational activity instead of a healthpromoting activity in HK (HKCIPRG, 1998; TD, 2004). In addition, the community always focuses only on the issue of bicycling safety. However, in TSW, many residents ride a bike as a means of transportation within the town. Therefore, the services provided in the town and the demands of the residents should be mediated by emphasizing the individual responsibility for their needs and maintaining safety.

NEEDS ASSESSMENT Assessing the needs of the senior primary students for bicycling is the first phase in planning the health promotion program (Naidoo and Wills, 2003). A comprehensive picture of this issue in the community can be obtained through assessment and data collection. This will allow the Bikesmart team to identify the priorities and to response to the specific needs (Ewles and Simnett, 2003).

Felt Need The senior primary student is at the stage of late childhood, and will soon enter the stage of adolescence acting as a ‘last step before becoming an adult’ (Child Development Institute, 1998). They will gradually spend less time doing physical exercise (Centre of Health Protection, 2005b; CHP, 2007). They are preparing to make decisions about their future work and forming their own families in a few years’ time. Therefore, one of the first things they should do is to develop their decision-making ability based on their own needs and their surrounding environments under proper guardianship. They are encouraged to strive for a meaningful and healthy well-being by recognizing their felt needs (Hawe, Degeling, and Hall, 1990). Visiting to the school and classrooms is the first step to gain information from the target population by direct observations and face-to-face interviews (Anderson and McFarlane, 2000). The benefits and the safety of bicycling are discussed through playing some in-class games to assess their knowledge level and attitudes towards bicycling. They are encouraged to share their own experiences and obstacles on bicycling in TSW, and to verbalize their own concerns and suggestions on bicycling. Those factors affecting their compliance with maintaining bicycling safety are also discussed. Periodic questionnaires and telephone contact with the relevant teachers and parents can be performed to gather information on their knowledge about bicycling, the progress of the

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students in the program and also their comments and suggestions. This encourages collaborative efforts with the participants (Anderson and McFarlane, 2000).

Normative Need Normative needs are defined by the professionals based on their value judgments, knowledge and factual statistics (Hawe et al., 1990; Ewles and Simnett, 2003). In HK, various surveys and statistics are carried out by the different governmental departments on the number of daily bicyclists, related injuries, traffic prosecutions on bicycling, and so on. Then, safety policies, bicycling facilities and safety bicycling programs are established accordingly.

PLANNING Setting up a Bikesmart team is the first step in developing a Bikesmart program. A nurse can act as a team leader using different useful skills learned from the professional nursing training (Clements, 2005). In fact, nurses are the ideal people to implement a health promotion program (Salvage, 1993; Anderson and McFarlane, 2000; International Council of Nurses, 2008) because nurses have a variety of knowledge and skills to facilitate collaborative teamwork with other disciplines and to promote community involvement (Anderson and McFarlane, 2000). The Bikesmart team can work as cross-sectional collaborative approach. Different governmental organizations and NGOs can be invited to join and plan: nurses for health assessment and education, social workers for financial support and students’ behavioural affairs, Road Safety Council (Road Safety Council, 2007) and police for road support and safety advice, HKCA for skills in bicycling and bike maintenance, Leisure and Cultural Services Department (LCSD) for sponsorship of summer camps and advanced bicycling programs, parents for helping to prepare teaching materials, teachers for acting as facilitators of the students, and cycling shops in TSW and Yuen Long (adjacent to TSW) for bike maintenance and providing sponsors for the program (e.g., lending about 40 bikes to the school with basic associated equipments) and prizes (e.g., helmets, shoulder pads, leg pads). All of the team members can try to learn and to help each other in compensating for the shortages of their partners as the Bikesmart program is a new initiative in HK (Japhet and Hulme, 2004). The Bikesmart program can employ health education as a means of preventive health protection (Katz, Peberdy and Douglas, 2000) by promoting the physical activity of bicycling together with minimizing preventable cycling injuries in TSW. Accordingly, the current phenomenon of bicycling in TSW can be respected, and the Bikesmart promotion can be carried out according to the actual needs of the community. All aspects of bicycling can be reviewed and the related suggestions can be made for any improvements, such as asking the HK government to enforce the present legislations with establishing a ‘Child Safety Council’ to create a supportive and safe environment for bicycling.

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IMPLEMENTATION Direct observations and face-to-face interviews with the senior primary students during town, school and classroom visits is the first phase of implementing the program (Anderson and McFarlane, 2000). This can paint a comprehensive picture of the issue of bicycling in TSW, including the school’s surrounding environment and the present bicycling customs in TSW. The students recruited in the program can undergo a pre-program test to establish the baseline for the program assessment. This will help the Bikesmart team to allocate their resources according to what the students need. Then, the program can start with some advertisements in TSW through the school’s broadcast system with the mass media (TSWMPS, 2008) and through their specially-designed posters displayed in public areas to raise public awareness and cooperation (Tones and Tilford, 1994).

Education Sessions The parents of the recruited students can be invited to prepare the teaching materials with the Bikesmart team in order to enhance their knowledge through the preparation process, e.g., the monthly educational boards in the playground, teaching materials for in-class activities, and the prizes for in-class games. This approach of parent involvement can enhance the mutual support among themselves and the teachers. Different information about bikes can be introduced to the students monthly, including bicycling concepts and skills with bike maintenance, the benefits of bicycling, safety helmets and dress, the rights and the responsibilities of bicycling, rules of the road, and sources of help. Then, some in-class games, including bike safety crossword puzzles and catechetic matching on the benefits of bicycling, can be played for prizes to increase their willingness to participate. ‘Egg drop activity’ can be carried out to reinforce the importance of wearing a properfitted helmet while bicycling. Students are taught to imagine that an egg is the human brain inside the skull. They are encouraged to design a way to prevent the egg from breaking when dropped from a height with the helmet-like materials provided. The integrity of a well-fitting cover on the egg made with the helmet-like materials is demonstrated when the egg is dropped from a height. This activity lets the children understand the underlying concept in a dynamic way.

Bike Training Programs Theory and practice are inter-related for pursuing success. Attaining knowledge is not enough for the students to remember the benefits, concepts and skills of bicycling. The police can be invited to demonstrate on-road hand signals and road safety techniques in the school playground at three-week intervals for each class recruited before the summer holidays. The cyclists from HKCA can be invited to demonstrate bicycling techniques and simple bike maintenance. The students can in turn demonstrate their skills on the same day so that some bike-related problems can be sorted and their skills in decision-making and problem-solving

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can be trained. On-road practices can be performed along the students usual routes, which can be closed by the police to provide a safe learning environment. If the students are interested in advanced training on bike, the existing ‘easy sport program’ and ‘outreach coaching program’ on bicycling organized by the HKCA for senior primary students can be subvented by the LCSD and the Education Bureau (LCSD, 2007; HKCA, 2008).

Bikesmart Summer Camps Three Bikesmart summer camps can be organized in the Lady MacLehose Holiday Village for each grade of students. Their parents are also welcome to join if they are free from work. The camp aims to integrate the students’ knowledge by arranging several campaigns with rewards in the bicycling areas of the village during each camp: including a Bikesmart slogan competition, game booths, bike tours in the village, selection of a dress-smart cyclist and trivia competition. They are encouraged to share their newly-acquired knowledge and to solve the associated difficulties among themselves. The village can also be simulated as the community for practicing bicycling techniques. A Bikesmart student team can be formed by electing a Bikesmart student from each class in each grade. They can act as the Bikesmart health promoters in the school, giving them a sense of accomplishment, which can be the impetus for them to pursue a healthier life in the future.

EVALUATION A community health program should be evaluated from multiple perspectives (Baum, 2000), including the students and their parents, teachers, the Bikesmart team, and the government and the collaborative organizations. An impact evaluation should be performed (CHP, 2005a) as an integral part of the Bikesmart program (O’Connor-Fleming and Parker, 2001; Naidoo and Wills, 2003). Pre- and post-program tests should be designed by the Bikesmart team to assess the knowledge level of the students. As mentioned above, theory and practice are equally important to assess the level of the students’ understanding. The Bikesmart team should monitor the students with their specially-designed assessment checklist through the outreach training program and the summer camps. The students can be categorized as competent in bicycling if they can meet over 80% of the assessment criteria, including the proper dress for bicycling, road safety, hand signals on the road and so on. A certificate of completion can be offered for a sense of achievement. A feedback forum should be held with the students at the end of the summer camps to collect their comments and their feelings towards bicycling. A questionnaire designed by the Bikesmart team should be distributed to the relevant teachers and parents with telephone contact periodically. Any cognitive behavioral changes in the students should be discussed with any suggestions.

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The Bikesmart team should have monthly meetings throughout the program to discuss the effectiveness of the program and the need for any improvements. Any positive impacts or unexpected negative outcomes from the program should be monitored. As ~21% of the accident victims were children below 14 years of age in 2007 (TD, 2008b), governmental and non-governmental studies should be closely observed for any improvement or deterioration. Various studies on bicycling should be reviewed.

DISCUSSION The Bikesmart program has some limitations. The data collected is qualitative in nature as it is based on the cognitive behavioral changes of the students. It may be unable to distinguish the cause-effect relationships from the variables of the students. Also, the program will be implemented in one glassrod district that may not be applicable to other Hong Kong districts. However, the program will make a start to promote safe bicycling together with the benefits of bicycling as a healthy activity in TSW. The needs for cycling and its related services are assessed according to the characteristics of TSW, such as the majority of the population are low income classes, bicycling is used for short-trip travel to the railway station, inadequate parking for bikes and so on. As the Bikesmart leader will be a nurse, with multidimensional skills, the message of Bikesmart can be transmitted along with providing the related health advice considerately.

CONCLUSION For many people, HK is perceived as an unsafe city for cycling as compared with other countries; on the contrary, HK is a safe place for bicycling. It is good for heart, kind for joints, shape for leg muscles, balance for gait, relaxing from daily stress and also save the air from vehicular emissions of carbon dioxide. As riding a bicycle is popular in TSW, especially with the children, a Bikesmart health promotion program is worth implementing to optimize well-being and prevent injuries from bicycling. Although it is still a somewhat young science in HK, a start must be made before success is achieved.

AUTHOR’S BACKGROUND Cheng Sze Ki is an experienced nurse working in a gynecological-oncology ward in Queen Mary Hospital in Hong Kong and has worked with cancer patients physically and psychosocially for about ten years. (Email: [email protected])

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In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 4

GOOD NIGHT’S SLEEP PROGRAM FOR THE ELDERLY LIVING IN WAN HON ESTATE May M. Y. Li* and Zenobia C. Y. Chan ABSTRACT A local study in Hong Kong (HK) revealed a prevalence of insomnia at a rate of 38.2% in the elderly. The National Sleep Foundation’s survey in 2002 on the elderly in the United States also showed that 46% of people aged 65 to 74 and 50% aged 75 to 84 reported symptoms of insomnia. Negative outcomes of insomnia in the elderly are associated with poorer self-reported health status, cognitive decline, increased risk of falls and institutionalization. Sleep hygiene education provides a foundation for individuals to learn about effective sleep management. Our health promotion program will be a pioneering community-based program to enhance sleep hygiene for the elderly with sleep problems. It will be an intersectoral program for the marginalized elderly, whereas interactive and client-driven approaches will be focused in our program. Twenty elderly people with sleep problems living in singleton units in Wan Hon Estate in Hong Kong will be recruited. Our health promotion program aims at a partnership approach to improve the sleep hygiene of the elderly, enabling them to become aware of the potential causes of sleeplessness and facilitating these clients to learn relaxation skills to promote sleep. We will adopt comprehensive need assessment by interviewing the elderly before the planning and implementation stages. Health talks, workshops, home assessments and social activity will be included. We will invite one clinical psychologist, one physiotherapist, one part-time nurse, one social worker and volunteers as our health team members. Evaluation will be done by group interview, phone survey and questionnaires to weigh the effectiveness of our program.

*

Correspondence: May Li, Community Psychiatric Nursing Service, United Christian Hospital, Kwun Tong, Kowloon, Hong Kong. E-mail: [email protected]

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BACKGROUND A local study in Hong Kong (HK) revealed a rate of insomnia of 38.2% among the elderly and that insomnia was associated with impaired physical and mental health (Chiu, et al., 1999). Most people have and acquire little knowledge about normal and abnormal sleep. Sleep hygiene concepts, which include positive and negative sleep management behaviours, are important for individuals to learn regarding how to sleep better and how to avoid practices that disrupt sleep (Nau, and Lichstein, 2005). Sleep hygiene education provides a foundation for individuals to learn about effective sleep management. Currently, a limited number of health promotion programs have been developed to enhance the sleep hygiene of the elderly in HK. Since equitable access to health services is stressed by the World Health Organization (WHO) (1986 as cited in Liamputtong, Gardner, and McGartland, 2003), we propose a comprehensive primary healthcare-oriented health promotion program to enhance the sleep hygiene of the elderly with sleep problems. Our program will be a pioneering community-based program to improve the sleep hygiene of the elderly with sleep problems. Intersectoral, interactive and client-driven approaches will be focused for the marginalized elderly in our program. We will adopt some steps of the intervention mapping framework (O’Conner-Fleming and Parker, 2001), such as choosing our target population, setting up program objectives and designing a program in our proposal. The program leader aims at fostering community participation, partnership and reducing inequality in the elderly’s health care access due to their disadvantaged socioeconomic status, in line with the WHO’s (1981 as cited in Liamputtong, et al., 2003) global strategy for health for all. Our program objectives include increasing the elderly’s and family/caregivers/friends’ awareness of the potential causes of insomnia, enhancing sleep hygiene of the elderly and the facilitation of learning relaxation skills to promote sleep. Five core areas, i.e., comprehensive need assessment, planning, implementation, evaluation and discussion of the strengths and limitations of our program, will be addressed.

CLINICAL REVIEW ON SLEEP DISTURBANCE Sleep is defined as the “reversible behavioural state of perceptual disengagement from and unresponsiveness to the environment” (Carskadon and Dement, 2005, p. 13). According to the International Classification of Sleep Disorders, a persistent sleep disturbance that occurs at least three times per week for at least one month is regarded as insomnia (WHO, 1994). Common sleep complaints include difficulty in initiating sleep, disrupted sleep and early morning awakening (WHO, 1994). Potential causes of insomnia involve combinations of stress, biological, psychological and social factors (Committee on Sleep Medicine and Research, 2001). Sleep complaints are common in all ages (Ancoli-Israel and Ayalon, 2006). In 2003, a German study found that 30% to 40% of children aged 9 to 12 had problems falling asleep (Fricke-Oerkemann et al., 2007). A local school-based survey in 2003 to 2004 showed that adolescents aged 12 to 19 years had difficulty in falling asleep (5.6%), waking up during the night (7.2%) and early awakening (10.4%) (Chung and Cheung, 2008). Meanwhile, a telephone survey was done from 1993 to 1999 with 24,600 subjects aged 15 and older among

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the general population from France, the United Kingdom, Germany, Italy, Portugal and Spain, and a prevalence of insomnia at a rate of 16.8% was found (Ohayon and Roth, 2001). The Canadian Community Health Survey in 2002 also estimated that 13.4% of the household population or 3.3 million of Canadians aged 15 or above had insomnia (Tjepkema, 2005). Women are more likely than men to complain of insomnia symptoms since hormonal changes in menstruation, pregnancy and menopause may be the leading factors (Krishnan and Collop, 2006; Krystal, 2003; Leger, et al., 2000; Tjepkema, 2005). Older adults are even more vulnerable to insomnia (Ancoli-Israel and Ayalon, 2006). The National Sleep Foundation’s (2003) survey in 2002 on the elderly in the United States showed that 46% of people aged 65 to 74 and 50% of people aged 75 to 84 reported insomnia symptoms. A Hong Kong sample of the elderly aged 70 or above also reported insomnia at a rate of 38.2% (Chiu et al., 1999). The prevalence of insomnia increases with age, which is attributable to poorer health (Ohayon, 2002; Tjepkema, 2005). Medical problems associated with insomnia in the elderly include cerebrovascular disease, chronic obstructive lung disease and arthritis (Norman, Osama, Marc, and Mark, 2007). Psychiatric problems such as depression, anxiety and alcoholism may also cause insomnia in the elderly (Krystal, Thakur, and McCall, 2005). Inactivity is a predictor of insomnia in the elderly, while being active is a protective factor (Ohayon, Zulley, Guilleminault, Smirne, and Priest, 2001; Kawamoto, Yoshida, Oka, and Takagi, 2004). Negative outcomes of insomnia in the elderly are associated with poorer self-reported health status, cognitive decline, increased risk of falls and institutionalization (Cricco, Simonsick, and Foley, 2001; Billiard and Bentley, 2004). Promoting sleep hygiene will be important to improve the elderly’s health and quality of life. Health promotion in HK is still mainly based on a medical model that is expert-driven and overlooks the health determinants, e.g., social support and lifestyle of individuals which impact on health (Macdonald, 1992). The Ottawa Charter had set out five frameworks of health promotion action (WHO, 1986 as cited in Wass, 2000). These actions included building a health-promoting public policy, creating supportive environments, strengthening community action, developing personal skills and reorienting health services (WHO, 1986 as cited in Wass, 2000). For effective health promotion, the Charter stressed intersectoral collaboration between health and non-health sectors, community partnership to increase sense of control of individuals and community health and addressed health determinants, such as socio-economic and living environments of people (Tones, Tilford, and Robinson, 1990 as cited in Wass, 2000). Local primary healthcare sleep promotion programs for the elderly are limited.

COMMUNITY SETTING FOR HEALTH PROMOTION In HK, the population of Kwun Tong district was 587,800 and the elderly population (aged 65 or above) was 90,800 in mid-2005 (Census and Statistics Department, 2006). There were 184,808 elderly people receiving Comprehensive Social Security Assistance (CSSA) in HK, and the Kwun Tong district had a high number of CSSA recipients totalling 64,789 in 2004 (Chow, 2005). Wan Hon Estate, one of the public rental housing complexes in Kwun Tong, was built in 1998 (Hong Kong Housing Authority, 2008). The number of rental flats was 1,000 and the authorized population was 2,000 as at the end of December 2007 (Hong

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Kong Housing Authority, 2008). It had a high concentration of 885 elderly residents (Suen, 2003). Inferring from the CSSA figures, Wan Hon Estate has a large proportion of elderly people with low socio-economic status. Understanding the social determinants such as wealth and culture is important (Reidpath, 2004) and health promoters need to address poverty, powerlessness and lack of social support since the elderly’s health risks may be associated with these issues (Higgins, Young, Cunningham, and Naylor, 2006). Therefore, we will choose our target population of the elderly living in singleton units of Wan Hon Estate as they are marginalized. Empowerment and community involvement are important for health promotion (WHO, 1991). Through our program, the elderly can be empowered to gain better control over their health by taking active roles to engage in health promoting activities. We will adopt the setting approach in our program since the setting of people’s lives, e.g., neighbourhood will be good for health promotion by sustained patterns of communication and interaction (Mullen et al., 1995 as cited in McMurray, 2003). Wan Hon District Elderly Community Centre (DECC) in Wan Hon Estate will be chosen as the community-based setting for easy access by the elderly. Family members/caregivers/friends will be involved since family support will increase the elderly’s self-esteem, competency and autonomy (Siu and Philips, 2002).

COMMUNITY NEEDS ASSESSMENT WHO (1974, p.7 as cited in Stanhope and Lancaster, 1992, p. 254) defined community as “a social group determined by geographic boundaries and or common values and interests. Its members know and interact with one another”. Comprehensive need assessment is crucial since identifying and prioritizing individual and community needs will be the initial stage before health promotion program planning (Ewles and Simnett, 2003). There is continuous need for health care services but the supply is unevenly distributed so people always do not receive the health care they wish (Ewles and Simnett, 2003). Putting the service users' needs as the top concerns will be a client-centred and self-empowerment approach to health promotion (Ewles and Simnett, 2003). Community participation is the key to accurate assessment of individual and community needs (McMurray, 2003). Program participants can be recruited within targeted neighbourhoods (Kelly, Bobo, McLachlan, Avery, and Burge, 2006). With prior notice, we will pay an informal visit to elderly members of Wan Hon DECC. We will adopt the stage of community assessment and problem analysis of the qualitative methods as the need assessment framework in our program. This stage will include in-depth interviews, group interviews and field notes to collect relevant data from clients (Denzin and Lincoln, 1994; Stecker, McLeroy, Goodman, Bird, and McCormick, 1992 as cited in Farquhar, Parker, Schulz, and Isreal, 2006). In-depth interviews aim at collecting information and understanding of community networks (Farquhar et al., 2006). We will invite 10 elderly for in-depth individual interviews to allow understanding of their experiences and beliefs (Patton, 2002 as cited in Farquhar et al., 2006) about sleep problems and health needs. Besides, group interview will be useful to collect opinions of small group of clients concerning a commonly shared health problem (Basch, 1987; Eng, Clik, and Parker, 1989 as cited in Farquhar et al., 2006).

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After an in-depth interview, we will invite ten elderly for a group interview to listen to their feelings and experiences about sleep problems. We will encourage them to give opinions and feedbacks for our program planning. Health problems of individual and community can be prioritized after the comprehensive need assessment and objectives of program can be established (Hawe, Degeling, and Hall, 1990). Further, field notes are useful to minimize time between observation and recording (Lofland and Lofland, 1971 as cited in Farquhar, et al., 2006). Therefore, we will record my observations during individual and group interviews by field notes which will include the process of meetings, issues discussed, dialogue and interactions between participants. Need analysis can be done after need assessment. We will identify the needs of elderly with sleep problems as felt need since it is “the need that people feel” (Ewles and Simnett, 2003, p. 103). Expressed need will also be identified as it is a “felt need of people that turned into an expressed demand” (Ewles and Simnett, 2003, p. 103).

GOOD NIGHT’S SLEEP PROGRAM PLANNING Alma Ata Declaration (Navarro, 1986) emphasized on community partnership in program planning. To promote effective partnership work in our program, we will follow steps suggested by Japhet and Hulme (2004). Our first priority is to invite 10 elderly members (aged 60 or above) of Wan Hon DECC and their family/caregivers/friends to join individual and group interviews for need assessment. We will send a letter to the social worker in-charge of DECC to introduce my program, to invite the staff to join as our health team members and to gain informed consent for our informal visit to elderly members. Interview will be taken place in an interview room of the DECC to ensure privacy and confidentiality of participants. During interview, we will introduce our program topic and invite elderly to talk about their health concerns, share their experiences and viewpoints to help us know what they want since it will be on a client-driven approach. Our second priority is to write to the Hospital Authority (HA) of HK to gain ethical approval and human resource support for our program. Involving community organization’s commitment and creativity can facilitate community ownership of the program (Minkler and Hancock, 2003 as cited in Findley et al., 2006). Meanwhile, partnership and collaboration with health and non-health sectors are essential for health promotion (WHO, 1991). We will list out related community health and non-health organizations and send letters to invite staff to join our program as health team members since teamwork and intersectoral collaboration is important for effective health promotion. These workers will include one social worker, one clerical staff and some volunteers of Wan Hon DECC, one self-employed part-time nurse, one physiotherapist and one clinical psychologist from United Christian Hospital which is a local hospital in Kwun Tong district run by the HA. We will communicate with our team members by phone, electronic mail and meetings at DECC. Building client and family partnership by family-centred care is important for health promotion (Mercurio, 2007). Health promoters need to respect clients and family/caregivers/friends’ choices by incorporating their cultures, values and knowledge into planning and implementing program (Mercurio, 2007). We will arrange a program planning meeting with the elderly, their family/caregivers/friends and health team members one week after need assessment for information sharing, analyzing data, division of labour, decision and formulating plan for program implementation.

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Individual sleep assessment in DECC by standardized questionnaire (Appendix 1) will be employed to assess client’s sleep problems. Twenty elderly aged 60 or above, both sexes, with sleep assessment scores 7 or above will be recruited into our program after assessment. Our third priority is to invite television stars Ms. Law Lan and Mr. Wu Fung as the guest speakers in the health talks since they have a positive image of healthy ageing and may attract the elderly to join our program. We will write to the financial manager of Johnson’s pharmaceutical company to apply for financial sponsorship for our program. We will also write to the chief manager of Watson’s Store to appeal for donation of daily necessity items and cash coupons to my clients as incentives to join our program.

PROGRAM IMPLEMENTATION We will focus on Ewles and Simnett’s (1999 as cited in Jones and Naidoo, 2000) clientcentred, educational and behavioural approaches to health promotion in our program. Intersectoral collaboration is required for effective health promotion (Inchley, Muldoon, and Currie, 2006). Collaboration with related health and non-health sectors and community participation will be the main components of our program implementation. Setting-based approach which is derived from the Ottawa Charter’s health promotion action on creating supportive environment emphasized on changing people’s health and health behaviour by working on settings rather than individuals (Whitelaw et al., 2001 as cited in Kokko, Kannas, and Villberg, 2006). Therefore, we will choose Wan Hon DECC as the community-based setting to encourage community participation in our program. Health messages can be delivered by mass media, e.g., posters and leaflets in health promotion programs. It can reach the audience in a short time but there will be no interpersonal communication or support between the health promoters and mass audiences (Tones and Tilford, 1994). Large-sized banner and posters will be displayed in DECC and neighbourhoods to inform and invite elderly members and their family/caregivers/friends. Since TV stars Ms Law Lan and Mr. Wu Fung have positive images of healthy ageing, inviting them to act as the guest speakers in the health talks will be a good way to draw the elderly’s interests and attract them to participate. Visual and audio stimulations such as colourful pictures or photos, VCDs will be used to convey health messages to the participants since the elderly may be illiterate. Educational pamphlets with simple words and clear pictures will be designed and issued to all participants. Each recruited elderly participant is needed to complete a self-report questionnaire on sleep assessment (Appendix 1) before the first session of our program for baseline assessment. Team members will assist them to fill in the questionnaires if they have reading or writing problems. We will interview the high risk clients individually at DECC and refer them to get medical attention if they have severe sleep problems that affect their health. For effective implementation, leadership is crucial since leaders needs to plan, delegate work, support team members and liaise with community partners (O’Connor-Fleming and Parker, 2001). We will give our name cards and keep contact with team members and the elderly to resolve any problem encountered. We will invite the part-time nurse and the elderly to be the speakers and organizers of the health talks since the elderly can also teach us how to establish a healthy lifestyle to promote sleep. Sessions 1 to 4 of our program will include

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health talks on causes of insomnia, positive and negative sleep habits, environmental modification to improve sleep and sleep hygiene tips. Relaxation training workshops will help clients develop personal skills on relaxation to improve sleep since stress can affect one’s breathing (Griffey, 1999). Learning proper breathing is the key to effective relaxation. Physical exercise also promotes mental relaxation and meditation will help one to relax since worries can disturb sleep at night (Griffey, 1999). Physiotherapist and clinical psychologist will organize relaxation training workshops in Sessions 5 to 7 including meditation, breathing and physical exercise. Demonstration and practice will be stressed to facilitate the elderly to learn relaxation skills. In addition, social activity of Chinese tea gathering with the elderly, their family/caregivers/friends and health team members will be held in Session 8 to increase social interactions and communication in natural settings. The elderly can combat stress through social support from family/caregivers/friends since they can provide emotional concern and affirmation (Kwong and Kwan, 2004). Training the family/caregivers/friends to assist the elderly to develop sleep hygiene practice and recapitulation will be included in Sessions 9 and 10. Helping people obtain knowledge and skills can empower them to make health decisions (Ewles and Simnett, 1999 as cited in Jones and Naidoo, 2000). Through empowerment, health promoters can facilitate community and individual to plan interventions and undertake actions to achieve desired health outcomes (Commers, Gottlieb, and Kok, 2006). Moreover, environmental modification of light, noise and ventilation is required to promote sleep (Griffey, 1999). We will visit elderly clients at home if they agree to closely monitor the physical settings and conditions that hinder or promote sleep. We will fill in the home assessment checklist (Appendix 3) for data collection and record.

EVALUATION Evaluation is defined as a “comparison of an object of interest with a standard of acceptability” (O’Connor-Fleming and Parker, 2001, p. 98). Evaluation can let us know the outcomes and can allow us to modify our program. We will adopt the pilot approach (O’Connor-Fleming and Parker, 2001) to collect feedback from participants and team members concerning the various dimensions of the program from educational materials to health team members. Multiple baseline assessments can be done to collect data in different stages to ensure reliability of program (Yancey et al., 2006). Baseline assessment on sleep hygiene by group interview, standardized sleep assessment questionnaire (Appendix 1) and phone survey on sleep hygiene assessment (Appendix 2) will be done before Session 1, after Session 10 and then from 3 to 6 months after completion of program. This can help us explore effectiveness of the program in changing the health behaviours/lifestyles of clients to improve sleep hygiene. Pre-test (Appendix 4) will be done for clients before Session 1 and post-test (Appendix 5) will be done after Session 4 to see whether they can learn the potential causes of insomnia. Clients can be directly observed to check whether they can master relaxation skills during workshops. Clients, their family/caregivers/friends and team members will all be involved in the evaluation process and ongoing feedback will be collected from them.

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DISCUSSION The strengths of our program will include adopting intersectoral, interactive and clientdriven approaches to enhance the sleep hygiene of the elderly with sleep problems. The data and experiences gained from this program will be valuable for further development of programs in the future. Well-trained and committed health promoters will be one of the key factors affecting the success of the health promotion program. However, because this is our first time leading a community-based program, we may not have enough experience to lead our team members. We do not know the sustainability since ongoing sources of funds for health promotion may not be guaranteed. Clients’ responses are also difficult to predict and the drop-out rate is uncertain. Moreover, the effectiveness of program cannot be ensured because there is no full-time staff running the program. Environmental factors (Commers et al., 2006) are crucial in any health promotion program. There will be hurdles for the elderly without adequate resources in DECC if there is insufficient space or lack of audio-video facilities. Adequate funding, resources and participants’ interests will be important facilitators of health promotion (Robinson, Driedger, Elliott, and Eyles, 2006). Conversely, lack of participants’ interest, lack of skilled and committed health promoters, inexperienced leadership and lack of resources will be barriers (Robinson, et al., 2006). The Bangkok Charter (2005 as cited in Porter, 2006) suggested that sectors of government, civil society and private sectors have unique roles and responsibilities in health promotion. We wish the HK government to consider the health policy-making practice of providing funds to health and non-health sectors and to support community health promotion programs.

CONCLUSION Sleep problems may affect the elderly’s physical and mental status as well as quality of life. Sleep hygiene concepts provide important health knowledge that individuals need for better sleep management. Our health promotion program to enhance sleep hygiene for the elderly with sleep problems will be appropriate and timely. Our program will be a pioneering community-based program aimed at intersectoral, interactive and client-driven approaches for the elderly. Equity, empowerment, community participation, community involvement, community ownership, intersectoral collaboration and partnership in a community-based setting for clients/family/caregivers/friends will be targeted. We wish to do some community health promotion programs different from our clinical practice in hospitals. We hope that the funders can consider and support our proposal because we wish to work for the minority group of the elderly. Our program is justified because there are only a few programs developed for promoting the elderly’s sleep hygiene in HK.

AUTHOR’S PROFILE May Li is an Advanced Practice Nurse of Community Psychiatric Nursing Service at United Christian Hospital. She has attained Bachelor of Health Science (Nursing) and Master

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of Primary Health Care degrees. She is currently an adjunct tutor and nursing specialty mentor.

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World Health Organization. (1991). Community involvement in health development: Challenging health services. Geneva: WHO. World Health Organization. (1994). ICD-10 Classification of mental and behavioural disorders with glossary and diagnostic criteria for research. New York: Churchill Livingstone. Yancey, A. K., Lewis, L. B., Guinyard, J. J., Sloane, D. C., Nascimento, L. M., Gilliam, . G., Diamant, A. L., and McCarthy, W. J. (2006). Putting promotion into practice: The African American building a legacy of health organizational wellness program. Health Promotion Practice, 7 (3) 233S-246S.

APPENDIX 1 Sleep Assessment Questionnaires Name of client:

Sex/age:

Date:

Assessor:

1. Do you have any difficulty falling asleep or waking up early?

Yes □

No □

2. Do you have irregular sleep patterns?

Yes □

No □

3. Do you doze off often in the daytime?

Yes □

No □

4. Do you often smoke or drink alcohol before sleep?

Yes □

No □

5. Do you have frequent naps in the daytime?

Yes □

No □

6. Do you use sleeping pills?

Yes □

No □

7. Is there any environmental factor affecting your sleep?

Yes □

No □

8. Do you have any recent life stress?

Yes □

No □

9. Do you have any physical illness e.g., arthritis, chronic obstructive pulmonary disease?

Yes □

No □

10. Do you have any psychiatric illness, e.g., depression?

Yes □

No □

Remarks Yes (score 1)

No (score 0)

Total scores 7 or above indicate clients with severe sleep problems.

Good Night’s Sleep Program for the Elderly Living in Wan Hon Estate

APPENDIX 2 Sleep Hygiene Assessment Name of client:

Sex/age:

Date:

Assessor:

1. Do you have frequent daytime naps?

Yes □ No □

2. Do you do physical exercise daily to improve sleep at night?

Yes □ No □

3. Do you have regular sleep patterns?

Yes □ No □

4. Do you have improved total hours of night sleep?

Yes □ No □

5. Do you drink alcohol attempting to help you sleep?

Yes □ No □

6. Do you modify your home setting, e.g., opening windows to ensure adequate home ventilation to improve sleep?

Yes □ No □

7. Do you have a lot of night meals before sleep?

Yes □ No □

8. Do you engage in daytime activities?

Yes □ No □

9. Do you take drugs bought on-the-counter for insomnia?

Yes □ No □

10. Do you seek professional help for persistent insomnia?

Yes □ No □

APPENDIX 3 Home Assessment Checklist Name of client: Checklist items Lighting Noise Curtains Home Environment Home Ventilation Pillow Bed Mattress Others

Sex/age: Remarks

Date:

Assessor:

59

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May M. Y. Li and Zenobia C. Y. Chan

APPENDIX 4 Pre-Test of Health Talks Name of client:

Sex/age:

Date:

Assessor:

1. Light, noise and ventilation can affect sleep.

Yes □ No □

2. Stress can disturb sleep.

Yes □ No □

3. Taking a heavy night meal will improve sleep.

Yes

4. Frequent napping in daytime will disturb sleep at night.

Yes □ No □

5. Use of tobacco, alcohol and caffeine will promote sleep.

Yes □ No □

6. Physical illness e.g., asthma can affect sleep.

Yes

7. Psychiatric illness e.g. depression can affect sleep.

Yes □

8. Relaxation skills can promote sleep.

Yes

□

No □

9. A regular sleep pattern can help resolve sleep problems.

Yes

□

No □

10. Taking sleeping pills is the only way to resolve sleep problems.

Yes

□

No □

□

□

No □

No □ No □

APPENDIX 5 Post-Test of Health Talks Name of client:

Sex/age:

Date:

Assessor:

1. Light, noise and ventilation can affect sleep.

Yes □ No □

2. Stress can disturb sleep.

Yes □ No □

3. Taking a heavy night meal will improve sleep.

Yes

4. Frequent napping in daytime will disturb sleep at night.

Yes □ No □

5. Use of tobacco, alcohol and caffeine will promote sleep.

Yes □ No □

□

No □

Good Night’s Sleep Program for the Elderly Living in Wan Hon Estate

□

61 No □

6. Physical illness, e.g., asthma can affect sleep.

Yes

7. Psychiatric illness, e.g., depression can affect sleep.

Yes □ No □

8. Relaxation skills can promote sleep.

Yes

□

No □

9. A regular sleep pattern can help resolve sleep problems.

Yes

□

No □

10. Taking sleeping pills is the only way to resolve sleep problems.

Yes

□

No □

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 5

A HEALTH PROMOTION PROGRAM ON INCREASED FRUIT AND VEGETABLE CONSUMPTION FOR MIDDLE-AGED MALE OFFICE WORKERS IN CENTRAL DISTRICT, HONG KONG Michelle M. S. Wu and Zenobia C. Y. Chan ABSTRACT Health promotion programs that focus on a healthful diet have not been extended to central obesity. “Screen slave” middle-aged male office workers unlikely to seek health care services are particularly vulnerable to many chronic diseases associated with central obesity. This chapter aims to a) increase awareness of eating sufficient fruits and vegetables for the middle-aged male office workers in Central, b) create a supportive environment to increase fruit and vegetable consumption, c) increase the frequency of eating foods high in fruit and vegetable content, and d) reduce waist circumference of middle-aged male office workers. Needs assessment will be conducted in 400 interviews and questionnaires to guide development of a four-session program. Health education and “hot tips” on increasing fruit and vegetable consumption will be offered to 200 male office workers. Collaboration with Eat Smart restaurants and the men’s meal preparers to provide foods with high fruit and vegetable content creates a supportive environment and ensures sustainability. Evaluation of change in waist circumference and frequency of fruit and vegetable consumption will be done by interviews and partnership with health care providers in Central. Close intersectoral collaboration and community development is expected in this project. Uncertainty regarding the commitment of the Eat Smart restaurants is the major potential limitation. As pioneers in adopting a comprehensive PHC approach, we will continue future promotion programs in other districts to strengthen the message of adequate consumption of fruits and vegetables to middle-aged male office workers.

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BACKGROUND OF THE PROGRAM Recent programs for middle-aged men during the past few years have been concerned with lifestyle factors associated with health and chronic diseases. Cross-sectional studies include the relationship between consumption of cigarette smoking and body size to lymphoma aetiology (Lim, 2007), the link between increased consumption of vegetables and fruit and body weight, risk factors for cardiovascular disease and sleep-related breathing disorders (Svendsen, Blomhoff, Holme and Tonstad, 2007), the association between commuting, leisure time and total physical activity and risk factors for cardiovascular disease (Smith, 2007), and promoting physical activity with spiritually- and culturally-specific activities and social support to reduce health disparities (Bopp, 2007). In America, a new health screening program is targeted to men’s heart and circulation problems (Paton, 2008). In Canada, the need for heart disease prevention programs for Chinese immigrants has been determined, especially aimed at increasing fruit/vegetable consumption and regular physical activity (Hislop, 2008). Some longitudinal studies show that a dietary pattern of increased vegetables and fruits, reduced smoking and alcohol lowers the risk for chronic diseases (Ambrosini et al., 2008; Estaquio et al., 2008; Flood et al., 2008; Lockheart, 2007; Willcox, 2006) such as heart disease, stroke, diabetes, obstructive pulmonary diseases, sexual dysfunctions (Anonymous, 2007; Estaquio et al., 2008), different kinds of cancers, metabolic syndromes (Anderssen, Caroll, Urdal, Holme, 2007) as well as early death (Anonymous, 2008; Estaquio et al., 2008), particularly in men. Identifying strategies to avoid certain risk factors to remain healthy, vigorous, and disability-free at older ages has become a major priority of middle-aged men (Willcox, 2006). Large-scale studies show that the global obesity problem is caused by urbanisation, readily-available fast foods and sedentary life-styles, which bring about many chronic diseases including hypertension, diabetes, cardiovascular diseases, colorectal cancer and other musculoskeletal as well as psychological problems (Ackard, Neumark-Sztainer, Story and Perry, 2003; Coskram, 2000; Goran, Sothern, 2006; Tse and Mak, 2004; Wong et al., 2005; Xie et al., 2006). A joint expert consultation of the United Nations Food and Agriculture Organisation (FAO) and the World Health Organization (WHO) reports in 2002 that obesity contributes approximately 59% of the 56.5 million total reported deaths around the world, and scientific evidence on diets high in vegetables and fruit, together with regular physical activity, can prevent chronic diseases related to obesity (WHO and FAO, 2002). This report provides a foundation for the WHO to develop global strategies to prevent obesity. In April 2003, the WHO recommended daily consumption of fruits and vegetables of at least 400 grams, 40 minutes per day of moderate-intensity physical activity and that creating an environment with major stakeholders involved in food, physical activity and chronic diseases is needed in promotion programs (WHO, 2003). The traditional Chinese diet is rich in plant foods and only 20% comprises animal foods, which is far less than that of the typical Caucasian diet (WebMD, 2008). But due to Westernisation and mechanisation, the diet in Hong Kong has gained more and more fat and salt content, and people spend less and less time engaging in physical activity (Woo, Leung, Ho, Janus and Lam, 1998). Obesity has become significant, especially in children and adolescents (Lobstein and Uauy, 2004). Based on the WHO recommendation, the Department of Health

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(DH) in Hong Kong advocates five servings of fruits and vegetables per day and has produced many educational materials for different age groups and communities, and a series of initiatives, including “Enjoy Fruits and Vegetables, Every Day: 2 Plus 3 Is the Way”, “Eat Smart at School”, and “Eat Smart at Restaurants” have been launched since then (DH, 2008). However, central (visceral or abdominal) obesity is an increasing trend in middle-aged men and post-menopausal women (HKU, 2007). Cockram (2000) finds that the risk of diabetes is associated with central obesity, particularly in younger Chinese men, while Vgontzas et al. (2000) says that in addition to diabetes and heart disease, sleep apnoea, daytime sleepiness and fatigue are common in centrally obese middle-aged men. More recent studies finds that visceral fat causes a 145% increase in the risk for development of dementia, and an overall risk for colon cancer and premature death, especially in men (The Standard, 2006). It also causes a 3.3 times and 4 times higher risk for developing hypertension and diabetes, respectively, in centrally obese persons in Hong Kong (HKU, 2007). Although the problem of central obesity in Hong Kong in women (32%) is less serious than in Western countries (48%), the problem in men is highest (37%) among other Western countries (29%), such as Australia (22%), Western and Northern Europe (22%) or Canada (36%). Life expectancy is 79.3 in men and 85.4 in women (DH, 2008); we feel that a poor quality of life for men later in adulthood and in elder years can be anticipated. Apart from physical problems, central obesity imposes great social and psychological stress on men, as their families and friends depend on them. They want to be there for their families. Also, 90% of women prefer a man’s body that is “lean and athletic” rather than “big and bulky”; it is ugly to have belly fat (MSNBC, 2008). Actually, a healthy diet and regular exercise can lead to a substantial drop in abdominal fat, as it is metabolically very active (The Standard, 2006). Fruits and vegetables, with their high fibre and antioxidant vitamins, protect against chronic diseases (Ho, Yuen and Lam, 2006). However, promotion initiatives usually focus on promoting physical activity to lose visceral fat, rather than promoting intake of fruits and vegetables. As men traditionally underuse preventive care, they very often avoid proper health care unless experiencing a crisis (Meador and Linnan, 2006). Moreover, “men don’t cry” Chinese culture (Lau, 2002) aggravates the problem. In addition, clerks are the most sedentary occupation (DH, 2005) in Hong Kong. We think these middle-aged office workers are a minority group. Primary health care advocates for benefits for those marginalized, and most centrally obese middle-aged office workers frequently eat outside of the home. We are concerned about their health, and therefore propose a health promotion program for eating fruits and vegetables for the middleaged male office workers.

HEALTH PROMOTION PROGRAM OBJECTIVES The objectives of this health promotion program are: a.

to increase awareness among middle-aged male office workers of the importance of eating sufficient fruits and vegetables, b. to create a supportive environment to increase fruit and vegetable consumption, c. to increase the frequency of eating foods high in fruits and vegetables and

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Michelle M. S. Wu and Zenobia C. Y. Chan d. to reduce waist circumferences of the middle-aged male office workers.

TARGET POPULATION The target population is the middle-aged male office worker in Central. These men are at the age between 30 and 50, as 30–40% of these men significantly increase frequency of central obesity to 37% of the male population (HKU, 2007). Their occupations can be managers or administrators, professionals, professional assistants and clerks. They may be working or living in Central. Concerning their diet behaviour, focus group interviews (HKU, 2005) find that men working in offices in Hong Kong have knowledge about healthy eating, but less so than women. Many skip breakfast daily and often overeat later in the day. They do not like packing lunch for work because it is not tasty, it is troublesome and they perceive eating out with colleagues as a social function. Their meal habits are irregular due to varied working hours, heavy workload, and business meals. A total of 86.3% consume fewer than five servings of fruits and vegetables per day, as they prefer meat, are too lazy and not interested in fruits unless someone serves them. They believe that dietary practices can be influenced by people around them, especially their spouses, friends, and if fruits and vegetables are easily accessible. Besides, office workers are getting more sedentary than before due to increased use of sending messages to pass on information to others. They even send e-mails to colleagues who sit next to them. This “screen slave” culture has developed and many are missing out on the little exercise available to them; they are deskbound workers who fall well below the recommended 40 minutes of exercise per day as recommended by the WHO.

HEALTH PROMOTION FRAMEWORK The planning of this program follows the Eight-Step model of evaluation (O’ConnorFleming and Parker, 2001). With a focus on increasing intake of fruits and vegetables by middle-aged male office workers in tackling the problem of central obesity, I will thus design the program plan, evaluation methods and ways to reassess and continue in the future. The WHO has initiated Health Promotion as a strategy for achieving Health for All (WHO, 1984). The five key domains of the Ottawa Charter for Health Promotion (WHO, 1986) give me concepts and ideas to design this program, which adhere the seven primary health care principles, including community participation, intersectoral collaboration, effectiveness, teamwork, budget reorientation, equity and social justice (WHO, 1978). These five actions include the following: (a) building a health-oriented public policy wherein a promotion program should involve legislation to work for social and behavioural change. We think that lowering license fees for restaurants providing healthy meals, nutrition labelling in Hong Kong, increasing tax on unhealthful foods, etc. are possible methods for promotion. (b) creating a supportive physical and social environment that supports middle-aged male office workers in making healthful food choices. We think that continuing the “EatSmart at Restaurant” campaign to recruit more food sites in Central to provide foods high in fruits and

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vegetables impart a message to the office workers that eating healthful food is trendy and an art of wisdom. Advertising for “2 Plus 3” healthful eating concepts by displaying posters near the restaurants, banners in the streets and other eye-catching areas can be introduced to this program. (c) strengthening community actions enabling all people to develop empowerment to determine their own needs and control over their health. We believe that collaboration with those food premises in Central who provide rewards in the “EatSmart at Restaurant” campaign by offering discounts for the program’s participants can be effective. Participation of the participants’ spouses or their meal preparers to cook healthful dishes at home can gradually change their eating habits. Also, partnership with healthcare providers in Central to include waist circumference measurement as part of regular check-ups (HKU, 2007) can be incorporated into this program. (d) developing personal skills giving people the knowledge and tools to deal with their health problem. We suggest that the middle-aged male office workers should learn some “hot tips” on how to sneak fruits and vegetables into their diet. They should regularly check their waist circumference to effectively prevent central obesity. (e) reorientating health services—government should reallocate more funds into primary healthcare treatment. We realise that funding from the Hong Kong government should be reallocated to effectively prevent central obesity by treating associated chronic diseases for the middle-aged male office workers. This combination of strategies and PHC principles are in line with the model of health promotion, which claims that health promotion is based on interrelated actions of health education, health prevention and health protection (Katz, Peberdy and Douglas, 2000).

NEEDS ASSESSMENT Hong Kong is composed of Hong Kong Island, Kowloon and New Territories, wherein Central, the largest commercial district in the Hong Kong, is a metropolitan area that serves as one of the world’s primary global areas, exerting a powerful influence over worldwide commerce and finance. It is full of commercial buildings, distinctive historical relics and skyscrapers. It is a district where local, joint state/private businesses and civilian activities thrive. Central is home to about 125,000 people, and up to 250,000 people flock there daily to work (Hong Kong Fun in 18 Districts, 2007). The majority of office workers there work five or six days a week. They always work overtime, walk in at a fast pace, and rush their lunch, are busy talking on the phone and usually leave the office at around seven in the evening. Most residents there live in private housing; many are luxury homes on the Peak and in MidLevels. There are an estimated 150,000 men aged 30 to 50 in Central, totalling about 2.3% of population. Among them, 68% are tertiary educated or above (Census and Statistics Department, 2007). Needs assessment in a health promotion program encompasses determining the health needs of a community and establishes priorities among these needs (Hawe, Degeling and Hall, 1990). It requires community involvement, helping to understand the problems in the process of program planning, finding solutions and performing evaluations. There are four

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types of need: normative need, felt need, expressed need and comparative need (Bradshaw, 1972). Normative needs in the central obesity in middle-aged male office worker issue are gathered in many readily-available published reports, defined by experts or administrators (Robinson and Elkan, 1996). For instance, 37% of men in Hong Kong are centrally obese (>90cm/35.4 inches) (HKU, 2007), 57% of total deaths from chronic diseases in 2005 were associated with unhealthful eating habits (DH, 2008), and clerks hold the most sedentary occupation (DH, 2005). Another estimation of the extent of central obesity among middle-aged male office workers will be obtained by expressed need assessment. What the participants perceive or want regarding their eating habits will be turned into expressed demand (Ewles and Simnett, 2003). So, we will use the validated questionnaire adapted from the Hong Kong Adult Dietary Survey (Ho, Yuen and Lam, 2006) to evaluate fruits and vegetables eating frequency in a week for this community. In addition, we will invite interviewees to taste 680 Eat Smart Dishes (DH, 2008) to select those popular recipes for printing out cookbooks, which will be given to the participants and their meal preparers at home.

PROGRAM PLANNING This promotion program uses a workplace-based approach, as the workplace environment and culture are key leverage points for adults’ obesity control (Yancey et al., 2006). Within this model, contextual and social factors are considered that can strengthen the middle-aged male office worker’s sense of coherence, creating a supportive workplace environment and incorporating community actions (Kickbusch, 1997) to increase their fruit and vegetable consumption and bring about good health. Stages of the program development are illustrated in Figure 1.

APPLICATIONS OF HEALTH EDUCATION AND HEALTH PROMOTION STRATEGIES At stage 1, a partnership with a medical officer and a dietician from, preferably, Queen Mary Hospital (a tertiary hospital in Central) to develop health education on central obesity and eating fruits and vegetables will be established. Collaboration with the Central District Council to recruit administrators and volunteers who show enthusiasm will be selected through a brief interview process. A yoga instructor will be invited for demonstration in the last session. Other collaboration partners will include clinics and restaurants on the Eat Smart list in Central. Regular meetings will be held and suggestions will be carefully discussed. Volunteers will be trained. A budget from the Health Care Promotion Fund will be applied at a sum of around 20,000–30,000 Australian dollars, enough for 100 hours of the invited partners, advertisements, food, printing materials, administrative expenses and rewards used in this program. A slogan, “Belly-Free Healthy Man”, will be given to this program.

A Health Promotion Program on Increased Fruit and Vegetable Consumption . . .

69

Stage 1: Formulation of program committee (Jan, 09 – March, 09) z Liaise with different community partners z Identify roles and make commitment z Conduct formative research z Write up proposal for budget request

Stage 2: Need Assessment (400 interviewees) (April, 09 – June, 09) z Advertise the program in Central z Conduct questionnaire adapted from the Hong Kong Adult Dietary Survey z Taste of Eat Smart Dishes z Introduce the program z Give “Belly Free Healthy Man” membership card

Stage 3: Program implementation (2 weeks, 40 participants in each program) (July, 09 – Dec, 09, total 200 participants) z Evaluate need assessment results, prepare the program z Partner with primary health care providers, Eat Smart restaurants z Conduct the program

5 cycles Stage 4: Program evaluation (2 weeks between each program) z Assess if objectives achieved z Examine area of program modification or other change need z Modify the program

Stage 5: Follow up (up to 2-3 years) z Bimonthly boost up intervention: sending reminders, telephone contact or home visits to assess dietary lifestyle z Collaborate with health care providers to check up W.C. regularly z Continue to collaborate with Eat Smart restaurants in offering discount

Figure 1. “Belly-Free Healthy Man” program development.

At stage 2, needs assessment will be conducted for about 400 men, both in collaborating clinics while they are waiting and in the Statue Square (where many office workers congregate for lunch). Some questions will ask the target men to determine their age, contact mechanism, i.e., mobile phone number or e-mail address. Three Eat Smart dishes will be

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tasted and three satisfaction forms will be completed for each recipe. A “Belly-Free Healthy Man” membership card will be given to participants, but these must be verified when they join the program as a way of participant recruitment. Posters will be displayed in eye-catching areas. Advertisements on television, radio or the Internet delivered by an influetial figure, Mr. Tin Pak Chun, our legislative member as well as a successful, rich business man in his midlife, will be invited to advocate for this program. At the same time, actions to fight for lowering the license fee for the Eat Smart restaurants and nutrition labelling will be done. A total of 200 program participants are targeted by recruitment in needs assessment through e-mails and mobile phone contact and word of mouth recruitment, which is most welcomed as it helps to build a supportive social environment if colleagues or friends are joining together. In view of their busy life, the program is designed for four sessions and finished within two weeks. Forty participants enter the program at one time, and are predicted to finish after five cycles. Every participant is assigned an identification number so they are able to leave the program at any time and return later to pick up where they leave off. A multi-purpose activity room in City Hall (Owned by Hong Kong government) in Central will be the program site, as it is a convenient, comfortable place for the office workers, and support from the government is expected. The room should be around 800–1000 square feet, with cooking and audio-visual equipment. Grounded in an educational approach to health promotion, sharing time is provided in each session. Participants are encouraged to share their opinion, experience with and feelings on central obesity, “hot tips”, cooking a healthful diet and any other related issues. Since health education cannot be one way, interactive discussion on individual context and immediate feedback is important. Participants need to be well informed to make their health decisions (Tones and Tilford, 1994), otherwise it will be a one-sided health information session, and health education will not be effective. “Hot tips” are very practical strategies that the men, their spouse or their meal preparer can follow to increase fruits and vegetables consumption in their daily lives. They may include the following: “choose fruit for dessert, rather than sweet soup”; “put easy-to-eat fruits, like bananas or apples, in the briefcase for a snack”; “prepare a fruit box the night before”; “drink fresh juice instead of sweet beverages”; etc. Also, Chinese green tea can protect against both colon and rectal cancer (Ho, Yuen and Lam, 2006); this concept is reinforced every session. Giving cookbooks will bring about creating a supportive environment, as the effectiveness of individually-tailored print materials for changing to a healthful eating lifestyle has been demonstrated (Tessaro, et al., 2006). Also, they are all readily-accessible in the Eat Smart restaurants. Several participants will lead the cooking practice in session 3, as we believe that some of them are skillful and knowledgeable in cooking. Doing “Healthy Exercise for All” and yoga is introduced, as weight control is more effective with regular physical activity. The yoga instructor will come from Central. All of these activities involving cooking and physical activity make use of the wisdom and resources in the community and facilitate community development and empowerment of the participants, which is an important concept in PHC. According to the behavioural change approach, attitude and behaviour change is encouraged by positive reinforcement (Katz, Peberdy and Douglas, 2000). A reward will be given in last session for those participants who demonstrate eating more fruits and vegetables

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during the past week, even just little, so as to reinforce their positive change and set an example for the others.

PROGRAM EVALUATION The aim of the evaluation is to provide valuable input for the program committees, the participants and the stakeholders to assess whether the objectives and goal-attaining activities have been accomplished. Firstly, waist circumference of the male office workers will be evaluated by change in pre-intervention (session 1) and post-intervention measurement (upon follow-up contact or collaborating clinics). Secondly, change in frequency of intake of fruits and vegetables will be reflected by the results of the questionnaire adapted from the Hong Kong Adult Dietary Survey. Business changes in the Eat Smart dishes can provide information on the attitude of the program participants. Telephone interviews will be conducted with those not entering the program, to get more feedback and information on how to improve the program for future enhancement.

DISCUSSIONS Previous programs (Estaquio et al., 2008; Willcox, 2006; Anderssen, Carroll, Urdal and Holme, 2007) to examine healthful diet and lifestyle provide strong evidence of the effect of lowering the risk of chronic diseases. The National Nutrition and Health Program implemented in French (Estaquio et al., 2008) is a longitudinal study conducted over eight years which adheres to practical dietary guidelines on nutritional goals involving fruit, vegetable, and nutritient intake, nutritional status, and physical activity. It makes a great impact on promoting a healthful diet in a nation-wide basis. Whereas in Willcox’s study, the recruited middle-aged men are followed up for up to 40 years, their biological, lifestyle and sociodemographic risk factors are analyzed. This highlights the results that a healthful diet promotes a long life. Promotion programs in Hong Kong are mostly focused on obese children and their parents. My program has three main charisteristics. Firstly, there is no tailor-made program for central obesity. This program is a pioneer in promoting awareness of central obesity and targets middle-aged male office workers, who are a minority in Hong Kong and are overlooked by the medical healthcare system. In fact, central obesity in middle age is not confined to men, but also to women; not confined to office workers, but also to other occupational groups, such drivers; and not confined to Central, but also Tsim Sha Tsui (another commercial district). Secondly, this program is unique and pioneering in promoting a healthful diet in Central. There is no program targeted to a commercial and finance area. As an area with an international influence, Central accommodates thousands of businessmen with busy and stressful lives. They have arisen from the root class in the community, and they want to remain healthy and live longer in order to enjoy the fruits of hard work during their youth.

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Thirdly, this program is not conceptual, but practical, and is highly applicable with present resources in the local Hong Kong community. This program makes full use of the wisdom and resources in the community. The membership system of discounts at Eat Smart restaurants is attractive under the present high inflation economic situation. The restaurants can increase their business and promote their healthy image. Thus, the approach is win-win. Moreover, the measurement of W.C. by measuring tape is so simple and convenient that it should be feasible as a routine check in clinics. Also, using cookbooks of healthy recipes is an effective tool for the participants or meal preparers to follow. As the principles of food choice and cooking method are stated clearly, they can modify the recipes as they like. It enhances community development and empowerment of the meal preparers, and a dietary lifestyle that includes more fruits and vegetables can be sustained more readily. However, the commitment of Eat Smart restaurants to offer discounts for up to 2 to 3 years is not reliable in this program under unpredictable economic changes. Perception of the distance between the men’s office and the Eat Smart restaurants is unknown; after all, men may not bother to go far because of the little time allowed for lunch. Without an easily accessible environment, the office workers can hardly comply with a healthy diet. Also, the program for each participant lasts merely two weeks, but a longer period is required to boost intervention to maintain participants’ cognition and behavioural change. Close and significant coordination is required to maintain community participation and partnership. Poor working committees’ communication skills stand to weaken the program’s effectiveness. Sustainability of a healthy diet requires other actions to succeed and to impart societal change beyond this program in Central. To change the eating culture more thoroughly, the Hong Kong government needs to reallocate more funds to control nutrition labeling, to continue the year’s promotion strategies in healthy diet initiatives and to continue to educate the public on healthful eating habits.

CONCLUSION Chronic diseases caused by central obesity threaten Hong Kong middle-aged male office workers, particularly due to the “screen slave” and fast-food culture, and lack of motivation to seek health care. Out of social justice, this pioneer “Belly-Free Healthy Man” promotion program in Central based on setting approach, proposes health education on central obesity, skill development of using “hot tips” as well as community collaboration with Eat Smart restaurants and the men’s meal preparers to create supportive environment for increase fruits and vegetables consumption. This close community collaboration ensures sustainability of dietary lifestyle change. However, commitment and availability of these restaurants are main uncertainty in this program. Success in changing eating lifestyle is a social responsibility. It needs to work with other actions like policy making of the government in nutrition labelling, budget reallocation in continuing promotion strategies and numerous initiatives to develop personal skills in food choices for years. As pioneer in adopting a comprehensive PHC approach, we will continue future promotion programs in other districts to strengthen message of adequate eating of fruits and vegetables to the middle-aged male office workers.

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AUTHOR’S BACKGROUND Michelle Wu Mei Shan is currently practicing as an occupational therapist at United Christian Hospital, which is an acute hospital in the Kwun Tong district of Hong Kong. She earned her professional diploma in occupational therapy at Hong Kong Polytechnic University in 1991, her post-graduate diploma in business administration at the University of Hull, UK in 2000, and is studying for her master degree of primary health care at Hong Kong Baptist University. She has been worked in Singapore, and has worked with orthopedic, stroke and brain-injured clients in Hong Kong. She is particularly interested in teaching Qigong to chronically ill clients for self-sustainable health prevention and maintenance.

REFERENCES Ackard, D.M., Neumark-Sztainer, D., Story, M. and Perry C. (2003). Overeating among adolescents: prevalence and association with weight-related characteristics and psychological health. Pediatrics, 105, e15. Ambrosini, G.L., et al. (2008). Fruit, vegetable, vitamin A intakes, and prostate cancer risk. Prostate Cancer and Prostatic Disease. Houndmill, 11(1), 61-66. Anderssen, S.A., Caroll, S., Urdal, P., Holme, I. (2007). Combined diet and exercise intervention reverses the metabolic syndrome in middle-aged males: results from the Oslo Diet and Exercise Study. Scandinavian Journal of Medicine and Science. 17(6), 687-695. Anonymous (2007, October). 5 tips for staying sexually active. Urology Times.: Modern Health for Men. 6. Anonymous (2008, June 30). The Endocrine Society: Low testosterone appears to increase long-term risk of death. NewsRx Health and Science, 88. Bradshaw (1972). The concept of social need. New Society, 30, March. Bopp, M., et al. (2007). Understanding physical activity participation in members of an African American church: a qualitative study. Health Education Research. 22(6). 815826. Census and Statistics Department. (2007). 2006 Population By-Census. Retrieved June 6, 2008, from http://www.censtatd.gov.hk/freedownload.jsp?file=publication/ stat_report/ population/B11200512006XXXXB0400.pdf and title=%ad%bb%b4% e4%a4G%b9s%b 9s%a4%bb%a6%7e%a4%a4%b4%c1%a4H%a4f%b2%ce%adp+-+%a5D%adn%b2 %ce%adp%aa%ed and issue=- and lang=2 and c=1 Cockram C. S. (2000). The epidemiology of diabetes mellitus in the Asia-Pacific region. Hong Kong Medical Journal. 6 (1), 43-52. Department of Health. (2007). EatSmart web site. Retrieved June 25, 2008, from http://www. eatsmart. gov.hk/ Department of Health. (2008). Department of Health [email protected] Campaign. Retrieved June 25, 2008, from http://restaruant.eatsmart.gov.hk/eng/content.asp? content_id=29

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Department of Health. (2008). Health Facts of Hong Kong 2008. Retrieved June 25, 2008, from http://www.dh.gov.hk/english/statistics/statistics_hs/files/ Health_Statistics_pamphlet_ 2008e.pdf Department of Health. (2008). Major Health Behavioral Factors. Retrieved May 25, 2008, from http://www.chp.gov.hk/files/pdf/grp-hkphps-iv_behavioural_determinants_of_health. pdf Esposito, K., et al. (2008). Obesity and sexual dysfunction, male and female. International Journal of Impotence Research. 20(4), 358-365. Estaquio, C., et al. (2008). The French National Nutrition and Health Program Score is Assoicated with Nutritional Status and Risk of Major Chronic Diseases 1-3. The Journal of Nutrition. 138(5), 946-953. Ewles, L., and Simnett, I. (2003). Identifying health promotion needs and priorities. In Promoting health: A practical guide. London: Bailliere Tindall. Flood, A., et al. (2008). Dietary patterns as identified by factor analysis and colorectal cancer among middle-aged Americans. The American Journal of Clinical Nutrition. 88(1), 176. Hawe, P., Degeling, D. and Hall, J. (1990). Evaluating health promotion. Sydney: MacLennan and Petty. Hislop, T.G., et al., (2008). Knowledge and Behaviour Regulating Heart Disease in Chinese Canadian Immigrants. Canadian Journal of Pubic Health. 99(3). 232-235. Ho, J.W.C., Yuen, S.T. and Lam T.H. (2006). A case-control study on environmental and familial risk factors for colorectal cancer in Hong Kong: dietary determinants of colorectal cancer risk. Hong Kong Medical Journal. 12 (2). Supplement 1. Hong Kong Fun in 18 Districts. (2007). Welcome to 18 Districts-Central and Western District. Retrieved June 23, 2008, from http://www.gohk.gov.hk/eng/welcome/ cw_intro.html Katz, J., Peberdy, A., and Douglau, J. (Eds.). (2000). Promoting health: Knowledge and practice (2 nd ed.). London: Macmillan. Kickbusch, I. (1997). Health promoting environment: the next step. Australian and new Zealand Journal of Public Health. 21(4), 431-434. Lim, U., et al. (2007). Alcohol, Smoking, and Body Size Relation to incident Hodgkin’s and Non-Hodgkin’s Lymphoma Risk. American Journal of Epidemiology. 166(6), 697-708. Lockheart M.S.K., et al., (2007). Dietary patterns, food groups and myocardial infarction: a case-control study. The British Journal of Nutrition. 98(2), 380-387. Lobstein T, Baur L. and Uauy R. (2004). Obesity in children and young people: a crisis in public health. Obes Rev.:5(Suppl 1): 4-97. Lopez, D.G., et al. (2007). Effects of strength and endurance training on antioxidant enzyme gene expression and activity in middle-aged men. Scandinavian Journal of Medicine and Science. 17(5), 595-604. Meador M. G. and Linnan L. A. (2006). Using the PRECEDE Model to Plan Men’s Health Programs in a Managed Care Setting. Health Promotion Practice. 7 (2), 186-196. Msnbc. (2008). Unique dietary strategies. Retrieved June 23, 2008, from http://www.msnbc. msn.com/id/15389873 O’connor-Fleming, M. L. and Parker, E. (2001). Program planning and evaluation. In Health promotion: Principles and practice in the Australian context (2nd ed.). Sydney: Allen and Unwin.

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Paton, N. (2008). New health screening scheme set to target middle-aged men. Occupational Health 60(2), 7. Robinson J. and Elkan R. (1996). Health Needs Assessment: Theory and Practice, Churchill Livingstone. Smith L.v.H., Johnsen, K. B. and Jorgensen, T. (2007). Commuting physical activity is favourably associated with biological risk factors for cardiovascular disease. Euopean Journal of Epidemiology. 22(11), 771-779. Svendsen, M., Blomhoff, R., Holme I. and Tonstad, S. (2008). The effect of an increased intake of vegetables and fruit on weight loss, blood pressure and antioxidant defense in subjects with sleep related breathing disorders. European Journal of Clinical Nutrition. 61(11), 1301-1311. Tessaro, I., et al. (2006). Cookin’ Up Health: Developing a Nutrition Intervention for a Rural Appalachian Population. Health Promotion Practice. 7 (2), 252-257. The Standard. (2006). When your health goes belly-up. Retrieved June 25, 2008, from http://www.thestandard.com.hk/news_print.asp?art_id=17669 and sid=7724864 The University of Hong Kong. (2005). A qualitative study on dietary and exercise practices of people in Hong Kong-Main report. Department of Health. The University of Hong Kong. (2007). Abdominal Obesity-Waistline Measurement as a New and Independent Risk Marker for Heart Disease. Retrieved June 25, 2008, from http://web3.hku.hk/facmed/hkumed/news_list.php Tones, K., and Tilford, S. (1994). Health education: Effectiveness, efficiency and equity. (2nd ed). London: Chapman Hall. WedMD. (2008). The Chinese Diet. Retrieved June 25, 2008, from http://www.webmd. com/content/ pages/10/1671_51429 Willcox, B. J. (2006, December 9). Diet and Nutrition: Men who avoid certain risk factors in midlife may have a longer, healthier life. Obesity, Fitness and Wellness Week. 4. Woo J., Leung, S.S.F., Ho, S.C., Janus, E.D. and Lam T.H. (1998). A nutritional survey of the Hong Kong population in relation to cardiovascular health. Health Services Research Committee Reports. World Health Organization. (1978). Declaration of Alma-Ata, World Health, August/September 1988: 16-17. World Health Organization (1984). Health Promotion: A Discussion Document on the Concepts and Principles. WHO Regional Office for Europe, Copenhagen, Denmark. World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion, November 1986. WHO Regional Office for Europe, Copenhagen, Denmark. World Health Organization. (2003). FAO/WHO launch expert report on diet, nutrition and prevention of chronic diseases. Retrieved June 24, 2008, from http://www.fao.org/ english/newsroom/news/2003/16851-en.html World Health Organization and Food and Agricultural Organization. (2002). Diet, nutrition and prevention of chronic disease. Retrieved June 24, 2008, from http://www.fao.org/DO CREP/005/AC911E/AC911E00.HTM Wong, J.P. et al. (2005). Overweight, obesity, weight-related concerns and behaviors in Hong Kong Chinese children and adolescents. Acta Paediatric, 94, 595-601.

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Yancey, A. K., et al. (2006). Putting Promotion Into Practice: The African Americans Building a Legacy of Health Organizational Wellness Program. Health Promotion Practice. 7 (3). 233S-246S. Xie, B., et al. (2006). Weight perception and weight-related sociocultural and behavioral factors in Chinese adolescents. Preventive Medicine. 42. 229-234.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 6

HEALTH PROMOTION PROGRAM FOR PROMOTING A HEALTHFUL DIET TO FORM 2 STUDENTS IN SECONDARY SCHOOL IN SHATIN Rosanna K. Y. Lai and Zenobia C. Y. Chan ABSTRACT The prevalence of some chronic diseases throughout the world can be related to diet. In Hong Kong (HK), 57% of registered deaths were due to chronic diseases relating to unhealthful eating habits. ‘Fun in Seven’ and ‘Eat Smart At School’ (ESAS) were launched by Department of Health (DH) in HK to focus on primary school pupils. However, these health promotion campaigns made light of adolescents who have more autonomy and independence in choosing their daily foods. Therefore, we will launch a pilot school-based program to fill the gap and maintain the sustainability of previous campaigns with further development of adolescents’ personal skill in choosing a healthful diet. The program described in this chapter will be focus on a group of Form 2 (F2) students at a secondary school in Shatin. Health education will be provided as to achieve their behavioural change and further promote a healthful diet to the people around them. This chapter will raise the public’s recognition of the importance of a healthful diet for adolescents.

BACKGROUND The change in dietary pattern to a highly energy-dense and low fibre diet throughout the world has increased the prevalence of some chronic diseases, such as obesity, diabetes, cardiovascular disease and even cancer (WHO, 2003; Swinburn et al., 2004; Hassink, 2007). Adolescents, who are aged between 10 to 19, make up around 20% of the total world population (WHO, 2005), and they are also facing the risk of an unhealthful diet. Along with an increase in the prevalence of Western-style food and fast food in HK, there were 38.4% obese people with BMI > 23 in 2007 (Centre for Health Protection, 2007); 57% of registered deaths in 2005 were due to diet-related chronic diseases and 81.1% people ate fewer than five

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servings of fruits and vegetables per day (Centre for Health Protection, 2007). During 1997 to 2005, the number of obese children increased from 16.4% to 18.7% (DH, n.d.). In 2001 to 2002, a group of health and educational professionals, including advisors from The Chinese University of Hong Kong (CUHK) launched a ‘Fun in Seven’ campaign with funding from the Quality Educational Fund (QEF) (CUHK, 2002), which committed to improve young people’s eating habits. Meanwhile, the HK government also launched the ESAS campaign to promote healthy eating practices to primary schools pupils since 2006 (DH, n.d.). Health promoters, however, usually ignore adolescents in promoting a healthy lifestyle. This was because, compared with children and the elderly, adolescents were considered to be a population in relatively good health (Senderowitz, 1995); moreover, people give them less attention and care than to children (WHO, 2005). In HK, this ignorance was evidenced by the fact that most of the QEF adolescence development programs were only focused on the aspects of physical activity, literature and technology, but almost no healthful diet promotion, and less effort was given to sustain the ESAS effort in adolescents. It was also very difficult to find local references in this aspect. The prevalence of unhealthful eating habits was high among adolescents, even though they had significant knowledge to differentiate an unhealthful from a healthful diet, which posed a risk to their health (Kooten et al., 2007). They are at the stage of developing their own responsibility for health and gain more autonomy and independence in their diet habits, so promoting healthful diet to them is far more important because they will soon comprise the population of adults (WHO, 2005; Buchanan and Coulson, 2007). Therefore, we will launch a pilot school-based healthful diet promotion program to adolescents in a secondary school. The program described in this chapter will fill the gap, maintain the continuity of ESAS, and be tailor-made for their temperament (eager to be independent and with autonomy) by empowering them with control over their own health and to be health promoters. Shatin is situated in the New Territory of HK, with a higher population (607,544) than other districts (District Council, 2008) and 51 secondary schools. We will choose Pentecostal Lam Hon Kwong School (PLHKS), which is located near the Prince of Wales hospital. Since ESAS was launched in 2006, F2 students may have already come across a healthful diet program and basic concepts of a healthful diet while they were in primary school. Parents usually think that adolescents are more independent, so they may have more discretionary spending money than during their childhood, which allow more financial capacity to buy their favourite snacks and foods. They are at the stage in which they are eager to take control over their own life, and they like to have lunch outside of school with peers. For convenience and saving their lunch time, they usually have fast food which lacks vegetables and has a high fat and high protein content. This is why healthful diet promotion target to adolescents cannot be neglected. We hope that this chapter can raise the government’s awareness of the need to promote a healthful diet to all adolescents in HK.

OBJECTIVE In Primary health care (PHC), people should be enabled to create and sustain their own health status by participating in the health promotion process instead of relying on health

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professionals (WHO, 1986; Catford, 2004). The goal of this chapter is to promote a healthful diet to F2 students in PLHKS. The objectives are as follow: 1. To reinforce the knowledge of a healthful diet to F2 students. 2. To enhance students’ ability to choose a healthful diet. 3. To empower students to promote a healthful diet to others.

LITERATURE REVIEW There are different kinds of diet promotion programs in different counties focusing on improving peoples’ eating habits and empowering them to have a better choice of food. In 2007, the United States commenced a national partnership program: ‘The National Fruit and Vegetable Program’, to raise all Americans’ awareness of the importance of a diet high in fruits and vegetables (Centers for Disease Control and Prevention, n.d.). It is a computerbased approach program in partnership with the American Heart Association, the American Diabetes Association and the United Fresh Fruit and Produce Association. In the past, a ‘onesize-fits-all’ approach was applied in nutrition-promoting programs in the United States (Casazza and Ciccazzo, 2006), but recognizing that different people have different needs in nutrition, ‘MyPyramid.gov’ (United States Department of Agriculture, n.d.) allows more citizens, including adolescents to access the resources that are suitable for themselves. Americans can just key in their own data into the Web site and then they can find the amount of fruits and vegetables which they need everyday. In Asia, Singapore replaced the controversial school-based ‘Trim and Slim’ program (Gill, n.d.) with another holistic programs, such as ‘The Model School Tuckshop Program’ and ‘Gobble Bobble’. Since obesity can be prevented through the modification of the environmental setting (Gittelsohn et al., 2006), ‘The Model School Tuckshop Program’ provides a supportive environment for students by ensuring the supply of healthful food in school tuckshops. The healthful food race program, ‘Gobble Bobble’, reinforces the students’ healthful diet knowledge through games (Health Promotion Board, n.d.). The government in HK is also aware of the problem of increased rates of obesity in the young population and thus launched the ESAS campaign. However, attention to the promotion of healthful diet to adolescents is rare. This is why we propose to launch a fundamental pilot school-based healthful diet program for them. One of the easy ways to prove that adolescents are consuming unhealthful diet is by their apparent overweight, obesity or poor skin condition, which come into view immediately. The increasing trend toward obesity in the population (Swinburn et al., 2004) was proven in relation to an unhealthful diet (WHO, 2003; Hassink, 2007). Youth’s behaviour would affect their health status and might result certain diseases in adulthood (Torabi and Yang, 2000). Hunt and Martin (1988) argued that behaviour was an outcome without decision-making, but Hassink (2007) stated that providing health-related information might result in behavioural change. It may be correct as adolescents buy unhealthful foods and snacks simplity because they are used to doing so, but we believe that if we can keep on reinforcing the knowledge about health, their attitude towards unhealthful foods may gradually change. It was pointed out that school was the most significant institution for promoting health, developing

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knowledge and skills for health to adolescents (WHO, 2005). Therefore, we propose a schoolbased program for them. PHC emphasizes that empowering a community with skill and knowledge develops its self-reliance and determination in decision-making to attain health (WHO, 1978; Wass, 2000). It should count on low technology community service instead of high technology disease treatments, along with health promotion, which involve the context of the importance of people’s daily living (Wass, 2000; Catford, 2004). The program described in this chapter prevents diet-related diseases among adolescents with low technology. Self-reliance and determination are the two elements that adolescents aiming. However, if they are not guided by correct information, they will lead to wrong direction in their health behaviour. Therefore, we will empower them by means of health education on a healthful diet. Health education is a strategy that helps individuals in decision-making and lifestyle modification during health promotion (Anspaugh, Dignan and Anspaugh, 2000) mass media can also result in unexpected achievement in health education (Tones and Tilford, 1994). Therefore, Web information will be developed over the intranet to provide easily accessible knowledge for adolescents. Three important elements in PHC are: equity, intersectoral collaboration and participation (Macdonald, 1992). Three of the priorities for health promotion are a) to increase investment in multisectors other than health sectors, such as education as to achieve health development in society; b) to consolidate the partnership of the health sector and others, and c) to empower the community with the skill and knowledge for attaining health status (WHO, 1997). The program outlined in this chapter clears the gap—lack of healthful diet promotion to adolescents—and will maintain their equity in attaining health. Funding will be granted from QEF so that all F2 students can join the program without worrying about the activity fee. It will be a cooperative program that exhibits intersectoral collaboration among health professionals (nurses and dietitian), educators and lay persons (parents committee). Participants will work with team members to achieve self-reliance and self-determination instead of complying only with teachers’ education. Five approaches in health promotion are the medical approach, behavioural approach, socio-environment approach, client-centred approach, and educational approach (Katz and Peberdy, 2000; Laverack, 2004). The medical approach focuses on disease treatment and prevention (Katz and Peberdy, 2000), and can only achieve selective PHC. The behavioural approach intends to shape the subjects’ attitude and behaviour (Katz and Peberdy, 2000). However, the temperament makes adolescents eager to take the control of their life instead of being controlled, and to have a say in public. Therefore, we will put away medical and behavioural approaches. The educational approach (to equip adolescents in decision making with knowledge) and client-centred approached (to work with participants and empower them) (Katz and Peberdy, 2000) will be used to facilitate adolescents in developing their ability to maintain healthful eating habits, and to work with them during the process of achieving their own health. We hope to attain community development (Macdonald, 1992) among participants instead of just telling them what is suitable to eat.

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NEED ASSESSMENT Failure to address a target group’s need is the obstacle to implementation of PHC (WHO, 2003), therefore needs assessment is essential in health-promotion planning. There are four types of needs: normative need based on professionals’ opinion; felt need is what people want; expressed need puts the felt need into practice; and comparative need is predicted by comparing similar circumstances (Hawe et al., 1990; Ewles and Simnett, 2003). Although a medical approach in health promotion which valued experts’ knowledge has been criticized as a top-down approach (Laverack, 2004), we value normative need because professionals’ knowledge is evidence-based, and it is worthy to be considered during the planning of a health promotion program. A healthful diet is conducive to a community’s health, and reduces the rate of overweight, obesity, chronic diseases and even cancer (WHO, 2003; Hassink, 2007). However, adolescents may only concern about overweight and poor skin condition as they will be teased about their outer appearance by their classmates. They may be willing to have a healthful diet due to constipation because of the annoying condition , but chronic diseases and cancers are far beyond their concern. Therefore, we will also consider adolescents’ felt need. Informant interviews, participant observation, windshield survey, secondary analysis of existing data and survey are the commonly reported methods of collecting data to analyze people’s concept of health (Stanhope and Lancaster, 1992). We will use the method of informant interviews, participant observation and windshield survey as secondary analysis of data and survey are time-consuming and costly. Through the windshield survey, I found that there were not many overweight or obese students in PLHKS, but some of them had pimples. They liked to have a fast-food lunch in a nearby food shop with their classmates. This raised up a concern for healthful diet promotion. We will interview 20 F2 students to find out their concept of healthful diet value in relation to their health status. Pre-questionnaires will be distributed to F2 students to explore their felt need and collect baseline data. Names of students will not be required to be written in this questionnaire. The aims of this assessment are to collect some quantitative data (age, gender, body weight, height, waistline, and BMI) and some qualitative data (how students perceive the impact of a healthful diet on their daily life, such as appearance, skin and bowel habits) for future evaluation.

PLANNING Team Members Team members include us (registered nurses), principal, teachers, a dietitian, representatives from the parents committee of the school, an adviser from CUHK, a QEF representative, and 10 representatives of the participants. Health promotion requires collaboration among all sectors (WHO, 2000). Therefore collaboration among the educational, health sectors and parents committee can be seen in this program. High-quality scientific background knowledge would lead to successful health

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promotion (Carlson et al., 2006). We and dietitian will be responsible for providing reliable knowledge about a healthful diet and provide health talks to empower participants. CUHK’s adviser, experienced in launching ‘Fun in Seven’ and ESAS, will provide professional advice and set up relevant health information on the school intranet so that students and their parents can access the information easily. The principal will facilitate the smoothness of the cooperation among different members of the team and teachers will act as mediators to transmit health knowledge to participants during the absence of health profession members. A representative of QEF will be responsible for funding and ensure the proper use of it. Representatives of the parents committee and participants will comment on the progress of the program from their point of view, so that we will grasp the effects and the limitations of the program as to make improvements on it in the future.

Target Subjects and Recruitment There are five F2 classes in PLHKS (PLHKS, n.d.) and 100 to 150 F2 students will be recruited. Details of program and invitations will be sent to the F2 students through e-mail individually and announced on the school Web site. Activities will be held throughout the program in order to attract students. All activity fees in this program will be sponsored by QEF. Participants need to submit an application form with pre-program questionnaires.

Instrument for Evaluation Pre- and post-questionnaires (in quantitative and qualitative approach), and participants’ eating diary will be used as instruments for evaluation. Pre-questionnaires will provide baseline data about F2 students’ concept of healthful diet and their diet habits before the program. Post-questionnaire will identify any change in their diet habits and diet-related conditions. Group interviews with participants and meetings with team members will be held to receive comments from them in the middle and at the end of the program.

Implementation A preliminary proposal will be submitted to the PLHKS principal. The first meeting will be held to gather comments from the principal and teachers who are responsible for cooking. This program will be integrated into the curriculum as an optional subject. A final proposal will be submitted to QEF for approval of funding. At the same time, we will start needs assessment with a windshield survey to observe the eating habits of students of PLHKS in a food shop near the school during lunchtime and after school for a week. A second meeting will be held with team members except for the representatives of the participants. We will find the best ways to integrate this program into the subject of cooking. An eating diary with simple instructions on a healthful diet will be distributed to each participant. They will be requested to provide particulars such as pre-program and postprogram body weight and waistline, monthly weight and waistline, BMI, bowel habits, and rough eating habits for the past month. They do not need to fill in their name so to encourage

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them to provide true details, and teachers will give an explanation on how to fill out this diary. A beautifully-designed pin will be awarded to those who submit the diary at the end of program and the confidentiality of the diaries will be guaranteed. We will use an educational approach in this program and knowledge of a healthful diet will be provided to participants in the cooking lessons. We will also hold five different onehour talks on healthful diet bimonthly. Talks will be held on Friday of the first week in odd months after school, and healthful snacks and drinks will be provided to introduce healthful snacks to participants. The topics of the talks are food pyramid for adolescents, diet and charming body figure, diet for handsome boys and girls, diet and healthy bowels, and your enemy—unhealthful diet. It will enhance participants’ knowledge about choosing proper foods that are conducive to their health. The third meeting will include all members, discussing the details of the ‘Smart Chef’ competition. After the meeting, cooking teachers and participants’ representatives will brief all participants on guidelines of healthful recipes, and participants will form 20 groups. Based on their knowledge, each group will design two healthful dishes. A healthful cooking competition will be held during the first week of November on a Saturday. There will be three panels: 10 non-participanting F2 students will form one panel; dietitian, teachers and we nurses will form a second panel; and 10 representatives of the parents committee will form the last panel. Briefing and guidelines will be given to each panel for choosing the winning dishes. Three winning groups will be selected and every participant will be awarded with specially-designed pins and food coupons. Winning recipes will be printed and distributed to other students in the school and will be given to lunch box suppliers to prepare lunch boxes for the whole school. The fourth meeting will make an evaluation of the progress of the program and discuss the competition in a ‘Health Talk Show’. In February, participants will be divided into five groups and two representatives will be selected from each group to join the fourth meeting with team members. Participants’ representatives will pass the guidelines of the competition to their groups after meeting and each group will be assigned one topic on a healthful diet. They will have three months to prepare their half-hour talk and collect relevant information about their topic by themselves. Teachers, dietitian, adviser from CUHK and nurses will act as facilitators providing professional advice to them when they have doubt, and this service will be available on Friday afternoon and last for one hour. One month before the ‘Health Talk Show’, facilitators will have another one-hour meeting with each group to finalize the materials, clarify any unclear concepts and provide appropriate professional advice. Facilitators will provide minimum assistance because it is hoped that participants can be selfreliant. Parents of participants and potential lunch box suppliers will be invited to this talk show. Participants will be also encouraged to invite their classmates to the talk. Health and educational professionals, the parents committee and nurses will form the panel. An award will be given to the winning group, and certificates will be given to all participants. Members of the winning group will be the ‘Healthy Diet Ambassadors’ in the coming academic year.

Evaluation The effectiveness of the program can only be reflected by evaluation (Stanhope and Lancaster, 1992), and different team members might have different outcome expectations of

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the program (Baum, 2000). We agree that although all team members will aim at promoting a healthful diet to adolescents, expectations of team members may be different. Health sector professionals will focus on disease prevention, educators will focus on development of students, parents will be concerned more about their children’s health, and adolescents will hope to gain autonomy. Therefore, all people will be involved in evaluation. Creswell (2003) stated that the quantitative method provides evidence-base knowledge, and that the qualitative method provides constructive knowledge. We will use the mixed method in evaluation. A post-questionnaire will be distributed to all participants at the end of program. They will be required to provide information about portions of servings of different kinds of food in their diet, and BMI at pre- and post- program. Moreover, participants will be requested to grade their satisfaction with the program; a higher satisfaction rate may mean that the program attracts them. Focus group interviews which can generate in-depth feelings of the participants (Farquhar et al., 2006), will be done after the ‘Smart Chef’ competitions and ‘Health Talk Show’. Participants will reflect their comments on the achievement of the activities. Teachers, dietitian and nurses will observe the achievement of participants and record field notes which can be analyzed during evaluation. Self-reliance was essential in developing personal capacity which contributed to health (WHO, 1978). Therefore, if participants can demonstrate that they are well equipped with knowledge they gain in two competitions, then the program is effective.

DISCUSSION The programs in the United States are nation-wide with a computer-based approach and thus can be accessed by most Americans across the country. The effectiveness of computertailored nutrition interventions was affirmed (Tessaro et al., 2006). ‘MyPyramid.gov’ targets people of different genders and different age groups. Based on different people’s personal data, it provides appropriate healthful diet plans that are suitable for them. In ‘The National Fruit and Vegetable Program’, parents are provided tools to encourage their kids to join in the program, and assistance is given to them to reinforce their children’s healthful diet knowledge. Therefore, we find that the whole community can involve in these healthful diet promotion programs. In Singapore, ‘Gobble Bobble’ is a full-of-fun gaming health-promotion program that can attract children and adolescents’ attention and can reinforce their healthful diet knowledge with fun. Environmental change was a strategy of health promotion (McMurray, 2003) and increasing the accessibility of healthful food. Decreasing the temptation of unhealthful food could uphold people’s adoption and continuance of healthful eating habits (Wahnefried et al., 2008). In ‘The Model School Tuckshop Program’, healthful food choices in the schools are provided to the students and the temptation of unhealthful food is eliminated. Although HK government has succeeded in launching ESAS, it ignores the importance of its sustainability to adolescents. Our pilot program is designed to fill up the gap. Compared with those programs in the United States and Singapore, our program is small in size and yet it will be more practical and feasible since it will be integrated into participants’ curriculum, to be easier to control the outcome. In addition, we can employ the participants as role models to their peers (Saksvig et al., 2005). According to adolescents’ eagerness for having a say in

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their daily life, ‘Smart Chef’ will allow them to design their own healthful dishes and it will grasp the preference of adolescents and their eating culture during the promotion. Our program is unique as it will not spoon feed knowledge of a healthful diet to participants, but will assist them to master it through the process of promoting a healthful diet to others.

STRENGTH OF THE PROGRAM The program outlined in this chapter will fill the gap of fewer instances of healthful diet promotion program for adolescents. Although ESAS was a success in raising people’s attention to unhealthful dietary habits in pupils, DH acknowledged that this was only a temporary achievement and did not show a change in children’s eating habits (DH, n.d.). It was stated that developing eating behaviours would last to adulthood (Slater, Powell and Chaloupka, 2007) and it is worth launching a healthful diet promotion program for adolescents. Catford (2004) pointed out that social capital is stressing the importance of partnership and alliances. A client-centred approach will change participants’ role from learners to partners. A competition called ‘Smart Chef’ provided them an opportunity to sort through the healthful recipes for themselves. Through the process of searching for relevant information in a ‘Health Talk Show’, participants’ knowledge of a healthful diet will be reinforced. Moreover, the program is designed for the unique temperament of adolescents, and helps them to develop a sense of self-efficacy.

LIMITATIONS OF THE PROGRAM One academic year is too short for promoting healthful diet habits that involves a change in lifestyle. Moreover, the number of participants is small and not all of the students in PLHKS have the opportunity to join due to the shortage of funding. It is expected that the success of the pilot program will convince the DH to launch a larger scale healthful diet promotion program to all adolescents in all secondary schools just like they do for pupils in HK, and maintain the sustainability of ESAS. Furthermore, the reliability of questionnaires for evaluation has not been validated. Adolescents have a unique temperament and it will be more effective if we can invite psychologists to provide further advice on strategy.

CONCLUSION The prevalence of diet-related chronic disease is a global health issue. HK is also affected by this challenge evidenced by an increased number of obese children from 16.4% to 18.7%. Being considered the healthiest group, adolescents are usually neglected during promotion of a healthful diet. The HK government launched ESAS which is successful in promoting healthful eating habits to children but failed to sustain it in a group of adolescents. This chapter discussed a program promoting a healthful diet to adolescents to fill the gap. PHC concepts: intersectoral collaboration, participation and equity are its framework. Adolescents are eager to be independent and to have autonomy over their life, so strategies of health

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promotion that encompass an educational approach and client-centred approach will be used. However, the effectiveness of the program is affected by the small size of the population, lack of funding and invalid of the evaluation instrument. Nevertheless, it is a pilot program is designed to convince the government that there is a need to sustain a healthful diet promotion program in adolescence.

AUTHOR’S BAKGROUND The author is a master’s degree student of primary health care at the University of Western Sydney working as a registered nurse in Prince of Wales Hospital, which is a teaching hospital of the medical faculty of the Chinese University of HK, located in Shatin.

REFERENCES Anspaugh, D. J., Dignan, M. B., and Anspaugh, S. L. (2000). Developing Health Promotion Programs: The Need for Health Promotion. Boston: McGraw-Hill. Baum, F. (2000). The new public health: An Australian perspective (2nd ed.) Oxford: Oxford University Press. Buchanan, H., and Coulson, N. S. (2007). Consumption of carbonated drinks in adolescents: a transtheoretical analysis. Child: Care, Health and Development, 33(4), 441-447. Carlson, B. A., Neal, D., Magwood, G., Jenkins, C., King, M.G., and Hossler, C. L. (2006). A Community-Based Participatory Health Information Needs Assessment to Help Eliminate Diabetes Information Disparities. Health Promotion Practice, 7(3), 213-222. Catford, J. (2004). Health Promotion: Origins, obstacles and opportunities. In H. Keleher, and B. Murphy (Eds.), Understanding health: A determinants approach (pp. 134-155). Oxford: Oxford University Press. Casazza, K., and Ciccazzo, M. (2006). Improving the Dietary Patterns of Adolescents using a Computer-Based Approach. The Journal of School health, 76(2), 43-46. Centers for Disease Control and Prevention. (n.d.). Eat a variety of fruits and vegetables every day. Retrieved September 25, 2008, from http://www.fruitsandveggiesmatter.gov/index. html Centre for Health Protection. (2007). Obesity. Retrieved June 18, 2008, from http://www.chp.gov.hk/content.asp?lang=en and info_id=8802 and id=25 and pid=9 Creswell, J. W. (2003). Research Design: Qualitative, Quantitative, and Mixed Methods approaches (2nd ed.). California: Sega. Department of Health. (n.d.). ‘Eat Smart At School.hk’ Campaign. Retrieved June 12, 2008, from: http://school.eatsmart.gov.hk/eng/template/index.asp?pid=316 and id=28 District Council. (2008). Special Features of Shatin. Retrieved June 19, 2008, from http://www.districtcouncils.gov.hk/st/english/welcome.htm Ewles, L., and Simnett, I. (2003). Promoting health: A practical guide (pp. 102-120). London: Bailliere Tindall.

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Farquhar, S. A., Parker, E. A., Schulz, A. J., and Isreal, B. A. (2006). Application of Qualitative Methods in Program Planning for Health Promotion Interventions. Health Promotion Practice, 7(2), 234-242. Gill, T. (n.d.). Childhood Obesity Prevention – What have we learned so far? Retrieved September 24, 2008, from http://72.14.235.104/search?q=cache:vFl_7nlnNZ0J: www. health.nsw.gov.au/obesity/adult/summit/pres/Speech_TimGill.pdf Gittelsohn, J., Dyckman, W., Tan, M. L., Boggs, M. K., Frick, K. D., Alfred, J., Winch, P. J., Haberle, H., and Palafox, N. A. (2006). Development and Implementation of a Food Store-Based Intervention to Improve Diet in the Republic of the Marshall Islands. Health Promotion Practice, 7(4), 396-405. Hassink, S. G. (2007). A Clinical Guide to Pediatric Weight Management and Obesity. Philadelphia: Lippincott Williams and Wilkins. Hawe, P., Degeling, D., and Hall, J. (1990). Evaluating health promotion. Sydney: MacLennan and Petty. Health Promotion Board. (n.d.) Nutrition. Retrieved September 24, 2008, from http://www.hpb.gov.sg/hpb/default.asp?pg_id=1709 Hunt, S. M., and Martin, C. J. (1988). Health-related behavioural change – a test of a new model. Psychology and Health, 2:209-230. Katz, J., and Peberdy, A. (Eds.). (2000). Theories and models in health promotion. In Promoting health: knowledge and practice (2nd ed., pp. 80-94). London: Open University Press. Kooten, M. V., Ridder, D. D., Vollebergh, W., and Dorsselaer, S. V. (2007). What’s so special about eating? Examining unhealthy diet of adolescents in the context of other health-related behaviours and emotional distress. Appetite, 48(3), 325-332. Laverack, G. (2004). Promoting health: It all depends on what we mean by ‘health’. In Health promotion practice: Power and empowerment (pp. 16-32). London: Sage. Macdonald, J. J. (1992). Primary health care: Medicine in its place. London: Earthscan. McMurray, A. (2003). Community Health and Wellness: A socioecological approach (2nd Ed.). Sydney: Mosby. Pentecostal Lam Hon Kwong School. (n.d.). Introduction. Retrieved June 19, 2008, from http://www.plhks.edu.hk/spi.php Saksvig, B. I., Gittelsohn, J., Harris, S. B., Hanley, A. J. G., Valente, T. W., and Zinman, B. (2005). A Pilot School-Based Healthy Eating and Physical Activity Intervention Improves Diet, Food Knowledge, and Self-Efficacy for Native Canadian Children. American Society for Nutrition, 135(10), 2392-2398. Senderowitz, J. (1995). Adolescent health: reassessing the passage to adulthood. Washington: World Bank. Slater, S. J., Powell, L. M., and Chaloupka, F. J. (2007). Missed Opportunities – Local Health Department as Providers of Obesity Prevention Programs for Adolescents. American Journal of Preventive Medicine, 33(4S), 246-250. Stanhope, M., and Lancaster, J. (1992). Community as client: using the nursing process to promote health. In Community health nursing: process and practice for promoting health (3rd ed., pp. 254-255). St. Louis: Mosby. Swinburn, B. A., Caterson, I., Seidell, J. C., and James, W. P. T. (2004). Diet, nutrition and the prevention of excess weight gain and obesity. Public Health Nutrition, 7(1A), 123146.

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Tessaro, I., Rye, S., Parker, L., Trangsrud, K., Mangone, C., McCrone, S., and Leslie, N. (2006). Cookin’ up Health: Developing a Nutrition Intervention for a Rural Appalachian Population. Health Promotion Practice,7(2), 252-257. Tones, K., and Tilford, S. (1994). The mass media in health promotion. In Health education: Effectiveness, efficiency and equity (2nd ed., pp.180-216). London: Chapman Hall. Torabi, M. R., and Yang, J. Z. (2000). Comprehensive School Health Model: An Integrated School Health Education and Physical Educational Program. Retrieved June 22, 2008, from http://www.ied.edu.hk/icpe2004/English%20Sample.pdf The Chinese University of Hong Kong. (2002). Fun-In-Seven. Retrieve June 15, 2008, from http://octopus.bch.cuhk.edu.hk/fun7/english/about_us.shtml United States Department of Agriculture. (n.d.). My Pyramid.gov. Retrieved September 26, from http://www.mypyramid.gov/index.html Wahnefried, W. D., Rock, C. L., Patrick, K., and Byers, T. (2008). Lifestyle Interventions to Reduce Cancer Risk and Improve Outcomes. American Family Physician, 77(11), 15731578. Wass, A. (2000). Health promotion in context: Primary Health Care and the new public health movement. In Promoting health: The Primary health care approach (2nd ed., pp. 7-17). Sydney: Harcourt. World Health Organization. (1978). Primary health care. Report of the international conference on primary health care, Alma-Ata, USSR. Reproduced in E. Tarimo, and E. G. Webster, (1994). Primary health care concepts and challenges in a changing world: Alma-Ata revisited. (pp. 107-110). Geneva: WHO. World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion. Denmark: WHO. World health Organization. (1997). Jakarta Declaration on Health Promotion into the 21st Century. Retrieved May 23, 2008, from http://www.who.int/healthpromotion/ conferences/previous/ jakarta/declaration/en/index.html World Health Organization. (2000). Fifth Global Conference on Health Promotion: Mexico Ministerial Statement for the Promotion of health: From ideas to action. Geneva: WHO. World health Organization. (2003). Primary health: A framework for future strategic directions (Global Report). Geneva: WHO. World health Organization. (2005). Nutrition in Adolescence – Issues and Challenges for the Health Sector. Retrieved June 15, 2008, from http://whqlibdoc.who.int/publications/ 2005/9241593660_eng.pdf

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 7

THE PROMOTION OF A HEALTHFUL DIET FOR MALE NURSES IN A GOVERNMENT HOSPITAL IN HONG KONG Mandy Y. M. Kwan* and Zenobia C. Y. Chan ABSTRACT Healthful diet promotion activities can be found globally and locally. However, the majority of them are for the general public, and there is a lack of such a promotion for health care professionals. People believe that because nurses have knowledge of the components of a healthful diet, there is no need for a related promotion program for this group. However, the fact is that nurses, especially male nurses, do not engage in this health practice. The main reason is the limited availability of easily-accessible healthful foods. Our two-month program, ‘The Promotion of Healthful Diet for Male Nurses in a Government Hospital in Hong Kong’, specific for 30 male nurses, highlights and improves this phenomenon. Document review, interview and field notes are used in the need assessment stage. Participating male nurses are invited to be partners in the planning, implementation and evaluation process. Behavior change and client-centred approaches are adopted. Eight team members, including a dietician, volunteers and coordinators of the male staff canteen, nursing quarters and snack company collaborate together within the program. Evaluation by discussion and interview will be done after the program. Our program is a pioneer program and can help male nurses to adapt a healthful diet within their workplace through their partnership with environmental support.

INTRODUCTION Promotion of healthful diet is a strategy of the World Health Organization (WHO) and the Hong Kong (HK) Government. There have been various healthful diet promotion programs in HK. However, they were all targeted to the general public such as students and *

Correspondence: Mandy Kwan, Registered Nurse, Queen Elizebeth Hospital, Hong Kong. E-mail: [email protected]

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workers. Nurses were neglected because it was believed that nurses had the knowledge to adopt a healthful diet themselves. Although nurses are equipped with knowledge of healthful diet practices, not all of them apply this knowledge to their daily life. Some nurses, especially male nurses, prefer eating out and making choices based on taste without thinking of the nutrient values. Nurses are the patients’ role models. There is a need for a healthful diet promotion program to help male nurses change their unhealthful eating habits. In the past, there were promotion programs only for physical health, such as sports day and swimming gala, and psychological health such as stress management in my hospital. Our program, ‘The Promotion of a Healthful Diet for Male Nurses in a Government Hospital in Hong Kong’, is a pioneer and tailor-made healthful diet promotion program for male nurses. Our program has two objectives: first, to increase male nurses’ awareness of and intention to choose better and more healthful food; second, to create a supportive environment by increasing the choices and availability of a healthful diet for male nurses in HK hospitals. This program can further help male nurses to adapt a healthful diet within their workplace through their partnership with the support of the environment.

LITERATURE REVIEW Under the WHO strategy on healthful diet, the HK government has launched several activities to promote the importance and increase availability of healthful diet. Two typical examples were the ‘Two Plus Three Everyday’ program in 2005 and the 2007 campaign called ‘[email protected]’. They recommended at least two servings of fruits and three servings of vegetables daily and the more healthful menu options with more fruits or vegetables, and less oil, salt and sugar (Central Health Educational Unit [CHEU], 2006; Department of Health [DH], 2007; GovHK, 2005). However, existing local programs are targeted to the general public such as students at schools or workers in offices. The phenomenon is similar to that of Canada and Australia, where healthful diet promotion programs were launched at schools or offices (An Australian Government, 2007; Canadian Produce Marketing Association, 2006). Yet, some populations, such as nurses in hospitals, were neglected. The general public expects nurses to be equipped with the knowledge of and skills in healthful life styles, including healthful diet adoption. Moreover, the public expects nurses to be positive role models in health, leading to the idea that healthful diet promotion programs are not necessary for nurses. However, existing evidence surrounding the health practices of nurses reveals that many nurses do not practice what they have learned. For example, only a small percentage of nurses said that they limit fat, salt and sugar intake in their diet. In the past, there have been research studies and health programs regarding the eating habits, beliefs, attitudes and knowledge among nurses (Riordan and Washburn, 1997; Yeh, Chen, Wang, Wen and Fetzer, 2005). Those specially targeted to male nurses were limited. Although there was limited evidence showing the dietary attitudes among male nurses, other related data showed that male nurses’ eating habits were worse than those of female nurses. They revealed that males do not always consider the nutrient level of foods. Their diets, which lack fiber, are always too high in fat, oil, animal protein and calories. The reasons behind this were not because of knowledge deficit, but related to the limited availability of healthful foods and the unattractive tastes of healthful foods at the hospital

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canteens (Centre of Health Protection [CHP], 2004; Centre for Nutrition Studies, 2006; Diseases Prevention and Control Division, 2002). Another reason is that the majority of female nurses would bring their homemade food to work, but the male nurses would not and they would frequently dine at the canteen. Since the availability of healthful foods was limited in their workplace, they had no motivation for adopting a healthful diet under this unsupportive environment. Therefore, there is an urgent need for our program, which is a pioneering one for male nurses in promoting a healthful diet at the hospital. Our program is a health promotion program, which enables the male nurses to control what they eat and improve their health. The male nurses can identify what they need to eat and realize the importance of a healthful diet so that they can attain physical, mental and social health. Our program offers availability and various choices of healthful food at the hospital canteen (Catford, 2004). The Ottawa Charter on health promotion creates a supportive environment with three key elements: changing the work environment, developing personal skills by provision of health information and enhancing life skills, and strengthening community action by empowerment and partnership. It addresses the underlying determinants of health and ensures the resources that enable people to achieve their health (World Health Organization [WHO], 1986). The Declaration of Alma-Ata, focusing on primary health care, addressed emphasized community participation, intersectoral collaboration and equity (WHO, 1978). Later, in 1997, the Jakarta Declaration on Health Promotion further emphasized the consolidation and expansion of partnerships, community capacity, and social responsibility for health (WHO, 1997). After the above review, we adopted the Ottawa Charter and the Declaration of Alma-Ata and Jakarta on Health Promotion in our program. Our program is different from the traditional client-driven programs owing to its emphasis on working together with the male nurses as partners in the program planning, implementation and evaluation processes, i.e., in working together with them in the design of the healthful diet menu together with the dietitian and the canteen. The hospital male staff canteen will create a supportive environment by increasing the availability of healthful choices that meet the male nurses’ demands.

NEEDS ASSESSMENT As the very beginning of the program, it is essential to assess the actual states, condition and factors for the program. Needs assessment provides realistic data and evidence for individual action and program development (Gilmore and Campbell, 2005). There are four different types of need, including normative, felt, expressed, and comparative needs (Ewles and Simnett, 2003). The normative and expressed needs can be identified for this program. Recently, we have read through the article ‘Application of qualitative methods in program planning for health promotion interventions’ written by Farquhar, Parker, Schulz and Israel, published in Health Promotion Practice in 2006, We would like to adopt three of their qualitative methods: document review, interview and field notes in the needs assessment stage (Farquhar, Parker, Schulz and Israel, 2006). Our needs assessment is integrated with a component of the PRECEDE model, ‘educational and organizational diagnosis’ (Meador and Linnan, 2006).

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Before the needs assessment, the program community is defined. Place, people and function are the three factors of community (Stanhope and Lancaster, 1992). In this healthful diet promotion program, place refers to a Government Hospital male staff canteen and the nursing quarters. People are referred to the male nurses in this hospital. Male nurses in this community are there to provide nursing services to patients. Normative need is identified by the documents and literature review that were written by the experts. As mentioned in the literature review section, many male nurses did not adopt healthful eating practices even though they are familiar with them (Riordan and Washburn, 1997; Yeh et al., 2005). The document also revealed the expressed need of the male nurses, i.e., the limited availability of healthful foods hindered their practice of healthful diet at the hospital (CHP, 2004; Centre for Nutrition Studies, 2006; Diseases Prevention and Control Division, 2002). Five registered nurses on a male ward of the targeted Government Hospital were interviewed. They all pointed out that they have no intention to adopt a healthful diet at the hospital and prefer tasty foods without nutrient value because they have limited choices in the canteen, or dislike the food. They cited lack of encouragement and intention regarding healthful diet practice. The above assessment shows the urgent need for our program. After identification of the need for the program, the determinants of healthful eating by male nurses should be assessed. As mentioned in the PRECEDE model, ‘educational and organizational diagnosis’, the predisposing, reinforcing and enabling factors of male nurses’ healthful diet are assessed. We need to identify why male nurses do not eat healthfully, the suitable methods promoting and enhancing a healthful diet, especially for them, and the factors that contribute to the health practice (Meador and Linnan, 2006). Individual interviews and field notes with the male nurses in the male staff canteen are performed. We will interview them to find out their determining factors regarding a healthful diet, their frequency of eating at the canteen, and their present and preferred food choices. Geography and environment assessment are important in understanding their relationship with the place (Kokko, Kannas, and Villberg, 2006; McMuary, 2003). Field notes and site visit are done to assess the menu and setting of the male staff canteen and nursing quarters. We will also interview the male staff canteen owner and the cook to know their food stocking and cooking methods. After defining the health needs by assessment, we will proceed to the planning stage.

PLANNING The planning process includes setting the program’s objectives, selecting strategies and organizational location, identifying resources, and planning the evaluation methods (Ewles and Simnett, 2003; O’Connor-Fleming and Parker, 2001). Before the commencement of the program, we will need the ethics board’s approval from the targeted hospital. We have mentioned the two programs’ objectives in the introduction section. Our program integrates behavior change and client-centred approaches (Laverack, 2004). The male nurses will be invited to join the planning, implementation and evaluation processes. They have the right to express their opinion on the food choices and tastes that they prefer. A tailor-made, clientcentred program will be designed according to their view. Afterwards, the male nurses will be

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encouraged to adopt a healthful diet, which will be defined by the dietitian with the opinion collected from the male nurses. Organization location will be the hospital male staff canteen and nursing quarters. They are chosen because the worksite is one of the key channels for the delivery of interventions and health promotion among adult populations. It provides easy and regular access to a relatively stable population and it encourages the peer support inside the nursing community (Commers, Gottlier and Kok, 2006; Noblet and Lamontagne, 2006). This place is also socially acceptable to males and prevents embarrassment in participation (Gittelsohn et al., 2006). Elements of intersectoral collaboration and partnership are adopted in our program. Since it is a diet promotion program, the health sectors cannot go forth alone; related sectors such as food company should be involved. They can share their existing professional resources for our program to achieve a better outcome (Baron-Epel, Darch-Zahavy and Peleg, 2003; Japhet and Hulme, 2004; Tarimo and Webster, 1994; WHO, 1978). In our program, we will invite a dietitian, the male staff canteen owner, personnel of the hospital male staff association and nursing quarters and a snack company to join our program. Three male nurse volunteers will be invited from the male nurses association. Building participant partnership is an element of our program; as mentioned above, we will invite, encourage and support the participating male nurses throughout the program. We will listen to their voices and communicate with and inform them about the program details (Mercurio, 2007). Leadership is crucial for the program’ legitimacy (O’Connor-Fleming and Parker, 2001; Tones and Tilford, 1994). In total, there will be eight persons on the program team. Besides the program team members, the participating male nurses will also be invited to give ideas on healthful diet and have discussions with the team members. They will work as partners with team members in setting up the menu for the male staff canteen. Identifying resources and mass media for promotion is one of the steps in the planning process. We will determine the existing facilities and materials that can be used in my program. Resources including posters, stickers, pamphlets and signposts about a healthful diet will be ordered (Central Health Education Unit Health Zone, 2006). Although there is no interpersonal communication from the mass media, these materials provide outside support and energy to the program (O’Connor-Fleming and Parker, 2001). They will be placed in the male staff canteen and nursing quarters as encouragement. Additionally, they are all printed in HK, which are culturally appropriate for my program’s participants (May, 1996). Our program’s time frame is about two months, and 30 male nurses will be invited to participate. The hospital male nurse association will be invited to sponsor the miscellaneous items. Private snack companies are invited to sponsor healthful snacks, motivated by the benefit that male nurses can act as promoters of their food in the nursing field and in for their patients (Japhet and Hulme, 2004).

IMPLEMENTATION In the first stage, the health needs will be identified and analyzed. Literature and documents will be reviewed through library, database and the Internet. Normative needs will be identified. We will interview them to determine the male nurses’ perspectives on healthful

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diet, including their attitudes, culture, intention, experiences and knowledge of healthful diet (Wass, 2000). We have interviewed five of my male colleagues to determine their expressed need. After assessment of need, the program to promote healthful diet among male nurses in a Government Hospital in HK will be confirmed. Before forming the program’s team members, we will conduct a site visit around the targeted hospital and choose the place for our program. The hospital male staff canteen and nursing quarters will be chosen. The owner and personnel of these two places will be contacted through visits and by phone. We will explain my program proposal to them to seek their collaboration. The next step is to recruit the team members. Letters with the program proposal will be sent to the hospital dietitian, male staff association and snack company personnel. Phone contact will be made afterwards. We will contact the male nurse association personnel to invite three male nurse volunteers to join my program. Building trust and adequate communication is crucial in partnership (Japhet and Hulme, 2004). We will organize several face-to-face meetings with our team members in QEH to discuss the components of the program and task assignment. Our program will include interviewing the male nurses, seeking advice from the dietician and cooperating with the male staff canteen owner on the availability of healthful diet options. Our team members will launch the invitation of male nurses to participate and interview them during lunch and dinner hours at the male staff canteen. The nurses will be asked about their favorite food choices, such as what kinds and tastes of food they like to eat. At the same time, another team member will order the promotional materials from the government, such as posters, stickers, pamphlets and signposts about healthful diet. He or she will contact the snack company sponsor for free healthful snacks, such as cereal and dried fruits. After getting the information, he or she will approach the dietitian and seek his or her expert advice on the food choices and tastes and invite him or her to suggest several healthful menu dishes that are suitable for male nurses according to the collected information regarding their favorite choices. After visiting the dietitian, the menu will be passed to the male staff canteen and the team member will discuss with the coordinator adding these menu to the existing food choices with reasonable and attractive prices. When the canteen is ready to serve the healthful dish, the promotional materials will be placed on the walls, tables and at the stations of the male staff canteen and nursing quarters. Participating male nurses will be contacted and informed again in order to provide them with a 5% discount card and free healthful snacks. They will be strongly encouraged to consume the dishes with an additional 5% discount. Since the male staff canteen is still open to other staff, they can also consume the dish but with the original price. It will last for two months. After two months, the participating male nurses will be contacted for evaluation of the program, which will be discussed in the next section.

EVALUATION Evaluation is the process of assessing what the program has achieved and how it has been achieved. Through this process, we can know whether it is effective in increasing male nurses’ awareness of and intention to choose better and more healthful food and whether the

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environment is supportive to this action. Moreover, the feedback from the team members and different sectors will be collected for improvement of the program (Ewles and Simnett, 2003; O’Connor-Fleming and Parker, 2001). Group interviews with six participants in a group will be used to evaluate whether they have increased awareness of their diet and intention to adapt the healthful diet. Group interviews can stimulate the participants to express more opinions because they will build on or disagree with one another (Farquhar et al., 2006). We will invite six participants each time to discuss the frequency of choosing or eating the healthful diet provided at the canteen, whether the taste is good and their awareness of the promotion materials around the canteen and nursing quarters. We will also encourage them to discuss whether they have increased their intention to continue with a healthful diet after the program, the use of promotional materials and healthful snacks. In addition, they will be asked whether the environment is supportive of them in adapting a healthful diet by asking whether they agree and are satisfied with the availability of healthful diet choices at the male staff canteen. Lastly, we will collect their comments on the program satisfaction by survey. Data will be collected on their satisfaction with the content, place, time, and method of the program. There is an element of intersectoral collaboration and partnership in my program. Comments and opinions will be collected through discussion with the dietician, volunteers and all of the personnel of the male nurse association, male nursing quarters and snack company. Each of them have a chance to express their comments and opinions. We will record all of the opinions as information for program improvement. Furthermore, these comments can show the possibility of future programs in which they will collaborate.

DISCUSSION Since it is a healthful diet promotion program, the male staff canteen plays a major role. The canteen should provide adequate choices of healthful foods so that male nurses will be attracted and choose to consume their food. Moreover, the prices and food taste should be acceptable to them. Our program provides a good start, and suggests to the food provider that they should collect opinions from clients frequently and improve their menu to fit clients’ needs. Ongoing encouragement and attractiveness regarding a healthful diet is a must to maintain the ongoing effectiveness of the program. For example, the modification of tastes and new elements of dishes should be provided frequently. Since there are many male nurses in the hospital, and with the limitation of manpower, the number of participants in my program is limited. Moreover, because of the shifting duty, male nurses may not be free to eat at the selected canteen. The frequency of eating healthful dishes may be affected. Since some of our members have no training in leadership and program organization, we may encounter many difficulties, such as poor interview skills or time management throughout the program (Japhet and Hulme, 2004). Future programs on promotion of healthful diet for healthcare workers are suggested. There are computers on wards; future program can use the Internet, electronic learning or a staff welfare Web site for promotion. This promotion method can be accessed when it is convenient, and saves time (Leger, 2006).

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CONCLUSION A gender-specific healthful diet promotion program for male nurses has an important role in the world of nursing. This pioneer program is believed to be effective in providing a supportive environment to male nurses by increasing the availability and choices of healthful diet options according their favorites. For the long run, male nurses will adapt a healthful diet in their lives and act as a positive role model to their patients, family and friends.

WORKSHOP DESIGNER Mandy Kwan, a registered nurse working in a Government Hospital in Hong Kong, has earned a Bachelor of science degree in nursing and a master’s degree in primary health care. As a member of her hospital voluntary working team, she has demonstrated great ambition in empowering her colleagues in health-promoting issues.

REFERENCES Australian Government. (2007). Go for 2 and 5 [E-text type]. http://www.gofor2and5. com.au/article.aspx?c=2 and a=134 and n=1 Baron-Epel, O., Darch-Zahavy, A., and Peleg, H. (2003). Health promotion partnerships in Israel: motives, enhancing and inhibiting factors, and modes of structure. Health Promotion International, 18(1), 15-23. Canadian Produce Marketing Association. (2006). 5 to10 a day - A cooperative, national health campaign [E-text type]. http://www.5to10aday.com/en_mc_summary.asp Catford, J. (2004). Health promotion: Origins, obstacles and opportunities. In H. Keleher and B. Murphy (Eds), Understanding health: A determinants approach (pp. 134-151). Oxford: Oxford University Press. Central Health Education Unit. (2006). Two plus Three Every Day' Program in Millennium City, Kwun Tong [E-text type]. http://www.cheu.gov.hk/eng/activities/content. asp?id=188 and page=5 Central Health Educational Unit Health Zone. (2006). Educational resources, Exercises and Nutrition [E-text type]. http://www.cheu.gov.hk/eng/resources/exercise2_printed.htm Centre for Health Protection. (2004). Men’s Health: Finding of Focus Group Discussion, Summary of report- the General Male population. Hong Kong Special Administrative Region: Department of Health. Centre for Nutrition Studies. (2006). Nutrition Articles [E-text type]. http://www. sph.cuhk.hk/website/male.htm Commers, M.J., Gottlier, N., and Kok, G. (2006). How to change environment conditions for health. Health Promotion International, 22(1), 80-87. Department of Health. (2007). Eatsmart menu to promote healthy eating in restaurants [Etext type]. http://www.dh.gov.hk/english/press/2007/070720-1.html

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Diseases Prevention and Control Division. (2002). Topical Health Report No.1, Men’s Health. What’s the Numbers say. Hong Kong Special Administrative Region: Department of Health. Ewles, L., and Simnett, I. (2003). Promoting health. A practical guide (5th ed.). Edinburgh: Bailliere Tindall. Farquhar, S.A., Parker, E.A., Schulz, A.M., and Israel, B.A. (2006). Application of qualitative methods in program planning for health promotion interventions. Health Promotion Practice, 7(2), 234-242. Gilmore, G.D., and Campbell, M.D. (2005). Needs and capacity assessment strategies for health education and health promotion (3rd ed.). Boston: Jones and Bartlett publishers. Gittelsohn, J., Dyckman, W., Tan, M.L., Boggs, M.K., Frick, K.D., Alfred, J., Winch, P.J., Haberie, H., Palafox, N.A. (2006). Development and implementation of a food storebased intervention to improve diet in the republic of the Marshall Islands. Health Promotion Practice, 7(4), 369-405. GovHK. (2005). DH promotes Two plus Three Every Day among working population in Kwun Tong [E-text type]. http://www.info.gov.hk/gia/general/ 200509/26/ P2005 09260201.htm Hankey, C.R., Eley, S., Leslie, W.S., Hunter, C.M., and Lean, M.E.J. (2003). Eating habits, beliefs, attitudes and knowledge among health professionals regarding the links between obesity, nutrition and health. Public Health Nutrition, 7(2), 337-343. Japhet, G., and Hulme, A. (2004). Hands-on health promotion. Melbourne: IP Communications. Kokko, S., Kannas, L., and Villberg, J. (2006). The health promoting sports club in Finland-a challenge for the settings-based approached. Health Promotion International, 21(3), 219229. Laverack, G. (2004). Promoting health: It all depends on what we mean by ‘health’. In Health Promotion practice: Power and empowerment (pp.16-32). London: Sage. Leger, L. (2006). Communication technologies and health promotion: opportunities and challenges. Health Promotion International, 21(3), 169-171. May, G. (1996). Koori heart health screening program. In NH and MRC, Promoting the health of Aboriginal and Torres Strait Island communities: Case studies and principles of good practice. Canberra: Australian Government Publishing Service. McMuary, A. (2003). Community health and wellness: A sociological approach (2nd ed.). (pp.69-73). Sydney: Mosby. Meador, M.G., and Linnan, L.A. (2006). Using the PRECEDE model to plan men’s health program in a managed care setting. Health Promotion Practice, 7(2), 186-196. Mercurio, A. (2007). The evolving role of health educators in advancing patient safety: forging partnerships and leading change. Health Promotion Practice, 8(2), 119-127. Miller, S. K., Alpert, P.T., and Cross, C.L. (2008). Overweight and obesity in nurses, advanced practice nurses, and nurse educators. Journal of the American Academy of Nurse Practitioners, 20(5), 259-265. Noblet, A., and Lamontagne, A. D. (2006). The role of workplace health promotion in addressing job stress. Health Promotion International, 21(4), 346-353. O’Connor-Fleming, M.L., and Parker, E. (2001). Program planning and evaluation. In Health promotion: principles and practice in the Australian context (2nd ed.). (pp. 79-109). Sydney: Allen and Unwin.

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Riordan, J.M., and Washburn, J. (1997). Comparison of Baccalaureate student lifestyle health behaviours entering and completing the nursing program. Journal of Nursing Education, 36(6), 262-265. Stanhope, M., and Lancaster, J. (1992). Community as client: Using nursing process to promote health. In Community nursing : process and practice for promoting health (3rd ed.) (pp.254-255). St. Louis: Mosby. Tarimo,E., and Webster, E.G. (1994). Primary health care concepts and challenges in a changing world: Alma-Ata revisited (pp.19-22). Geneva: World Health Organization. Tones, K., and Tilford, S. (1994). Health Education: Effectiveness, efficiency and equity (2nd ed.). London: Chapman and Hall. Wass, A. (2000). Promoting health: The primary health care approach (2nd ed.) (pp.7-17). Sydney: Harcourt. World Health Organization. (1978). Primary health care: report of the international conference on primary health care, Alma-Ata, USSR (p.44-52). Geneva: World Health Organization. World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion. Denmark: World Health Organization. World Health Organization. (1997). Jakarta Declaration on Leading Health Promotion into the 21st Century. Jakarta: World Health Organization. Yeh, L., Chen, C.H., Wang, C.J., Wen, M.J., and Fetzer, S.J. (2005). A preliminary study of a healthy-lifestyle-promoting program for nursing students in Taiwan. Journal of Nursing Education, 44(12), 563-565.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 8

A HEALTH PROMOTION PROGRAM ON PROMOTING FAMILY HARMONY FOR NEW IMMIGRANT HOUSEWIVES IN TIN SHUI WAI W. Y. Wong and Zenobia C. Y. Chan ABSTRACT There has been a significant growth in the number of immigrants to Hong Kong from mainland China since 1997. Most new arrivals in Hong Kong face many social problems, such as communication barrier, unemployment and experience domestic violence. In recent years, domestic violence has been on a rising trend in Hong Kong. More than 3,700 cases were recorded in the first half of 2007. The majority of victims are new immigrant housewives. They are traditional Chinese women who observe the Confucian decorum of ‘the three obediences and four virtues’. They treat their husbands as the core of their families. Several tragedies occurred and were reported in Tin Shui Wai (TSW). We would like to organize a health promotion program to promote family harmony for new immigrant housewives in TSW. This program is under the guidance of primary health care (PHC) and health-promotion principles. Intersectoral collaboration of government departments and non-government organizations (NGO) are crucial in providing health services for the housewives. Needs assessment will be identified by indepth telephone interviews and questionnaires. Evaluation will be analysed by quantitative and qualitative questionnaires. A potential limitation of this program is lack of funding. We will try to stimulate the government to allocate more public resources for the implementation of this program in the community, in addition to fund raising via the social welfare department’s assistance.

BACKGROUND In the United States, approximately 5.3 million women are abused by their intimate partners each year, and one in three are injured, requiring medical treatment (Tjaden and Thoennes, 2000). The rapid demographic, social, and economic changes in Hong Kong have weakened family solidarity and resulted in an increasing number of socially pathological incidents, especially domestic violence. The number of battered spouse cases has increased

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tremendously, from 1,009 in 1998 to 1620 in 2005, and is no doubt on the rise. A total of 90% of victims are female (Hong Kong Government Information Centre, 2005 in Tsui, Chan, So and Kam, 2006). In the first nine months of 2005, Yuen Long recorded 398 cases of spousal abuse (Lau, 2006). Tin Shui Wai (TSW) is a relatively new satellite town in Hong Kong that houses nearly 300,000 people. It is situated at the northwest part of Yuen Long where it is quite secluded from other new towns. Most TSW residents are new immigrants from China, and are lowincome and unemployed families living on Comprehensive Social Security Assistance (Chan, Lam and Cheng, 2006). Most of the immigrants find it hard to adapt to the Hong Kong lifestyle and face a lot of social problems comprising unemployment, poverty and low selfesteem. They also feel frustration with a new dialect, customs and social systems. All of these factors affect family harmony, yet they remain silent and are too shy to get along with others. Very often they encounter sexual harm and domestic violence. Domestic violence is defined by the World Health Organization as any behaviour within an intimate relationship that causes physical, psychological or sexual harm to those in the relationship (Krug 2002). It impacts the mental and physical health of individuals, causes harm to families and children, and creates a financial burden on the economy (Bloom, 2001). Sometimes, suicide and homicide may result (Archer, 2000). Husband’s unemployment, alcohol abuse, low educational level, extramarital affairs and mental illness are significant risk factors (Tsui, Chan, So and Kam, 2006). The ideal woman was traditionally a dependant being whose behaviour was governed by the ‘three obediences and four virtues’. The three obediences were obedience to father before marriage, the husband after marriage, and the son in the case of widows (Lee, 1999). They think that the husband in a family is the legal head and responsible for all aspects of the family, including finances and behaviour of the other members. They also have a culture of treating the husband as the core of family. Men may use violence to solve problems when there are arguments between a couple (Cheng, 2007). Husbands spend a long time at work, from dawn to midnight, and hardly communicate with their family members. Under a stressful situation, people are likely to have conflicts with one another. The root of domestic violence sprouts and grows. Another factor is adverse in-law relationships, a centuries-old conflict in Asian societies (Lee, Yip, Leung and Chung, 2004). Campbell and Soeken (1999) stated that women do not like to disclose violent domestic events because they are affected by traditional cultural expectations. They want to preserve family harmony and avoid shame and stigmatization. They fear breaking up their family, and leaving their partner, which could further escalate the violence. They are not acquainted with the services or assistance offered by the government and NGOs; they are financially dependent and lack vocational skills. They are easily depressed, as they fail to disclose their anxiety. Some of them may commit suicidal or have homicidal ideas. They may think of hurting or killing the man as a final and desperate solution. However, there are some buffers against domestic violence that promote family harmony—for instance, stress management, high levels of family cohesion and adaptability, community support and a strong social network (Women’s Commission, 2006).

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GOALS AND OBJECTIVES Health promotion aims to improve the health of a population through health education, health prevention and health protection (Butler, 2001). Health education is a crucial element in this health promotion program (Katz, Peberdy and Douglas, 2000). Based on these, a planned health education program is formulated. It provides an opportunity for the housewives to acquire relevant knowledge and skills. The goal of this program is to raise TSW new immigrant housewives’ awareness of the need for family harmony, on which the theme of this health promotion program rests. The objectives are to help the housewives become more familiar with Hong Kong’s culture, improve their communication skills with Hong Kong people, promote good relationships among their family members, empower the housewives’ knowledge of domestic violence prevention, and last, but not the least, find a way to seek assistance during encounters with unfortunate events. The program will lead them well in addressing the specific health-related issue for this group, i.e. domestic violence prevention.

LITERATURE REVIEW Family Family is the primary institution in a society that preserves and transmits culture and provides a source of moral training (Friedman, 1990). Chinese people have been influenced by the philosophy of Confucianism, Taoism, and Buddhism (Chen and Rankin, 2002). Each generation has its moral demands and obligations within the family. Each member has a specific role and performance in his or her relationship with others. Older people are usually considered to be the most authoritative persons in the family, and are highly respected and supported by their family members (Xiaolian et al., 2002). The senior male member is the decision maker. The father is regarded by children as a strict disciplinary figure and has the authority to employ the carrot-and-stick method when necessary. The sons, in particular the firstborn, are accorded special status to continue the family name and play a leading role in conducting the rituals of ancestor worship (Slote and Devos, 1998). They are expected to sacrifice their own interests for the well-being of their elderly parents. This is mostly found in the continuation of the fraternal business. The daughter-in-law is obligated to carry out her filial duties by caring for the children and parents-in-law within a hierarchical concept of serving (Lan, 2002). Filial piety is about authority, power, transmission of knowledge and values, and the continuation of the family lineage (Chow, 1996). It defines duties and obligations between parents and children that maintain the fundamental order and harmony in the family (Jung, 1998). In order to maintain harmony in the family, peace is considerably important, and conflict must be avoided under all circumstances. There is a strong emphasis on family solidarity, such as bringing honour to the family, and not disgracing its good name (Shek, 2001).

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Family Harmony Harmony means ‘when people live or work together without fighting or disagreeing with each other’ (Longman, Dictionary of Contemporary English, 2008). The Cambridge Advanced Learner’s Dictionary (2008) also explains that harmony occurs ‘when people are peaceful and agree with each other, or when things seem right or suitable together’. Shek (2001) pointed out that Chinese families encourage harmony and prohibit conflict. To achieve harmonious social order, family members were regulated by the rules of ‘five cardinal relations’ (wu lun) which prescribe clear guidelines regarding the power, roles and responsibility of each family member. Parents maintain their responsibility, respect, sacrifice and family harmony, which regulates children’s attitudes and behaviour towards family-based support (Sung, 2000 in Bengtson, Kim, Myers and Eun, 2000). Children are raised to respect their parents. They are socialized to obey their fathers and to consider the collective interest to be more important than individual interest. Otherwise, family harmony is hardly preserved.

Parenting Relationship Families play an important role in adolescence. A positive parent-child relationship can enhance adolescents’ self-esteem and emotional regulation (Wagner, Cohen, and Brook, 1996). The children can talk with family members about their personal failure and believe that they can comfort them. Advantageously, children grow up with proper guidance in a family with harmony and more easily navigate those long roads with the encouragement of those around them. Chinese culture has high expectations for their children, particularly the sons. Their academic achievement can enhance their family pride. Clearly-prescribed rules and roles are passed from generation to generation. Obedience of children to their parents or parents-in-law is regarded as an expression of filial piety. Moreover, Confucianism emphasizes the duty of children to take care of their elderly parents, because caregiving is a voluntary return to the older generation in Chinese literature and morality (Smith, 1992).

In-Law Relationship Elders are to be honoured, obeyed and cared for. Mother and father are caught between caring for the older generation and the younger generation. They must take care to provide financial support to their old parents while working and raising a family of their own (Kwok, 2006). Liu and Kendig (2000) stated that woman always acts as a caregiver in performing the primary task of providing support to the older people in the family. However, it is also recognized from Confucian precepts that the son also has the responsibility of caring for his old parents as a structural requisite of the system of patriarchy. It is worthwhile to mention that mother and daughter-in-law conflict in many aspects of daily living. They are brought up in different family units and setups. Their values regarding autonomy, respect, hierarchy and filial piety depart from each other. Their views of trivial matters affect their daily routine, and they tend to struggle over their correct role play and methodology. Their conflicting roles mostly result in an unhappy ending.

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Study on Hong Kong Families In Hong Kong, social changes brought about by urbanization and Western influences have gradually eroded the traditional Chinese family relationship. Hong Kong families are now at the crossroads of modernism and traditionalism (Chan and Lee, 1995). Young people prefer individual development rather than fulfilling culturally-prescribed family obligations. There are an escalating number of young couples who choose to cohabit or delay marriage, remain childless or have fewer children and prefer not to live with their parents. Social problems may be associated with changing family relationships. Increasing rates of divorce, extramarital affairs, child abuse, spouse abuse, and elder abuse have been commonly reported in Hong Kong in recent years (Tang and Cheung, 1999).

Health Promotion Framework According to the Declaration of Alma-Ata, issued by the WHO and UNICEF (1978, reproduced in Tarimo and Webster, 1994), PHC acts as a guidance for planning and organizing health promotion program in the community. Macdonald (1993) stated that the three pillars of genuine PHC are participation, intersectoral collaboration and equity. We will invite new immigrant housewives and their husbands from different age groups and different social classes to attend the seminar (WHO, 1978). They can obtain access to health information and take control of their healthcare decisions that can meet the equity of the PHC principle. The housewives are encouraged to attend the seminar. It entirely meets the PHC principle of community participation. They receive social services information and enrich their knowledge of stress management and conflict resolution. Their awareness of promoting family harmony will be increased and eventually they will have more control over their own health. This demonstrates the empowerment of the PHC principle. Established partnerships among different ranges of entities will create mutually beneficial relationships towards respect, trust and understanding. It will reduce duplication and fragmentation of services (Japhet and Hulme in Moodie and Hulme, 2004). Collaboration with government departments and NGOs spreads the responsibilities for the promotion of health (WHO, 2000). The government departments include the Social Welfare Department (SWD), the Leisure and Cultural Department and the Police Force, whereas the NGOs comprise Harmony House, Star Bright and the Women’s Commission. The social workers will empower women and help them maintain a harmonious relationship within their family (Cheng, 2007). They also act as a resource person and make referrals to various government departments, NGOs and professionals to prevent and combat domestic violence. They will introduce their services to the participants in case of encounters with domestic violence. In the meantime, they will deliver counselling services to the needy; provide 24-hour outreach service to carry out immediate investigation, and crisis intervention in domestic violence cases that demand timely resolution. A Police Force officer will conduct an educational talk. He will introduce the role of the Police Force to the housewives, i.e., protecting the victims and their children from suffering further violent attacks in battering, taking firm and positive action against offenders and enforcing Hong Kong laws. Police should sensibly and promptly refer recurrent cases of domestic violence to social welfare department. The Leisure and Cultural Department

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provides venues for meeting. Harmony House is an NGO-arranged facility serving domestic violence victims. It provides a refuge for battered women. A group of TSW housewives, Star Bright, started a neighbourhood watch against domestic violence, offering group sharing and voluntary work (Cheng, 2007). The Women’s Commission is tasked with promoting the wellbeing and interests of women in Hong Kong (Women’s Commission, 2006). According to the Ottawa Charter for health promotion, cited by WHO (1986), we will invite their husbands to attend the program, which creates a supportive environment and allows accessibility (WHO, 1978) in getting information on promoting family harmony, enabling couples live in healthful practice and prevent domestic violence. A video show is arranged for the participants. The content of the film is to introduce Hong Kong culture. Communication skills and a Cantonese training program will be conducted by experienced volunteers and social workers so as to develop their personal communication skills. Hence, they can communicate well with the locals and fuse into Hong Kong cultural life. They can also acquire knowledge of how to maintain a good relationship among their family members, and domestic violence will be lessened. The government has built a health-promoting public policy, which is the action of health promotion (WHO, 1986). The government has enacted a Domestic Violence Ordinance, Chapter 189, providing protection to married persons and cohabiters through injunction orders. The government has also produced advertisements on TV and radio programs that promote family harmony as well as strengthen community action. Media plays a supportive role in the health program. We will use limited reach strategies by providing valid educational information in the form of an educational pamphlet, video show and educational talk which will be effective in the program (McFall, Michener, Rubin, Flay, Mermelstein and Burtaon et al., 1993; reproduced in May, West, Hajek, Nilsson, Foulds and Meadow, 2003). Posters and banners are eye-catching media strategies that attract attention and create a sense and atmosphere of community involvement. Pamphlets can allow participants to have more detailed information on promoting family harmony, and their small size makes them convenient to keep. The information in the video show is easy to understand. A number of family tragedies have occurred in recent years that have hit not only newspaper headlines but also the hearts of the Hong Kong people. Through intersectoral collaboration of government departments and NGOs, we will launch a program on promoting family harmony for the new immigrant housewives in TSW.

Needs Assessment First, we will identify their needs through needs assessment. This requires community participation. A questionnaire with a well-designed inquiry including age group, number of children, interest, time living in Hong Kong, husband’s occupation, socioeconomic factors (income, living with in-law, type and size of housing), and social factors (extramarital affairs, drink, smoking, drug abuser, and gambling) (Tsui, Chan, So and Kam, 2006). Open-ended questions including their attitude towards family harmony, abuse experience and the sources of social services available for help will be asked (Rhodes et al., 2007). Their telephone numbers will be recorded and kept confidential for further follow up. Useful information about a community’s knowledge, beliefs, and values can identify their needs (Stanhope and Lancaster, 1992). For normative need (Hawe, Degeling and Hall, 1990), TSW has the highest

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rate of child and domestic violence (Lau, 2006). For expressed need, a group of 40 housewives started a neighbourhood watch against domestic violence which was formed after one of the city’s worst cases of family violence (Cheng, 2007). An in-depth telephone interview is conducted by volunteers. Trust and an understanding environment are considerably important in facilitating housewives to disclose their problems (Nicolaidis, 2002). Once we detect current domestic violence, appropriate linkage to domestic violence services is critically informed with empathy and a supportive attitude (Dienemann, Glass and Hyman, 2005). A questionnaire will also be given in each session. In this case, our team identified the need for ‘family harmony’ for new immigrant housewives in TSW.

PLANNING As cited by the WHO (2000), health promotion should be the basic component of a program in the pursuit of equity and better health for all. We will propose two identical programs on promoting family harmony. This program is a comprehensive PHC program. The target groups are about 100 TSW new immigrant housewives. It consists of six sessions. Each session will be held conveniently on the first Sunday morning of each month in a community hall. As suggested by Liamputtong and Gardner (2003), community members are needed to participate in planning, implementation, managing and evaluation of health strategy during community development. We will act as a key person, PHC provider, who mediates the community group to achieve our goal and objectives (McMurray, 2003). Our team members include five volunteers, social workers and a police officer. We will orient the program details to team members, including budget, resources and arrangement. Community development is based on commitment to the empowerment of the housewives in such a way that they have real options for their future healthful lifestyle (Kenny, 1999). This program follows the model mentioned by McMurray (2003b). Community education and participation are seen as the core element in achieving health and rely on partnership between governments and NGOs (WHO, 1997, reproduced in McMurray, 2003b). We will introduce knowledge regarding promotion of family harmony and the importance of domestic violence prevention, thus increasing their awareness. We also enhance their communication skills so that they can improve their social relationships with others and family members, especially their parents-in-law. Owing to limited resources, we should carefully plan and utilize everything available to us. We will recruit five rehabilitee migrant housewife volunteers to act as role models for group sharing. A pamphlet and video tape will be provided by the Police Force. Supermarket coupons and recycling shopping bags can be sponsored by voluntary organizations. Other expenditures will be granted by SWD through fundraising. A questionnaire will be used to collect accurate data from the housewives and to assess their attitudes towards family harmony after each session. A meeting will be held and interim evaluation of members will be done after every session. We will fine-tune every detail and draw up overall planning for implementation.

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IMPLEMENTATION A behavioural approach (Laverack, 2004) and an educational approach will be adopted, as discussed by Ewles and Simnett (1999) in Katz, Peberdy and Douglas (2000). For a behavioural approach, we will provide knowledge about family harmony, domestic violence prevention and related services to the participants, giving them knowledge of the importance of maintaining a harmonious family so as to prevent domestic violence. For an educational approach, a communication skills lecture and a film show on Hong Kong culture will be organised for the housewives. First, our team will set up a counter in a TSW market by hanging a banner spelling out clearly what program functions the day holds. Target housewives, who routinely buy food at the market in the morning, will be given the questionnaire. Those returning a well-completed questionnaire will be given a recycling shopping bag as souvenir. In addition, those who join the program will receive stamps with cumulative marks when they attend the program talks. They will get a US$10 supermarket coupon when they collect five stamps. A questionnaire will be given at each session and returned to us at the end for evaluation. Their husbands will also be encouraged to attend the meeting for family cohesion and synergy. At the first session, we will hold a meeting with all team members. The program framework will be introduced to gain cooperation and maintain good communication. Volunteers and we will have an in-depth telephone interview with housewives to assess their needs. Prior to the collection of information, verbal consent from housewives is to be obtained and they will be informed that all of the content of the questionnaire will be kept strictly confidential. At the second session, we will orient the participants about the content of the program at the beginning of the meeting. Furthermore, housewives will be encouraged to introduce themselves and share their mother countries’ culture and customs. According to teachinglearning guidelines (Wass, 2000b), it is of paramount importance to understand their cultures and to respect the uniqueness of their characteristics. At the third session, a film show and educational talk will be conducted by the Police Force. Health information delivered by talks is an effective way to pass along knowledge to a large group of people (Wass, 2000). The video tape will illustrate Hong Kong culture and demonstrate the way to maintain family harmony and prevent domestic violence. Therefore, participants can become familiar with Hong Kong culture and recognize community resources through the seminar. This in turn will enhance their self-confidence and sense of belonging. Pamphlets will be delivered to them for reinforcement. During the educational talk, we will also introduce government departments, such as SWD and the Police Force, and NGOs such as Harmony House and Star Bright. A taskforce can offer even more information. In addition, a Web site and telephone hotlines for information regarding services will be ready for ease of access. Post-program follow up will be given to the housewives for provision of further assistance in the future. They will also be enriched with the government policy, such as a law (Cap189) that provides enforcement arms in protection of married persons and cohabiters through injunction order. At the fourth session, a Cantonese dialect speaking and communication skills training programme will be organised by social workers and volunteers. The new immigrant housewives, who in the past had spoken only their native dialect, will understand and speak

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simple Cantonese with local residents. It will empower them to integrate into the local living environment. Learned communication skill techniques can enable them to maintain a better relationship among their family members. At the fifth session, there will be a group sharing. Discussion provides an opportunity for housewives to examine the issue by comparing a variety of views (Wass, 2000b). Promoting their family harmony skills with instruction and useful services related to domestic violence are explained by the NGOs staff. Participants and volunteers will form five small groups for discussion. Forming a mutual-help group can facilitate the development of an informal support network and stipulate potentials and skills from group members to help one another and allow problems to be solved in daily life. Formation training may be explored to identify those who will undergo ‘training the trainer’, so that the experienced group equipped with more in-depth skills and appropriate attitude can serve their neighbourhood in the community. The process facilities forming a learn-to-teach cycle that can act proactively and initiate their personal development and self-fulfilment in the community. At the last session, a competition in the form of a variety show will be held. It will consist of role play, dancing and karaoke. The content should concern promoting family harmony in Cantonese. As cited by Wass (2000b), role play can provide an opportunity for housewives to practice new behaviours with their husbands. At the same time, we can observe in their performance whether they can exercise family cohesion. A prize award ceremony will be held. We will thank all of the participants for their cooperation. Their feedback will be shown on questionnaire, forming the basis for program evaluation to improve future program planning and organization skills.

EVALUATION We will distribute pre- and post-questionnaires to the housewives. The questionnaires will be designed with a quantitative and qualitative approach. Hence, we can gather data and evaluate the effects of the program, determine the program’s effectiveness, efficiency, adequacy, appropriateness and unintended consequences by contrasting the objectives and results (Stanhope and Lancaster, 1992). During the program, they will demonstrate to us their understanding about promoting family harmony, communicating with others in Cantonese about how to maintain a good relationship with their family members and knowledge about preventing domestic violence and the ways to seek help. The participants will give their views after they cover the whole program and reflect what they acquired and express their views and problems with suggestions for improvement. A meeting will be held and interim evaluation will be done at the end of each session. At last, we will monitor the effectiveness of the program and reassess the objective achievement periodically (Baum, 2000). Evaluation results can reflect the effectiveness of a good health-promotion strategy (WHO, 2000) and provide very useful information for future modification and improvement in similar PHC programs.

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LIMITATION OF THE PROGRAM Educational materials, including banners, posters, pamphlets and video, can only provide one-way communication. Questionnaires will be used as a needs assessment tool and an evaluation tool which involve more technical and manpower. Program funding may be a constraint. The program covers only new immigrant housewives, but not all housewives in TSW. Also, fundraising through arrangement of SWD may contribute only a small resource. Some of the housewives may lack support from their husbands because they are unwilling to attend the seminar or are busy at work. Moreover, some of the housewives may be too shy to discuss their problems because they feel embarrassed and perceive a loss of face in expressing their own real case in the program (Lau, 2006b). Crystallizing the problem of the tendency towards family disharmony is to unveil the mask over the ‘sufferers’ face’ because they are ashamed of that their problems or difficulties are known by their relatives or neighbours. If this phenomenon prevails, family harmony is doomed to break and family conflicts continue. More government funding and social support aided by professionals in this aspect have surely been a great help with a view to alleviating this social headache. Since there is little evidence pertaining to studying family violence or promoting family harmony in Chinese society, the present chapter is at attempt to put forth some ideas to fill the knowledge gap and to provide certain means to promote family harmony in Hong Kong Chinese families.

STRENGTHS OF THE PROGRAM Health talk is interactive and provides detailed information. The PHC provider can communicate with a target group and provide an opportunity for housewives to increase their knowledge regarding promotion of family harmony. The video show is easy to understand. The women will have information about domestic violence and be provided with an easy-toread pamphlet on related services. Group sharing allows idea exchange and provides opportunities for exploring their perception and understanding. The variety show competition allows them to demonstrate their understanding of the learned knowledge and explore their interest. Competition prizes will be given to them for encouragement. Questionnaires will be used as baseline and post-intervention assessment.

CONCLUSION While identifying the need to preserve family harmony is particularly important in the TSW group of housewife immigrants, there should be a good detailed plan to organize a health-promoting program to focus on family harmony with a view to reducing the social problematic issue of domestic violence, which is largely a hidden crime, especially dominant in certain relatively isolated new and secluded towns. Prevention of domestic violence will be achieved by health education about non-violent problem-solving strategies for the target group and their families. It is critical to solicit community involvement and support to acquire a cohesive force to render their families safer and more harmonious. By providing the

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knowledge and synergic effect to the target recipient housewives and their family members, this target population would change their attitude proactively and turn a new leaf in facing their daily life. Domestic violence might fall considerably and people might enjoy life more harmoniously and peacefully. Moreover, reducing domestic violence undoubtedly reduces the burden of unnecessary high costs on the health care system, ultimately benefitting taxpayers. More significantly, financial savings can be achieved if domestic violence can be perceived earlier and dealt with appropriately so that its severity and frequency can be well controlled.

AUTHOR’S BACKGROUND Ms. W. Y. Wong, is an Advanced Practice nurse in the Department of Surgery, Prince of Wales Hospital. She holds a bachelor’s degree in nursing from Monash University of Australia, and a master’s degree in primary health care from the University of Western Sydney. E-mail: [email protected]

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Longman Dictionary of Contemporary English. (2008). Harmony. Retrieved September 15, 2008, from http://www.ldoceonline.com/dictionary/harmony Macdonald, J.J. (1993). Primary Health Care: Medicine in Its Place (2nd ed.). London: Earthscan. McFall, S. L., Michener, A., Rubin, D., Flay, B. R., Mermelstein, R. J., Burtaon, D., Jelen, P., and Warnecke, R. B. (1993). The Effects and Use of Maintenance Newsletters in a Smoking Cessation Intervention. Addictive Behaviour. 18(2), 151-158. Reproduced by S. May, R. West, P. Hajek, F. Nilsson, J. Foulds, and A. Meadow (Eds.), The Use of Videos to Inform Smokers about Different Nicotine Replacement Products. Patient Education Counselling, 51(2), 143-147. McMurray, A. (2003). Community Health and Wellness: A Sociological Approach (2nd ed.). Sydney: Mosby. McMurray, A. (2003b). Health Promotion: Concepts to Practice. Community Health and Wellness: A Sociological Approach (2nd ed.). Sydney: Mosby. Nicolaidis, C. (2002). The Voices of Survivors Documentary: Using Patient Narrative to Educate Physicians about Domestic Violence. Journal of General Internal Medicine, 17, 117-124. Rhodes, K. V., Frankel, R. M., Levintghal, N., Prenoveau, E., Bailey, J., and Levinson, W. (2007). You’re Not a Victim of Domestic Violence, Are You? Provider- patient Communication about Domestic Violence. Annals of Internal Medicine, 147, 620-627. Shek, D. T. L. (2001). Chinese Adolescents and Their Parents’ Views on a Happy Family: Implications for Family Therapy. Family Therapy, 28, 73–103. Slote, W., and Devos, G. A. (1998). Confucianism and the Family. New York: State University of New York. Smith, D. C. (1992). The Chinese Family in Transition: Implications for Education and Society in Modern Taiwan, ERIC Report. Washington, DC: Education Resources Information Service, US Department of Education. Stanhope, M., and Lancaster, J. (1992). Community as Client: Using the Nursing Process to Promote health. Community Health Nursing: Process and Practice for Promoting Health (3rd ed.). St Louis: Mosby. Sung, K. (2000). An Asian Perspective on Aging East and West: Filial piety and Changing Families. In V. Bengtson, K. Kim, G. C. Myers, and K. Eun (Eds.), Aging in East and West: Families, States, and the Elderly. New York: Springer Publishing Company. Tang, C., and Cheung, F. (1999). Violence against women in Hong Kong. In F. Cheung (ed.), Breaking the Silence: Violence Against Women in Asia (pp. 38-58). Hong Kong: Equal Opportunities Commission. Tjaden, P., and Thoennes, N. (2000). Full Report of the Prevalence, Incidence and Consequences of Violence against Women: Findings from the National Violence Against Women Survey. Washington: Department of Justice. Retrieved September 15, 2008, from www.ncjrs.org/txtfiles1/nij/183781.txt Tsui, K.L., Chan, A. Y., So, F. L., and Kam, C. W. (2006) Risk Factors for Injury to Married Women from Domestic Violence in Hong Kong. Hong Kong Medical Journal, 12, 289293. Wagner, B. M., Cohen, P., and Brook, J. S. (1996). Parent/adolescent Relationships: Moderators of the Effects of Stressful Life Events. Journal of Adolescent Research, 11, 347-374.

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Wass, A. (2000). Promotion Health: The Primary Health Care Approach (2nd Ed.). Sydney: Harcourt Saunders. Wass, A. (2000b). Education for Health. Promoting Health: the Primary Health Care Approach (2nd ed.). Sydney: Harcourt. Women’s Commission. (2006). Women’s safety in Hong Kong: Eliminating Domestic Violence. The Women’s Commission report. Retrieved June 18, 2008, from http://www. women.gov.hk/down/oad/safety_Chinese_final.pdf World Health Organization. (1978). Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR. Geneva: WHO World Health Organization. (1978). Primary Health Care: Report of the International Conference on Primary Health Care, Alma-Ata, USSR. Reproduced in E. Tarimo, and E. G. Webster (Eds.), Primary Health Care Concepts and Challenges in a Changing World: Alma-Ata revisited. Geneva: WHO World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion. Denmark: WHO. World Health Organization. (1997). The Jakata Declaration on Health Promotion into the 21st Century. Jakarta: WHO. In A. McMurray, (Ed.), Health Promotion: Concepts to Practice. Community Health and Wellness: A Sociological Approach (2nd ed., pp. 76-98). Sydney: Mosby. World Health Organization. (2000). Fifth Global Conference on Health Promotion. Mexico Ministerial Statement for the Promotion of Health: From Ideas to Action. Geneva: WHO. Xiaolian, J., Chaiwan, S., Panuthai, S., Cheng, Y., Lei, Y., and Li, J. (2002). Family Support and Self-care Behaviour of Chinese Chronic Obstructive Pulmonary Disease Patients. Nursing and Health Sciences, 4, 41-49.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 9

‘LET’S TALK AND LISTEN’: A TWO-DAY COMMUNICATION SKILLS WORKSHOP FOR NURSES Mandy Y. M. Kwan* and Zenobia C. Y. Chan ABSTRACT Effective communication between nurses and patients and between colleagues is crucial to maintaining and fostering a better quality of health care, as well as a supportive working environment. Many nurses have found difficulty and stress when they need to communicate with either their colleagues, patients, or their patients’ relatives. This phenomenon is especially prevalent among those with less working experience in the nursing field. Therefore, there is a need to train them in communication skills. A two-day communication skills workshop—‘Let’s talk and listen’—will be recommended. Nurses who are working in medical wards with less than two years of working experience in the nursing field will be targeted. Through participation in informative lectures, interactive puzzle and picture games, real case studies, group discussions, a mini-survey and role-plays, participating nurses can learn about the elements of interpersonal communication and different communication skills, learn to identify the potential barriers and the solutions of communication processes, and have a chance to demonstrate strategies to build and nurture effective communication skills with colleagues, patients and their relatives. Through the workshop, participants will increase their understanding of the elements of communication, and gain self-confidence in both liaising with colleagues and communicating with patients and their relatives.

BACKGROUND Nurses need to communicate with different people, including their colleagues, patients and patients’ relatives. Communication can be stressful for nurses. Poor communication skills are often the cause of great misunderstanding and conflict. Research has shown that newly*

Correspondence: Mandy Kwan, Registered Nurse, Queen Elizebeth Hospital, Hong Kong. E-mail: [email protected]

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recruited nurses or those with less experience have more difficulty in communicating with colleagues and their patients because they lack the chance to practice or have had little training in effective communication skills (Grover, 2005; Wilkinson, Bailey, Aldridge and Roberts, 1999). This phenomenon can also be found among the nurses working in Hong Kong (HK) hospitals. Due to the busy working environment and the lack of training, nurses face difficulties and stress in communicating with others. Therefore, nurses need to be empowered with effective communication skills. With the appropriate communication skills, they can increase their job satisfaction and the effectiveness of their work. In the past, a survey has shown that nurses have pointed out that the need for communication skills is one of the most important educational area in their profession (Pascoe, 2007). In view of the urgent need for education in communication skills, we have therefore developed a workshop that is specific for medical ward nurses with less than two years’ working experience. It is designed to support and empower them with effective communication skills. This further promotes better nursing care and patients’ recovery outcome in the long run.

OBJECTIVES AND EXPECTED OUTCOME There are three workshop objectives: first, to increase the participants’ understanding of the elements of interpersonal communication and different communication skills; second, to teach the participants to identify the potential barriers in communication processes and the ways to overcome these barriers; and last, to enable participants to demonstrate different strategies to build and nurture effective communication with colleagues, patients and their relatives. After the workshop, there are several expected outcomes. The participants will learn to understand the processes and different modes and channels of interpersonal communication. Additionally, they will learn to understand the characteristics and identify the application of different communication skills. Furthermore, they will be able to identify the potential barriers in communication processes and their related solutions. The participants should be able to determine the methods to overcome these barriers. Finally, they will be confident in liaising and communicating with their colleagues, patients and patients’ relatives by applying appropriate communication strategies and manners. They will learn to recognize the benefits of improving the effectiveness of their interpersonal communication skills.

WORKSHOP RATIONALES Nursing has been developing in HK for several years. People who want to practice as registered nurses (RNs) or enrolled nurses (ENs) in HK must be enrolled as a RNs or ENs by the Nursing Council of HK. Nurses are not allowed to practice nursing in HK unless they hold a valid practicing certificate from the Nursing Council (Nursing Council of Hong Kong, 2008). In the last century, hospital-based nursing schools were the main providers of nursing education through the apprenticeship system. With the increasing need of society and the need for professional standards, in 1990, nursing education started to move towards university degrees. Today, three local universities are offering pre-registration nursing degree programs

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(Mak, 2003). Since 2006, the Nursing Council of HK has also developed mandatory Continuing Nursing Education (CNE) for practicing nurses in order to maintain the quality of health care. It proposes that nurses obtain 45 CNE credits within a three-year cycle to renew their certificate beginning in 2010 (Nursing Council of Hong Kong, 2006). Nurses need to keep up with their learning in order to maintain the standard of nursing care and to equip themselves with updated nursing knowledge, leadership skills being one area. Leaders are the most important people within any organization. Leadership cannot occur except in relationship to other people (Tappen, 2001). Nurses always act in the role of leaders in their working environment, as they are required in their profession to lead a team of nurses and support staff or a team of patients. To be effective leaders, they need to have some specific interpersonal characteristics. Effective communication skills are one of the crucial characteristics (Arta, Barbara, Elfi and Clara, 2008). Communication is a two-way process by which we can give, receive and exchange thoughts, ideas or information through different levels, such as verbal or nonverbal. It includes the talking and listening processes (Dobson, 1995; Marquis and Huston, 2003). Talking and listening are the major behaviors in communication, and getting along with people. Talking is speaking to someone or saying a word aloud, while listening is paying attention to someone in order to hear him or her (Cambridge, 2008). Since leaders need to get along with their team members, communication is the activity leaders engage in most often to inform, convince, direct, develop, collaborate and achieve (Shultz, 2003). In the hospital setting, through communication with colleagues, patients and relatives, nurses can achieve common tasks, build teamwork and trust, and achieve better rapport with patients. Better communication skills would further increase their job satisfaction and decrease work-related stress among nurses (Hanlon, 1996). Therefore, communication skills are exteremely important as a leadership quality. The need to train effective communication skills will be addressed. In the past, research studies and articles addressed the need for communication skills training for nurses. They all point out that workplace communication, such as communication with colleagues and communication with patients, is important. Inside the workplace, a study in California found that nearly 25% of errors were due to poor communication skills and a lack of training (Panting, 2003). A research survey in Australia revealed that 94.1% of nurses identified communication skills as the most important educational area, compared with 93.7% on infection control and 91.4% on first aid (Pascoe, 2007). Nurses point out that better communication skills towards patients can improve patients’ satisfaction and adherence to treatment and disease outcome. They can further maintain a sustained partnership with patients when they know how to listen and talk with their patients (Lein and Wills, 2007; Markova and Broome, 2007). Most nurses view communication as an important element in their profession and understand its benefits. However, real situations have shown that most of them are not well equipped with the skills. This situation is commonly found in those with less working experience in the nursing field. Nurses who have been working for more than five years perceive themselves as being more skilled in facilitating communication. They have a higher level of confidence in helping their clients become self-reliant and responsible for their care when compared with those with lesser experience (Haley, 2007). Past research studies have suggested the great need for communication skills training for nurses, especially for those with less working experience in the nursing field. In order to empower the nurses with effective communication skills, training in the related area is needed. Communication skills workshops are effective in empowering nurses

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with communication skills. A three-day training course for cancer nurses in England has successfully led to clinically-relevant behavioral change and improvements in perceived confidence in communication and utilization of skills among nurse caring for their patients (Wilkinson, 2004). Similarly, a three-day workshop on communication skills in London also showed that this kind of workshop was effective in equipping nurses with communication skills. It suggested that follow-up or further training is needed to solidify the communication skills (Wilkinson et al., 1999). The evidence gives a clear indication that communction skills workshops are functional. In HK, communication skills training workshops can be found at the university level and in hospitals. In the three local universities, there are basic communication theory classes and skills training for undergraduates (The Chinese University of Hong Kong, 2008; The Polytechnic University of Hong Kong, 2008; The University of Hong Kong, 2008). Although undergraduate nursing students can learn communication theories and skills in their curriculum, they do not have much chance to practice or relate the skills to real situations. This results in poor communication practices in the future. In hospitals, the Hospital Authority (HA) has organized some patient-centered communication skills workshops. However, the majority of them are targeted towards nurses with more than two years of experience, or for medical officers (Hospital Authority, 1997). Workshops for those with less than two years’ experience seem lacking. We are aware that there is a special need for nurses with less working experience, but very few workshops can be found for that specific target group. We therefore suggest organizing our communication skills workshop. In view of the limited number of these kinds of workshops, we, accordingly, have developed a two-day communication skills workshop for nurses with less than two years’ working experience. The following provides the details of our workshop.

WORKSHOP DETAIL The workshop is targeted towards nurses in medical wards with working experience below two years in the nursing field in a acute general government hospital (HA, 2007). The workshop is open only to participants working in the medical department, in order to enhance group cohesion. Furthermore, because participants have the same working background, by choosing scenarios familiar to all participants and through the sharing of similar working experiences, this can help to promote learning (Farrell, Ryan and Langrick, 2001). Thirty participants are recruited on a first-come, first-served basis. The participants are divided into five groups, six persons in a group, throughout the workshop to facilitate learning. Lunch and coffee breaks are provided during the course of the two-day workshop to facilitate a supportive learning environment. Lecture notes are delivered as references. Participants will be accredited with 12 CNE credits. The workshop consists of four parts (table 1). There are question-and-answer sessions (Q and A) at the end of each part. The first two parts focus on the introduction of the elements of interpersonal communication and different communication skills. These two parts provide participants with the basic concepts of communication. The last two parts focus on the strategies of communication with colleagues, patients and relatives, which let the participants practice the skills learned in real situations.

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The first part, ‘What is interpersonal communication?’, is held in the morning session of day one and introduces the communication processes, channels and modes through a puzzle game, a picture game and lecture. Before beginning, a welcome note, self-introduction and a discussion of the workshop agenda are provided. Participants are invited to introduce themselves to their group so that they can become familiar with one another to facilitate group and peer learning throughout the workshop. The first part starts with a puzzle game within each group to introduce the definition and processes of communication. Each group is provided with several name cards written with the names of communication processes. The participants need to arrange them in the right sequence of communication processes within the group. Having arranged the cards in the right sequence within each group, the speaker then explains the definition and processes of communication by lecture. The elements of communication channels, modes and characteristics are initiated with a picture game. Each group takes turn in joining the picture games. In the game, a group member takes a card and describes what he or she has seen from the card without verbally communicating with his or her members. The group members need to guess the answer. This game lets the participants know that communication is not just verbal, but also includes non-verbal aspects. The speaker explains the details by lecture and ends the first part by introducing part two of the workshop. The second part, ‘How to talk and listen effectively’, is held in the afternoon session of day one and introduces effective speaking and active listening skills through group discussion, puzzle game, lecture and video demonstration. Participants are encouraged to discuss and present the barriers of effective speaking in their group. A puzzle game with the Chinese word ‘listen’ (聽) is played to stimulate the participants to understand the elements of listening. The speaker sums up the participants’ feedback, and by lecture concludes the points and introduces the elements of effective speaking and active listening and how to overcome the barriers. A demonstration video is played to conclude and highlight the important skills. Day one ends with the introduction of the agenda of day two. The third part, ‘Communication with colleagues’, is held in the morning session of day two and lets the participants learn how to liaise and communicate with colleagues effectively through a mini survey, a case study and lecture. Welcome notes and the workshop agenda are introduced. The workshop starts by carrying out a mini survey. This allows the participants to vote on the main communication barriers with colleagues from a list. In doing so, the participants have a chance to express their main concerns. The speaker provides a lecture explaining the ways to overcome the communication barriers according to the survey results. Finally, guidelines to facilitate good communication are shown using two cases studies. One case study is about speaking skills when asking for help and liaising with colleagues. The second one is about listening skills when receiving information and orders from colleagues. The morning session ends after introducing the agenda of the final part of the workshop. The final part is ‘Communication with patients and relatives’. This part lets the participants learn ways to communicate and reassure patients and their relatives through scenarios, role-plays, video demonstration and lecture. Scenarios showing the communication processes between medical ward nurses and patients are shown and the participants are asked to identify the communication barriers in the scenario within their group. Each group is invited to role-play and modify the scenarios to show how they should act to overcome the barriers. These activities stimulate and give the participants a chance to think of the solution for themselves. The speaker draws a conclusion after the role-play and points out the

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guidelines for communicating with patients and relatives by video demonstration and lecture. The whole workshop ends after the collection of the workshop evaluations. A self-administered questionnaire (Appendix A) is used to assess whether the participants have achieved the expected outcome of the workshop. The evaluation includes two parts: first, participants are asked to give overall feedback on satisfaction with the workshop’s content, place, time and method; second, participants give feedback on whether they can utilize the communication skills learned. All of these opinions are crucial for workshop improvement and the development of related workshops in the future (Ewles and Simnett, 2003; O’Connor-Fleming and Parker, 2001). Table 1. Workshop content outline Topics Content

Day 1 (AM session) What is interpersonal communication? -Welcome note and self introduction -Introduce the workshop agenda and objectives -Ice breaking -Communication definition and processes

Day 1(PM session) How to talk and listen effectively -Barriers of effective speaking skills -Effective speaking -Barriers of effective speaking -Elements of effective speaking skills and overcoming the barriers

BREAK (20 minutes.) BREAK -Different communication channels and modes and their characteristics -Q and A -Introduction of PM session LUNCH (2 hours)

Topics Content

Day 2 (AM session) Communication with colleagues -Welcome note -Introduce the second day workshop agenda and objectives -Identify the barriers to communication in the workplace -Ways to overcome the barriers

Active listening -Chinese character of listening -Barriers of active listening -Elements of active listening skills and overcoming the barriers -Q and A -Introduction of the second day workshop Day 2 (PM session) Communication with patients and relatives -Identify the barriers to communication patients and their relatives -Ways to overcome the barriers BREAK

BREAK

-Guidelines to facilitate good communication -Workshop conclusion

-Guidelines to facilitate good communication

-Q and A

-Q and A

-Collect workshop evaluation

Introduction of PM session LUNCH (2 hours)

DISCUSSION Several things need to be deeply considered to facilitate learning. Since the participants are Chinese nurses, the medium is mainly Cantonese supplemented by English as necessary.

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By considering the relatively young age of participants and their favorite learning modes, interactive and interesting modes of delivery will be used. These include lectures, puzzle and picture games, cases studies, group discussions, mini-survey and role-plays. All of these modes need participants to actively participate and provide feedback (Dignan and Carr, 1992). Peer group learning and reflection also allows the participants to learn from one another’s perspective and discover new ways of looking at problems (Boud, Keogh and Walker, 1998). With regards to the learning environment, the size, lighting, temperature and setting of the room are considered to ensure comfort and support. Lecture notes are delivered to supplement the workshop and facilitate learning (Henry,1997; Wass, 2000). Should there be any latecomers, class will begin after a waiting period of five minutes. Group discussions will not begin if there is an insufficient number of group participants. Finally, since this workshop occupies the participants for two whole days, they can be accredited with 12 points of CNE after finishing the workshop as a reward. Communication is a crucial element of leadership. Empowering nurses with effective communication skills is greatly beneficial to both themselves and the patients. As mentioned earlier, better communication skills can prevent misunderstanding of treatments and patients’ needs, and thus help to prevent errors and promote safety in the workplace. Inevitably, our workshop can foster a better and more supportive working environment in the long run. The concept of primary health care and health promotion emphasizes collaboration with others, teamwork, a supportive environment and empowerment (World Health Organization, 1978; 1986). However, all of these elements cannot exist without the skills of communication. Therefore, communication skills are the energy and the basic elements that can enhance the spirit of collaboration and teamwork among colleagues. Moreover, letting nurses have a chance to learn and join the workshop is a simple way to empower them. It also promotes partnership and rapport between nurses and patients as the participants learn how to speak and listen to their patients. Communication skills also correlate greatly to other important elements of leadership, such as reflection and power of change. Our workshop is the pioneer that can empower participants to speak for and reflect upon themselves in an appropriate manner, and lead to further improvement of workplace changing processes. Follow up and further training are greatly important in order to solidify the communication skills (Wilkinson et al., 1999).

CONCLUSION A two-day workshop on communication skills is outlined above with the evidence of literature review. The needs of the workshop for less experienced nurses are addressed. Our workshop is believed to be effective in empowering participants with effective communication skills. With the collection of workshop evaluations, follow-up activities are suggested to maintain a better workshop outcome. In conclusion, the need for the workshop is crucial so that our nurses can work with increased self-confidence and a greater sense of work value.

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AUTHOR’S BACKGROUND Mandy Kwan, a registered nurse, holds a bachelor of science degree in nursing and a master’s degree in primary health care. As a member of her hospital voluntary working team and a guide nurse, she shows great ambition in empowering the junior nurses.

REFERENCES Arta, F., Barbara, M., Elfi, N., and Clara, W. (2008). Nurses’ views on the characteristics of an effective leader. AORN Journal, 87 (2), 363-371. Boud, D., Keogh, R., and Walker, D. (Eds.). (1998). Reflection, turning experience into learning (pp.7-17). London: Kogan Page. Cambridge. (2008). Cambridge Advanced Learner's Dictionary [E-text type]. http:// dictionary.cambridge.org/define.asp?key=46535 and dict=CALD Dignan, M.B., and Carr, P.A. (1992). Program planning for health education and promotion (2nd ed.). Philadelphia: Lea and Febiger. Dobson, A. (1995). How to communicate at work. Making a success of your working relationships. Plymouth: How to Nooks Ltd. Ewles, L., and Simnett, I. (2003). Promoting health. A practical guide (5th ed.). Edinburgh: Bailliere Tindall. Farrell, M., Ryan, S., and Langrick, B. (2001). ‘Breaking bad news’ within a peadiatric setting: an evaluation report of a collaborative education workshop to support health professionals. Journal of Advanced Nursing, 36(6), 765-775. Grover, S.M. (2005). Shaping effective communication skills and therapeutic relationships at work. The foundation of collaboration. AAOHN Journal, 53(4), 177-182. Guilar, J.D. (2001). The interpersonal communication skills workshop. A trainer’s guide. New York: AMACOM Haley, J.E. (2007). Experience shown to affect communication skills of nurse case managers. Case Management Journals, 8 (2), 50-57. Hanlon, J.M. (1996). Teaching effective communication skills. Nursing management, 27(4), 48B. Henry, J.M. (1997). Gaming: A teaching strategy to enhance adult learning. The Journal of Continuing Education in Nursing, 28(5), 231. Hong Kong Tuberculosis, Chest and Heart Diseases Association. (2008). Registration Form. Hong Kong Special Administrative Region: Hong Kong Tuberculosis, Chest and Heart Diseases Association. Hospital Authority. (1997). Training programmes [E-text type]. http://www.ha. org.hk/ ho/hr/TProgram.htm Hospital Authority. (2007). Queen Elizabeth Hospital [E-text type]. http://ha.org.hk/ hesd/nsapi/?Mival=ha_visitor_index and intro=ha%5fview%5ftempte%26group% 3dO SR%26Area%3dHNI Lein, K., and Wills, C.E. (2007). Using patient-centered interviewing skills to manage complex patient encounters in primary care. Journal of the American Academy of Nurse Practitioners, 19(5), 215-220.

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Mak, M. K. F. (2003). Future direction of nursing development in Hong Kong [E-text type]. http://www.hksne.org.hk/newspaper/200309-02.htm Markova, T., and Broome, B. (2007). Effective communication and delivery of culturally competent health care. Urologic nursing, 27(3), 239-242. Marquis, B.L., and Huston, C.J. (2003). Leadership roles and management functions in nursing. Theory and application (4th ed.). Philadelphia: Lippincott. Nursing Council of Hong Kong. (2006). Implementation of continuing nursing education on a voluntary basis. Hong Kong Special Administrative Region: Nursing Council of Hong Kong. Nursing Council of Hong Kong. (2008). Practicing certificate. Hong Kong Special Administrative Region: Nursing Council of Hong Kong. O’ Connor-Fleming, M.L., and Parker, E. (2001). Health promotion: principles and practice in the Australian context (2nd ed.). Sydney: Allen and Unwin. Panting, G.. (2003). The importance of communication. Hong Kong Medical Journal, 9(5), 389-390. Pascoe, T. (2007). The educational needs of nurses working in Australian general practices. Australian Journal of Advanced Nursing, 24(3), 33-37. Shultz, B.J. (2003). What makes a good leader? AORN Journal, 78 (1), 9-10. Tappen, R.M. (2001). Nursing leadership and management. Concept and practice (4th ed.). Philadelphia: F.A. Davis Company. The Chinese University of Hong Kong. (2008). Bachelor of Nursing [E-text type]. http://www.cuhk.edu.hk/med/nur/en/prog_undergrad1.html The Polytechnic University of Hong Kong. (2008). Bachelor of Science (Honours) in Nursing [E-text type]. http://nhs.polyu.edu.hk/sn/eng/programmes/bsc.asp The University of Hong Kong. (2008). Bachelor of Nursing [E-text type]. http://www. hku.hk/nursing/prospective_students/bachelor.htm Wass, A. (2000). Promoting health: The primary health care approach (2nd ed.). Sydney: Harcourt. Wilkinson, S.M. (2004). Health and Medicine Week: Nursing, three-day programs can improve nurses’ communication skills in cancer care. Atlanta: NewsRx. Wilkinson, S., Bailey, K., Aldridge, J., and Roberts, A. (1999). A longitudinal evaluation of a communication skills programme. Palliative Medicine, 13, 341-348. World Health Organization. (1978). Primary health care: report of the international conference on primary health care, Alma-Ata, USSR. Geneva: World Health Organization. World Health Organization. (1986). Ottawa Charter for Health Promotion: An International Conference on Health Promotion. Denmark: World Health Organization.

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APPENDIX A Please give a 9 to the number that best represents your reaction to the workshop. 1=Disagree

2=Somewhat disagree

3=Neutral

4=Somewhat agree 1

2

3

5=Agree 4

5

1. The objectives of the workshop were clear 2. The speaker’s delivery met professional expectations 3. The speaker helped you learn. 4. The techniques and activities helped you learn 5. The materials presented met your needs 6. You will be able to apply these skills to your work 7. You are satisfied with the workshop venue 8. You are satisfied with the workshop length 9. The workshop fee is reasonable 9. Overall, you will rate the workshop as excellent.

Other comments: ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ________________________________________________________________________ Reference: Guilar, J.D. (2001). The interpersonal communication skills workshop. A trainer’s guide. New York: AMACOM.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 10

APPLYING CRISIS MANAGEMENT PLANS TO PUBLIC TRANSPORTATION ACCIDENTS S. Y. Lee and Zenobia C. Y. Chan ABSTRACT In Hong Kong, public transportation, including subways, franchised buses, public light buses and taxis, plays an important role in a citizen’s daily life. A crisis exists in public transportation that affects all people in Hong Kong. Recalling a fatal traffic disaster in 2003 in Hong Kong, a double-decker bus plunged about 31m off Tuen Mun Road, resulting in 21 fatalities and 20 injuries. Was the rescue conducted in an effective manner? Was the recovery process of the victims facilitated? Did the authorities take any actions to prevent similar traffic accidents from happening again? Crisis management is the answer to these questions. It helps enhance the effectiveness of crisis prevention and the handling procedures. Considering that this is not a common subject in Hong Kong, there is great room for improvement. This chapter provides a comprehensive review of the current trend and the most common contributing factors to traffic accidents in Hong Kong from 1997 to 2006. The information analysis makes recommendations and proposes crisis management plans based on evidence. On the other hand, there is a lack of action plans for multi-sectors to prevent and handle major traffic accidents in an organized manner. This chapter functions as a reference for the related authorities, i.e., the Transport Department, the Road Safety Council and the Hong Kong Police Force, etc., to evaluate the current road safety policy.

INTRODUCTION Crisis is an event or series of events representing a critical threat to the health, safety, security or well-being of a community, usually over a wide area (WHO, 2007a). It can increase psychological vulnerability, resulting in potentially dangerous, self-destructive or socially unacceptable behavior (Shives, 2008). Runciman and Merry (2005) explicitly define a “crisis in a health care system” as “the point in the course of a disease at which a decisive change occurs, leading either to recovery or to death”. Within healthcare settings, the

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potential for incidents is higher and the risks are even greater (Duff, 1999). For example, under circumstances relating to public health, such as handling contaminated blood, severe acute respiratory syndrome and avian flu, crisis management is absolutely essential for the protection of citizens (Carole, 2007). Crisis management is known as the study of organizations and crisis, and how the organizations handle those events (Runyan, 2006). Such management in health care settings could be divided into three levels: the clinical level, the health service level and the regional level. Firstly, Runciman et al. (2005) suggest using a crisis management model during anaesthesia to reduce the risk of surgery. Secondly, crisis management helps to bring crisis situations and the consequences to life for healthcare professionals (Johnson, 2006). Thirdly, Peltz et al. (2006) performed a qualitative research study after the Tsunami flooding to study the Thai health system in terms of leadership, disaster management, and response. Hence, crisis management plays an important role in healthcare settings, and we could apply the same concept to public transportation. With a total area of 1,102 km2, Hong Kong had a population of 6.9 million and 609,959 licensed vehicles by the end of 2006. The length of public roads runs 1,932 km, with 111 km being expressways. Hong Kong is a congested city in which the traffic network plays an important role in people’s life. Unfortunately, there were 14,849 road traffic injury accidents (RTIAs) in the territory in 2006. Among them, over 45% involved public transportation such as franchised buses, public light-buses, taxis and subways, while over 30% happened on public buses (Transport Department, 2008). RTIAs bring great impact to the survivors of traffic incidents who often suffer from disability or health impairment—physical or psychological (WHO, 2008a). Therefore, preventive measures of RTIAs should be further strengthened to avoid any RTIAs, especially RTIAs occurring on the franchised buses. Without a successful crisis management system, a crisis recovery process could be unresponsive and ineffective (Nick et al., 2004). Through crisis management, the policies, measures and responses taken could minimize the risk of man-made crisis, save lives and mitigate the negative impact of crisis (Runyan, 2006). However, crisis management is not a familiar subject to Hong Kong people because of inadequate education and insufficient crisis management promotion. Therefore, the findings in the chapter are intended to formulate a crisis management action plan. In this chapter, we will focus on the prevention of crisis and the emergency phase of crisis management of a major RTIA. The objectives of this chapter are to enhance crisis management awareness of public transportation accidents, suggest preventive measures for accidents to reduce the risk, minimize the severity of consequences and recommend crisis management action plans to enhance the efficiency of handling RTIAs. In this chapter, the current trend and contributing factors to traffic accidents in Hong Kong from 1997 to 2006 will be firstly analyzed. Secondly, two major defects relating to road user education and the traffic legislation will be pointed out. Thirdly, two crisis management models and recommendations on road user education will be introduced. Finally, the difficulties in implementing the recommendations will be explored in the discussion part, and a conclusion will be made by the end of this chapter.

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ANALYSIS OF TRAFFIC ACCIDENTS IN HONG KONG The Current Trend According to the Annual Transport Digest of the Transport Department (2008), the number of RTIAs involving all classes of vehicles in Hong Kong in 2006 was 13,539, represented by a 4% decrease when compared with the figure in 1997. However, the number of RTIAs involving franchised public buses in 2006 was 1,897, represented by a 22% increase when compared with the figure in 1997. Over the last decade, the number of overall RTIAs showed a slightly decreasing trend, while the number of RTIAs involving public buses showed an aggressively increasing trend. The data draw our attention to the issue of RTIAs involving public buses. As suggested by Nick et al. (2004), a crisis management effort, comprising prevention, emergency and reconstruction phases, is an effective way to handle a crisis, and we could apply crisis management concepts to stop the increasing trend of RTIAs. Measures for a preventive phase will be discussed in the later part of this chapter.

Causes of Traffic Accidents The causes of RTIAs should be analyzed based on the hardware system and software system (Mike et al., 2005). The former refers to road environment, design of roads and vehicles, while the latter refers to road users, i.e., drivers and pedestrians. However, we will merely focus on the software system in this chapter. The top three contributing factors to RTIAs were driving too close to the vehicles in front, loss of control of vehicles, and careless lane changing which, respectively, accounted for 15%, 11% and 8% of the total number of RTIAs in 2006. Swerving and starting negligently totally accounted for 45% of the total number of RTIAs for the same period. The above factors totally relate to driving behavior of motorists. In addition to driving behavior, some of the RTIAs are caused by pedestrians or passengers themselves. In 2006, 26% of the total number of RTIAs resulted from jaywalking, distraction, falling inside buses and falling on the stairway in buses. Additionally, the contributing factors involving vehicles and environment only accounted for 5% of the total number of RTIAs in 2006 (Transport Department, 2008).

LEGISLATION Legislation and enforcement are the key to combat undesirable driving behavior. Serious traffic offences are addressed in the Road Traffic Ordinance (Chapter 374) (Department of Justice, 2008) and Hong Kong Police Force (HKPF) is the enforcement agency. With the highly congested traffic flow in Hong Kong, it is necessary to review the current statutory standards to meet the changing needs of the community (Cheng et al., 2003). Therefore, the Hong Kong government should review the ordinances relating to traffic on a regular basis to ensure road safety in town.

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After the review of the ordinances relating to traffic issues in 2005, the Hong Kong government simplified the enforcement procedures by making new legislation in 2006. The new legislation included increasing the fixed penalty for jumping a red light, applying fixed penalty tickets to anyone caught for using a mobile telephone or other telecommunications equipment while driving, failing to drive in the nearside lane of an expressway, and motorcycles or motor tricycles driving without the obligatory lit headlamps (Road Safety Council, 2006). These new legislations were well received by the general public to enhance road safety standard and enforcement. With reference to the current road traffic ordinances and regulations in effect, most of them regulate unsafe driving behavior, including dangerous/careless driving, alcohol/drug use while driving and failure to comply with traffic signals, signs and markings, etc. However, there is room for improvement, such as establishing regulations for road user education. Apart from the formulation of the essential laws above, we should take a forward- looking attitude to further enhance road safety.

DEFECT ANALYSIS After analyzing the causes of RTIAs in Hong Kong, a shortcoming is very obvious: lack of road user education to avoid unsafe driving behavior and maintain a safe driving attitude. Concerning this defect, one of the solutions is to educate road users in an organized way by legislation. Another defect is that there is no comprehensive evaluation of the road safety measures conducted by the Road Safety Council (“RSC”), which is the authority in coordinating road safety measures in Hong Kong since 1983. RSC provides road safety education through three main channels: Safe Towns, Safe Buses and Seminars (Road Safety Research Committee, 2004). While RSC organizes a series of road safety promotion campaigns and activities annually, the degree of community participation and the effectiveness of the promotion programs are in doubt. To remedy these defects, we must formulate action plans for the prevention phase.

CRISIS MANAGEMENT MODELS Prevention of Traffic Accidents WHO (2007b) stated that emergency preparedness and response encompass a range of activities to protect communities, property and environment. McConell and Drennan (2006) stated that crisis preparedness does occur in many front-line sector-specific organizations in order to plan for rail crashes, air disasters and so on. These principles could also be applied to crisis management of traffic accidents. In the case of a crisis management system in New Zealand, the Ministry of Civil Defence and Emergency Management (MCDEM) was established in 1999 and is responsible for developing and maintaining the preparedness of the New Zealand community for any natural and technological hazards or disasters. In 2002, MCDEM adopted a national and regional framework as the emergency management strategy

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and plan (Dantas and Seville, 2006). To prevent traffic accidents in a systematic and effective manner, crisis management concepts should be applied to the current road safety framework. A crisis management team, comprising representatives from the Transport Department, the Highways Department, the Hong Kong Police Force, the Road Safety Council and traffic engineers, should be formed to bear the responsibility of road safety enhancement. The team should also meet regularly to review the causes of traffic accidents and compare the current statutory standards for road safety with the rules implemented in foreign countries for analyzing any defects relating to road safety. Recommendations to different parties should be made by the team to strengthen the road safety. Then, departments and the authorities relating to the traffic issues should take follow up actions after receiving the recommendations from the team. Finally, the effectiveness of the recommendations should be monitored and evaluated by the team from time to time. The crisis management model for prevention of traffic accidents is shown in Figure 1.

* The crisis management team should be superior to all organizations designated for road safety. Figure 1. Crisis management model for the prevention of traffic accidents prior to the occurance of a crisis.

Handling Major Traffic Accidents The effective response from the crisis management team will ensure the safety and effectiveness of the rescuers (Nick et al., 2004). The immediate actions after major accidents

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are summarized by six Rs rules: rescue the victims; release all factual information to the victims’ relatives and the general public; repair destruction caused by the traffic accident; rehabilitate the victims to facilitate recovery; reconstruct the safety management system and the hardware; and regain reputation and the confidence of the public. According to the six Rs rules, a crisis management team is essential for handling major traffic accidents. The team should also coordinate and organize all work based on the rules. The crisis management model for major traffic accidents is shown in the Figure 2.

Figure 2. Crisis management model for major traffic accidents.

RECOMMENDATIONS Sustainable Education Program Education is a process of training to change people’s behavior (Brain Media, 2008). To enhance the road safety in Hong Kong, more resources should be allocated to organize

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education programs. Moreover, these education programs should target at all walks of life, instead of merely at minors and the elderly. RSC should also enhance the road safety awareness among adolescents and adults through school, local communities and commercial corporations. In addition, the sustainability of the education program is also vital. Through sustainable road safety education programs, road safety concepts, and safety awareness messages can be promoted to the public. It is necessary to organize a sustainable publicity program to improve road safety awareness among drivers. Given that road safety promotion programs are resource consuming, RSC should put more effort into evaluating its road safety promotion programs.

Statutory Driver Improvement Scheme The introduction of the Driver Improvement Scheme (DIS) is meant to promote road safety and improve driving behavior and attitude. The Transport Department began the initiative in September 2002 and authorized a number of driving improvement schools to provide driving improvement courses with a view to enhancing the safety of drivers and other road users in Hong Kong (Transport Department, 2008). In order to combat dangerous driving, the Transport Department should consider the feasibility of implementing the DIS in a compulsory manner. If a driver accumulates a trafficoffence point of 5 or above, the driver must enroll in the DIS to revise his/her dangerous driving attitude. The effectiveness of the DIS should also be evaluated by recording whether the DIS-enrolled drivers commit any traffic offence within 1 year.

Occupational Driver Education Programs The quality of occupational drivers is neither guaranteed nor monitored. There is even no test or evaluation for them in Hong Kong. Therefore, a standardized pre-occupation driving training should be prepared for the potential occupational drivers. Additionally, there should be a code of practice and a safety driving guideline for them to comply with. Employers should initiate the occupational driver training, for their perspectives on crisis management provide a useful descriptive framework to prevent crisis (Acquier et al., 2008). With the pre-occupational driving training, the quality of occupational drivers can be guaranteed and the Transport Department should establish a monitoring system for all occupational drivers. A test should be held by employers or any parties authorized by the Transport Department for drivers before they become occupational drivers. If any drivers fail to fulfill the requirements of the monitoring system, they should be required to re-take the training and re-sit the test until they pass the test.

Evaluation of Education Programs for Drivers The overall effectiveness and efficiency must be appraised by reviewing as many relevant indicators as possible (WHO, 2008b). A set of applicable and representative indicators are necessary for RSC to review and evaluate the effectiveness and efficiency of the promotional

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programs for road safety. The numbers of RTIAs, and fatalities and injuries are the quantitative indicators while the contributing factors to RTIAs are the qualitative indicator to reflect the results of the promotional programs. Moreover, a pre-post comparison program should be implemented to evaluate whether drivers commit any traffic offence after joining the education programs.

DISCUSSION There are a few difficulties in implementing the recommendations for road safety education. Firstly, RSC is just a non-government organization. It has no legal authority or power to reinforce community participation in its promotional programs. Moreover, RSC has no evidence-based practice to evaluate the effectiveness of its promotional programs. Therefore, RSC may have no convincing power in implementing the road safety promotional programs. It would be more convincing if RSC is granted the authority to implement road safety campaigns and activities. Secondly, the Driver Improvement Scheme is now operated by private motoring schools. If drivers with traffic-offence points of 5 or above were required to join this initiative, these schools would not have enough resources to provide training courses to drivers without extra resources from the Hong Kong government. Under these conditions, the teaching quality of the initiative would definitely become worse and the schools could not closely follow up on the drivers’ driving behavior for one year. Hence, it is better to allocate more resources to the motoring schools to organize the DIS courses. Thirdly, the Occupational Driver Education Program has not yet started. The Hong Kong government and the general public should welcome this program; however, current occupational drivers are in opposition to this proposal. The occupational drivers believe that they are more than competent to drive commercial vehicles safely on the road. Therefore, the associations representing drivers of various commercial vehicles should be consulted to collect their opinions on this matter. Finally, the actions taken by the crisis management team to prevent traffic accidents may be duplicated with tasks done by other parties, e.g., reviewing the statistics of the current trend of traffic accidents by the Transport Department and RSC. Hence, resources may be wasted given such duplication. Better coordination and division of labour can optimize resources utilization of the different authorities, such as the Transport Department, the Highway Department and RSC.

CONCLUSION A crisis could take place anywhere and anytime. Although the number of total RTIAs has been decreasing since the last decade, the number of RTIAs involving public transportation has increased, especially regarding public buses. Unfortunately, most of the accidents are caused by human factors. Could these crises be prevented? The answer is absolutely yes. Crisis management is an effective way to reduce the risk of a man-made crisis. We should stop inflating the trend by educating drivers and road users with crisis management models.

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On the other hand, in the event of major traffic accidents, we could apply the crisis management concept to a real situation to save lives and facilitate recovery by forming a crisis management team. To enjoy a safe traffic flow in Hong Kong, road safety education is always the initial and the most important step to take.

AUTHOR’S BACKGROUND Sau-Yam Lee holds a bachelor of science (with honours) in physiotherapy (The Hong Kong Polytechnic University), a professional diploma in health promotion and health education (The Chinese University of Hong Kong), a diploma in occupational health and safety (Lingnan University), and is a registered physiotherapist (Hong Kong) working at Chuk Lam Ming Tong Care and Attention Home for the Aged in Hong Kong.

REFERENCES Acquier, A., Gand, S. and Szpirglas, M. (2008). Crisis episodes: a case study in a public transportation company. Journal of Contingencies and Crisis Management, 16 (2), 101114. Brain Media (2008). Definition of Education. http://www.brainyquote.com/words/d/ education158399.html Carole Lalonde (2007). The potential contribution of the field of organizational development to crisis management. Journal of Contingencies and Crisis Management, 15 (2), 95-104. Cheng, H. K., Leung, K. H. and Wong, S. C. (2003). Report on enhancement of highway safety. Hong Kong: Government Logistics Department, the Hong Kong Special Administrative Region. Dantas, A. and Seville, E. (2006). Organizational issues in implementing an information sharing framework: lessons from the Matata flooding events in New Zealand. Journal of Contingencies and Crisis Management, 14 (1), 38-52. Department of Justice (2008). Bilingual laws information system. http://www.legislation. gov.hk/eng/index.htm Duff, A. (1999). Crisis management. Nursing Management, 6 (3), 21-22. Johnson, R. L. (2006). Crisis communication: case studies in healthcare image restoration. Suite: Pan Pohly Associates. McConnell, A. and Drennan, L. (2006). Mission impossible? planning and preparing for crisis. Journal of Contingencies and Crisis Management, 14 (2), 59-70. Mike S., Peter G. and Paul M. (2005). Traffic engineering design: principles and practice (2nd Edition). Oxford: Elsevier Butterworth-Heinemann. Nick, D. T., Susan, M. R., Srilatha, N. and Zhenhua, J. Y. (2004). Disaster recovery preparedness through continuous process optimization. Bell Labs Technical Journal, 9 (2), 147-162. Peltz, R., Ashkenazi, I., Schwartz, D., Shushan, O., Nakash, G., Leiba, A., Levi, Y., Goldberg, A. and Bar-Dayan, Y. (2006). Disaster healthcare management and crisis

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intervention leadership in Thailand: lessons learned from the 2004 Tsunami disaster. Prehospital and Disaster Medicine, 21 (5), 299-302. Road Safety Council (2006). Road safety council annual report 2006. Hong Kong: Hong Kong Road Safety Council. Road Safety Research Committee (2004). Hong Kong road safety review. Hong Kong: Hong Kong Road Safety Council. Runciman, W. B., Kluger, M. T., Morris, R. W., Paix, A. D., Watterson, L. M. and Webb, R. K. (2005). Crisis management during anaesthesia: the development of an anaesthetic crisis management manual. Quality and Safety in Health Care, 14, e1. Runciman, W. B. and Merry, A. F (2005). Crisis in clinical care: an approach to management. Quality and Safety in Health Care, 14, 156-163. Runyan, R. C. (2006). Small business in the face of crisis: identifying barriers to recovery from natural disaster. Journal of Contingencies and Crisis Management, 14 (1), 12-26. Shives, L. R. (2008). Basic Concepts of Psychiatric-Mental Health Nursing (7th ed.). Philadelphia: Lippincott Willimas and Willkins. Transport Department (2008). Annual transport digest 2007. Hong Kong: Transport Department of the Hong Kong Special Administrative Region. World Health Organization (2008a). Global assessment of national health sector emergency preparedness and response. Switzerland: WHO Document Production Services. World Health Organization (2007a). Risk reduction and emergency preparedness: WHO sixyear strategy for the health sector and community capacity development. Switzerland: WHO Document Production Services. World Health Organization (2007b). Mass casualty management systems: strategies and guidelines for building health sector capacity. Switzerland: WHO Document Production Services. World Health Organization (2008b). WHO module 8. studying management systems. http://www.who.int/hac/techguidance/tools/disrupted_sectors/module_08/en/index5.html

APPENDIX I. (TABLES A-D CITIED FROM THE ANNUAL TRANSPORT DIGEST, 2007) A) Road Traffic Injury Accidents by Class of Vehicle Involved, 1997–2006 Class of vehicle All motor vehicles Motor cycle Class of vehicle Private car Public light bus (All goods vehicles) Franchised public bus Non-franchised public bus Taxi

1997 14136 2676 1997 5995 950 (4000) 1573 103 3045

1998 13414 2317 1998 5836 891 (3524) 1593 99 2865

1999 13796 2528 1999 5925 995 (3561) 1802 380 2819

2000 14046 2674 2000 6053 1008 (3644) 1838 362 2932

2001 14538 2856 2001 6052 992 (3517) 1934 430 3323

2002 14434 2681 2002 6088 1048 (3618) 1858 436 3238

2003 13139 2671 2003 5165 958 (3172) 1764 378 3057

2004 13502 2698 2004 5190 1090 (3304) 1839 491 3083

2005 13795 2775 2005 5244 1091 (3476) 1864 436 3327

2003 2736 6282 1008 2728 1108 1828 391 3397 19743

2004 2742 6279 1154 2822 1197 1899 508 3457 20355

2006 13539 2741 2006 5095 1027 (3371) 1892 424 3320

Note: In a single accident, there may be more than one class of vehicle involved.

B) Accident Involvements by Class of Motor Vehicle, 1997–2006 Class of motor vehicle Motor cycle Private car Public light bus Light goods vehicle Medium and heavy goods vehicle Franchised public bus Non-franchised public bus Taxi All motor vehicles*

1997 2718 7460 982 3490 1330 1631 105 3346 21568

1998 2354 7145 926 3075 1218 1645 104 3181 20152

1999 2561 7227 1049 3114 1235 1871 394 3101 20842

2000 2724 7461 1055 3232 1217 1909 379 3274 21530

2001 2914 7433 1040 3041 1185 2009 436 3706 22057

2002 2718 7508 1098 3117 1249 1928 452 3617 21967

2005 2835 6303 1132 3008 1180 1928 451 3752 20850

Note: * All motor vehicles exclude bicycles, handcarts and vehicles with unknown vehicle type. 1. Since 1999, vehicle class recognition changed from being visually distinguished by police officers to direct extraction from VALID through matching of vehicle registration number.

C) Road Traffic Casualties by Class of Road User, 1997-2006 Class of road user Pedestrian Passenger Driver (Total)

1997 5321 7366 7106 19793

1998 4933 7280 6863 19076

1999 4830 7153 7439 19422

2000 4785 6970 7674 19429

2001 4978 7244 8096 20318

2002 4805 7477 8318 20600

2003 4517 6104 7689 18310

2004 4577 6723 8102 19402

D) 2006 Road Traffic Accidents by Top Five Contributory Factors Contributory Factor—Driver

No. of Drivers

Driving too close to vehicle in front

2096

Lost control of vehicle

1452

Careless lane changing

1119

Trying to avoid collision or otherwise : swerving

817

Starting negligently

549

Contributory Factor—Casualty (Driver, Passenger or Pedestrian)

No. of Casualties

Crossing road heedless of traffic (elsewhere)

1214

Inattentive

876

Crossing road heedless of traffic (at crossing)

669

Falling inside bus/PLB (sudden stopping/starting)

610

Falling on stairway of bus

166

Contributory Factor—Vehicle

No. of Vehicles

Unidentified vehicle (hit-and-run)

56

Defective brake

45

Inadequate or no lights

18

Tire blown out before impact

16

Defective or illegal tyre

16

Contributory Factor—Accident Environment Slippery road (not related to weather)

No. of Incidents 154

2005 4404 6557 8259 19220

2006 4233 6312 8328 1887

D) 2006 Road Traffic Accidents by Top Five Contributory Factors (Continued) Contributory Factor—Accident Environment

No. of Drivers

Object or animal in road

150

Pedestrian negligence

133

Slippery road (caused by weather)

111

Obstructed road

45

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APPENDIX II. ROAD TRAFFIC ORDINANCE (CAP. 374) AND THE ASSOCIATED REGULATIONS (CITED FROM THE BILINGUAL LAW INFORMATION SYSTEM) Road Traffic Ordinance (Cap. 374) Section 36 Causing death by dangerous driving Section 37 Dangerous driving Section 38 Careless driving Section 39 Drinking/drug use while driving Section 39A Driving with alcohol concentration above the prescribed limit Section 41 Driving in excess of speed limit Section 55 Restriction on motor racing Road Traffic (Traffic Control) Regulations Regulations 18 and 59 Failure to comply with traffic signals, signs and road markings Road Traffic (Expressway) Regulations Regulations 12 and 13 ‘Not confining to nearside lane’ and ‘Overtaking from the nearside’

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C.Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 11

CRISIS MANAGEMENT PLAN IN AN EPISODE OF INFECTION OF H5N1 IN POULTRY WORKERS K. L. Hui and Zenobia C. Y. Chan ABSTRACT Avian influenza is widely spread in both human beings and birds all around the world. The possible cradle of this virus is transmitted from mainland China and the Hong Kong Special Administrative Region (HKSAR). The World Health Organization (WHO) and most countries are well prepared against the threat if a mass outbreak in humans occurs. Under the traditional practice of the poultry business in HKSAR, poultry workers, however, comprise a high-risk group that can accelerate the spread of avian influenza virus among the community. A crisis management plan is prepared for sudden onset of H5N1 in poultry workers. The focus of this chapter includes two scenarios: Serious Response Level and Emergency Response Level.

BACKGROUND In the Hong Kong Special Administrative Region (HKSAR), the live poultry markets are divided into two different types: 1) the wet markets managed by the Food and Environmental Hygiene Department (FEHD) where live poultry, fish, meat and vegetables are sold within a complex building in which all stalls are near each other without physical separation; 2) onstreet poultry stalls selling live poultry with different kinds of shops nearby. During the crisis of the avian influenza outbreak in HKSAR, 18 people were infected and one-third died from the newly-known case of human infection by avian influenza virus (H5N1) in 1997. Most research has revealed that the virus was transmitted from chickens to humans [1-3]. In 2001, H5N1 virus was detected again in poultry stalls before the occurrence of a zoonotic infection. H5N1 virus had caused about 370 persons to become ill, and 235 people have died worldwide as of 4 March 2008 [4]. In response to the increasing threat, HKSAR implemented a series of plans to control live poultry: separating the selling of live chickens and minor poultry; central slaughtering of

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ducks and geese in 2001; a ban against selling quail in live poultry stalls since March 2002; executing a rest day every month since July 2001, increasing to two rest days from March 2003, which has proven effective in interrupting virus transmission in the poultry market [5]; vaccination of all live chickens against H5 influenza from January 2004; and building a central poultry slaughterhouse to replace the live poultry markets after three years [6]. As there is a high potential risk of H5N1 virus transmission from poultry workers to the public, about 5,000 poultry workers and transport workers are regarded as the top priority to be protected; workplaces include 209 on-street stalls, 261 market stalls with 64 wet markets and two wholesale markets. It is essential to prepare a contingency plan with an explicit instruction to follow when the crisis occurs.

OBJECTIVE This chapter examines the necessary actions to be taken before a crisis of H5N1 infection arises, and then identifies the different scenarios at the emergency stage to stop and slow down the spread of H5N1 virus among the poultry workers so as to reduce the risk of human infection among the community.

LITERATURE REVIEW Avian Influenza in Birds Avian influenza is an infection caused by avian (bird) influenza (flu) viruses. These influenza viruses are very contagious and can be fatal to some domesticated birds, including chickens and ducks. Domesticated birds may be infected through direct contact with infected waterfowl, poultry, or through contact with virus-contaminated surfaces (dirt or cages), or water or feed. Infection with avian influenza viruses in domestic poultry causes low or high extremes of virulence. The highly pathogenic form (avian influenza A, H5N1 virus) spreads rapidly through flocks of poultry and becomes highly contagious to human beings.

Infections in Humans According to the statistics of the WHO [4], more than half of those people reported to the WHO infected with H5N1 virus died in Cambodia, Indonesia, Thailand and Viet Nam. As of 10 September 2008, the highest number of H5N1 cases to date had been reported from Indonesia and Vietnam. Almost all human infection can be linked to contact with infected poultry, but isolated instances of the inefficient human-to-human transmission have occurred in Viet Nam in 2004, and possibly in Thailand and Indonesia [7].

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Mode of Transmission In the already known and reported transmission, avian influenza A H5N1 viruses may be transmitted from animals to humans in two main ways: • •

directly from birds or from avian virus-contaminated environments to people, and through an intermediate host, such as pigs.

Although there is no evidence to prove that all cases of human infection in HKSAR were caused by H5N1 virus from the poultry market, the original source of H5N1 virus was from wild birds and poultry [8]. In the study conducted by Gray [9], about 10% of HKSAR poultry workers were infected with H5N1 in 1997 and 1998. The virus also may be capable of human-to-human transmision under close human contact [7] or after mutation, re-assortment and re-combination [10]. The live poultry markets were the prime culprit of the outbreak. Gray agreed that poultry workers in close contact with infected poultry are a high-risk group. This may lead to a rapid sudden onset among the community [9]. As influenza viruses have the ability to mutate, scientists are concerned that H5N1 viruses could spread among human beings more easily after “antigenic shift” [11, 12]. As these viruses are limited in some countries, there is no immunity in a community in which people have not been previously infected. Once a sudden outbreak of influenza H5N1 occurs, it may spread at a fast pace among people within a community.

Signs and Symptoms According to the key facts of the CDC [13], the signs and symptoms reported in humans have ranged from eye infections (conjunctivitis) to influenza-like illness symptoms (e.g., fever, cough, sore throat, and muscle aches) to severe respiratory illness (e.g., pneumonia, acute respiratory distress, and viral pneumonia), sometimes accompanied by nausea, diarrhea, vomiting and neurologic changes. The median duration from onset of symptoms until death was nine days, as shown in a weekly report of the WHO [12, 14], and the mortality rate is greater than 50% [13].

Treatment [15] Oseltamivir (commercially known as Tamiflu) and zanamivir (commercially known as Relenza) can reduce the severity and duration of illness caused by seasonal influenza. The efficacy of the neuraminidase inhibitors depends on their early administration (within 48 hours after symptom onset). For cases of human infection with H5N1, the drugs may improve prospects of survival, but clinical data are limited. The H5N1 virus is expected to be susceptible to neuraminidase inhibitors. Antiviral resistance to neuraminidase inhibitors has been clinically negligible so far, but is likely to be detected with widespread use during a pandemic. Amantadine and rimantadine could potentially be used against pandemic influenza, but resistance to these drugs can develop rapidly and this could significantly limit their

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effectiveness against pandemic influenza. Some currently circulating H5N1 strains are fully resistant to these drugs. However, should a new virus emerge through reassortment, the above two drugs might be effective.

Social Impact of H5N1 According to traditional Chinese custom, whole freshly-slaughtered chickens, including head, feat, lungs and offal, are used for the worship of ancestors. People often blow into the checken to see the chicken vent when selecting fresh chicken. According to a survey conducted by Fielding in 2004 [16], about 20% of Hong Kong people had direct contact with live chicken when purchasing them in wet markets. Therefore, the potential risk of H5N1 infection is be greatly increased. In 1997, a mass culling of more than 1.25 million chickens was carried out after six lethal cases reported in HKSAR. The Government had spent a total of 264 million HK dollars, equivalent to $34 million US dollars, to reduce the risk of avian influenza through the following measures; an ex-gratia payment scheme, reaching a total of 600 million HK dollars in September 2008, equivalent to $85 million US dollars, to attract the poultry stall holders to surrender their licenses; a vaccination program for the public, especially poultry employees and poultry-related workers; strengthening the bio-security in local poultry farms; and quarantine measures for imported poultry. This pandemic flu had posed a huge impact on social, financial and political aspects in Hong Kong. For crisis managers, a high preparedness contingency plan helps an organization to tackle with a sudden onset of crisis. Mcconnell and Drennan [17] also indicate the efficacy of a clear set of identified roles and responsibilities for decision makers in a contingency plan. The study of Balicer [18] and Janssen [19] reveal that there is a significant link between the importance of communication in an influenza crisis and the impact of public and health workers. As a result, good communication training and information delivery is considered necessary in each stage of such an event. In 2005, the World Health Organization instructed governments to prepare influenza pandemic contingency plans to cope with the likely outcome of H5N1 [20]. In HKSAR, the Hospital Authority and Centre for Public Health under the Department of Health tailored a contingency plan [21 and 22] based on the WHO instructions. Thorson and Ekdahl [23] also mentioned that pandemic planning will be beneficial to humans in enhancing the capacity of response during a pandemic. This chapter is based on the WHO instructions and part of HKSAR to prepare a contingency plan specified for poultry workers during a pandemic period.

ACTION PLAN In order to prevent of an influenza pandemic, a crisis management plan based on the riskgraded epidemiological scenarios to protect poultry workers is suggested. This plan is to be activated in the event of human(s) (poultry worker(s)) infection with Highly Pathogenic Avian Influenza (HPIA), and depicts two possible scenarios.

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First scenario: Serious response level—there is evidence confirmation of human case(s) (poultry worker(s)) of HPIA in Hong Kong. Second scenario: Emergency response level—there is evidence confirmation of human case(s) (poultry worker(s)) of mutated HPIA in Hong Kong.

CRISIS MANAGEMENT TEAM I. Government Committee A crisis management team consists of the Food and Health Bureau (FHB), Department of Health (DH), Agriculture, Fisheries and Conservation Department (AFCD) and the Food and Environmental Hygiene Department (FEHD), Centre Health Protection (CHP), Hospital Authority (HA) as the main parties. The other departments provide assistance under these two scenarios.

II. Non-Government Committee Three poultry worker organizations, Hong Kong and Kowloon Poultry Dealers Guild, Hong Kong and Kowloon Five Guilds Union, and Hong Kong Livestock Industry Association, are voluntary and provide support, such as providing the information on farms, transporters, vehicles and the routes of vehicles in Hong Kong and China. The Hong Kong University provides the virology test in emergency level. Figure 1 shows the involved departments that form the command structure for the two response levels. During normal times, there are a lot of measures in relation to influenza illness that have already been put place by Centre for Health Protection [24] (Appendix I). In addition to the existing government preventive measures, the following measures are adopted before the crisis:

Operational Preparedness • •

• • •

Obtain personal particulars of each poultry worker and their family members, namely, address, contact numbers, and medical history. Obtain particulars of transporters responsible for transportation of poultry from wholesale market to market stalls or wet markets and from mainland China farms to the wholesale market in Hong Kong. Obtain routes of transport vehicle from wholesale market to poultry stalls or wet markets. Obtain the registered record of farms in HKSAR and Mainland China that supply poultry. Obtain the record of poultry supply list from market stalls or wet markets to restaurant or food premises (if any).

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•

Obtain the floor plan, ventilation system, drainage system, and refuse collection point details of wet market, poultry stalls, Cheung Sha Wan Temporary Wholesale Poultry Market and Western Wholesale Food Market. An emergency rehearsal not less than four months for individual departments and six months for inter-departments.

Figure 1. Command Structure for Response to HPAI Pandemic during Serious and Emergency Response Level.

Surveillance •

Random sampling of live poultry present in Cheung Sha Wan Temporary Wholesale Poultry Market, Western Wholesale Food Market and retail outlets.

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Bi-weekly sampling of sewage and premises in individual market stall, wet markets and the wholesales markets. In the check point of Man Kam To, conducting a quick test of HPAI of every vehicle before the import of poultry to Hong Kong. Monthly survey conducted by CHP to observe poultry worker health in the individual market stalls, wet markets and wholesale markets.

Communication • •

• • • • •

Train staff in putting on and taking off their protective cloth and gear to minimize the self-infection rate. Inform internal staff that the government has adequate preparation for a flu pandemic (e.g., resources, different contingency plans, drugs and vaccines, manpower preparedness). Educate the public not to come into contact with poultry, game and wild birds when purchasing. Training for poultry workers to identify suspected avian influenza poultry, and culling and disposal procedures. Personal and premises disinfection procedures for poultry workers. Leaflets for enhancing the wearing of protective clothing and personal hygiene to prevent avian influenza. Delivery of health advice and information to different organizations, namely, public transport organizations, public estates, special care groups in the community, elderly centres, and schools (kindergarten and primary).

Resources • •

Keep adequate stock of preventive clothing kit, sampling kits and disposal kits. Prepare adequate stockpiles of antiviral drugs for the target groups.

Serious Response Level When there is confirmation of Highly Pathogenic Avian Influenza (HPAI) outbreaks of human case(s) (poultry worker(s)) including in wet markets, wholesale markets or poultry stalls in Hong Kong, the following measures will be launched by the crisis management team and FHB will activate the Serious Response Level.

DH • • •

Conduct epidemiological investigation to determine the case; identifying the source of infection and role of transmission by CHP. Monitor the suspected flu-like illness in poultry workers and transporters. Conduct surveillance of poultry workers with close contact (e.g., colleagues and family members).

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•

Provide laboratory support for testing of specimens from the human cases. Conduct surveillance for suspected farms in Hong Kong (if the suspected farm is in mainland China, inform the Ministry of Health, the People’s Republic of China through FHB, and the WHO). Trace vehicles and transporters for delivery of suspected poultry from China to Hong Kong and wholesale markets to market stalls.

AFCD • Before FEHD, conduct a culling operation of poultry, sampling affected market stall, wholesale market or poultry stall (remaining live and dead poultry, drainage system, and ventilation system) for avian influenza. • Activate the culling operation of all live poultry (farms and two wholesale markets) in Hong Kong. • Disinfect farms and two wholesale markets. FEHD • Activate the culling operation of all live poultry (poultry stalls and wet markets) in Hong Kong. • Disinfect the poultry stalls and wet markets. • Suspend the import and export of all live poultry. • Disinfect transport vehicles of suspected poultry from China to Hong Kong and wholesale market to market stalls. EPD will take the following actions – • Assist AFCD and FEHD in poultry disposal after culling operation.

ImmD • Monitor health status of travelers and visitors in different control points, seaport, Hong Kong International Airport GLD •

Provide vehicles and resources support to different departments.

ISD • • •

Deliver the public education on prevention measures. Provide daily updates of governmental response plan and actions. Educate the public regarding self-management of influenza like illness.

Emergency Response Level When there is confirmation of mutated HPAI outbreaks with evidence in effective transmission in human. Human case(s) (poultry worker(s)) include wet markets, wholesale market and poultry stall) in Hong Kong. The following measures will be launched in crisis management team.

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DH • • • • • • •

Conduct epidemiological investigation to determine the case; identify the source of infection, role of transmission by CHP. Trace vehicle and transporters for delivery of suspected poultry from Mainland China to Hong Kong and Wholesale market to market stalls. Conduct surveillance and isolate the patient having suspicious flu-like illness. Quarantine those in close contact with infected patient (colleagues, family members, and transporters) until confirmation of infection/no infection. Submit patient laboratory samples to the WHO for further analysis. Provide laboratory support for testing of specimens from the suspected case according to the WHO guideline. Trace customers with contact with the patient’s premises (purchase, contact with live poultry, poultry carcass) and conduct surveillance of this population.

Communication • Provide daily updates to internal staff through intranet, SMS, and e-mail. • Provide daily updates to the public of the cumulative number of cases and government response and actions. • Provide daily updates to the Ministry of Health, the People’s Republic of China through EHB, and WHO. • Establish a hotline with trained clinical staff to provide information. Public Health Issue • Assess the utility rate of hospital under HA. • Assess the need for declaration of Hong Kong as an HPAI infected place. • Assess the need for closure of schools, public places, non-essential government services and activities. • Assess the need for closure of all control points, seaport, and Hong Kong International Airport. • Enact legislation to enable enforcement of quarantine, isolated and control measures. Antiviral Check the stockpile of antiviral drugs to provide treatment to patients. AFCD • Conduct surveillance of suspected poultry workers in farms of Hong Kong. • Activate the culling operation of all live poultry and birds (farms, two wholesale markets, and pet bird markets) in Hong Kong. • Conduct surveillance of farms for other food animals in Hong Kong. • Suspend the import and export of non-food animals, namely, birds, game and wild animals. FEHD • Activate the culling operation of all live poultry (market stalls and wet markets) in Hong Kong, and disinfect all poultry stalls and wet markets.

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EPD • SWD • •

GLD •

If the infected poultry worker worked in wet market, close the wet market and hold all utensils and other items in the wet market. If the infected poultry worker worked in a poultry stall, close the infected stall and hold all utensils and other items in the stall. Conduct surveillance of nearby stalls. Suspend the import of all live poultry. Suspend the export of all live poultry, poultry products, food animals, and food animal products/by-products. Detain vehicles that transport suspected poultry from China to Hong Kong and wholesale market to market stalls.

Assist AFCD and FEHD in poultry disposal after culling operation.

Provide counseling services to staff of different departments and public. Help to update guidelines on preventive measures to organizations and social communities.

Provide vehicles and resources to support different departments.

ImmD • Monitor health status of travelers and visitors at different control points, seaport, and Hong Kong International Airport. • Assist DH to close the control points if necessary. GL • •

HAD •

ISD • •

Assist DH in emergency diagnosis and sampling. Arrange redirecting a potential overflow of samples to The Hong Kong University for virology test assistance.

Mobilize professionals in the private sector and voluntary agencies to provide assistance in hospitals or clinics when necessary.

Assist DH in delivery of information to the general public through different media, TV, radio announcements, and the Internet. Provide information in different languages.

HKPF • Maintain the proper order of the community.

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DISCUSSION The role of poultry in disease transmission to humans is well defined. Most agree that poultry is responsible for spreading the H5N1 virus to humans according to the past evidence. In the event that H5N1 is transmitted in the community, a series of plans from different governments and organizations has been prepared. However, not one is focused on the high risk group—poultry workers. As a starting point, this chapter provides an important lesson for the government to alert agencies to the growing threat of H5N1. This chapter also suggests obtaining more information and detail related to poultry workers before a crisis takes place that enables the government to take the proper measures under a sudden onset of pandemic. At the time of the writing of this chapter, the Education Bureau (EB) ordered kindergartens and primary schools to suspend classes for two weeks beginning 13 Mar 2008 after the reported death of four children in a flu outbreak. This chapter omitted the Education Bureau (EB) in the contingency plan to deal with the assessment of school closure. It would be better to include the EB in the contingency plan to assess the effect in schools and prevent the cause of further disorder. In the event of the onset of a crisis, there are some steps and procedures found that duplicate the existing CHP and HA plans during execution. To maintain the effectiveness of the contingency plan, the integration of manpower from different organizations is required. To improve the contingency plan, preparation of a postcrisis plan is considered necessary. A post-crisis recovery plan with economic support for poultry workers is essential in helping them get through the crisis, and helps the public rebuild confidence regarding the consumption of poultry.

CONCLUSION The only means of eliminating human exposure to H5N1 virus is the central slaughtering of poultry and game. A central poultry slaughterhouse will replace live poultry stalls and wet markets in 2011 to 2012 in Hong Kong. Within this period of time, a contingency plan for poultry workers is a very small and relatively cost effective investment. If a powerful species of virus develops through several generations after mutation, there would be huge economic loss and social disruption, such as damage to the tourist industry, the cost of culling poultry, and unemployment in the poultry industry. A well-prepared contingency plan for H5N1 transmission in poultry workers enables coping with this latent high-risk outbreak.

BRIEF BIOGRAPHY Mr. Hui Ka Lok graduated with a higher diploma in environmental health in 2000 and has been a health inspector for the Food and Environmental Hygiene Department for seven years, from which he obtained a bachelor’s degree in 2007. He has worked mainly at FEHD carrying out inspections of food premises, and has monitored slaughterhouses to ensure that their operations meet the required hygiene and environmental standards established in 2005.

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APPENDIX Surveillance •

•

•

•

• • • •

•

Influenza A (H5N1) has been a notifiable disease in Hong Kong since 30 January 2004 and all practitioners are required to report any suspected or confirmed cases to DH. A sentinel surveillance system is in place to monitor influenza-like illness (ILI). The system operates through the support of a network of 64 general outpatient clinics in the public sector and some 50 doctors in the private sector. Specimens are also collected from patients for isolation and typing of influenza virus. Infectious disease sentinel surveillance is set up in residential care homes for the elderly, which collects information on the number of residents with ILI on a weekly basis. Information on hospital discharges, admission to intensive care units and deaths due to diagnosis of influenza or pneumonia are collected from public and private hospitals on a weekly basis. Hospital admissions of elderly home residents with provisional diagnosis of pneumonia or chest infection are being monitored. Monthly figures on ILI are exchanged with Guangdong and Macao health authorities. Information on unusual patterns of infectious diseases is exchanged with Guangdong and Macao health authorities on an ad hoc basis. There is an ongoing surveillance programme at live poultry retail outlets, along with monitoring of poultry farms, pet bird traders, imported birds, recreational parks and wild birds. Close monitoring of the number of live poultry present in Cheung Sha Wan Temporary Wholesale Poultry Market, and at retail outlets, is ongoing.

Investigation and Control Measures •

Epidemiological investigation and control measures are being conducted and implemented respectively in institution outbreaks.

Laboratory Support • •

Confirmatory testing for influenza is being provided to both public and private sectors. Typing and subtyping of all influenza isolates are performed at the Public Health Laboratory Services Branch (PHLSB) of DH. Antigenically atypical isolates would be genetically characterized and forwarded to the WHO Collaborating Centres for further analysis.

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Infection Control Measures • • •

Risk-based clinical management and infection control guidelines are provided to healthcare providers. Supplies of personal protective equipment (PPE) are being maintained. Training on infection control is being provided to community, government departments and healthcare workers in public and private sectors.

Antiviral • •

Antiviral agents are being stockpiled. Strategies for administration of antiviral medications are developed and prioritization of target groups for antiviral administration is defined in the scenario of pandemic influenza.

Vaccination • •

An annual influenza vaccination programme is being organized around November/ December each year. Vaccination strategies for avian influenza epidemics are developed and prioritization of target groups for vaccine administration is defined, in case a vaccine is available for avian influenza.

Port Health Measures •

Strategies are in preparation to prevent and control human cases of avian influenza at immigration control points.

Other Control Measures • •

Agreed protocol has been establisihed with the Mainland on importation of live poultry. Control of live birds and poultry products imported into Hong Kong is in place.

Communication •

Health education activities are organized and health advice on prevention of influenza is provided through various means to educate the public on personal and environmental hygiene.

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A working group on risk communication has been formed to develop a risk communication strategy and action plan. Members of the medical profession are being informed through emails, fax and post.

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Claas E. C., Osterhaus A. D., van Beck R., de Jong J. C., Rimmelzwaan G. F., Senne D. A., Krauss S., Shortridge K. F., Webster R.G. (1998). Human influenza A H5N1 virus related to a highly pathogenic avian influenza virus. Lancet, 351(9101), 472-477. [2] Smith G. J., Fan X. H., Wang J., Li K. S., Qin K., Zhang J. X., Vijaykrishna D., Cheung C. L., Huang K., Rayner J. M., Peiris J. S., Chen H., Webster R. G., Guan Y. (2006). Emergence and predominance of an H5N1 influenza variant in China. Proceedings of the National Academy of Sciences, 103(45), 16936–16941. [3] Webster R. G., Peiris M., Chen H., Guan Y. (2006). H5N1 Outbreaks and Enzootic Influenza. Emerging Infectious Diseases, 12(1), 3-8. [4] World Health Organization. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO [online]. c2008 [cited 2008 September 25]. Available from: http://www.who.int/csr/disease/avian_influenza/country/ cases_table_ 2008_09_10/en/index.html [5] Lau E. H., Leung Y. H., Zhang L. J., Cowling B. J., Mak S. P., Guan Y., Leung G. M., Peiris J. S. (2007). Effect of interventions on influenza A (H9N2) isolation in Hong Kong's live poultry markets, 1999-2005. Emerging Infectious Diseases, 13(9), 13401347. [6] Food and Environmental Hygiene Department. Prevention of Avian Influenza: Consultation on Long Term Direction to Minimize the Risk of Human Infection [online] c2004. [cited 2008 March 1] Available from: http://www.fhb.gov.hk/ download/press_and_publications/consultation/040402_feh/e_avian_flu.pdf [7] Yang Y., Halloran M. E., Sugimoto J. D., Longini I. M. Jr. (2007). Detecting Humanto-Human Transmission of Avian Influenza A (H5N1). Emerging Infectious Diseases, 13(9), 1348-1353. [8] Guan Y., Chen H., Li K., Riley S., Leung G., Webster R., Peiris J., Yuen K. (2007). A model to control the epidemic of H5N1 influenza at the source. BMC Infect Disease, 7, 132. [9] Gray G.. C., Trampel D. W., Roth J. A. (2007). Pandemic influenza planning: Shouldn’t swine and poultry workers be included? Vaccine, 25(22), 4376-4381. [10] Yamada S., Suzuki Y., Suzuki T., Le M. Q., Nidom C. A., Sakai-Tagawa Y., Muramoto Y., Ito M., Kiso M., Horimoto T., Shinya K., Sawada T., Kiso M., Usui T., Murata T., Lin Y., Hay A., Haire L. F., Stevens D. J., Russell R. J., Gamblin S. J., Skehel J. J., Kawaoka Y. (2006). Haemagglutinin mutations responsible for the binding of H5N1 influenza A viruses to human-type receptors. Nature, 444(7117), 378-382. [11] World Health Organization- WHO Outbreak Communication. Who Handbook for Journalists: Influenza Pandemic [online]. C2005 [cited 2008 September 20]. Available from: www.who.int/csr/don/Handbook_influenza_pandemic_dec05.pdf

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[12] World Health Organization – Regional Office for the Western Pacific. Avian Influenza, Including Influenza A (H5N1), in Humans: WHO Interim Infection Control Guideline for Health Care Facilities [online]. c2007 [cited 2008 September 25]. Available from: http://www.wpro.who.int/NR/rdonlyres/EA6D9DF3-688D-4316-91DF5553E7B1DBCD/0/AI_Inf_Control_Guide_10May2007.pdf [13] Centers for Disease Control and Prevention. Key Facts about Avian Influenza (Bird Flu) and Avian Influenza A (H5N1) Virus [online]. c2007 [cited 2008 September 25]. Available from: http://www.cdc.gov/flu/avian/gen-info/facts.htm [14] Epidemiology of WHO-confirmed human cases of avian A (H5N1) infection. (2006). WHO Weekly Epidemiological Record [On-line serial], 81(26). [15] Epidemiology of WHO-confirmed human cases of avian A (H5N1) infection. (2006). WHO Weekly Epidemiological Record [On-line serial], 81(43). [16] Fielding R., Lam W. W., Ho E. Y., Lam T. H., Hedley A. J., Leung G. M. (2005). Avian Influenza Risk Perception, Hong Kong. Emerging Infectious Diseases, 11(5), 678-682. [17] Mcconnell, A. and Drennan, L. (2006). Mission Impossible? Planning and Preparing for Crisis. Journal of Contingencies and Crisis Management, 14(2), 59-70. [18] Balicer R. D., Omer S. B., Barnett D. J., Everly G. S. Jr. (2006). Local public health workers' perceptions toward responding to an influenza pandemic. BMC Public Health, 6, 99. [19] Janssen A. P., Tardif R. R., Landry S. R., Warner J. E. (2006). “Why Tell Me Now?” The Public and Healthcare Providers Weigh in on Pandemic Influenza Messages Journal Public Health Management Practice, 12(4), 388–394. [20] World Health Organization. WHO checklist for influenza pandemic preparedness planning [online] c2005. [cited 2008 March 12] Available from: http://www.who. int/csr/resources/publications/influenza/WHO_CDS_CSR_GIP_2005_4/en/index.html [21] The Hong Kong Hospital Authority. HA contingency Plan For Influenza Pandemic [online] c2007. [cited 2008 March 6] Available from: http://www3.ha.org.hk/ idctc/news_events/No.23%20-%20HA%20Contingency% 20Plan%20for% 20Influenza % 20Pandemic%20(As%20at%2029.7.2006).pdf [22] The Centre for Health Protection. Framework of Government's Preparedness Plan for Influenza Pandemic (Jul 2007) [online]. c2007 [cited 2008 March 6]. Available from: http://www.chp.gov.hk/files/pdf/flu_plan_framework_en_20050222.pdf [23] Thorson A. and Ekdahl K. (2005). Avian influenza—Is the world on the verge of a pandemic? … and can it be stopped? Journal of Contingencies and Crisis Management, 13(1), 21–28. [24] The Centre for Health Protection. Hong Kong's preparedness for influenza pandemicPrevention and Protection [online] c2007. [cited 2008 March 6] Available from: http://www.chp.gov.hk/files/pdf/Hong_Kong_Preparedness_for_Influenza_Pandemic_P revention_and_Protection.pdf

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C.Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 12

PRE-MARRIAGE COMMUNICATION: A CASE FROM HONG KONG Queeni T. Y. Ip and Zenobia C. Y. Chan ABSTRACT Global communication literature indicates the importance of listening in communication and in different settings. However, the importance of “invitation”, which also plays a prominant role in communication, is rarely mentioned. The pre-marriage discussion is a very crucial communication in Chinese society, and the number of marriages is increasing an average of 7% every year in Hong Kong. There were 46,000 marriages in Hong Kong in 2006 (Hong Kong’s Information Services Department, 2006). It is understandable that many instances of family violence were the result of a series bad communications. Sound, effective and smooth communication can make society much more harmonious. An example of a real case of negative pre-marriage communication between two families with detailed descriptions and critical analyses should be revisited with the objective to achieve sound and effective communication skills. Moreover, the importance of invitation in communication should be addressed.

INTRODUCTION Communication is already a hot global issue. Nobody can live without communication anywhere in today’s society. We talk and connect with others every day. Communication plays an important role in our lives, especially for reaching goals. However, it seems that many people do not communicate well with others, even themselves. They usually express what they want only, and lack invitation—listening to others’ needs and caring about others’ feelings. Ultimately, such dialogue elicits no reaction or communication between them, and the goal cannot be reached or performed well. Inefficient communication is connected with mental disorders such as infantile autism. In fact, good communication can be started by expressing concern for others’ preference and good listening. Expression is much more effective after invitation.

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In traditional Chinese culture, a new couple should hold a preparation discussion in which the male’s parents invite the female’s parents to discuss the wedding arrangements before the marriage, as the marriage of the new pair should be assigned by the parents of both sides. A variety of matters are discussed, including the cash gift, the most solemn of ceremonies, the number of tables on the big day, the weight of the roaster or pig, the number of traditional Chinese cakes and so on (we call this gou da li). Usually, both sets of parents meet for the first time at this discussion. The female’s parents will ask for quantities of the above items and the male’s parents will provide them in order to marry the bride. A real case of a wedding preparation discussion between two families that was not run effectively and that ultimately causes the bride and the groom some difficulties is presented. The general literature does not address some essential, common occasions, like pre-marriage discussion, which is one type of crucial communication. Communication skills should be analyzed.

LITERATURE REVIEW Marriage is a personal union of individuals (Wikipedia, 2008). Marriage is an institution that is usually intimate, and sexual interpersonal relationships are acknowledged by the legal or by religious authority and viewed as a contract. People marry for many reasons, but usually one or more of the following: legal, social, and economic stability; the formation of a family unit; procreation and the education and nurturing of children; legitimizing sexual relations; public declaration of love; or to obtain citizenship (Gallagher, 2002; Krier et al., 2006). Marriage may be a monogamous heterosexual marriage or polygamy (Murdock, 1949). Recently, some jurisdictions (Arce, 2004) and denominations have begun to recognize samesex marriage. A marriage is often formalized during a marriage ceremony (Eleanor, 1999). Marriage in Chinese culture is usually one man to one woman, assigned by their parents in the past, but today people are free to choose based on love. However, many of the details of marriage preparation are still handled by parents—for example, the parents of the groom invite the bride’s parents for a wedding discussion that sometimes resembles a deal. Certainly, the male side should provide lots of resources to the bride’s parents. A case study below will illustrate marriage in the Chinese culture. Marriage preparation is a key process, especially in Chinese culture. Both the groom and bride will face many difficulties before they get married. This is because the terms of the marriage are indicated by the parents or grandparents of both sides, and the couple is expected to comply. Many people are involved in the process. The main idea is not structured by the groom and bride: for example, holding a traditional ceremony near home rather than traveling, buying all of the wedding materials (pig, cakecard, dried seafood) rather than giving a monetary gift. The couple must face the stress of not being able to express their own ideas and wishes. In addition to practical and financial stresses, they also need to face relationship, role and workload changes, because in Chinese culture respecting the elder or senior members of the family is important. For example, conflict will arise if the bride continues to care for her own parents but not the groom’s parents after marriage. Conflict is usually formed when the couple neglects such role changes. Therefore, preparation is also crucial, otherwise many crises may arise after marriage and cause divorce.

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Different worldwided research topics about marriage include money (Bardasi and Taylor, 2008; Smock et al., 2005; Yodanis and Lauer, 2007), the unmarried (Harknett, 2008), honeymoon (Royce and Lee, 2008), cohabitation (Bourdais, 2004; Cunningham and Thornton, 2005; Hohmann-Marriott, 2006; Manning et al., 2007; Osborne et al., 2007; Seltzer, 2004), divorce (Amato and Hohmann-Marriott, 2007; Clarkwest, 2007), remarriage (Bramlett and Mosher, 2002), stress (Neff and Karney, 2007), intermarriage (Roer-Strier and Ezra, 2006), marital quality (Myers, 2006; Umberson et al., 2005), expectation (Crissey, 2005; Kurdek, 2005), homosexual marriage (Kurdek, 2004), and couple interaction (Tichenor, 2004). However, focusing on marriage preparation will allow better understanding of marriage and family. It is believed that good marriage preparation depends on good communication. Communication includes intrapersonal—what you think, talk, learn and evaluate with yourself, and interpersonal communication—interacting, sharing, developing ideas, making decisions with and support from others (Chan, 2008a). It is shown that a big challenge and the single most important element in the communication process is the ability to listen effectively (Fracaro, 2001). Without effective listening, misunderstanding and conflict will be formed, and even health will be affected. The general communication topics include small groups (Bonito, 2007), organizational stakeholders (Lewis, 2007), political communication (Besley and McComas, 2005; Habermas, 2006), and workplace (Bruno Teboul and Cole, 2005). And communication is the greatest single factor affecting a person’s health and relationship with others. Health in this context is mainly psychological health. It is indicated that there is a correlation between communication and intervention of physicians and their patients (Stewart, 1995). When doctors use communication skills effectively, both they and their patients benefit, including identifying their patients’ problems more accurately (Maguire et al., 1986). Their patients are more satisfied with their care and can better understand their problems, investigations, and treatment options. Patients are more likely to comply with treatment and behavioral change (Jenkins and Fallowfield, 2002; Silverman et al., 1998), patients’ negative emotions are reduced and finally doctors’ own wellbeing is improved (Parle et al., 1996; Ramirez et al., 1995; Roter et al., 1995). Much of the literature indicates the importance of listening in communication, but not “invitation”, which also plays an important role in communication, and is less often mentioned. The pre-wedding discussion should be an important occasion. The purpose of this chapter is to inform readers about how the concept can be applied in such a situation.

CASE ILLUSTRATION According to the background illustration, in a dialogue between the Leung and Ip families (the male’s and female’s representatives, respectively), they discuss the marriage issues. A total of six people—the parents of both sides, the bride named Sou and the groom named Kuen—are sitting around a table at a Chinese restaurant for lunch. Kuen’s parents: Hello, Mr. Ip and Mrs. Ip, please sit. Sou’s parents: Hello, Mr. Leung and Mrs. Leung. How are you? Kuen’s father: Fine, thanks. Sou’s father: That’s good. Let’s have a cup of tea first.

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Queeni T. Y. Ip and Zenobia C. Y. Chan All smile. After drinking, the purpose of meeting is stated. Kuen’s mother: Let’s discuss our main topic. How many tables do you want? Sou’s mother: 15 tables. Kuen’s mother: Ha?! 15 tables? So many. I just think 10 tables in total for two families. Sou’s mother: Impossible! We are a big family. Sou’s father has 9 brothers and sisters in total. Our family gathering already requires 4 tables. How come 10 tables for two families? How about Sou’s maternal families? How about our friends? How about Sou’s friends? Kuen’s mother: 15 tables are impossible. There is no need to invite the relatives who live in China. Sou’s mother: We don’t have relatives living in China. Kuen’s mother: Then there is no need to invite too many friends. Core relatives are enough. Sou’s mother: We just invite relatives only. All we invited are the relatives who have watched Sou grow up. They all are the core relatives who have said that they must join her big day. We must invite them. Kuen’s mother: If we invite all such witnesses. I think we can have 50 tables. Dead air……(around 15 seconds) Sou: Let’s have the food first. Kuen: Yes, it is all getting cold.

The atmosphere seems calm down a while, but Ip’s parents have changed their facial expression. Kuen’s mother: We all understand that they are employees; they are not rich enough. It is not necessary to spend too much money on the banquet. Sou’s father: We haven’t requested too much. We just need 15 tables and enough cake cards to invite the relatives to celebrate that Sou is going to be a bride. I do think it is necessary for the marriage. Sou: Yes, there is a large family tree on both parents’ side, so 15 tables are needed.

The discussion is finished after the meal.

DISCUSSION Communication means interacting with others so that we should show our personality or characteristics, caring and inviting others so as to perform in reality. Besides, we hope that with understanding and insight, we can build meaningful relationships and influence or persuade others through communication. In the above case, the most important cause of an inefficient discussion is that they have not communicated in a dynamic way, which is one of the crucial characterisitics of communication. They just communicate intrapersonally. And communication is unreapeatable and irreversible. Therefore, they cannot understand and persuade each other and build up a meaningful relationship (Chan, 2008a). According to the above dialogue, it is good that a suitable place is chosen. A round table is good for discussion, because it can hold people together and the atmoshpere will not be too

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silent in the Chinese restaturant for both sides of parents who have not met each other before. It is a relaxing place for chatting. This context is good, except that it is lunch hour and the noisy environment might promote argument. The noise will disturb good communication (Chan, 2008a). Both parents are nice in the greeting stage, with smiles. It reflects a welcome attitude for a chat. And it is also good that Kuen’s mother has asked Sou’s mother about her intention regarding the number of tables. However, she did not ask for the reason when the feedback was more than her expectation. She can ask Sou’s mother directly whether or not they have a big family. Waiting for Sou’s explaination is too late. If she can understand that Sou has a big family, her expectation can be changed. For Sou’s mother, when she responds immediately that it is impossible, she has not understood something else. She does not understand the reason that Kuen’s mother wants a small number of tables. Maybe Kuen’s mother does not want to increase the burden of her son. But it has already made the stituation stressful, and a meaningful relationship cannot be built. Even worse, a conflict will be developed. Conflict means perceived incompatible differences in beliefs, values and goals. It will cause struggle. A process of conscious settlement is need for resolution. Filley’s Model of Conflict Resolution can be introduced (Chan, 2008b).

Figure1. Filley’s Model of Conflict Resolution.

Besides, the problem should be defined clearly and the unmet needs should be identified. A time should be fixed to discuss the problem after a cooling-off period. Each person should describe his or her needs and problems while the other listens without interruption, ensuring that everyone should understand the complaints of others. A list of possible solutions should

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be defined and the alternative solutions should be evaluated. Then the best solution for everyone can be chosen and checked back on later (Chan, 2008c). Invitation is crucial and critical step to change the above case. Actually, Kuen’s mother has invited Sou’s mother to express her wishes regarding the number of tables and what she wants initally. However, she did not go deep to listen after hearing the unexpected answer, which stopped her from inviting Sou’s mother to explain ,and she replied in her own way and what she thought only. She thought friends, overseas relatives were included. She did not show interest in knowing from Sou’s mother why so many tables were needed and did not provide the chance or space for Sou’s mother to explain. Such one-way communication surely is not effective. Sou’s mother tried to explain the need for 15 tables. But her communication skills were not good. She replied simply, “Impossible!”, which brought difficulties to the conversation. Although 10 tables were not the answer she expected, she still needed to reply gently that she understood that Kuen’s mother must have a reason for that number of tables and invite her to say why and explain. If any one side can invite another to speak, a good discussion can be the result. However, poor invitation skills also demonstrates the importance of listening in communication. The ability to listen effectively is a big challenge in the communications process. Increased knowledge, broadened understanding, reduced misunderstanding, developing insight, reduced friction, resolution of problems, winning people’s trust and creating an audience all can be benefits of effective listening (Fracaro, 2001). Fracaro also indicated five key elements for effective communication: preparation, receiving, understanding, evaluation and reply. Preparation means finding a quiet place to hear the message in order to help a person to “open up” and getting him or her to say what is truly on his or her mind. It is how I define the term invitation. And admitting your own mistakes will inspire a speaker to admit his or her mistakes. Receiving means showing the speaker that you are listening and value what he or she is saying by empathizing with the true feeling and grasping the central idea. Understanding involves clarification by asking openended questions, summarizing and paraphrasing what you understood, and re-listening if you got the wrong message. Evaluation entails reviewing the facts and evidence presented without jumping to a quick conclusion. In reply, non-verbal or verbal responses should be given clearly and concisely. A case study in Hong Kong is not found in the literature. According to the case study presented in this chapter, marriage preparation through good communication is very important and useful to the groom and bride, parents from both sides and the people involoved because of the many complicated cultural traditions in the Chinese wedding ceremony. It will contribute a very good foundation to the marriage for the new couple, to their families and the extended families. It is also good for the holistic health of the couple and for social health. Although a single case must not make a broad generalisation, the case implicates the real barriers of marriage prepartion for the groom and bride. Hong Kong is an international city based on traditional Chinese culture but diffused by different Western cultures. The collision of the traditional complex wedding details and the new generation’s ideas can create many problems in the pre-marriage stage. Good communication skills are effective in overcoming difficulties in marriage. Therefore, it is necessary to explore premarriage communication much further: for example, the psychological barriers, the role changes and communication for the couple and their parents.

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CONCLUSION General communication skills show the importance of listening. But invitation is also a crucial and critical step in good communication. Chinese society gives weight to the prewedding discussion before a new couple’s marriage, which connects two independent families. Starting with good communication and giving a good first impassion is very important in preventing arguments and future family violence; these measures can also bring much more harmony to our society. Public health can be improved. It can be concluded that refraining from speaking is the main key to introducing invitation and listening in good communication, so that rapport building can result.

AUTHOR’S BACKGROUND Ms. Queeni T. Y. Ip, Beauty Therapist, BSc(Hons.), is a master’s student in health science at The Chinese University of Hong Kong. Email: [email protected]

REFERENCES Amato, P. R., and Hohmann-Marriott, B. (2007). A Comparison of High- and Low-Distress Marriages That End in Divorce. Journal of Marriage and Family, 69(3), 621-638. Arce, R. (2004). Massachusetts court upholds same-sex marriage. CNN. Bardasi, E., and Taylor, M. (2008). Marriage and Wages: A Test of the Specialization Hypothesis. Economica. London. Besley, J. C., and McComas, K. A. (2005). Framing Justice: Using the Concept of Procedural Justice to Advance Political Communication Research. Communication Theory, 15(4), 414-436. Bonito, J. A. (2007). A Local Model of Information Sharing in Small Groups. Communication Theory, 17(3), 252-280. Bourdais, L. C. (2004). Changes in conjugal life in Canada: Is cohabitation progressively replacing marriage? Journal of Married and Family, 66(4), 929-942. Bramlett, M. D., and Mosher, W. D. (2002). Cohabitation, marriage, divorce, and remarriage in the United States. Centers for Disease Control and Prevention. Bruno Teboul, J. C., and Cole, T. (2005). Relationship Development and Workplace Integration: An Evolutionary Perspective. Communication Theory, 15(4), 389-413. Chan, C. Y. Z. (2008a). Communication Lecture Handout. Centre for Health Education and Health Promotion, School of Public Health, Faculty of Medicine, CUHK. Chan, C. Y. Z. (2008b). Communication Skills Lecture Handout. Centre for Health Education and Health Promotion, School of Public Health, Faculty of Medicine, CUHK. Chan, C. Y. Z. (2008c). Communication Lecture Handout. Centre for Health Education and Health Promotion, School of Public Health, Faculty of Medicine, CUHK. Clarkwest, A. (2007). Spousal Dissimilarity, Race, and Marital Dissolution. Journal of Marriage and Family, 69(3), 639-653.

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Crissey, S. R. (2005). Race/Ethnic Differences in the Marital Expectations of Adolescents: The Role of Romantic Relationships. Journal of Marriage and Family, 67(3), 697-709. Cunningham, M., and Thornton, A. (2005). The Influence of Union Transitions on White Adults' Attitudes Toward Cohabitation. Journal of Marriage and Family, 67(3), 710-720. Eleanor, S. (1999). Cavendish Children’s Books: Navajo Wedding Day: A Dine Marriage Ceremony. Fracaro, K. (2001). Two ears and one mouth. Supervision, 62(2), 3-5. Gallagher, M. (2002). What is Marriage For? The Public Purposes of Marriage Law. Louisiana Law Review. Habermas, J. (2006). Political Communication in Media Society: Does Democracy Still Enjoy an Epistemic Dimension? The Impact of Normative Theory on Empirical Research. Communication Theory, 16(4), 411-426. Harknett, K. (2008). MATE AVAILABILITY AND UNMARRIED PARENT RELATIONSHIPS. Demography: Silver Spring, 45(3), 555-572. Hohmann-Marriott, B. E. (2006). Shared Beliefs and the Union Stability of Married and Cohabiting Couples. Journal of Marriage and Family, 68(4), 1015-1028. Jenkins, V., and Fallowfield, L. (2002). Can Communication Skills Training Alter Physicians’ Beliefs and Behavior in Clinics? Journal of Clinical Oncology, 20(3), 765769. Krier, James, E., Gregory, S. Alexander, Schill, M. H., and Dukeminier, J. (2006). Property. Aspen Publishers. Kurdek, L. A. (2004). Are Gay and Lesbian cohabiting couples really different from heterosexual married couples? Journal of Marriage and Family, 66(4), 880-900. Kurdek, L. A. (2005). Gender and marital satisfaction early in marriage: A growth curve approach. Journal of Marriage and Family, 67(1), 68-84. Lewis, L. K. (2007). An Organizational Stakeholder Model of Change Implementation Communication. Communication Theory, 17(2), 176-204. Manning, W. D., Longmore, M. A., and Giordano, P. C. (2007). The Changing Institution of Marriage: Adolescents' Expectations to Cohabit and to Marry. Journal of Marriage and Family, 69(3), 559-575. Marriage. 2008 from Wikipedia Web Site: http://en.wikipedia.org/wiki/Marriage. Marriage Registration. 31December, 2006 from the Hong Kong’s Information Services Department Web site: http://www.news.gov.hk/tc/category/lawandorder/ 061229/ features/html/061229tc08001.htm. Maguire, P., Fairbairn, S., and Fletcher, C. (1986). Consultation skills of young doctors: I— Benefits of feedback training in interviewing as students persist. BMJ, 292, 1573-1576. Murdock, G. P. (1949). Social Structure. New York: The MacMillan Company. Myers, S. M. (2006). Religious Homogamy and Marital Quality: Historical and Generational Patterns, 1980 – 1997. Journal of Marriage and Family, 68(2), 292-304. Neff, L. A., and Karney, B. R. (2007). Stress Crossover in Newlywed Marriage: A Longitudinal and Dyadic Perspective. Journal of Marriage and Family, 69(3), 594-607. Osborne, C., Manning, W. D., and Smock, P. J. (2007). Married and Cohabiting Parents' Relationship Stability: A Focus on Race and Ethnicity. Journal of Marriage and Family, 69(5), 1345-1366. Parle, M., Jones, B., and Maguire, P. (1996). Maladaptive coping and affective disorders in cancer patients. Psychological Medicine, 26(4), 735-744.

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Ramirez, A. J., Graham J., Richards, M. A., Cull, A., and Gregory, W. M. (1995). Mental health of hospital consultants: the effects of stress and satisfaction of work. Lancet, 347(9003), 724-728. Roer-Strier, D., and Ezra, D. B. (2006). Intermarriages Between Western Women and Palestinian Men: Multidirectional Adaptation Processes. Journal of Marriage and Family, 68(1), 41-55. Roter, D. L., Hall, J. A., Kern, D. E., Barker, L. R., Cole, K. A., and Roca, R. P. (1995). Improving physicians' interviewing skills and reducing patients’ emotional distress. Arch Intern Med, 155(17), 1877-1884. Royce, G., and Lee, P. (2008). Fringe stories: Among other strange, only-at-the-Fringe occurrences, newlyweds will “honeymoon” at this year's festival. McClatchy - Tribune Business News. Washington. Seltzer, J. A. (2004). Cohabitation in the United States and Britain: Demography, kinship, and the future. Journal of Married and Family, 66(4), 921-928. Smock, P. J., Manning, W. D., and Porter. M. (2005). “Everything's There Except Money”: How Money Shapes Decisions to Marry Among Cohabitors. Journal of Marriage and Family, 67(3), 680-696. Silverman, J., Kurtz, S., and Draper, J. (1998). Skills for communicating with patients. Oxford: Radcliffe Medical Press. Stewart, M. A. (1995). Effective physician-patient communication and health outcomes: a review. Canadian Medical Association Journal, 152(9), 1423-1433. Tichenor, V. (2004). Understanding Marriage: Developments in the Study of Couple Interaction. Journal of Married and Family, 66(2), 547-549. Umberson, D., Williams, K., Powers, D. A., Liu, H., and Needham, B. (2005). Stress in Childhood and Adulthood: Effects on Marital Quality Over Time. Journal of Marriage and Family, 67(5), 1332-1347. Yodanis, C., and Lauer, S. (2007). Managing Money in Marriage: Multilevel and CrossNational Effects of the Breadwinner Role. Jounral of Marriage and Family, 69(5), 13071325.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C.Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 13

USING ROLE-PLAYING TO TEACH MEDICAL TERMINOLOGY TO SOCIAL WORK UNDERGRADUATES Zenobia C. Y. Chan ABSTRACT During the author’s experience in teaching Social Aspects of Health and Illness to five separate classes in Hong Kong , the use of role-playing as a means to teach medical terminology to social work undergraduates was explored. The outline of the mentioned course was shown. Three specific lectures in which role-playing was used to teach medical terminology with four selected role-play scenarios—including the cardiovascular, nervous and urinary systems and ears—for demonstration and discussion were presented and analyzed. More effort should be made to test whether role-playing can be an effective approach in social work undergraduate education.

INTRODUCTION Some may assume that Western education is more interactive than Eastern education, and that Western teaching methods more creative than Eastern ones. The artificial divide between the West and the East is unnecessary, especially with the effects of globalization in terms of the instant delivery of knowledge via information technology advancement and traveling across geographical boundaries via transportation networking. Educators and scholars can share their knowledge and skills instantly and continuously. Through mutual exchange and modification of methods, they can improve their teaching skills. Students can easily take part in classes offered by various faculties or institutions, exposing them to different types of learning experiences and allowing them to compare teaching methods and evaluate which they find to be most interesting and effective. Students can provide feedback to educators, allowing educators to assess students’ learning needs, modify course contents, explore

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effective teaching methods, and evaluate the teaching and learning outcome in an ongoing and open manner. Ideologies of education should be both broad-based and specific. Students need general knowledge from various disciplines that will widen their horizons, sensitize them to contextual life issues and prepare them for the many challenges that require a multi-faceted approach to inquiry and problem solving. Apart from this, health is everybody’s business, and prevention of illness and promotion of health should be regarded as a whole-population activity. The involvement of hospitals and other health care professions is not adequate to face the challenges of the development of chronic diseases such as diabetes mellitus and coronary health disease, infectious diseases such as H5N1 and SARS, natural disasters such as tsunamis, and sudden terrorist attacks. The entire population must be educated about health in ways that can enhance their ability to assess their physical condition, modify unhealthful lifestyles, take up healthful ones, ensure good hygiene at home and in their communities and protect the environment. Investments in the educational sector aim to improve the quality of human capital and to equip the younger generation with sound knowledge and practical skills in order to respond to rapid socio-economic development and the need for employees who have a wide knowledge base. However, in reality, putting more resources into education does not necessarily lead to better intellectual development for every student. Many variables affect learning outcomes, but about one thing we can be sure: teaching methods matter. Academic success depends upon the student’s motivation and abilities, the purposes and contents of classes, the learning environment and learning cultures and the teacher’s qualities and their teaching methods. This article focuses on role-playing as a teaching method.

ROLE-PLAYING AS A TEACHING METHOD Role-playing has been stressed as an effective teaching method in medical education (Chan, Wun, Cheung, Dickinson, Chan, Lee, and Yung, 2003; Green, Gross, Kernan, Wong, and Holmboe, 2003; Kim, Stevens, and Pinsky, 2003; Lau, Stewart, and Fielding, 2001; Torke, Quest, Kinlaw, Eley, and Branch, 2004). Listening to students’ voices can enhance the outcome of medical teaching (Alford and Currie, 2004). Educators should seek to motivate their students to actively participate in any learning scenario, whether inside or outside the classroom (Pitts, 2004). Putting patients’ concerns uppermost during medical intervention is the hallmark of the patient-driven approach to medical care (Brown, Pfeifer, Gjerde, Seibert, and Haq, 2004). Through role-playing, students can practice interviewing patients to obtain relevant past and current illness history (Korenstein, Thomas, Foldes, Ross, Halm, and McGinn, 2003). Role-playing in medical classrooms is also an effective means for students to exercise their communication skills when facing a patient (Roter, Larson, Shinitzky, Chernoff, Serwint, Adamo, and Wissow, 2004). It improves students’ critical thinking ability (Simonneaux, 2001). Additionally, the learning needs of students should be given the highest priority in formulating courses, rather than being based on the lecturer’s preferences (Bernstein, Rieber, Stoltz, Shapiro, and Connors, 2004). Teaching and learning is socioculturally relevant (Alefred, 2003; Wiskin, Allan, and Skelton, 2004), meaning that

Using Role-Playing to Teach Medical Terminology to Social Work Undergraduates 165 examination of one’s own teaching and learning assumptions can provide a true guide to the best way to develop and conduct courses.

TEACHING AND LEARNING ASSUMPTIONS Five assumptions about teaching and learning underpin this chapter and its conclusion that role-playing is an excellent method for teaching medical terminology to social work undergraduates: 1. Education should empower students to take charge of their health. 2. It should equip them with a basic knowledge of medicine. 3. It should increase their awareness of health issues so that they can analyze those issues critically and comprehensively. 4. It should prepare them to work with health care professionals and to participate in health care activities; and 5. It should provide them with the opportunity to apply medical terminology to their daily lives.

PURPOSE During the author’s experience in teaching this subject to five classes totaling 180 students from 2002–2006 in Hong Kong, the use of role-playing as a means to teach medical terminology to social work undergraduates was explored. This chapter has three purposes: (1) to share the outline of the 12-lecture course titled “Social Aspects of Health and Illness”; (2) to describe the three lectures about medical terminology, and to show the process and outcome of using role-playing in the course of teaching with four role-play scenarios given for illustration and discussion; and (3) to highlight three limitations of this chapter.

OBSERVATIONS Course Description The information provided in this chapter is based on the author’s experience teaching the subject “Social Aspects of Health and Illness” offered by the Department of Social Work. Five separate classes of social work undergraduates in Hong Kong took part in this course. The first class, in 2002, had 59 students; the second class, in 2003, had 48 students; the third class, in 2004, had 36 students; the fourth class, in 2005, had 18; and the fifth class, in 2006, had 22. These enrollment numbers suggested that there was a declining trend among students selecting this subject. The reasons are unknown. There are many elective subjects offered at the University, and students might have thought that classes dealing with health issues were not closely enough related to their academic disciplines, and not important as they would not be pursuing a health care profession upon completion of their bachelor’s degree. But one

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thing is very certain: the four course evaluation reports on this subject scored average or above the departmental mean score of all undergraduate subjects. (During the second semester of 2003, due to the SARS epidemic, the university cancelled all course evaluation exercises because some classes had been suspended or called off in April that year. Therefore, course evaluation results for that year are not available.) The twelve lectures in this course each lasted one hour and 45 minutes. Three lectures (Lecture Two–Lecture Four) featured an overview of the medical terminology of bodily systems; this chapter focuses on these three lectures, but the themes of all 12 lectures are shown in Table 1. Table 1. Course Outline Lecture One Social Aspects of Health and Illness Contemporary Health Issues

Lecture Four Biomedical Model (III) Medical Terminology

Lecture Seven Medicalization and Strength-oriented Approach

Lecture Ten Health Education and Health Promotion

Lecture Two Biomedical Model (I) Medical terminology

Lecture Five Women’s and Men’s Health Issues

Lecture Eight Revealing Patient Experiences with Illness, Disability, Aging

Lecture Eleven Primary Health Care

Lecture Three Biomedical Model (II) Medical Terminology

Lecture Six Psychosocial Well-Being

Lecture Nine Patient and Caregiver Roles

Lecture Twelve Alternative Healing Modalities

THE CONTENT AND PROCESS OF THE THREE LECTURES ON MEDICAL TERMINOLOGY In these three lectures, some general medical terms and those describing eleven bodily systems were taught. The rationale for teaching these terms was that knowledge of general medical terms can give students a grasp of some primary concepts they will surely come across in their daily lives. The bodily systems that were covered all related to theirs and their family’s health, and could easily be associated with their past and current experiences of illness. With only three lectures and less than six hours of teaching time to devote to it, only the most significant and relevant medical terms were chosen. The author would begin by providing PowerPoint notes for the students so they could check their dictionaries and familiarize themselves with the terminology. For example, at Lecture One, notes and suggested readings for Lectures Two–Four were delivered. At Lecture Three, notes for Lectures Five and Six were offered. At Lecture Five, notes for Lectures Seven-Nine were given, etc. The structure of each of these three lectures was as follows: with the aid of PowerPoint, the assigned medical terminology would be discussed for about forty-five minutes. Video presentations of certain diseases would then be shown, usually lasting about ten minutes. Then, the students would be broken into groups—sometimes by random assignment, sometimes by their own preferences. Depending on class size, the groups would consist of

Using Role-Playing to Teach Medical Terminology to Social Work Undergraduates 167 four to six students. About 20 minutes would be allocated for group discussion. In the group discussions, students were asked to perform a role play with one student in the role of a doctor, another as a patient, and others as family members. They were to use the medical terminology of one bodily system studied in the lecture. During Lectures Two and Four, four bodily systems were discussed, providing four discussion topics for the groups to practice. Sometimes, due to the larger number of students in some classes, there would be more groups than body systems, so more than one group would work with the same bodily system. However, even though the groups were assigned the same medical terminology, they could role-play with different characters, plots and settings. Afterwards, each group was given three minutes to share their ideas in front of the class. Finally, the author would offer concluding remarks. The contents of the lectures on medical terminology are shown in Table 2. The author’s approach to teaching insists that undergraduates take the initiative to prepare thoroughly before attending class. Being spoon-fed by their teachers or subjected to lecturers who allow little student participation is not ideal. Every educator should use class time to stimulate the students to think and share their personal feelings and comments as much as possible. Knowledge should be shared through a teacher-student partnership. More importantly, educators should be humble enough to be open to hearing their students’ feedback and should show appreciation of their students’ innovative and original thoughts. Table 2. The three lectures on medical terminology Lecture Two Cardiovascular system Hypertension Ischemia Heart murmur Palpitation Bradycardia Tachycardia Coronary artery disease Myocardial infarction Varicose veins

Lecture Three Skin Acne Burn Dermatitis Rubella Eczema Gangrene Herpes Zoster Psoriasis

General terminology Etiology Febrile Localized and Systemic Malaise Morbidity and Mortality Prognosis Prophylaxis Recurrent Sign and Symptom Syndrome

Nervous system Coma Dementia Motor deficit Sensory deficit Convulsion Syncope Cerebrovascular accident Epilepsy Hydrocephalus Meningitis

Ears Otitis media Deafness Conductive hearing loss Microsurgery Tympanoplasty Ear instillation Antibiotic

Urinary system Dysuria Hematuria Incontinence Urinary retention Nephritis Cystitis Urinary tract infection Cystoscopy

Endocrine system Diabetes mellitus Hyperthyroidism Hypothyroidism Pancreatectomy Thyroidectomy Hormone replacement

Eyes Cataract Conjunctivitis Glaucoma Retinal detachment Eye instillation Eye irrigation

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Zenobia C. Y. Chan Table 2. (Continued).

Lecture Four Respiratory system Hyperventilation Hypoventilation Hypoemia Pulmonary edema Bronchitis Chronic obstructive pulmonary disease Sinusitis Tonsillitis Upper respiratory infection

Musculoskeletal system Rigidity Spasm Tremor Gouty arthritis Closed fracture Opened fracture Osteoporosis Amputation Bone grafting

Gastrointestinal system Anorexia nervosa Ascites Diarrhea Dysphagia Hepatomegaly Jaundice Nausea Gingivitis Peptic ulcer Gastric ulcer Duodenal ulcer

Blood and lymph systems Hemoglobin Immunosuppression AIDS Anemia Hemophilia Leukemia Septicemia Intravenous infusion Blood transfusion

The latest class, held from January to April 2006, was selected for presenting the in-class dynamics and the author’s observations of using role-playing as a method of teaching the specific thematic medical terminology of particular bodily systems. Due to the limited space of this paper, only four role-play scenarios will be presented for illustration and discussion.

ROLE-PLAY ONE: MEDICAL TERMINOLOGY OF THE CARDIOVASCULAR SYSTEM This group of four students chose to portray a family practitioner, a nurse, a mother in her seventies, and her eldest, middle-aged daughter in order to demonstrate their understanding and application of the medical terminology of the cardiovascular system as follows: Doctor: Good morning, how can we help you today? Mother: I feel shortness of breath, a little dizziness and fatigue. Daughter: Doctor, last night my mother experienced chest pain and that’s why we came here this morning, so she can get checked. Doctor: How is the chest pain now? Mother: No chest pain anymore. I just feel unwell. Doctor: I checked your records, and see that you had myocardial infarction last year and were hospitalized for a week. You were prescribed some antihypertensive drugs. Nurse: I am going to take your blood pressure. Doctor: Your blood pressure is a little higher than usual, but it’s not serious. Let me listen to your heart…no bradycardia or tachycardia. It’s quite normal. Daughter: But last night my mother said she had palpitations. Doctor: I suggest we do an ECG. Daughter: Do you think my mother has coronary health disease? Doctor: We’d better do a thorough check-up first.

This group used their imagination and played different characters to demonstrate their understanding of the medical terminology. In an actual doctor’s office, of course, the patient’s medical history would have to be much more thoroughly explored and comprehensive medical screening would have to be arranged. However, because the group had less than three

Using Role-Playing to Teach Medical Terminology to Social Work Undergraduates 169 minutes to present its understanding of the assigned terms, it had to show how they might be used in an admittedly artificial context.

ROLE-PLAY TWO: MEDICAL TERMINOLOGY OF THE NERVOUS SYSTEM Another group used the medical terminology related to the nervous system to perform a role-play of a medical emergency of a young adolescent having an epilepsy attack. The setting was on the street. A student pretending to be the epileptic boy suddenly fell on the street and all his limbs tightened up. Three students pretending to be pedestrians were walking near the boy. Pedestrian A: Look! That boy is having convulsions. Pedestrian B: Be calm! I learned first aid in the university and I know what to do to help.

Pedestrian B unbuttoned the boy’s overcoat so he could breathe more easily. She told the other two pedestrians to move any nearby obstacles out of the way to prevent any injury from the boy’s involuntary movements. She also asked Pedestrian C to call an ambulance. She observed the duration, frequency and pattern of the convulsions so she could give this information to the medics. Pedestrian A said that they should put a spoon in the boy’s mouth to prevent him from biting his tongue. Pedestrian B replied firmly that they should not put anything in his mouth because it might cause him to suffocate. The previous group used as many medical terms as they could in their role-play. This group used only two medical terms: epilepsy and convulsion. However, the students’ understanding should not be evaluated solely on the number of medical terms used; appreciation should be shown for their efforts to try and help the victim and handle the emergency. It was surprising that the student playing the boy did not mind lying down on the floor of the classroom, proof that they were very involved in their role-play and tried to portray as real a medical situation as they could.

ROLE-PLAY THREE: MEDICAL TERMINOLOGY OF THE URINARY SYSTEM This group consisted of an urologist, an old man, the man’s wife and a nurse. The setting was a urology clinic. Old man: Doctor, I can’t pass urine and feel my bladder is very full. Doctor: When did you experience urinary retention? Old man: Last night. And I saw a few drops of red in the urine. I am really scared. Doctor: It sounds like hematuria. Wife: Doctor, I have a problem too. When I urinate, I feel pain. Doctor: Nurse, take their temperatures and have them give us urine samples.

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Zenobia C. Y. Chan Wife: Doctor, this feels like the time I got a urinary tract infection. Could this be a UTI again? I also have incontinence whenever I cough heavily and lift heavy objects. Doctor: I’ll need the results of the urine test before I can give you a diagnosis. Nurse: Sir, the doctor suggests you have a cystoscopy. Ma’am, you should take a course of antibiotics in order to treat your UTI.

This group portrayed two patients with different manifestations of urinary system problems.

ROLE-PLAY FOUR: MEDICAL TERMINOLOGY OF THE EARS This group had a father, two sons and an ENT doctor. The setting was a clinic. Father: Doctor, my two sons and I all have ear problems. Doctor: Please tell me one by one what the trouble is. Father: I think I am deaf! Doctor: That’s not likely, as you can hear and respond to me quite well. Can you tell me why you think you are deaf? Father: Because people tell me that they have to talk to me loudly when my right ear is turned toward them. No matter how loudly they speak at my right ear, I can’t hear clearly. Doctor: Something might be going on in your right ear. We’ll have to do a thorough examination. How about your two sons? Elder son: Yesterday, I was diving, when suddenly I couldn’t hear. I am afraid my eardrums were ruptured. I’ve heard about a microsurgery called typanoplasty. Am I going to need this surgery? Doctor: Let me take a look. Younger son: Doctor, I have fever, ear pain and a headache. What’s wrong with me?

The Doctor looks at the younger son’s ears and says he is suffering from otitis media. Ear instillation and a course of antibiotics are prescribed. This group showed three patients with ear problems and tried to fully utilize the medical terms in one scene. They developed a plot with a sense of coherence, and added the multigenerational aspect of a father and his two sons.

LIMITATIONS Based on the above observations of the students’ involvement in role-playing, three limitations should be noted. Firstly, the veracity of this discussion would be improved if consent could be obtained from the university and the students to videotape the class for future research purposes. The role-play scenarios presented above are based on the author’s personal recall and notes made after class. Some important content and narrative might be missing. Secondly, the presentation, observations, and analyses were all performed by the author. The interpretation might therefore be too subjective. Peer checking or inter-rater reliability of the contents and analyses of the role-plays should be included. Thirdly, a

Using Role-Playing to Teach Medical Terminology to Social Work Undergraduates 171 comparison of using role-play as a teaching method with medical undergraduates as compared to non-medical undergraduates was not included. More effort should be made in these areas in order to understand truly whether role-playing can be an effective and wellreceived approach in social work undergraduate education in both the Chinese and Western context.

CONCLUSION Undergraduates need to cultivate a diverse knowledge base, and all citizens need to be prepared to take better control of their health. In consideration of these needs, three questions emerge. Is it fair that only medical students have the opportunity to learn medical terminology? Finally, which teaching method is most effective for teaching non-medical undergraduates medical terminology? There is still much work to be done to answer these questions. Nevertheless, this chapter wishes to suggest that teaching medical terminology to social work undergraduates should be considered. The role-plays described above prove that the students are very creative and are willing to fully participate and work hard to apply the terminology. And finally, by employing creative and interactive teaching and learning methods, medical education for social work undergraduates can be fun!

REFERENCES Torke, A. M., Quest, T. E., Kinlaw, K., Eley, J. W., and Branch, W. T. (2004). A workshop to teach medical students communication skills and clinical knowledge about end-of-life care. J. Gen. Intern. Med. 19, 540-544. Green, M. L., Gross, C. P., Kernan, W. N., Wong, J. G., and Holmboe, E. S. (2003). Integrating teaching skills and clinical content in a faculty development workshop. J. Gen. Intern. Med.18, 468-474. Kim, S., Stevens, N. G., and Pinsky, L. (2003). Casting anxiety in small group facilitation: faculty development via role play. Medical Education, 37, 489. Lau, K. C. J., Stewart, S. M., and Fielding, R. (2001). Preliminary evaluation of “interpreter” roles plays in teaching communication skills to medical undergraduates. Medical Education, 35, 217-221. Chan, C. S. Y., Wun, Y. T., Cheung, A., Dickinson, J. A., Chan, K. W., Lee, H. C., and Yung, Y. M. (2003). Communication skills of general practitioners: any room for improvement? how much can it be improved? Medical Education, 37, 514-526. Alford, C. L., and Currie, D. M. (2004). Introducing first-year medical students to clinical practice by having them “shadow” third-year clerks. Teaching and Learning in Medicine, 16(3), 260-263. Pitts, S. E. (2004). Lessons in learning: learning, teaching and motivation at a music summer school. Music Education Research, 6(1), 81-95. Brown, R. L., Pfeifer, J. M., Gjerde, C. L., Seibert, C. S., and Haq, C. L. (2004). Teaching patient-centered tobacco intervention to first-year medical students. J. Gen. Intern. Med. 19, 534-539.

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Korenstein, D., Thomas, D. C., Foldes, C., Ross, J., Halm, E., and McGinn, T. (2003). An evidenced-based domestic violence education program for internal medicine residents. Teaching and Learning in Medicine, 15(4), 262-266. Roter, D. L., Larson, S., Shinitzky, H., Chernoff, R., Serwint, J. R., Adamo, G., and Wissow, L. (2004). Use of an innovative video feedback technique to enhance communication skills training. Medical Education, 38, 145-157. Simonneaux, L. (2001). Role-pay or debate to promote students’ argumentation and justification on an issue in animal transgenesis. International Journal of Science Education, 23(9), 903-927. Bernstein, H. H., Rieber, S., Stoltz, R. A., Shapiro, D. E., and Connors, K. M. (2004). Assessing the learning needs of maternal and child health professionals to teach health promotion. Maternal and Child Health Journal, 8(2), 87-93. Alefred, M. V. (2003). Sociocultural contexts and learning: Anglophone Caribbean immigrant women in U.S. postsecondary education. Adult Education Quarterly, 53(4), 242-260. Wiskin, C. M. D., Allan, T. F., and Skelton, J. R. (2004). Gender as a variable in the assessment of final year degree-level communication skills. Medical Education, 38, 129137.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 14

CHINESE HERBAL MEDICINE IN HEALTH CARE: WHAT CAN BE LEARNED FROM THE CONTEXT OF HONG KONG? W. F. Lai and Zenobia C. Y. Chan ABSTRACT Chinese herbal medicine (CHM) is a popular form of complementary and alternative medicine (CAM) endorsed by the World Health Organization (WHO). Nowadays, the utilization of CAM is growing dramatically worldwide, albeit within the context of the domination of Western medicine (WM) in global medical systems. Based on the scattershot observations of situations in different places, we discern that the establishment of nomothetic control would be one of the necessary initial stages of CHM development. In this chapter, apart from explaining why such a legislative framework can function as a potential indicator regarding the growth and modernization of CHM in a region, we will also discuss the practical aspect of CHM and explore some of its exciting potential in health care sectors. It is worth noting that this is the first publication in the field to use the context of Hong Kong as a reference to comprehend and infer potential challenges and pre-conditions needed for furtherance of CHM in the direction of integrative Chinese and Western medicine (ICWM) and other practical areas under the social environment of an incompletely sinicized society.

INTRODUCTION Chinese herbal medicine (CHM), as a form of complementary and alternative medicine (CAM) endorsed by the World Health Organization (WHO) (Patrick, 1995; McGrath, 2005), is an invaluable part of Chinese civilization and an integral component of traditional Chinese medicine (TCM). The oldest known pharmacopoeia in Chinese materia medica is ShenNong’s Ben Cao Jing; it described more than 250 herbal drugs commonly used in bygone days. Another canon, The Yellow Emperor’s Inner Classic, is reckoned the earliest TCM classic, as multitudinous traditional medical philosophies were explicated inside. Ranging

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from vision enhancement with Lycium barbarum fruits to botanical cancer treatments (Cohen, Tagliaferri et al., 2002; Rui, 2002; Simpson, 2003; Xu, Jin et al., 2007; Tan, Liu et al., 2008), CHM has unwittingly assimilated into the life of people in East Asia for millennia. Clinically, CHM practitioners will diagnose ailments based on the Taoist doctrine of Yin/Yang and Five Elements (gold, wood, water, fire, and earth) (Patrick, 1995; McGrath, 2005), and then administer drugs in accordance to Four Natures (cold, hot, warm, cool), Five Tastes (pungent, sweet, sour, bitter, salty), and Meridians the medicines follow (Zhang and Cheng, 1996). Based on the therapeutic role of an herb in a prescription, each herbal drug can function as “Monarch”, “Minister”, “Assistant” or “Guide”. Together with other TCM practices like acupuncture, moxibustion, message therapy and bone-setting, CHM constitutes the kernel of the health care system adopted in the past in China. In latter years, the utilization of CAM has been growing markedly worldwide despite the preponderance of Western medicine (WM) in conventional health care settings. According to the WHO (2003), over 50% of the populations in Europe and North America and 70% of people in Canada have been using CAM at least once a year. Statistics revealed that the annual global market for herbal medicines could stand at over US $ 60 billion. In the United Kingdom alone, the annual expenditure on CAM was estimated to be US $ 230 million (World Health Organization, 2003). Owing to the flourishing CAM market and the rising role of China globally, CHM is now receiving more and more attention in healthcare platforms. At present, CHM development is no longer localized in China, but also officially supported in Western countries. The National Center for Complementary and Alternative Medicine (NCCAM) is one of the examples of current U.S. bodies actively supporting research and furtherance of CHM in the West. Recently, the potential of CHM has begun to be discerned in biomedical science sectors as well. Many medicinal chemists and pharmacognosists have endeavored to explore a variety of herbs and to develop pharmaceuticals from active ingredients isolated from medicinal plants. An example of this is the anti-cancer drug Kanglaite (an investigational drug with its active substance extracted from Semen coicis), its injectable form was approved by China’s State Drug Administration and has been clinically applied to more than 250,000 Chinese patients suffering from lung, breast, liver and several other cancers (Basu, 2004). Another drug, ephedrine, a sympathomimetic amine isolated from Ephedra vulgaris in the 1880s, is now widely used in the following applications: a hypertensive agent, bronchodilator, cardiac stimulant and hyperglycaemic agent (Cruz and Juárez-Juárez, 2004). Barring the aforementioned examples, some other botanically-derived pharmaceuticals are listed in Table 1. Accompanying the changes in global attitudes towards Chinese herbs, CHM has rendered a myriad of prospects in miscellaneous areas. In this chapter, we will center on the practical aspect of CHM in health care, and use the context of Hong Kong to understand the challenges and opportunities in the advancement in and modernization of this growing traditional medicine under the social environment of an incompletely sinicized society. The rationale of choosing the context of Hong Kong is based on the unique historical background there. Hong Kong was colonized by Britain under the Convention of Chuen Pi since 1841, and was returned to mainland China in 1997. The prolonged and persistent cultural influence on the Hong Kong society in this 150-year colonial period induced a strong sense of “nonChinese” identities among the population (Bond, 1987, 1993). Additionally, during the handover of sovereignty, vehement Chinese socio-cultural impact was exerted on the Westernized Hong Kong culture. The historical transition and cultural conversion make Hong

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Kong a very good example to illustrate the obstacles that may be encountered when Chinese culture and its components (e.g., TCM) are attempting to co-exist with the local cultures in areas where the local populations have not yet been substantially sinified, such as many of the places where the struggle for official recognition of CHM is occurring nowadays. Table 1. List of chemicals isolated from Chinese medicinal herbs as drugs Therapeutic Applications

Active Compound

Botanical Origins

References

Treatment of Cancer

Irisquinone

Iris pallasii Fisch. var. chinensis Fisch.

Indirubin

Isatis tinctoria, Baphicacanthus cusia

Taxol

Taxus brevifolia

Oridonin

Rabdosia Rubescens

Harringtonine

Cephalotaxus hainanensis Li

Homoharringtonine

Cephalotaxus hainanensis Li

Monocrotaline

Crotalaria sessiliflora L.

Xue Bao PG2

Astragalus membranaceous

Engels et al., 1992; Huang, 1993; Zhu and Woerdenbag, 1995; Liu and Chiou, 1996; Kunikata et al., 2000; Bisset, 2001; Ikezoe et al., 2003; Bensky et al., 2004; Iwata et al., 2004; Wang et al., 2004; Yunmbam et al., 2004; Wong et al., 2007; Zhao et al., 2007; Miller et al., 2008

Berbamine

Berberis poiretil Schneid

Tanshionone II-A

Salvia miltiorrhiza Bunge

Sodium ferulate

Liguistrum chuanxiong Hort.

Tetramethylpyrazine

Liguistrum chuanxiong Hort.

Cyclovirobuxine D

Buxus microphylla Sieb. et Zucc. var. sinica Rehd. et.Wils.

Sarmentosine

Sedum sarmentosum Bge.

Schisantherin A

Schizandra chinensis (Turcz.) Baill. and Schisandra sphenanthera Rehd. et Wils.

Anabasine hydrochloride

Alangium chinensis (Lour.) Harms

Cissampelin methiodide

Cissampelos pareira L.

Tetrandrin dimethiodide

Stephania tetrandra S. Moore

Apocynin

Picrorhiza kurroa

Artemisinin

Artemisia annua

Matrine

Sophora subprostrata

Treatment of Coronary Heart Diseases

Treatment of Hepatitis

Muscle Relaxation

Miscellaneous

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DEVELOPMENT OF CHINESE HERBAL MEDICINE IN HONG KONG AND ITS IMPLICATIONS The development of CHM in Hong Kong was synchronized with that of TCM, and the importance of establishing a relevant legislative framework on herbal medicine started to be recognized only in the late 1980s during which the Working Party on Chinese Medicine (which was responsible to advice on proper use of TCM) was formally appointed. Before that, CHM had long been deemed nugatory, and had sporadically received much attention by the health care practicians of the mainstream, albeit its length of existence in the territory. After the handover of sovereignty from the United Kingdom to the People’s Republic of China (PRC) in 1997, CHM began to develop dramatically in Hong Kong. In Article 138 of the Basic Law enacted by the Seventh National People’s Congress in 1990, it stated that “The Government of the Hong Kong Special Administrative Region shall, on its own, formulate policies to develop Western and traditional Chinese medicine and to improve medical and health services” (Hong Kong Government, 2008). In the light of this, the former Chief Executive Chee-Hwa Tung proclaimed on behalf of the government to “lay a solid foundation for the future development of traditional Chinese medicine” in his first Policy Address in October 1997 (Hong Kong Government, 1997). Since then, CHM in Hong Kong has been brought into a clearer regulatory framework. In July 1999, the Hong Kong Legislative Council enacted the Chinese Medicine Ordinances and before long the Chinese Medicine Council was established (Chinese Medicine Council of Hong Kong, 2003). Henceforth, trade on Chinese herbs is regulated via a licensing and registration system. Except under special circumstances, all businesses (including import, manufacture and local distribution) vending therapeutic herbs and proprietary Chinese medicines (pCm) are regulated by the Chinese Medicines Board (Chinese Medicine Council of Hong Kong, 2003). Apart from this, all practitioners of CHM, acupuncture and bone setting must be registered. As a pre-requisite of registration, all Chinese medicine practitioners (CMPs) are now mandated to complete a full-time on campus TCM degree course for not less than 5 years (or its equivalent) prior to their professional practice (Chinese Medicine Council of Hong Kong, 2003). In regard to this, three local universities (University of Hong Kong, Hong Kong Baptist University and Chinese University of Hong Kong) are now providing medical trainings for prospective CHM practicians. In 2006, to further increase the quality of TCM consultation services and to provide more training opportunities to local medical graduates, the Hospital Authority (HA) opened five more Chinese medicine out-patient clinics (Hong Kong Government, 2006). Hitherto, eight TCM clinics have been established by the HA. Together with those supported by Non-Governmental Organizations (NGO) and local universities, there are now in total 11 CHM clinics available in Hong Kong. By virtue of the increasing official recognition of TCM and the aforementioned regulations, the number of registered CMPs in Hong Kong steadily increased from 4,783 in 2003 to more than 5,500 in 2008 (Chinese Medicine Council of Hong Kong, 2004, 2005, 2006, 2007, 2008a, 2008b). This trend is expected to continue over the next decade. As a matter of fact, Hong Kong is not the only place to establish statutory control on herbal medicine; the same observations can also be found in some other Eastern and Western countries where herbal medicine is currently being developed (World Health Organization,

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2002, 2005) (Table 2). In substance, the establishment of regional guidelines and rules is one of the necessary initial stages of the advancement in CHM, and it can also function as a useful local indicator to extrapolate the readiness of the growth and modernization of the medical practice in a region. Here we propose two reasons for this. Firstly, the symbolic significance of this indicator signifies the official concerns about the local status of CHM and the recognition of the importance of putting it under legislative control. It is this enlightenment that fosters a more systemic platform to initiate further headway in CHM in that place. Secondly, the establishment of regulations can provide a more favorable social environment for the advancement in CHM by ensuring the safety and quality of the herbal medical practice (its therapeutics and products), promoting the recognition of these systems and modalities, and clarifying the roles of CHM in modern health care systems. As both the official recognition and external factors have played a significant role in advances in CHM, we have sound reason to believe that the development of the medical practice in areas without such fundamental elements would very likely be thwarted by unreadiness in the population. We have to note, however, that the mere presence of the indicator above is not a guarantee for the success of CHM unless a significant level of community acceptance towards CHM is procured. This will be further discussed in the following sections. Table 2. Regulations of herbal medicines in different places Places

Regulatory Control

Hong Kong

The practice of Chinese herbal medicine is regulated by the Chinese Medicine Ordinance. The same Ordinance also regulates trades of herbal products and proprietary Chinese medicines in Hong Kong.

China

Herbal drugs are regulated by the Drug Administration Law. Good Manufacturing Practice (GMP), Good Clinical Practice (GCP) and Good Laboratory Practice (GLP) are introduced to the development, testing and manufacturer of herbal drugs.

European Unions

Guidelines and standards for herbal medicines and the medical practice are provided mainly by the European Pharmacopoeia and the Committee for Proprietary Medicinal Products (CPMP). Legislation on herbal medicinal products is proposed by European commission, but it is still at the draft stage.

Canada

All natural health products, including herbal products, are proposed to be governed by the Natural Health Products Regulations. In addition, all manufacturers, packagers and labelers of natural health products should employ GMP.

Thailand

People involving in manufacture, import and trade on herbal drugs have to obtain a license from the Food and Drug Administration (FDA) of Thailand. Guidelines of GMP are applicable to the manufacture of herbal products.

Islamic Republic of Iran

Good Agricultural Practice (GAP) is recommended for herbal medicines. National policies on herbal medicine are designed by the National Herbal Medicine Expert Committee under the Pharmaceutical Department of the Ministry of Health.

Ghana

Manufacture, import, export, distribution, use and advertisement of herbal drugs and food are regulated under the Food and Drugs Law. GMP inspection is introduced to the manufacturer of products.

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CHINESE HERBAL MEDICINE IN HONG KONG: LOCAL HEALTH CARE AND ITS IMPLICATIONS At present, the Hong Kong community is still not ready to fully incorporate CHM and other TCM practices as part of the mainstream health care system (Chan, Mok et al., 2003). Among different age groups, younger people (mean 26 years of age), who were expected to have longer education and a higher income, were found to have the lowest trust in traditional medicine (Chan, Mok et al., 2003). More recent research on students of pharmacy (Hon et al., 2004), nursing (Hon et al., 2006) and Chinese medicine (Hon et al., 2005) also revealed that less than half of the respondents in Hong Kong had positive attitudes towards TCM. Under such circumstances, the increase in the popularity of utilizing CHM over the last decade was almost negligible. Compared to 1993 in which 73% of outpatients resorted to WM practicians and 10% sought TCM advice (Wong, 1993), only an 8% increase in the percentage of outpatients attending TCM private clinic was observed after about 10 years (Hong Kong Government, 2006). Public skepticism of CHM in Hong Kong may be partially caused by the strong faith of the populace in modern science, which is something Hong-Kongers have exposed to during their school-life. Due to the empiricism of CAM practices, the gradual accumulation of related scientific supports published during the past quarter century are easily overlooked by Hong Kong people. In fact, testaments to the use of CHM treatments and publications on the therapeutic mechanisms of traditional herbs have been growing since the turn of the century. For instance, the anti-proliferative and anti-migratory properties of Coptis chinensis, and its therapeutic effects on neointimal proliferation and restenosis were demonstrated to be germane to a plant alkaloid, berberine, which could inhibit platelet-derived growth factor (PDGF)-induced vascular smooth muscle cells (VSMC) growth via activation of AMPK /p53 /p21 (Cip1) signaling, and reduced the expression of Rac1 and Cdc42 proteins (Liang et al., 2008). Currently, the methanolic extract of adlay hull was also shown to exhibit inhibitory effects on uterine contraction in vivo, which may partially explain the therapeutic effect of the herb in dysmenorrhea (Hsia et al., 2008). Notwithstanding the increasing volume of scientific findings, the skepticism of TCM is still deep-set in Hong Kong (Hon et al., 2004, 2005, 2006; Wong et al., 2006). Such a situation illustrates that merely the establishment of a statutory framework on herbal medicine does not necessarily guarantee a high level of social acceptance towards CHM in a society. Moreover, despite the introduction of legislative control, the furtherance of CHM would be stagnant if it is not in coordination with the positive atmosphere towards traditional medicine in the population. To procure advances in CHM, coordination with measures to further promote the level of social cognizance and acceptance will be a sine qua non.

OPPORTUNITIES IN HEALTH CARE Integrative Chinese and Western Medicine There is an apophthegm in China: “TCM treats humans while WM treats diseases”. In contrast to the scientific compartmentalized approach adopted by the Western medical

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system, experienced-based CHM treats the human body as a microcosm consisting of both internal and external conditions, and emphasizes the equipoise of “energies” in the five zangviscera (the heart, liver, spleen, lung and kidney) (Liu and Dong, 1998). For this reason, both CHM and WM have their own strengths and shortcomings. For example, Chinese materia medica has the merit of being attentive to the root of the medical problem, but is perceived to be slower in action (Lam, 2001), whereas WM cures a disease by direct confrontation with the pathological problems; however, the sides effects of the chemical drugs are one of the major concerns in the eyes of the general public (Lam, 2001). In the light of this, integrative Chinese and Western medicine (ICWM), which signifies the collaboration of both medical practices, is becoming a desirable approach in contemporary medicine. Started at the turn of the century, the quantity of corroborative evidence supporting the viability of ICWM has been growing rapidly. One of the studies on older adults suffering from idiopathic nephrotic syndrome indicated that those treated with ICWM (with prednisone, Cytoxan and Chinese medicinal herbs) could generally have higher remission rate, lower adverse reaction rate and longer remission period (Wei et al., 2000). In comparison with WM, ICWM could also lead to shorter fever period and hospital stay, lower damage to the lung, higher lung infiltrate absorption, and lower incidence of complications in SARS (severe acute respiratory syndromes) patients (Hai, 2003; Xiao et al., 2003a, 2003b). In addition to the aforementioned examples, the potency of ICWM is also supported by clinical studies on its therapeutic effects on hemophilic arthritis and severe post-kidney-transplant lung infection. Hemophilic arthritis is a major problem for joint malformation and deformity caused by hemophilia, a hemorrhagic disease with no radical therapy at present (Ye, 2004). To study the efficacious and safety of different treatments, Liu et al. (2007) have recruited 40 hospitalized patients and classified them into four stages based on their conditions. For stage I patients, RICE treatment (rest, ice, compression and elevation), together with oral administration of Chinese herbal pills (consisted of thorowax root, Chinese angelica root, achyranthes root, red sage root, notoginseng, bitter orange and red Peony root) and intravenous dripping of a drug mixture (etamsylate and aminomethylbenzole acid), were provided for three weeks. The same strategy is adopted with an additional intra-articular injection of another drug mixture (triamcinolone acetonide and methotrexate) or extra administration of sodium hyaluronate to stages II, III and IV patients (Liu et al., 2007). Results showed that 85% of the patients were completely remitted with only 5% showing no remission. More surprisingly, over 80% remission sustaining rate was observed in a six-month post-treatment follow-up. Examinations of patients’ liver and kidney functions, levels of electrolytes, electrocardiograms and blood glucose levels revealed the negligibility of adverse effects in the ICWM intervention. Though the actual therapeutic efficiency of ICWM in comparison with that of conventional TCM or WM in hemophilic arthritic is still yet to be ascertained, a reliable basis for the feasibility of this collaborative approach has already been provided. The viability of ICWM was also shown in a study on the treatment of severe post-kidneytransplant lung infection. During the experimental period, Yao et al. (2006) simultaneously provided both herbal remedies (dandelion, herba patriniae, giant knotweed and barbed stullcap) and WM treatments to 18 recruited patients. The herbal prescriptions administered were slightly modified based on the patients’ actual symptoms. Among all the subjects, 15 of them showed statistically significant positive outcomes, this was believed to be associated with the capacity of the herbal drugs in increasing the patients’ blood neutrophilic

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granulocyte phagocytic index, elevating the blood plasma total complementary levels, and hence promoting the patients’ immune functions to fight against pathogenic infections (Ma et al., 1981). In spite of the increasing research evidence on ICWM, it is none the less important to recognize the disease- and remedy-dependent limitations involved in this intervention. In fact, one of the factors that ruin the course of an ICWM treatment is the incompatibility of the simultaneously adopted WM and TCM remedies. Some of the herbs and pharmaceuticals may diminish the potencies of each other or even cause serious health consequences. One of the most illustrative examples is the herb Hypericum perforatum, it was found to reduce the serum concentrations of certain drugs (including cyclosporine, indinavir, irinotecan and nevirapine) via the induction of cytochrome P450 enzymes and/or P-glycoprotein, and, in turn, to lower the effectualness of respective treatments (Izzo, 2005). Moreover, an early in vivo study on pulmonary fibrosis Sprague-Dawley rat models discovered that, compared to the control groups, the health conditions of animals treated with a combined therapy consisting of azathioprine and Chinese herb Caulis Tripterygium wilfordii were worsen (Dai et al., 2004). Hence, herb-drug compatibility is one of the issues to be considered when an ICWM remedy is planned. Another linchpin of success for ICWM is the curability and level of scientific understanding of a malady. Diseases (e.g., eczema, dementia and Alzheimer’s disease) that are incurable by either modern scientific medicine or CHM at present are very unlikely to be instantly cured after the integration of both medical practices. Thus, the practicality of ICWM is still limited to the types of diseases being tackled and the current technology. For ICWM to succeed, further clinical studies, risk assessment and safety tests are evidently in dire need. However, based on the Hong Kong context, we inferred that in order to facilitate the pursuit of ICWM, some more pre-conditions have to be met. The first one is the coordination of facilities. According to the data released by the Ministry of Health of PRC, up to 2007, there are in total 2,718 TCM- and 13,374 general hospitals (excluding those rural community health institutions) in mainland China (Ministry of Health of the People's Republic of China, 2008), some of them have the ICWM unit as well. However, both TCM hospitals and ICWM departments are absent in Hong Kong. As medical institutions (especially hospitals) are very important sources of first-hand clinical data, deficiency of such facilities not only exploits the training opportunities of local medical professionals in CHM and ICWM practice, but also reduces the chances of ICWM clinical trials and evaluations. In the light of this, the coordination of medical facilities is elemental. Additionally, as health care services require team work, the quality of communication among different medical professionals can determine the success of collaboration. However, different medical terminologies adopted by both WM and TCM systems may impose tremendous challenges for practitioners to exchange ideas in their collaborative work. Though there are possible solutions to solve the communication problems (such as incorporating TCM trainings in the curriculum of local WM educations and vice versa to increase the mutual understandings on the rudiments of each medical practice, or standardizing all the medical terms used by both medical systems), governmental support and official coordination would be a prerequisite. The unequal social status of TCM and WM practitioners in a community is another reason hindering the development of ICWM. This kind of status inequality may partially come from the inadequate official recognition of TCM, but also is related to the strong

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exclusiveness of the preponderant WM in conventional medical settings. In addition, some WM practitioners may believe that WM is enough to solve the majority of the problems without the help of TCM which, according to them, may be deemed only for psychological consolation without real therapeutic values. Thus, it is worth establishing an esprit de corps and mutual respect among different medical workers in order to prepare a favorable environment for ICWM to make a headway. Barring all the factors mentioned above, promoting public cognizance of ICWM is also important. Though ICWM has been dramatically developed in China over the last decade, its development may not be so mature in some of the other non-Chinese nations. In order to let the public to build confidence in this new therapeutic approach, more community education and promotion are required. .

Chinese-Western Cooperative Oral Health Management Apart from the potential of CHM in ICWM, the prospect of incorporating herbal medicine into contemporary dental health care and dental health practices cannot be ignored, either. In Beijing, an ethnographic study done on 67 informants (23 TCM providers, 19 stomatologists, three stomatology students, four TCM stomatologists, seven nurses and 11 patients) (Hom, 2007) demonstrated that respondents were prone to describe or interpret symptoms of oral health problems with the concept of “shang huo” (rising heat). In Hong Kong, a cross sectional epidemiological telephone survey on a random sample of 500 adults showed that one-third of the sample population had used TCM for managing oral health before, mostly for oral mucosal lesions and periodontal reasons (McGrath, 2005). Over 80% of the informants also showed interests in TCM approaches for oral management, especially when it was administered by dental surgeons (McGrath, 2005). Among different TCM treatments (including acupoint therapy, acupuncture, CHM and cupping) available in Hong Kong, 47% of the respondents would prefer to choose CHM (McGrath, 2005). In practice, though CHM has not been granted any respective roles in conventional medical settings and has not gained significant community trust in Hong Kong yet, its popularity in oral health management is none the less relatively high. This is partly because oral problems usually are not life-threatening; hence the general populace may accept CHM as a complementary way to tackle dental complaints more easily. In the light of this, ChineseWestern cooperative oral health management (CWCOHM) is becoming another prospective direction for CHM. As more studies on the role of CHM in conventional dentistry are being carried out, the efficacy of CWCOHM is also increasingly being supported. For example, in a study of 200 glossodynia patients, the effective rates in subjects treated with Chai Pu Tang (a CHM remedy) was found to be approximately 1.5-fold higher than those treated with diazepam (a benzodiazepine derivative drug) with vitamin B complex supplementation (Bessho et al., 1998). Regardless of the above encouraging picture, what is worth noting is that there is no easy way in the pursuit of either ICWM or CWCOHM. In fact, most of the hurdles and preconditions for ICWM (like augmentation of scientific research, coordination with facilities, establishment of mutual respect between different medical professionals and promotion of social cognizance) are virtually applicable to the current situation of CWCOHM in Hong Kong. (For a detailed discussion on those pre-conditions and challenges, please refer to the

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section “Integrative Chinese and Western Medicine” above.) Furthermore, under the influence of Chinese culture, people in mainland China and Hong Kong have long been imperceptibly taught about the association between “huo” (heat) and “oral mucosal lesions” (Schwarz and Lo, 1995; Cao, 1998); therefore the possible roles of CHM in oral health management will be comparatively easy to recognize in the societies. However, similar concepts are usually absent in most of the other non-Chinese nations; CWCOHM may be more difficult to be incorporated in those places.

Herbal Health Food in Preventive Medicine There is an old saying “prevention is better than treatment”. In recent decades, the importance of disease prevention has started to be recognized worldwide in contemporary medicine. Such increase in awareness not only is germane to the ethics that preventing a disease is more humanistic than attempting to tackle the maladies and related sufferings (Council on Long Range Planning Development, 1996; Harris, 1996), but also is based on substantive success in the health care sector through preventive interventions (Council on Long Range Planning Development, 1996), such as the decline in coronary heart disease mortality rates in Massachusetts (Kabir et al., 2008) and the improvement in cholesterolrelated knowledge and plasma cholesterol levels in San Luis Obispo and Modesto (Frank et al., 1992). Echoing the global augmentation of the awareness of disease prevention is a surge of healthy products and health food consumption in Hong Kong. An early survey of 1,802 Hong Kong adults [765 males (43%) and 1,037 females (57%)] randomly selected between October 1999 and January 2000 indicated that 10% of males and 18% of females were consumers of health food (Guldan, 1999), and on average, $300 was spent per month on purchasing those products (Guldan, 1999). It is very likely that the prevalence of health food consumption will further escalate when the society is more aware of healthy lifestyles and fitness. Among different functional food ingredients, medicinal herbs are one of the most popular choices. One of the reasons is CHM’s track record of success in body nourishment and life cultivation in East Asia (Common herbs with dietotherapeutic values are shown in Table 3); another reason is the increasing volume of testaments to its role in disease prevention. For example, Yupingfeng-san (a Chinese herbal medicine) was shown to suppress the reduction of bone mineral density in the whole and metaphysis of tibia in rats induced by ovariectomy, and to slightly increase the levels of estradiol and progesterone in the serum (Sassa et al., 2001). The preventative effects of CHM remedy, Sho-saiko-to, on septic shock symptoms were also demonstrated by the ability of the medicines to increase the activity of hepatic delta-aminolevulinate synthetase and cytochrome P-450 level, and to suppress the increase in heme oxygenase activity in liver microsomes after the intraperitoneal administration of endotoxin in rat models (Sakaguchi et al., 2005). However, as the proverb goes, “Every coin has two sides”. It is the dosage of an herb that differentiates a remedy from a poison. Misuse of herbal medicines not only fails to promote health, but in extreme cases can be life-threatening. For instance, though ephedrine alkaloids is medically used as a cardiac stimulant, myocardial infarction (Forte et al., 2006; Kranjec et al., 2008) and ventricular tachycardia (Rakovec et al., 2006) may be resulted if it is used

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inappropriately. Other examples of potentially harmful botanical chemicals include aristolochic acid and pyrrolizidine alkaloids. Table 3. Examples of medicinal herbs used for food purposes Consumable Parts

Representative Examples

References

Seeds

Nelumbo nucifera, Phaseolus calcaratus, Dolichos lablab, Canavalia gladiata (Jacq.) DC., Cerasus japonica (Thunb.) Lois, Euryale ferox Salisb., Ginkgo biloba L., Raphanus sativus L., Torreya grandis Fort.,

(Chau and Wu, 2006; Chen and Zong, 2006)

Leaf

Lophatherum gracile Brongniart, Nelumbo nucifera Gaertn, Perilla frutescens (L.) Britt., Raphanus sativus L.,

Fruits

Cannabis sativa L., Citrus medica L., Ziziphus jujube, Lycium barbarum, Crataegus pinnatifida, Crataegus pinnatifida Bunge, Dimocarpus longan Lour., Foeniculum vulgare Mill., Gardenia jasminoides Ellis,

Flowers

Citrus aurantium L., Dendranthema morifolium (Ramat.) Tzvel., Lonicera dasystyla Rehd., Nelumbo nucifera Gaertn, Sophora japonica L., Chrysanthemum morifolium,

Stem and Cortex

Glycyrrhiza glabra L., Glycyrrhiza uralensis Fisch., Lophatherum gracile Brongniart,

Rhizomes and Roots

Dioscorea opposita Thunb., Glycyrrhiza glabra L., Glycyrrhiza uralensis Fisch., Nelumbo nucifera Gaertn, Polygonatum cyrtonema Hua, Polygonatum odoratum (Mill.) Druce, Raphanus sativus L., Panax ginseng, Glycyrrhiza glabra, Dioscorea alata,

Whole Plants

Elsholtzia splendens Nakai ex F. Maekawa, Houttuynia cordata Thunberg, Hordeum vulgare L., Pogostemon cablin (Blanco) Benth., Portulaca oleracea L., Taraxacum sinicum Kitag.

Miscellaneous

Lilium lancifolium Thunb., Zingiber zerumbet Smith, Ganoderma lucidum,

Regarding the potential toxicity of the herb, proper dosage control of the herbal ingredients in food will be a decisive factor to determine its desirable health effects. However, CHM experts are generally lacking in the food industry. Furthermore, comestibles with general health claims are not strictly regulated in Hong Kong (Wu, 2001). Under such a circumstance, health products can arrive at the store without adequate evaluation and safety tests. The manufacturers also sporadically seek for professional advice on utilizing the medicinal plants, albeit their uncertainty in proper use of the medicine. All these problems not only jeopardize public health, but lead to serious repercussions for local health food market. In fact, herbal health food is expected to be a promising area for future applications of CHM; this is principally because of the rising global awareness of public health and the potentially increasing demands on health food worldwide. However, as an object lesson learned from Hong Kong, we can see that unlike the situation in primary and dental health care, mere legislative control on CHM practice and herb trade is not sufficient to ensure the

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proper use of CHM in the food sector. For this reason, coordination of extra statutes and operational regulations pertaining specifically to the use of functional ingredients in comestibles are of cardinal importance.

LIMITATIONS OF THE HONG KONG CONTEXT Although Hong Kong is used in this chapter as a reference to infer potential challenges and pre-conditions (Table 4) for furtherance of CHM in various medical directions, we also have to note that different places have disparate social, economic and political conditions; therefore their readiness for CHM development is very diverse. Because the social and cultural contexts in different countries vary, the growth and modernization of CHM in Hong Kong may not be exactly the same as those in other areas. In addition, distinctive factors, including the Chinese race, socially-induced long-term dual identities adopted by the Hong-Kongers (Brewer, 1999), and the strong sense of official commitment in promoting Chinese culture (including CHM) in Hong Kong after the handover in 1997, may proffer extra benefits for the integration of CHM into the Hong Kong society and local health care sectors. However, those factors are usually absent in many of the non-Chinese places where CHM is developing; slight deviations may occur when extrapolation from the Hong Kong context is directly applied to other places in real practice. Table 4. Summary of prospects and potential challenges for Chinese herbal medicine in health care as inferred by the Hong Kong context Fields of Application

Pre-conditions for Development

Direction (S)

Potential Challenges

Primary Health Care

1. Establishment of a nomothetic framework 2. Governmental support 3. Provision of enough facilities (e.g., TCM clinics, research laboratories, etc.) 4. Official recognition of professional qualifications of CMPs 5. Public trusts on TCM

CAM

1. Lack of official recognition of TCM practices 2. Strong exclusiveness of WM in conventional medical settings 3. Insufficient scientific understandings on TCM treatments 4. Communication problems between WM and TCM practitioners 5. Public skepticism

Preventive Medicine

1. Same as above 2. Enactment of regulations pertaining to the use of functional ingredients in health food

ICWM CWCOHM

Health Food

1. Same as above 2. Lack of safety tests and scientific evaluation 3. Insufficient regulations on food claims

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CONCLUSION CHM is an integral part of TCM and has a history of more than 2,000 years in China. Recently, substantive shifts in its organizational structure have occurred, and CHM is now emerging as one of the most popular CAM practices worldwide. In order to spur the development of CHM, the presence of nomothetic control seems to be the most fundamental criterion. However, this factor alone is not enough to ensure the full advancement in herbal medicine; coordination with other external factors (such as public acceptance, attitude of key personnel, etc.) is also a linchpin of success. But such appropriate coordination is usually absent in most of the places where CHM is developing nowadays. Moreover, the general belief that Chinese materia medica is an unscientific means of adjunct remedy still permeates many societies and impedes the growth of traditional medical practice. Based on the current global situation, it is anticipated that aiming for official and public recognition will still be a challenge for CHM over the next decade. However, as its prospects in ICWM and other medical applications have already been recognized, once some of the deep-set prejudices against traditional medicine are eliminated, fascinating possibilities for the use of herbal medicine in global health care will immediately be opened up.

AUTHOR’S BACKGROUND Wing-Fu Lai graduated from the University of Hong Kong with a bachelor’s degree in food and nutritional science. He was on the Dean’s Honors List 2005/06 and 2006/07 of the Faculty of Science, and is currently pursuing a PhD degree in chemical biology. He can be contacted at [email protected].

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In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 15

NUTRITIONAL STATUS OF THE ELDERLY IN HONG KONG: WHAT DO WE KNOW AND WHERE SHOULD WE GO? W. F. Lai and Zenobia C. Y. Chan ABSTRACT With the rapid extension of life expectancy in both males and females in Hong Kong, the aged population is rising. It is expected that the demand for health care services and nursing care will rapidly increase over the next decade. Nutrition, which plays a pivotal role in health maintenance, is gaining more and more attention in both elderly care institutions and general health settings. In this chapter, apart from offering an overview of the elderly’s nutritional status in Hong Kong, reasons for their general proneness to malnutrition will also be discussed. Based on the current social, health care and political situations, three practical areas worth prioritizing for nutritional management of elderly people will be highlighted. As the case of Hong Kong illustrates, in order to establish a social environment that could contribute to optimal nutritional health in the aged, the following pre-conditions are required: public awareness of the importance of nutrition for the elderly, coordination of social and political conditions by the local government, and proper recognition of nutritional professions in health care sectors.

INTRODUCTION In 2007, the mid-year elderly population (aged 65 or above) in Hong Kong was 871,400. Compared with the total (777,100) in 2002 (Census and Statistics Department, 2008), there is a net increase of 12%. By 2031, the senior population is projected to reach almost 2.1 million (Census and Statistics Department, 2002). Based on the above statistics, the demand by the elderly for nursing care and medical support will rapidly increase over the forthcoming decades. Though few studies on the nutritional status of the aged in Hong Kong have been published, and the prevalence of malnutrition in the elderly population is unknown, the proneness of older adults to nutrition risks has already been illustrated by a multitude of

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Western literature (Baker et al., 1979; Morgan et al., 1986; Sahyoun et al., 1988; Rudman and Feller, 1989; Cederholm and Hellstrom, 1992; Abbasi and Rudman, 1993). As proper management of nutrition in the elderly’s diet plays an important role in health maintenance and can delay progressive physiological decline in normal aging, it is important to first understand the cause and prevalence of malnutrition in the aged population and then promptly tackle the problems with proper strategies. This can not only improve the quality of life of aged people via maintaining their independence in the community, but also alleviates the economic burden of certain common ailments among the elderly (such as diabetes and high blood pressure) to the society. In this chapter, we will first have an overview of the elderly’s nutritional status in Hong Kong, followed by a detailed discussion of reasons that explain why older adults are usually prone to undernutrition. Finally, based on the context of Hong Kong, three practical areas worth prioritizing in nutritional management of the aged will be highlighted.

NUTRITIONAL STATUS OF THE HONG KONG AGED POPULATION Poor nutritional status of non-institutionalized elderly adults, who form a large part of the Hong Kong senior population, is becoming an emerging public health problem. Though local research has established the apparent requirements of dietary intake in energy and most nutrients in reference to the Recommended Dietary Allowances for East Asia, among the free-living elderly in Hong Kong, their intake of the following micronutrients are known to be deficient: calcium, vitamin A, riboflavin and niacin (Ho et al., 2008). As each of the above nutrients also has its unique bodily functions, such a deficiency may finally lead to adverse health consequences. For example, a prolonged inadequate intake of calcium is associated with reduced bone mass and osteoporosis (Nieves, 2003). The deficiency of vitamin A may also be linked with an increased susceptibility to infections. Niacin, which comes in the form of either nicotinic acid or nicotinamide, contributes to more than 50 vital bodily processes. It may help to regulate blood sugar level, maintain the health of blood vessels and nerves, release energy from carbohydrates, lower blood levels of cholesterol and triglyceride, and alleviate depression (Goldsmith, 1975; Kamanna and Kashyap, 2008). Low intake of niacin may compromise overall health, and in the most severe case can lead to pellagra. Similar to niacin, riboflavin is a member of the vitamin B complex. It is required in energy metabolism and tissue renewal. Its prolonged deficiency may lead to skin concerns (e.g., cheilosis and angular stomatitisis) and a number of nervous symptoms, including numbness of the hands and insensitivity of skin to external stimuli (Goldsmith, 1975; Hoppel and Tandler, 1990). Compared with the non-institutionalized group in Hong Kong, elderly residents in institutions are generally more prevalent to malnutrition, in spite of the provision of food with higher quantity and quality. As indicated by an early study, institutionalized subjects are significantly more often found to have vitamin K intake below the recommended daily level (Tse et al., 2002). This may partially be explained by their higher dependency, but may also be associated with the low-vegetable Hong Kong diet which is relatively deficient in phylloquinone, the major source of vitamin K commonly found in green leafy vegetables, certain vegetable oils (e.g., rapeseed and soyabean oils) and some legumes (Suttie, 1992; Vermeer and Schurgers, 2000; Tse et al., 2002; Booth, 2007). As vitamin K is an essential co-

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factor for the post-translational synthesis of γ-carboxyglutamic acid in osteocalcin, matrixGla protein and certain coagulation-related proteins (e.g., factors II, VII, IX and X) (Vermeer and Schurgers, 2000), persistent vitamin K deficiency may compromise the health of the aged or even predispose them to osteoporosis (Booth, 2007). As far as the consequence of malnutrition in elderly health is concerned, it is important to note that undernutrition of the aged is far more than merely a matter of the affected individual; it also has a tremendous impact on families and even the society. At the family level, the most obvious consequence is caregiver burden arising from the frailty of the elderly family member. As documented in a multitude of studies (Jones and Salvage, 1992; Vitaliano et al., 1996; Berg-Weger et al., 2000; Arai et al., 2001; Scazufca et al., 2002; Carter, 2003), such a burden can not only compromise the emotional and socio-psychological health of the care provider, it can also cause deterioration of his or her physical health status and put him or her at a higher risk for problems such as physical impairments, elevated insulin levels, chronic fatigue, insomnia and immunosuppression (Kiecolt-Glaser et al., 1987; Cochran, 1994; Ranelli and Aversa, 1994; Vitaliano et al., 1996; Travis et al., 2000; Miura et al., 2005; Travis et al., 2007). Consequently, the health of both the elderly care recipient and family care provider will be impaired. In addition to their impact at the family level, health risks caused by elderly malnutrition can increase the financial burden of medical provision and social welfare on the society. Among different ailments in the aged population, osteoporosis is one of the diseases causing severe economic burdens on Western countries and Europe (Repa-Eschen, 2000). In the United States alone, there were more than two million incidents of fractures at a cost of US $17 billion in 2005 (Burge et al., 2007). The numbers are projected to double by 2025 (Burge et al., 2007). In Hong Kong, detailed studies on the actual prevalence of osteoporosis are lacking, but the high vulnerability of the Hong Kong population to the disease has been suggested by local research. According to an early epidemiological study (Ho et al., 1999), females aged 60–69 in Hong Kong had a prevalence of osteoporosis in the spine approximately 5-fold higher than those aged 50–59. Moreover, around one out of two women over the age of 70 was reported to have osteoporosis in the hip (Ho et al., 1999). Regarding the positive correlation between the incidence of osteoporosis and age, it is believed that, accompanied with the aging of the Hong Kong population, the impact of the disease on the society will be greater in the future, and burdens on the health care system will be elevated as well.

FACTORS OF MALNUTRITION IN OLDER ADULTS The nutritional status of the aged population is affected by a number of factors, including dietary intake and practices. Woo et al. (1998) has found that around 50% of the Hong Kong people have a daily cholesterol intake equal to or greater than 300 mg. A total of 60% have at least 30% of their total dietary energy intake coming from fat, and over 80% of the population of Hong Kong has a saturated fat intake higher than the recommended level. In addition, the diet of men in Hong Kong usually has a relatively low nutrient density of a number of vitamins, as well as iron, copper, calcium and polyunsaturated fatty acids, with the intake of

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nutrients decreasing with age (Woo et al., 1998). In such a circumstance, the nutritional status and hence the physical health of the aged are likely to be easily compromised. Barring the unhealthful diet pattern, certain functional-physiological changes (like impairment in visual acuity, decreased cognitive functioning, increased taste thresholds, decreased olfactory perception, and poor dentition) may also contribute to the phenomenon of prevalent malnutrition among the elderly (Woo, 1993). For instance, oral diseases (like dental caries, tooth loss and periodontal disease) can compromise the strength of teeth and the health of supporting tissues, and influence food choices and dietary intake of the aged (Mojon et al., 1999; Baker, 2007; Henshaw and Calabrese, 2008). In a study conducted by Mojon and his colleagues (1999), around two-thirds of the subjects (mean age = 85 years with S.D. = 6.9, 70% female, 30% male) with compromised oral functional status were found to be functionally dependent, and half of them were discovered to have malnutrition, which was manifested by either a body mass index less than 21 kg/m2 or having the serum albumin concentration less than 33g/L. Other studies also illustrate that, compared with elderly adults with healthy teeth, those with dentures generally have a lower mean bone density and serum ascorbic acid level (McGandy et al., 1986; Baker, 2007; Henshaw and Calabrese, 2008). Apart from dental complaints, other physiological changes in the swallowing process— including xerostomia (the subjective feeling of dry mouth caused by hyposalivation and reduced parotid secretion), abnormal cricopharyngeus muscle relaxation, reduced peristalsis, lower oesophageal sphincter and dilation of the oesophagus—may also affect swallowing and digestion of food, thereby compromising the absorption of nutrients (Woo, 1993; Matear et al., 2006; Pescio, 2006). Chronic or acute diseases are another factor influencing the food intake of the aged. Studies on randomly recruited subjects from general medical wards of a district general hospital reveal that elderly patients and those with infections, heart failure, malignancies, and chronic obstructive airways disease (COAD) normally have poorer nutritional status (Woo et al., 1991). Some pathological conditions may increase the utilization of nutrients by patients and cause them to be prone to undernutrition as well. For example, the thiamine status and plasma concentrations of vitamins A and C may decrease in patients suffering from infections, but resume normal levels after recovery (Puxty, 1985). The use of certain drugs in disease treatments can also lead to undernutrition. For instance, serious symptoms of vitamin D deficiency (such as exacerbation of seizure activities, fractures, carpopedal spasms, status epilepticus, osteomalacia and rickets) are usually manifested in epilepsy patients undergoing chronic antiepileptic drug therapy (Mikati et al., 2003). Severe vitamin K deficiency also occurs in certain people receiving the drug wash-out procedure with cholestyramine (Chalumeau et al., 2007). Judging from the evidence offered in the discussion above, there is no denying that both dental and physical health play a fundamental role in determining the elderly’s nutritional status. But in Hong Kong, compared with those living freely in the community, the institutionalized aged generally have a higher prevalence of edentulousness (19%) and untreated dental diseases (McMillan et al., 2003). These, together with their physical health problems and comparatively high levels of dependency, have led to the fact that elderly residents in institutions are more prone to malnutrition than those non-institutionalized. In fact, barring the aforediscussed health factors, nutritional intake of the aged can also be jeopardized by social factors like poverty; this will be discussed later in this chapter.

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STRATEGIES AND CHALLENGES Regarding the prevalence of aforementioned nutrition risks and the health consequences thereof in the senior population in Hong Kong, there is a dire need for solutions to the current nutritional problems. For accomplishing this goal, here we would like to highlight the following three strategic conditions under the context of Hong Kong: the promotion of public awareness, nutritional interventions, and coordination with social welfare and security.

PROMOTION OF PUBLIC AWARENESS Social understanding of the influence of nutrition on health is one of the fundamental preconditions to aid nutritional restoration and maintenance in older adults. In order to establish a favorable social environment to offer comprehensive nutritional interventions to the elderly and foster a systemic platform to initiate relevant social, medical and political measures, the followings are needed: community concerns regarding the local nutritional status of the aged, the governmental realization of the importance of nutrition to health, and social recognition of the qualifications of dietetic professionals. But in Hong Kong, social awareness of the significance of nutritional care is comparatively low, and this is partially manifested by the absence of a formal registration system for dietitians in medical sectors. Compared to countries like United States and Canada, the development of the nutrition profession in Hong Kong appears to be lagging behind. Among different strategies to raise public concerns about nutritional management, health promotion (such as talks and health campaigns) plays an important role. This is because it can not only promote primary prevention to avert the onset of diseases in the community, but also benefit the health status of the elderly population as a way of secondary prevention. Programs for promoting the health of the aged usually focus on improvement of health behaviors to lower cholesterol level, manage weight, increase intake of fruits and vegetables, and fulfill more healthful lifestyles. Based on some medical research and epidemiological data, effective health promotion and preventive strategies can contribute to secondary prevention of ailments like osteoporosis, diabetes, cardiovascular disease, obesity and hypertension (Patterson and Feightner, 1997; Chernoff, 2001). The literature also reveals that health promotion can increase life expectancy, improve the quality of life and extend the length of the healthy period of the elderly (Fishman, 1996; Heidrich, 1998). As the population in Hong Kong ages, the burden of increasing demand for gerontological care is likely to be partially alleviated by health promotion interventions (Heidrich, 1998; Boenke, 2001; Chernoff, 2001). In spite of the aforediscussed advantages, elderly-specific health programmes are relatively deficient in practice. This may be germane to the popular belief that elderly adults are too stubborn to comply with nutritional recommendations or to change their dietary patterns, thereby reducing the incentives of health educators to organize such programs (Chernoff, 2001). But contrary to general perception, some studies suggest that as long as information and health services for areas like health improvement, reduction of disability risks and alterations in health behaviors are provided, elderly people are generally willing to participate in health promotion activities and make changes in their lifestyles (Mayer et al., 1994; Quantock, 1994; Chernoff, 2001). In addition, the willingness of the elderly to

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participate in those programs can be further increased by the following strategies: peer education, conveyance of ideas on the health benefits brought about by healthful diet, and goal-setting via partnership between the older adult and health care provider (Ferrini et al., 1994; Caserta, 1995; Fox et al., 1997; Chernoff, 2001; Sahyoun et al., 2004).

NUTRITIONAL INTERVENTIONS As malnutrition is a major health risk factor in the aged population, nutritional support (including oral supplementation, targeted dietary guidance, artificial nutrition, dietotherapeutic therapy and even enteral feeding) is deemed to be an effective way to reduce the incidence of certain diseases (e.g., diabetes, osteoporosis and degenerative disorders) and improve the quality of life of the elderly by delaying their morbidity and dependence. The efficacy of nutritional interventions for health maintenance has been supported by an increasing volume of scientific evidence over the last several decades. For example, supplementation with beta carotene, vitamin E, and selenium was demonstrated in an earlier study to reduce cancer incidence among Chinese people (Blot et al., 1993). Recent research also shows that five-month oral supplementation of nutrients (containing a variety of vitamins, folic acid, calcium, magnesium, fat, protein and carbohydrates) given between meals in the afternoon and evening during the administration of medication can reverse the underweight problem of older dementia patients in group living (Faxen-Irving et al., 2002). In many different patient populations (including patients with lower limb fractures, especially older adults), their nutritional intake and motility are reported to be improved by dietotherapy and oral administration of protein- and energy-rich supplements (Bastow et al., 1983; MøllerMadsen et al., 1988; Hessov, 1994; Bachrach-Lindstrom et al., 2001; Hedstrom et al., 2006). One of the benefits of dietetic support in geriatric medicine is to help older adults to have a healthful diet which, in turn, can reduce their morbidity and dependency. Among a variety of diet patterns adopted by different nations, the Mediterranean diet has received much attention by health care providers due to Keys et al. (1986)’s observations of lower 15-year mortality risks of coronary heart disease (CHD) among residents of southern Europe where consumption of the diet is common. The beneficial health effects of the diet in lowering the incidence and mortality of CHD and myocardial infarction (de Lorgeril et al., 1999; 2006; Giugliano and Esposito, 2005; Singh et al., 2002), and in modifying the low-density lipoprotein (LDL) electrophoretic characteristics in women as characterized by those women’s smaller LDL particles at baseline (LDL peak particle diameter < 258.4Å) (Goulet et al., 2004) are further supported by more current studies. Contrary to the typical “high-meat, low-vegetable” diet in Hong Kong, the Mediterranean diet features low consumption of meat products, moderate intake of dairy foods and wines, and high consumption of the follows: fruits, vegetables, legumes, grains and foods with high monounsaturated to saturated fatty acid (SFA) ratio. (Ferro-Luzzi and Sette, 1989; Ferro-Luzzi and Branca, 1995; Goulet et al., 2003). As suggested in the literature, the cardioprotective properties of the Mediterranean diet may partially come from its ability to decrease levels of total cholesterol and apolipoprotein B in the serum (Goulet et al., 2003). Such effects may be, in part at least, due to the low level of saturated fatty acids (FA) and high content of α-linolenic acid, as well as omega-3

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polyunsaturated FA, in the diet (de Lorgeril et al., 1994, 1999, 2006; Singh et al., 2002). Recently, it is further proposed that antioxidants (which exist in abundance in vegetables, fruits, beverages, and virgin olive oil) also play a pivotal role in protecting health by inhibiting atherosclerosis, preventing plaque rupture and thrombosis, and protecting endothelial functions (Giugliano and Esposito, 2005; Huang and Sumpio, 2008). In spite of the evidence of the benefits of nutritional support mentioned above, there may still be challenges when those interventions are put into practice. For example, some elderly people may have difficulty in adapting to a new dietary pattern, thereby lowering their compliance with dietetic recommendations. Moreover, in order to make an appropriate intervention decision, efficient malnutrition screening and diagnosis is critical. But most of the current diagnostic tools for the elderly also have their own limitations; none of them can provide a comprehensive analysis on the actual nutritional needs of the older adult (Harris and Haboubi, 2005). For example, BMI is a commonly-used index to predict disease risks in underweight and obese subjects (O’Brien and Davies, 2007; Utter et al., 2007), but significant unintentional weight loss may not be identifiable by this method (Balcombe et al., 2001; Campillo et al., 2002; McKinlay, 2004; O'Brien and Davies, 2007). Moreover, as physiological changes like vertebral compression, postural changes and loss of muscles are common among the aged, a valid and reliable measurement of the height of the elderly subject is arduous (Balcombe et al., 2001; Guigoz et al., 2002; Harris and Haboubi, 2005); this further decreases the accuracy of BMI in health risk prediction. Another diagnostic method, anthropometry, has advantages such as low operational costs and ease of use (Corish and Kennedy, 2003), but it is also prone to interference from confounding factors like limb edema (Harris and Haboubi, 2005). In an attempt to ameliorate these limitations, several combinations of diagnostic methods (e.g., Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment (MNA)) have recently been proposed. However, they are far more complicated for health care providers to implement without receiving professional training in dietetic management, and elderly residents in institutions without on-site dietitians, therefore, can only sporadically benefit from them. In order to promote the efficacy of nutritional monitoring for the senior population, further research on developing a simple, cost-effective, accurate and sensitive tool pertaining to the physical conditions of the elderly would be required.

COORDINATION WITH SOCIAL WELFARE AND SECURITY When it comes to nutritional improvement in the aged population, the coordination of the political and social contexts is of utmost importance. There are a number of social factors that have negative influences on elderly health, such as social isolation, poverty, depression, bereavement and alcoholism. Among them, poverty has the greatest impact on elderly people. This is because other factors such as psychosocial concerns could be alleviated by social service workers and other professionals (Peterson, 1984; Lord and Pockett, 1998; Morrison et al., 2005); poverty can never be alleviated if societal, economic and political coordination are absent. In Hong Kong, elderly people are found to comprise one of the largest poverty groups (La Grange and Lock, 2002). In 2002, about 70% of those living in residential facilities were

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reported to be on social welfare (Chou and Chow, 2005). In 2004, compared with the nonelderly population in which only 6% of them were on welfare, around 20% of the people aged 60 or above relied financially on social assistance (Chou and Chow, 2005). There are a number of governmental schemes for retirement income maintenance in Hong Kong, but the social security network is still not adequate to widely cover the needs of old age in the general populace. For example, the Mandatory Provident Fund (MPF) is a contribution-defined retirement security system, but unless one has contributed to it for at least three decades before retirement, its benefits are generally insufficient to meet the needs of the elderly (Chou and Chow, 2005). Comprehensive Social Security Assistance (CSSA) and Normal Old Age Allowance (NOAA) are means-tested financial assistance schemes pertaining to the poor, but they can only allow the aged to reach the bottom-line financial and social standards. For those receiving such financial support, fulfillment of better healthful lifestyles or a higher quality of life may be difficult to attain because of the absence of extra money. In addition, due to the stigma effect and desire to maintain self-reliance, some aged people may be reluctant to seek financial help from CSSA and NOAA despite their poverty (Chui, 2002; Chou and Chow, 2005); this makes them more prone to nutritional risks. Though there is a non-means-tested high OAA scheme in Hong Kong to support those reaching the age of 70, its low rate and universalism provide few means of obliterating poverty among the senior population (Chou and Chow, 2005). In fact, income poverty and nutrient deficits are strongly associated in the senior population. Compared to the higher-income elderly, poorer aged people usually spend their disposable income for routine costs like utilities, telephone service and medications (FeyYensan et al., 2003). They are found to consume significantly fewer servings of major Food Guide Pyramid food groups, calories and most nutrients (Russell et al., 1999; American Dietetic Association, 2000; Lee and Frongillo, 2001; Guthrie and Lin, 2002). Regarding this fact, prompt establishment of a comprehensive social welfare system covering the elderly’s needs is of cardinal importance. This can be achieved by a number of strategies, such as increasing the benefits of social security schemes or introducing the Food Stamp Program of the United States to the social context of Hong Kong, but extensive public consultation and political planning will be needed. Moreover, a significant level of public and governmental awareness of the proneness of older adults to malnutrition would be a prerequisite for political amendments and reforms in social assistance for the elderly in Hong Kong.

CONCLUSION Resolving the nutrition risk in the aged population is a long-running process, and is also becoming a global challenge due to the general upward trend of the aging population worldwide. The alleviation of this challenge will not be obtained at the drop of a hat. In order to solve the problem, a combination of social and political coordination is required; efforts from both the general public and local government must also be involved. Based on the context of Hong Kong, we can see that the biggest problem at this moment is a lack of social recognition of the role of nutrition in health care, and this is manifested by the absence of a formal licensing system regulating the practice of dieticians. Under this circumstance, the development of nutritional professions, in both clinical and private sectors, is severely

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constrained, and public awareness of nutritional problems among the aged is generally inadequate. This may not only jeopardize the nutritional health of elderly people, but also makes them more susceptible to other health risks, thereby reducing their quality of life and raising their medical service consumption. To reverse such a situation, governmental enlightenment on the importance of nutrition to health is the first step. However, the mere presence of this factor is still not enough to entirely resolve the nutritional problem in the senior population. Promotion of public awareness of related issues, good accessibility of nutritional interventions by the elderly, and coordination with social welfare and security systems are also urgently needed.

AUTHOR’S BACKGROUND Wing-Fu Lai graduated from the University of Hong Kong with a bachelor’s degree in food and nutritional science. He was on the Dean’s Honors List 2005/06 and 2006/07 of the Faculty of Science, and is currently pursuing a PhD degree in chemical biology. He can be contacted at [email protected].

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de Lorgeril, M., Salen, P., Martin, J. L., Monjaud, I., Delaye, J., and Mamelle, N. (1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 99, 779-785. Faxen-Irving, G., Andren-Olsson, B., af Geijerstam, A., Basun, H., and Cederholm, T. (2002). The effect of nutritional intervention in elderly subjects residing in group-living for the demented. Eur. J. Clin. Nutr. 56, 221-227. Ferrini, R., Edelstein, S., and Barrett-Connor, E. (1994). The association between health beliefs and health behavior change in older adults. Prev. Med. 23, 1-5. Ferro-Luzzi, A., and Branca, F. (1995). Mediterranean diet, Italian-style: prototype of a healthy diet. Am. J. Clin. Nutr. 61, 1338S-1345S. Ferro-Luzzi, A., and Sette, S. (1989). The Mediterranean Diet: an attempt to define its present and past composition. Eur. J. Clin. Nutr. 43 Suppl 2, 13-29. Fey-Yensan, N., English, C., Pacheco, H. E., Belyea, M., and Schuler, D. (2003). Elderly food stamp participants are different from eligible nonparticipants by level of nutrition risk but not nutrient intake. J. Am. Diet. Assoc. 103, 103-7. Fishman, P. (1996). Healthy People 2000: what progress toward better nutrition? Geriatrics. 51, 38-42. Fox, P. J., Breuer, W., and Wright, J. A. (1997). Effects of a health promotion program on sustaining health behaviors in older adults. Am. J. Prev. Med. 13, 257-264. Giugliano, D., and Esposito, K. (2005). Mediterranean diet and cardiovascular health. Ann. N. Y. Acad. Sci. 1056, 253-260. Goldsmith, G. A. (1975). Vitamin B complex. Thiamine, riboflavin, niacin, folic acid (folacin), vitamin B12, biotin. Prog. Food Nutr. Sci. 1, 559-609. Goulet, J., Lamarche, B., Charest, A., Nadeau, G., Lapointe, A., Desroches, S., and Lemieux, S. (2004). Effect of a nutritional intervention promoting the Mediterranean food pattern on electrophoretic characteristics of low-density lipoprotein particles in healthy women from the Quebec City metropolitan area. Br. J. Nutr. 92, 285-293. Goulet, J., Lamarche, B., Nadeau, G., and Lemieux, S. (2003). Effect of a nutritional intervention promoting the Mediterranean food pattern on plasma lipids, lipoproteins and body weight in healthy French-Canadian women. Atherosclerosis. 170, 115-124. Guigoz, Y., Lauque, S., and Vellas, B. J. (2002). Identifying the elderly at risk for malnutrition. The Mini Nutritional Assessment. Clin. Geriatr. Med. 18, 737-757. Guthrie, J. F., and Lin, B. H. (2002). Overview of the diets of lower- and higher-income elderly and their food assistance options. J. Nutr. Educ. Behav. 34 Suppl 1, S31-41. Harris, D., and Haboubi, N. (2005). Malnutrition screening in the elderly population. J. R. Soc. Med. 98, 411-414. Hedstrom, M., Ljungqvist, O., and Cederholm, T. (2006). Metabolism and catabolism in hip fracture patients: nutritional and anabolic intervention--a review. Acta Orthop. 77, 741747. Heidrich, S. M. (1998). Health promotion in old age. Annu. Rev. Nurs. Res. 16, 173-195. Henshaw, M. M., and Calabrese, J. M. (2008). Oral health and nutrition in the elderly. Nutrition in Clinical Care. 4, 34-42. Hessov, I. (1994). Oral diet administration and supplementation. In J. Payne-James, G. Grimble, and D. Silk (Eds.), Artificial nutrition in clinical practice. (1st edition, p. 187). London: Edward Arnold.

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Ho, S. C., Donnan, S., and Sham, A. (2008). Dietary intake among elderly Chinese in Hong Kong. Journal of Human Nutrition and Dietetics. 1, 205-215. Ho, S. C., Lau, E. M., Woo, J., Sham, A., Chan, K. M., Lee, S., and Leung, P. C. (1999). The prevalence of osteoporosis in the Hong Kong Chinese female population. Maturitas. 32, 171-178. Hoppel, C. L., and Tandler, B. (1990). Riboflavin deficiency. Prog. Clin. Biol. Res. 321, 233248. Huang, C. L., and Sumpio, B. E. (2008). Olive oil, the mediterranean diet, and cardiovascular health. J. Am. Coll. Surg. 207, 407-416. Jones, D. A., and Salvage, A. V. (1992). Attitudes to caring among a group of informal carers of elderly dependants. Arch. Gerontol. Geriatr. 14, 155-165. Kamanna, V. S., and Kashyap, M. L. (2008). Mechanism of action of niacin. Am. J. Cardiol. 101, 20B-26B. Keys, A., Menotti, A., Karvonen, M. J., Aravanis, C., Blackburn, H., Buzina, R., Djordjevic, B. S., Dontas, A. S., Fidanza, F., Keys, M. H., Kromhout, D., Medeljkovic, S., Punsar, S., Seccareccia, F., and Toshima, H. (1986). The diet and 15-year death rate in the seven countries study. Am. J. Epidemiol. 124, 903-915. Kiecolt-Glaser, J. K., Glaser, R., Shuttleworth, E. C., Dyer, C. S., Ogrocki, P., and Speicher, C. E. (1987). Chronic stress and immunity in family caregivers of Alzheimer's disease victims. Psychosom. Med. 49, 523-535. La Grange, A., and Lock, B. Y. (2002). Poverty and single elders in Hong Kong. Aging and Society. 22, 233-257. Lee, J. S., and Frongillo, E. A. (2001). Nutritional and health consequences are associated with food insecurity among U.S. elderly persons. J. Nutr. 131, 1503-1509. Lord, B. and Pockett, R. (1998). Perceptions of social work intervention with bereaved clients: some implications for hospital social work practice. Soc. Work Health Care. 27, 51-66. Møller-Madsen, B., Tøttrup, A., Hessov, I.B., and Jensen, J. (1988). Nutritional intake and nutritional status in patients with fracture of the femoral neck: value of oral supplements. Acta Orthop. Scand. 59, 48. Matear, D. W., Locker, D., Stephens, M., and Lawrence, H. P. (2006). Associations between xerostomia and health status indicators in the elderly. J. R. Soc. Health. 126, 79-85. Mayer, J. A., Jermanovich, A., Wright, B. L., Elder, J. P., Drew, J. A., and Williams, S. J. (1994). Changes in health behaviors of older adults: the San Diego Medicare Preventive Health Project. Prev. Med. 23, 127-133. McGandy, R. B., Russell, R. M., Hartz, S. C., Jacob, R. A., Tannenbaum, S., Peters, H., Sahyoun, N. R., and Otradovec, M. A. (1986). Nutritional status survey of healthy noninstitutionalized elderly: Energy and nutrient intakes from three day records and nutrient supplements. Nutr. Res. 6, 785-798. McKinlay, J. (2004). Nutritional assessment: identifying patients' needs. J. R. Coll. Physicians Edinb. 34, 28-31. McMillan, A. S., Wong, M. C., Lo, E. C., and Allen, P. F. (2003). The impact of oral disease among the institutionalized and non-institutionalized elderly in Hong Kong. J. Oral Rehabil. 30, 46-54.

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Mikati, M., Wakim, R. H., and Fayad, M. (2003). Symptomatic antiepileptic drug associated vitamin D deficiency in noninstitutionalized patients: an under-diagnosed disorder. J. Med. Liban. 51, 71-73. Miura, H., Arai, Y., and Yamasaki, K. (2005). Feelings of burden and health-related quality of life among family caregivers looking after the impaired elderly. Psychiatry Clin. Neurosci. 59, 551-555. Mojon, P., Budtz-Jorgensen, E., and Rapin, C. H. (1999). Relationship between oral health and nutrition in very old people. Age and Ageing. 28, 463-468. Morgan, D. B., Newton, H. M., Schorah, C. J., Jewitt, M. A., Hancock, M. R., and Hullin, R. P. (1986). Abnormal indices of nutrition in the elderly: a study of different clinical groups. Age Ageing. 15, 65-76. Morrison, R. S., Chichin, E., Carter, J., Burack, O., Lantz, M., and Meier, D. E. (2005). The effect of a social work intervention to enhance advance care planning documentation in the nursing home. J. Am. Geriatr. Soc. 53, 290-4. Nieves, J. W. (2003). Calcium, vitamin D, and nutrition in elderly adults. Clin. Geriatr. Med. 19, 321-335. O'Brien, G., and Davies, M. (2007). Nutrition knowledge and body mass index. Health Educ. Res. 22, 571-575. Patterson, C., and Feightner, J. (1997). Promoting the health of senior citizens. CMAJ. 157, 1107-1113. Pescio, J. J. (2006). Clinical epidemiological study of xerostomia in elderly totally edentulous. Rev. Fac. Cien. Med. Univ. Nac. Cordoba. 63, 6-12. Peterson, K. J. (1984). Integration of medical and psychosocial needs of the home hemodialysis patient: implications for the nephrology social worker. Soc. Work Health Care. 9, 33-44. Puxty, J. H. (1985). Infection, vitamins and confusion in the elderly. In: J. R. Kemm (Ed.), Vitamin Deficiency in the Elderly. Prevalence, Clinical Significance and Effects on Brain Function (pp. 103-116). Oxford, England: Blackwell Scientific Publications. Quantock, C. (1994). Promoting health with elderly people. Nurs. Stand. 8, 30-33. Ranelli, P. L., and Aversa, S. L. (1994). Medication-related stressors among family caregivers. Am. J. Hosp. Pharm. 51, 75-79. Repa-Eschen, L. (2000). The necessity of a managed care approach for osteoporosis. In: L. V. Avioli (Ed.), The Osteoporotic Syndrome. (pp. 1-23). San Diego, California: Academic Press. Rudman, D., and Feller, A. G. (1989). Protein-calorie undernutrition in the nursing home. J. Am. Geriatr. Soc. 37, 173-183. Russell, R. M., Rasmussen, H., and Lichtenstein, A. H. (1999). Modified Food Guide Pyramid for people over seventy years of age. J. Nutr. 129, 751-753. Sahyoun, N. R., Otradovec, C. L., Hartz, S. C., Jacob, R. A., Peters, H., Russell, R. M., and McGandy, R. B. (1988). Dietary intakes and biochemical indicators of nutritional status in an elderly, institutionalized population. Am. J. Clin. Nutr. 47, 524-533. Sahyoun, N. R., Pratt, C. A., and Anderson, A. (2004). Evaluation of nutrition education interventions for older adults: a proposed framework. J. Am. Diet. Assoc. 104, 58-69. Scazufca, M., Menezes, P. R., and Almeida, O. P. (2002). Caregiver burden in an elderly population with depression in Sao Paulo, Brazil. Soc. Psychiatry Psychiatr. Epidemiol. 37, 416-422.

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Singh, R. B., Dubnov, G., Niaz, M. A., Ghosh, S., Singh, R., Rastogi, S. S., Manor, O., Pella, D., and Berry, E. M. (2002). Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial. Lancet. 360, 1455-1461. Suttie, J. W. (1992). Vitamin K and human nutrition. J. Am. Diet. Assoc. 92, 585-590. Travis, S. S., Bethea, L. S., and Winn, P. (2000). Medication administration hassles reported by family caregivers of dependent elderly persons. J. Gerontol. A Biol. Sci. Med. Sci. 55, M412-M417. Travis, S. S., McAuley, W. J., Dmochowski, J., Bernard, M. A., Kao, H. F., and Greene, R. (2007). Factors associated with medication hassles experienced by family caregivers of older adults. Patient Educ. Couns. 66, 51-57. Tse, S. L., Chan, T. Y., Wu, D. M., Cheung, A. Y., and Kwok, T. C. (2002). Deficient dietary vitamin K intake among elderly nursing home residents in Hong Kong. Asia Pac. J. Clin. Nutr. 11, 62-65. Utter, J., Scragg, R., Ni Mhurchu, C., and Schaaf, D. (2007). What effect do attempts to lose weight have on the observed relationship between nutrition behaviors and body mass index among adolescents? Int. J. Behav. Nutr. Phys. Act. 4, 40. Vermeer, C., and Schurgers, L. J. (2000). A comprehensive review of vitamin K and vitamin K antagonists. Hematol. Oncol. Clin. North Am. 14, 339-353. Vitaliano, P. P., Scanlan, J. M., Krenz, C., Schwartz, R. S., and Marcovina, S. M. (1996). Psychological distress, caregiving, and metabolic variables. J. Gerontol. B Psychol. Sci. Soc. Sci. 51, P290-P299. Woo, J. (1993). Nutrition in the elderly. Journal of the Hong Kong Geriatric Society. 3, 1518. Woo, J., Leung, S. S., Ho, S. C., Lam, T. H., and Janus, E. D. (1998). Dietary intake and practices in the Hong Kong Chinese population. J. Epidemiol. Community Health. 52, 631-637. Woo, J., Mak, Y. T., and Swaminathan, R. (1991). Nutritional status of general medical patients--influence of age and disease. J. Nutr. Biochem. 2, 274-280.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 16

THE IMAGE OF DOCTOR AND ITS SIGNIFICATION IN HONG KONG CINEMA AND TELEVISION Sobel K. L. Chan Department of English Communication School of Social Science and Humanities, University of Macau Department of Journalism and Communication, Chu Hai College of Higher Education, Hong Kong

INTRODUCTION Dr. Georgios Pappas (2003) said that Medicine has been always overlooked by cinema. Admittedly, scientific study is a repetitive and, therefore, “boring” procedure, the specific nomenclature used in science can easily alienate non-specialists, and surgical procedures may be unsuitable for viewing by sensitive audiences. Thus, cinema has had no apparent affinity for medicine, until at least the past decade. Mainly because of the success of the television show E. R., which has managed, by means of frantic editing, to simulate the atmosphere of any emergency department worldwide, the public and the film industry have focused more on medicine. Similar medical movies and TV series include the television series L.A. Doctors (Gary Fleder, 1998), Grey’s Anatomy (Peter Horton, 2005) and movies such as The Young Doctors (Phil Karlson, 1961), Emergency (Jack Webb, 1972), Vital Signs (Marisa Silver, 1990), and John Q. (Nick Cassavetes, 2002). Moreover, Patch Adams (Tom Shadyac, 1997) depicts a doctor named Patch Adams who cures patients with his sense of humor. He is willing to do just about anything to make his patient laugh, even at risk to his own career. One films depicts nurses in a comic way: Yes Nurse! No Nurse! (Pieter Kramer, 2003), etc. The aim of this article is to review the image of the doctor and its significance in Hong Kong cinema and television.

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MEDICAL SYSTEM AND POLITICS In Hong Kong Films and Television, Help!!! (Producer/Director: Johnnie To and Wai Ka Fai, 2000) tells a story about a new female doctor named Yan and her first day working at Sir Kau Kei Ho Charity Hospital’s accident and emergency (A and E) department. Yan is disappointed to find Jim, her supervisor, teaching her how to evade job responsibilities. One night, an old man is taken to A and E after being struck by lightning. Each department dispatches him to another but then scrambles to take him after finding out that he is Ho Kau Kei. Ho wants to abolish the bureaucratic system and appoints Yan (Cecilia Cheung) together with Doctor Joe (Ekin Cheng) and Jim (Jordon Chang) the task of reforming the hospital. There is a repeated slogan: “It is not simple to become a doctor.” Help!!! is a satiric comedy. Help!!! can also be interpreted as a political satire of the Hong Kong Special Administration Region, a similar absurdly mismanaged and bureaucratic system, under the leadership of HKSAR chief executive Tung Chee Hwa. Most of the doctors (symbolizing senior government officers) shirk their duties and make a lot of mistakes without taking responsibility. The creative ideas of Help!!! can probably be traced back from another Hong Kong film, Doctor’s Heart (David Lam, 1990). Doctor’s Heart also portrays a backward and corrupted hospital. Arrogant Prof. Lawrence Chu (Simon Yam) manages the hospital with his overlypowerful administration. One new intern, Kenny (Mark Cheng), a bright and promising medico, criticizes the medical system, so Prof. Chu decides to fail his examination. When Prof. Chu further discovers that his girlfriend is social worker Anita (Michelle Lee), and he downgrades Kenny to assistant in the mortuary. Kenny discovers blood clots in Anita. He asks his herbal medicine doctor father for help in performing an operation on Anita illegally in the mortuary. Luckily, the operation is successful. Now Kenny is the best-known surgeon in the hospital. Doctor’s Heart was made after 64 incidents in 1989. The audience can easily connect the autocratic character of Prof. Lawrence Chu with the Communist Party in China. There are similar connections between Help!!! and Doctor’s Heart. The first similarity is the new doctor reforming the bureaucratic and autocratic medical system, which metaphorically criticizes politics. The second point is the reconfirmation of the doctor’s heart and virtue at the end of story.

DOCTOR’S VIRTUE AND ROMANCE Mack the Knife/Dr. Mack (Lee Chi Ngai, 1995) portrays a kind-hearted doctor called Lau Mack (Tony Leung), who gives up his brilliant career in a famed hospital and opens a small clinic in the Hong Kong red-light district, because he realizes that a good doctor should have respectful moral concern for his patients apart from sophisticated medical techniques and medical qualifications. Dr. Mack not only heals the patients’ wounds, but also their broken hearts. Tony Leung plays a passionate, carefree but romantic doctor with his marvelous acting techniques. Mack the Knife is a comedy-drama based on a popular Japanese comic. Healing Hearts (Gary Tang, 2000) portrays romantic and heart-broken doctor Lawrence (Tony Leung) whose wife has died in a tragic car collision. He never really recovers from the pain of losing his wife pain. His friend Doctor Paul (Kenny Bee) and his girlfriend, a coma patient named

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Jackie (Michelle Reis), miraculously awakens, but Jackie can’t accept Paul’s love. Jackie gradually falls in love in Lawrence. But, finally, Lawrence discovers a brain cancer in Jackie. A doctor can’t heal his lover. Gary Tang is well known for his E.R.-style medical TV drama in Hong Kong. The Beautiful Life (Yip Wai Ying, 2004) also portrays a young male doctor, Kevin, who is not concerned about the patients and their families until his aunt one day suffers from blood cancer. He finally feels what the patients’ families feel. Doctor No… (Albert Mak, 2001) portrays an illegal doctor Lok (Stephen Ma), who once was a young and promising doctor but is arrested for murder. Finally, he flees to Macao where he establishes an illegal medical practice. He meets an old lady, Ann (Yoyo Mung), who helps him recall his memory of the manslaughter, and he finally realizes that she is the actually the one he once loved. Actually, Doctor No… is a drama about a broken-hearted doctor who can’t escape from the shadow of his past.

CHRISTIAN DOCTOR Christian-value production companies tends to depict a very good Christian doctor, evidenced by several gospel films and TV series. The most successful film is The Miracle Box. The Miracle Box (Adrian Kwan Shun-Fai, 2004) is produced by the Christian communication company Media Evangelism. According to Kozo’s review1, respect has been garnered by The Miracle Box, a Christian-themed drama from Hong Kong-based Media Evangelism, which chronicles the life and times of doctor Joanna Tse, who was martyred by the outbreak of SARS in 2003. Her story is an inspirational one, promoting hope in the face of adversity, along with faith in God. As portrayed by Ada Choi Siu-Fun, Joanna Tse was a angelic doctor, putting her responsibilities and love above all else, and never giving up when the people around her apparently did. It’s a nice message, and director Adrian Kwan handles it with obvious loving respect. Unfortunately, the movie itself really isn’t much of a movie. According to Kozo’s review of The Miracle Box, it is a gospel film that aims to preach Christian values and beliefs. Actually, The Miracle Box is more like a romance film. It also was successful at the box office (HKD 6,535,338), and received positive film reviews at that time. The true story of Joanna Tse was also adapted in a TV serial drama called Asian Heroes by Media Evangelism Limited.

CONCLUSION Hong Kong films about professions like doctor are few in number and mainly focus on human emotions and relationships. Most of the doctors face the difficulty that they can’t cure their own pain or their lover’s disease and escape from their past gloomy memories, as in Healing Hearts (Gary Tang, 2000), The Beautiful Life (Yip Wai Ying, 2004), Doctor No… (Albert Mak, 2001), The Miracle Box (Adrian Kwan Shun-Fai, 2004), etc. Another dilemma is that they try to reform the bureaucratic system of the hospital, as in Help!!! (Johnnie To and Wai Ka Fai, 2000) or even leave the so-called famed hospital in Mack the Knife/Dr. Mack 1

http://www.lovehkfilm.com/reviews/miracle_box.htm

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(Lee Chi Ngai, 1995). Realistic depiction of the profession and the difficult specific nomenclature and surgical procedures are not the main focus of these films. There is even a phony herbal doctor in The Doctor in Spite of Himself (Lau Kwok Wai, 1999) in this extreme story.

REFERENCES Films: Doctor’s Heart (David Lam,1990) Doctor No…(Albert Mak, 2001) Help!!! (Johnnie To and Wai Ka Fai, 2000) Healing Hearts (Gary Tang,2000) Mack the Knife/Dr. Mack (Lee Chi Ngai, 1995) The Doctor in Spite of Himself (Lau Kwok Wai, 1999). The Beautiful Life (Yip Wai Ying, 2004) The Miracle Box (Adrian Kwan Shun-Fai, 2004) Article: Georgios Pappas (2003). Infectious Diseases in Cinema: Virus Hunters and Killer Microbes. In Clinical Infectious Diseases (Vol. 37, Issue 7). U.S.A: The University of Chicago Press.

In: Health Issues in Chinese Contexts, Volume 2 Editor: Zenobia C. Y. Chan

ISBN: 978-1-61209-438-0 © 2009 Nova Science Publishers, Inc.

Chapter 17

INVITING THE BROTHER TO TAKE HIS PLACE AS “ELDER BROTHER”: ANOREXIA NERVOSA AND FAMILY TREATMENT Zenobia C. Y. Chan and Joyce L. C. Lai ABSTRACT The process and outcome of family treatment for a Chinese family with a daughter suffering from anorexia nervosa are seldom addressed. The subjective experiences of the family members in family treatment have been inadequately heard. To respond to the above missing links, We present a case from Hong Kong for an in-depth qualitative inquiry. The rich narratives of the family’s experiences toward the course of family treatment when struggling through anorexia nervosa will be presented. Rose (a pseudonym), 17 years old, received six sessions of family therapy with a remarkable outcome. She weighed 35 kg at a height of 157 cm (BMI =14.2) when she first sought help in 2000. One year later, she weighed 57.5 kg (BMI =23.3). Based on the review of the family sessions, several observations were identified in the process of Rose’s recovery: “Over-involved Mother,” “Inviting the Brother to Take His Place as ‘Elder’ Brother,” “I Like My Job,” and “Goodbye Anorexia Nervosa or Welcome Bulimia?” A health care forum should provide a means for giving patients and their family members a voice, and for allowing health care professionals to hear these families’ voices in their socio-cultural contexts.

INTRODUCTION Anorexia nervosa has been defined as a mental disorder. Characteristics of anorexia nervosa include weight loss that brings the weight to less than 85% of ideal, intense fear of weight gain, self-evaluation highly influenced by perceived weight and shape, and absence of at least three consecutive menstrual cycles (American Psychiatric Association, 1994). The above criteria can assist in classifying the mental disorder of patients who are suffering from anorexia nervosa with these manifestations. Standardization of diagnostic criteria can help

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benefits include preventing the imposition of an “expert” interpretation of the effectiveness of treatment, promoting equality between the client and the professional, facilitating a partnership approach to the therapeutic relationship, and allowing the client to have a sense of ownership during the course of family treatment. As a result, in the clinical sense, patients’ voices should be highly recognized—and that should be conceptualized in the research process. This article offers the details of Rose’s family’s experience in family treatment and comprises three sections. Section I is the family plot. Section II is the description of the process and intervention of family treatment; Section III is the discussion.

FAMILY PLOT Rose, a 17-year-old girl who lives with her family (mother, 45; elder brother, 19; and younger sister, 12; her father had died of cancer) in public housing, received five family therapy sessions. When Rose first sought help on 18 November 2000, she weighed 35 kg and was 157 cm tall (BMI=14.2); on 2 June 2001, she weighed 57.5 kg (BMI=23.3). At that time it was determined that she did not require any further psychiatric or regular follow-up services. Rose’s mother spoke with a dialectic accent that revealed her origins—she was born in China. She was not working and the whole family was supported by public welfare. Rose had a sister and a brother. The sister was very quiet and shy and rarely spoke. Rose’s brother was in high school. He gave the impression of being very pragmatic and had excellent analytical abilities. This was why Rose always thought that her brother was looking down on her, and thought that her abilities were poor in comparison with his. Yet Rose honestly believed that her brother’s opinions could help her, especially in planning her road ahead. Here, we could see how Rose’s brother had taken on the role of “father” after their father died. Of all her children, Rose’s mother was most satisfied with this son, as his problem-solving skills were the strongest. She was most worried about Rose, especially about her academic results and career. As for Rose, she hated her mother most for saying she was too fat and that she should not eat too much. Our first impression of Rose’s family relationships was the following: Rose lost her temper easily, especially with her mother. She hated the way her mother would compare her academic results with those of her siblings, and scold her for not doing better with her studies. She was afraid of her brother. Rose scolded her sister when her sister wouldn’t listen to her or when her sister tried to force her to eat. Rose missed her father; he had been a very positive presence in her life. On the whole, her family relationships were not enjoyable. As for school, Rose mentioned that she did not like the school in which she spent Form 6, because she found it difficult to get acquainted with her classmates. She wanted to be a kindergarten teacher because she liked children very much. Her mother commented that Rose was disobedient and rebellious, and she scolded Rose frequently because she could not keep up with her schoolwork. Additionally, the mother disliked Rose attending church, as she worried that it would distract Rose from her studies. When Rose was diagnosed with anorexia nervosa, her mother was very frustrated and sad, because she feared Rose would destroy her whole life. If that happened, she must have

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done something wrong as Rose’s parent—especially since she had to be both father and mother in the family. It was understandable that she would feel such a burden after the death of the husband. When she spoke about her relationship with her husband, she said it was good, but she remained calm and mostly unemotional when speaking about him. Still, no one could know her inner feelings about this, and she might well have been trying to hide her sadness from the children. As described by the mother, there was no big change in the relationship between Rose and herself before and after the manifestation of anorexia nervosa, but in the post-treatment interview, after receiving family treatment, she found that the mother-daughter relationship was much improved—she had learned more about Rose’s feelings and study plans. The brother was a mature, humble and responsible person. He thought and behaved as one older than his age, perhaps because the family environment forced him to grow up quickly. His father’s death cast him as the man of the family, and he took up the male role of protecting his mother and two younger sisters from external challenges. The brother was perceived as the best child through his mother’s eyes. The brother respected and was loyal to his mother. She gave him a lot of freedom in term of choosing what type of part-time job to get and which subjects to study, because he behaved in ways that made her feel confident in and proud of him. The relationship between Rose and her brother was a bit distant, but in the presence of the therapist they could talk to each other, and the brother’s opinions about studying and career plans were useful to Rose. The youngest sister was proper and well-behaved. She would ask for her mother’s advice, and respected Rose’s and her brother’s words. Her daily life was very routine: school, returning home, doing homework, playing at home, with few social activities with her peers. Her introverted nature and her family’s poor financial situation hindered her from going out with her friends or participating in social gatherings. She did have certain leisure activities, like watching television and meeting her classmates at school for extra-curricular activities. The relationship between Rose and her sister was mutual. For example, the sister would support Rose when the mother criticized her during family sessions. Rose also accepted her sister’s views and responded patiently. The sister respected the elder brother very much. The brother supported her as well. Rose’s family was full of love and strength, and even though it was a single-parent, lowincome family, it functioned like many families with two parents. It showed that when all members can adjust after the death of one family member, it can still be a happy family.

THE COURSE OF FAMILY TREATMENT Rose’s expectations of family treatment embraced two main points: she hoped that her relationship with her mother could be improved, and she hoped to receive sympathy and understanding from her family. Six sessions were conducted on the university campus.

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Session One: Family Drama The main family pattern observed in this session was that Rose’s mother cared about her too much—so much, in fact, that she did not allow Rose enough personal space for selffulfillment. For her part, Rose counted heavily on her mother’s advice and was overly affected by her mother’s feelings. Rose was very hesitant to create and execute her own plans for study and a career. Rose and her mother were too concerned with each other’s feelings. This enmeshed mother-daughter relationship resulted in three undesirable effects: 1. Rose did not have the chance to develop her own interests and talents and to transition smoothly from adolescence to early adulthood, because of inadequate individuation and autonomy; 2. The mother blamed herself for Rose’s anorexia nervosa, was extremely stressed about the prognosis of Rose’s recovery, and was disappointed with Rose’s irregular eating habits (restricted eating during the day and binging at night) because of her over-involvement in Rose’s daily life; and 3. Rose’s brother was also influenced by the quarrels about eating between Rose and their mother. For example, he would often come home from work to find his mother shouting at Rose when Rose refused to eat or had a binge eating episode, followed by Rose crying heavily and being in a bad mood, all of which upset him as well. Session One was conducted as follows. The therapist (the second author) wore a warm smile and greeted the family by shaking hands with the mother. She then invited the mother to introduce her family members to her. This caring and respectful attitude could help break the ice. The mother commented about her children as follows: her son was the best among the three children, and her second daughter was like a baby. (The therapist noted that this daughter, aged 12, liked her mother whether she called her a baby or not. She checked in with the daughter at once with a smile: the daughter replied that she did not like her mother addressing her like that.) As for Rose, the mother introduced her only by name, without any other description. To reveal the effects of anorexia nervosa on family interactions, the therapist explored the family’s living environment and checked for any influence Rose’s symptoms might have on her family members. The brother was disturbed by the conflicts, centering on Rose’s eating habits, between Rose and their mother. The therapist probed for information about how the sister viewed such conflicts. Asking for the siblings’ opinions could help them realize that these conflicts affect the whole family, and that in turn the associated problems of anorexia nervosa are not merely individual problems, but part of the family agenda. In order to observe the actual dynamics between Rose and her mother, the therapist asked them to sit face-to-face. She lowered her head and moved her chair away from the conversation to maintain a certain physical distance from them, aiming to create a venue for them to engage in a dialogue. A long pause followed. The therapist asked the siblings whether such ineffective communication between Rose and their mother occurred at home also. The siblings replied “Yes.” Rose felt guilty for having created so many problems for the family, like the way her anorexia nervosa caused her mother to worry. The therapist empathetically showed her

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concern and understanding for Rose by telling her that anorexia nervosa might not be easily and quickly handled. This helped make it clear to the family members that Rose was already under great pressure from blaming herself. The more they blamed Rose, the worse Rose would feel. After ten minutes, the therapist perceived that in addition to treating Rose’s anorexia nervosa as the first priority, the tense relationship between Rose and her mother, with its pattern of mutual misunderstanding and blaming, should be further explored. So, the therapist facilitated a dialogue between them. After they had talked for a few minutes, the therapist acknowledged Rose’s ability to express herself so directly to her mother. At this point, it became clear that everyone was tired, so the therapist closed the session by offering another appointment and summing up several points: the mother had the ability to raise her three children alone after her husband died; Rose was a normal adolescent who had a bad temper; and ups and downs are part of every teenager’s life.

Over-Involved Mother Here are some highlights of Session One: Rose said that she did not like to feel manipulated, and seemed to want more autonomy. Rose also claimed that her mother sometimes talked very loudly, which made her feel that she did something wrong. The therapist asked Rose’s brother and younger sister about this. She also helped Rose tell her mother how she felt and what she wanted her mother to change. The conversation follows. Coding: P: Patient M: Mother S: Sister B: Brother T: Therapist P: She always says I’m slow. T: Does your mother say a lot? P: She says that I’m slow. T: Do you like the way your mother interacts with you? So obviously you want to interact with her in another way? Try to tell her how you want to interact with her. P: Don’t hurry me. Don’t be so anxious. Then you won’t be frustrated. M: I’m afraid that you’ll be late. T: Don’t tell me. Tell her.

Two therapeutic intentions are illustrated in the above dialogue: to assess whether Rose could express her feelings and negotiate with her mother directly, and to motivate Rose and her mother to talk to each other. Rose seemed to want more autonomy from her mother. Rose also claimed that her mother sometimes talks very loudly which makes her feel that she has done something wrong. M: If there were enough time…I’m afraid you’ll be late. It’s better to be early. Next time if you have more time then I won’t rush you. P: I don’t want to be manipulated. T: Besides this, is there any reason why you get upset? Does she always act like she did just now? P: Sometimes she is very loud and it makes me feel that I have done something wrong.

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T: Was she quieter just now? P: Yes. T: Is this how your mother and Rose usually are? B: Yes, except if they’re having an argument. T: Your elder sister thinks that your mother always thinks she is wrong, is that true (pointing to the younger sister)? S: Yes.

The therapist tried to deal with these complaints by asking Rose’s brother and younger sister questions. Asking the siblings for their views has several advantages: to check with them about the veracity of Rose’s statements; to empower Rose by revealing her siblings’ understanding of her situation; and to let the mother hear her children’s perceptions of Rose and herself during their quarrels. The following piece of dialogue shows how the mother experienced the death of her husband: T: I heard from Ms. Chan (the first author) that your husband passed away a few years ago. How long ago? M: About six years ago. T: So you have to support the family. Has it been difficult? M: It was very difficult at first. T: What is most difficult? M: As the children grow older, they can take care of themselves.

The mother seemed quite calm when recalling the death of her husband, and although she acknowledged that her children had grown up and could now take care of themselves, later in the session she scolded Rose for coming home late and accused her of having poor time management skills—giving the impression that perhaps she did not have much confidence in Rose’s ability to take care of herself. This could be causing a repeating pattern where the more the mother worried, the more dependent Rose remained. The mother should encourage Rose to be more independent, or she would continue to rely on her mother’s care in a way that a much younger child would. The main therapeutic directions of Session One were: to loosen the tight relationship between Rose and her mother, and to strengthen the sibling subsystem between Rose and her brother. The assumptions of these goals were: 1. to create some space between the mother and Rose, in part so the mother would not be so worried about Rose’s physical condition. In fact, during that time, Rose’s health was quite stable, as evidenced by her weight and vital signs (normal respiratory rates, level of consciousness and body temperature), which the first author assessed before each session; 2. to allow Rose to take charge of her health at this initial stage and to pave the road for her to take charge of other personal matters—like studying—in subsequent sessions; 3. to minimize the mother-daughter quarrels when they returned home, which in turn helped every member enjoy a less tense family atmosphere, allowing all to relax; and 4. to invite the brother to play a significant role in detangling the tight knot of Rose and the mother: the brother could relieve the mother of sole responsibility for Rose’s

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These goals could not be reached in a single session, but this was the direction in which Rose’s family needed to move, so they were pursued further at subsequent sessions.

Session Two: Family Drama Prior to continuing with the above-described therapeutic interventions, a thorough assessment of the actual family dynamics was required. Such an assessment would allow the therapist to explore family interactions in their most current context and to verify whether the treatment directions formulated in Session One were indeed appropriate and useful. Observations from Session Two follow. The therapist announced Rose’s 1.5 kg weight gain and shook hands with her. In discussing how she made such good progress, Rose revealed that she ate a lot of junk food. Her mother jumped into the conversation at once and scolded Rose for not eating rice, saying she was binge-eating at night. The therapist asked why Rose liked to overeat at night. Rose believed that it was because she felt free to eat at night when her mother was sleeping. That way, she could prevent direct conflicts with her. The therapist supported Rose as she revealed her fear of being scolded by her mother for her eating habits. The mother listened attentively and seemed more accepting of Rose’s feelings than during Session One. The therapist then asked the younger sister for her view of the relationship between Rose and their mother. This sibling perspective helped enrich understanding of the tense, conflicting interaction between Rose and her mother. The therapist then asked for the elder brother’s opinion about Rose’s binge eating, and he explained that Rose sometimes ate in the kitchen, but he never said anything to her about it. It seemed that he did not interact much with Rose. Their relationship was quite distant. The therapist realized she had to discourage the mother from blaming Rose about her eating habits, so she showed her understanding by stating that it must be hard for the mother to use a balanced approach with Rose: on the one hand, she had to let Rose grow up and develop more self-control; but on the other hand, she hesitated to let Rose stand on her own feet as long as Rose seemed unable to maintain normal eating habits. This approach to building a rapport with the mother succeeded because at no time did the therapist blame the mother. The mother was then able to express her worries to Rose, and Rose was able to clarify her mother’s concerns about her health and dieting. The therapist remained silent and simply observed the communication patterns between the two women. After listening for ten minutes, the therapist said she was confused about something Rose said: that she gained weight because she wanted to please her family, and especially her mother. The therapist wanted to understand what Rose did for herself versus what she did for her mother. What emerged was a new perspective of Rose as a deeply filial daughter. The therapist realized that the elder brother was in the best position to offer Rose advice about future studies. The brother was a student as well, two grades ahead of Rose. The therapist paved the way for Rose and her brother to discuss and share views about her studies. Surprisingly, the brother was very patient and gave Rose some valuable advice. Most

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significantly, his caring tone and sincere attitude were effective in helping Rose through this puzzling stage of deciding to which institutions she should apply. The brother also knew about the current situations at technical institutions far better than the therapist or the cotherapist. This fact supported the truth that a family member can often be a pivotal resource in assisting another family member in any struggle. The conversation between Rose and her brother lasted more than thirty minutes. The mother and younger sister did not participate in the conversation, but they seemed to believe the brother’s input was useful to the whole family. During this conversation, the brother appeared very mature, and took on a leadership role, like his father in the past. Based on the family members’ experience and reactions in Session Two, it seemed that some additional therapeutic directions had to be implemented, including: (1) letting Rose express the feelings that led to her binge eating; (2) allowing the mother to express her difficulty trusting Rose if she did not control her binge eating; and (3) inviting the brother to give support and advice to Rose about her study plans. Some of the therapeutic directions formulated in Session One could not be implemented in Session Two due to other issues that had to be tackled first, but some repeating family patterns—like the enmeshed motherdaughter relationship—were noted. The potential of inviting the brother to be a resource to improve the relationship between Rose and her mother was not fully explored and would have to be revisited in the next session as well.

Session Three: Family Drama Session Three was conducted on the university campus on 7 December 2000. Rose weighed 43 kg and had gained 4.5 kg since Session One. Session Three shows how the therapist began to encourage Rose to take a partnership approach to planning her future. Amazingly, the tense relationship between mother and daughter had improved. The first ten minutes of the session revealed that they could engage in conversation with far less anger. On the contrary, the elder brother was more passive than at previous sessions. The therapist sought to explore the reasons for this, and inviting him to talk was the first step. He said that he did not know how to help improve the family’s relationships, but he seemed unwilling to express fully his feeling of helplessness. Before he could do so, more trust and a better rapport had to be built between him and the therapist. Prior to learning the brother’s views of the family relationships, the therapist connected with him by asking about his daily life—such as his study plans and his work in the supermarket. Eventually, some issues that bothered him a lot began to emerge, such as the family’s poor financial situation and his wish to study further: he hoped to receive a university education in the future. The brother had taken over the paternal role after his father died. He had to grow up fast in order to protect the family. He was very mature and wellmannered, as compared to other lower-class Chinese adolescent boys. Giving him a channel to express his difficulties could show the family that he was under stress as well. It could also shift the focus from being exclusively on anorexia nervosa, reframing it as a problem for the whole family—not only because it caused Rose’s poor health and created a tense relationship between Rose and her mother, but because it created more worries for the brother as well.

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Inviting the Brother to Take His Place as “Elder” Brother The main themes in this session were discussing Rose’s future and inviting the brother to help; and assessing whether there were any financial constraints on the family. For instance, the therapist urged Rose not to waste her time, and invited her brother to give some advice. Her brother suggested that Rose study something, and asked what her long-term plan was in order to give more detailed suggestions. The therapist then asked about the family’s income. The mother said it was around HKD10,000 (USD1282.05) per month—just enough to maintain the children. Rose’s brother said he had enough pocket money for transportation and meals. Both Rose and her brother tutored students to earn extra money. The session started with the following exchange. Coding: P: Patient M: Mother S: Sister B: Brother T: Therapist T: Can you give her some advice? It’s not good to waste time. B: I think she should learn something, not waste time. T: So you agree with that. So when do you think she should start and where should she go? B: What is your long-term plan? P: To get some information and apply for appropriate courses. T: You don’t want to postpone it endlessly. Would you like your brother to push you? P: Yes.

The therapist seemed to be persuading Rose to accept encouragement—and even a little pressure—from others. This conversation shows the therapist’s skills: she had Rose confirm that she would accept her brother’s advice, opening the door for that possibility to become a reality in the future—and for that advice to be welcomed, instead of resisted and resented. Inviting the brother to help Rose could increase family cohesiveness by strengthening their relationship, and could also relieve some of the mother’s stress that stemmed from her concern over Rose’s future. The financial status of Rose’s family is explained in the following excerpt. T: Are you financially okay? M: Just okay. About $10,000 per month. T: Do you have to be careful about spending? M: Yes. T: Do you have enough pocket money? B: Yes. For traveling and meals. T: So you ask your mother for more when you don’t have enough? B: Yes. I have a part-time job. I tutor. T: Do you tutor every day? B: About five days a week. T: You are very good. So does the tutoring fee support your spending? B: Yes. T: Do you tutor students? P: Yes. T: How many students do you have? Do you like tutoring? P: Umm…I think it’s better than other jobs. Sometimes I feel bored and I don’t have anything else to do during the summer. I think I’m the lazy type.

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Checking on the financial status of Rose’s family reflects the therapist’s underlying assumption that a low-income family might have financial difficulties. This could be either positive or negative for the family. On the positive side, if the family does have financial difficulties, the therapist can refer them to other social services and assistance. On the negative side, the family might have its own methods for managing its financial status effectively, and might feel the therapist considered it a poor family that lacked the ability to use its own resources for living. To conclude, a positive change was seen in Session Three, in the relationship between Rose and her mother. The brother was successfully invited to offer help to Rose and to relieve the mother of this particular burden. Hearing her son speak about work and study issues reassured the mother that he could serve as a crucial support for Rose through the uncertainty of her recovery and her future studies. In turn, Rose could feel that her mother was not monitoring her constantly, allowing her better self-differentiation.

Session Four: Family Drama From Session One to Session Three, progress was found in the relationship between Rose and her mother. The brother did a wonderful job of offering support to Rose and showed his mother that he was a capable person, able to help the family as a responsible son and a caring brother. Apart from dealing with family relationships, from Session Four onward, other issues were addressed, such as Rose’s career and social life. Revealing Rose’s interests and potential were the central themes. Session Four was conducted on 9 February 2001, eight weeks after Session Three. Rose weighed 48 kg and had gained 5 kg. The mother looked more relaxed than she had at any of the previous sessions. The therapist congratulated Rose on her weight gain. The therapist had not met the family for two months and wished to know what brought about such a positive change, so she asked, “What caused this progress?” Rose had a job tutoring children; she loved being with them. A sudden noise disturbed the session; the therapist left to try to find out the reason for the noise. It turned out to be some workers mending furniture in the next room. The noise was handled and the session continued. She continued the exploration of what caused the changes, but the family was not able to explain it. Rose did not show any interest in discussing her weight. When the therapist asked about Rose’s study plans, Rose was more animated and her voice was more mature and confident. The main topic discussed in the session was how Rose could continue her studies as a kindergarten teacher and how she could successfully apply to an institution offering a threeyear course about the theories and practice of preschool education. The brother was eager to offer Rose some advice. The mother was very supportive and welcomed Rose’s decision. Discussing Rose’s career and future seemed more constructive than only focusing on the issues of eating, weight, and mother-daughter conflicts. Even though these issues had not been fully solved, some time was required for the family to adapt to the changes, to ensure that they could tolerate and maintain them. Otherwise, too much massive change might lead to another extreme of unbalance. Before saying goodbye to the family, the therapist held Rose’s hands and wished her good luck with the preschool education course. Six months after that session, Rose’s

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application was accepted. She had taken the first step toward her dream of being a kindergarten teacher. Without the therapist’s encouragement to speak out about her dream, and the support from her family, it is unknown whether Rose could have ever begun to achieve her goal.

“I Like My Job” The session focused on Rose who had independently searched for a job as a kindergarten teacher. The therapist appreciated Rose’s strength in dealing well with the children, recognized Rose’s maturity as reflected by the fact that she started thinking about her career, and motivated the elder brother to help Rose. The therapist started the conversation with an encouraging tone. She sounded very inspiring to Rose and her mother by praising their good temperament. Coding: P: Patient M: Mother S: Sister B: Brother T: Therapist T: Congratulations! You look very well. You are almost recovered. Mother, you also look great. What has happened? Are you working or studying? P: Working at a childcare center. I like the job. T: Tell me more. P: I like working with children. I feel that this is suitable for me. T: You are happy? P: Pretty much. The children are attending primary school. Children are simpler. With adults, it’s difficult to tell what they really think. Working with children, I can develop more patience. T: This is really good. So what do you do in the morning? P: Nothing much, I just wait for the afternoon.

In the following, the therapist praises Rose in front of her family and shares a personal experience—as a friend might: T: She sounds more mature today. So with your current job, you are more certain that you like working with children. I have a relative who works in childcare and every time we have a family gathering, the children gather around her. P: I like to be with children. T: That’s a talent because not everybody can deal with children. (pointing to the brother) Can you deal with children?

The therapist also showed concern for the brother during this session: T: So there’s a lot of pressure on you too? B: Yes, if I cannot complete something. T: You judge yourself that way? B: Yeah. T: So what keeps you from completing things? B: I’m not focused. T: So thoughtful. Some teenagers don’t know how to view themselves and he knows how to improve himself. M: He has so much education, he should know.

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The therapist started the session with an encouraging tone. She seemed very impressed by Rose and her mother, and complimented them. The therapist then showed concern for Rose’s brother. The core treatment interventions in Session Four were: 1. to continue the theme of including the brother’s views to help Rose explore her own interests and potential; 2. to create a context for Rose and her brother to share views, thereby strengthening the sibling subsystem; 3. to free the mother from worrying too much about Rose; 4. to show the mother that Rose and her brother could together face common adolescent issues, such as whether to pursue further studies or not; 5. to set a clear boundary between the parental subsystem and the parent-child subsystem; and 6. to show the younger sister that her elder brother was capable not only of helping Rose, but also of helping her, if needed. To conclude, this session pursued three significant clinical directions: (a) creating space for Rose and her mother to find a less confrontational way to resolve their conflicts around Rose’s eating habits; (b) inviting the brother to relieve some of the mother’s responsibility in caring for Rose; and, (c) encouraging the continuing strengthening of the relationship between Rose and her brother.

Session Five: Family Drama The termination session is usually conducted in a more relaxed manner, but the therapist will normally still be curious about family interactions between the last session and the present one. Some distinct points have to be acknowledged in order to help the family stand on its feet for total recovery in the future. Session Five was conducted on 2 June 2001, four months after Session Four. The symptoms of anorexia nervosa had been successfully treated: Rose weighed 57.5 kg (BMI=23.3) and her menstruation had resumed. The tense mother-daughter relationship, as reported by the family members, was much improved. However, Rose reported that she had begun binge-eating. This newly emerging problem had to be handled, but without casting the symptoms as pathological, as it might be a normal physiological response to increasing food intake after a period of self-starvation. The therapist had to assess closely whether the bingeeating was an acceptable bodily response or a manifestation of another eating disorder. She had to keep an open mind to learn about the effects of Rose’s binge-eating on the family’s relationships, and to give each family member a chance to express his/her views on bingeeating. The plot of Session Five is here summarised. The therapist reminded Rose that it was her responsibility to make healthy choices, and wondered whether Rose thought that her mother, brother or sister could help. Rose bluntly insisted that she would not listen to others. The therapist wondered if the problem lay with the family members’ tones or methods, and asked for details. Rose got upset and cried as she told the therapist that her family kept saying she

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was fat. On the one hand, Rose felt frustrated because when she was thin, they said she was too thin; now they said that she was too fat. The therapist agreed that it was painful to be called fat, especially by her mother. Rose’s mother said that she knew Rose was upset with her and was buying things to oppose her. The therapist then said that perhaps Rose ate either too much or not enough because she wanted to oppose her mother. Rose’s mother insisted that she seldom said things about Rose, but just let Rose do what she wanted to. This was a bit surprising because Rose always said her mother was controlling.

Goodbye Anorexia Nervosa or Welcome Bulimia? The brother suggested that their mother let Rose do some things in her own way, but the therapist continued to stress that it was Rose’s responsibility to think for herself and be mature. She suggested Rose think about her weight and her work and write down her thoughts, and reminded Rose that she should not use overeating as a tool to oppose her mother. Suggesting that they meet again in two weeks, she closed by pointing out that Rose was not fat at the moment, but it was not good to gain too much weight. The dialogue below illustrates Rose’s new eating problem. Coding: P: Patient M: Mother S: Sister B: Brother T: Therapist T: (asking Rose) How do you think your mother and brother could help, or sister? Your situation is very problematic. I’m worried about your health. It’s not good for your heart or your health. Do you want to change it? You have to find ways to control yourself. P: I won’t listen to others. T: Even your mother, brother, and sister? Is it because of her tone or her method? P: They keep saying that I’m fat. (Rose starts crying) I want to be like others. When I was thin, they said I was too thin and now they say I’m fat.

The therapist showed her understanding of Rose’s situation. She first stated that it was not comfortable to be called fat, especially when the words came from the mother. This might give a hint to the mother. Rose’s mother said that she knew Rose was upset because of things she said, and was buying things to oppose her. The conversation continued. T: Being called fat is not very comfortable, especially when your mother says it. Do you think that you could be neither fat nor thin? T: Do you know that you make her very upset? M: A little bit. T: (pointing to Rose) You seem to oppose your mother by either eating a lot or refraining from eating. I think you know that you’re opposing your mother—when I was young, I opposed my mother. T: If you ignore her, she thinks that you don’t accept her. Brother, is there any way to tell her? Opposing means doing something that she doesn’t like. B: To lessen the conflict.

The therapist used her own experience here to identify with Rose. It might make Rose feel better to know that someone understood her situation. The brother suggested that it was

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not good to oppose. He advised Rose to just listen to the words, not the tone, and said that one could not simply listen to what he/she liked to hear. The therapist added that if one as ignored by others, she would think that people did not accept her. She told Rose that opposing means doing something she did not like, and asked the brother for his help. The following extract sheds a different light on the issue of control in the relationship between Rose and her mother: M: I don’t say anything. Seldom. I don’t care much. I let her do what she wants. B: There are things in which you can let her go her own way. T: (to Rose) Can you think for yourself a bit more? In some ways you are mature, in others not. P: It’s mostly not because of her. It’s like eating…I don’t like her talking about me.

Rose said that she would probably work in a kindergarten for her career. The therapist concluded the conversation by asking Rose to go back home to sit down quietly and think about what she wanted to do. She suggested Rose think about her weight and her work and write down her thoughts. The discussion follows: T: Besides eating, would you think about what you want to do in the future? Is that difficult to think about? P: The future? I will probably work in a kindergarten. T: Today when you go back, try to find a corner and think about what you want to do. Think about your weight and your work, write it down and tell me next time.

Next time, we will talk about it. What’s most important is whether you want to control your overeating. Don’t let this thing become the tool that you use to oppose your mom. I used to think that you had recovered and I didn’t need to meet with you. But can we meet two weeks from now? Prevention is better than cure. I don’t think you are fat now but it’s not good to keep growing fat. The therapist was skillfully hinting here that Rose should try to work hard to keep herself healthy because of her prospective career. During Session Five, everyone was more at ease than during previous sessions. The therapist emphasized the importance of Rose’s independence, such as her part-time job, which could provide financial support to the family, give Rose a sense of responsibility and help her transition from adolescence to adulthood. Additionally, Rose’s earnings could ease her elder brother’s worries about the family’s poor financial status. The most important change was that the mother finally realized Rose was growing up. Even the title of the session, “Goodbye Anorexia Nervosa or Welcome Bulimia,” suggests that the well-experienced therapist had a non-pathological view of Rose’s rapid weight restoration, but would offer some advice and follow-up on Rose’s progress after termination.

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DISCUSSIONS For families in Chinese culture without a father, in which the mother plays the role of the decision maker, whenever there is a crisis or an important issue arises the family may feel a need for leadership. Rose’s family, after the death of her father, was without a leader to manage the fight against her symptoms and to plan for the children’s futures. The therapist made an excellent assessment of the above problem by inviting the brother to take on the position of “elder” brother. In doing so, the therapist has to be cautious of the following: (a) the brother was playing his role as an elder brother in relating to his sister, Rose, and as an elder son in relating to his mother, rather than replacing the role of the deceased father; (b) the brother was willing to take an active role to help unlock the self-defeating mother-daughter patterns of interaction; and (c) he would not be overburdened psychologically. Full success cannot be achieved through one intervention. In this case, it was built gradually through many steps, such as assessing the family’s communication patterns, connecting with the brother, inviting him to support and offer advice to Rose, and evaluating the effectiveness of this therapeutic intervention in an ongoing process. Working with the family was the key to restructuring the leadership roles therein and to combating Rose’s symptoms. When the therapist shifted the focus of the conversation to the death of Rose’s father, this clinical move seemed to yield both advantages and disadvantages. The advantage was that the therapist could explore how the family was affected by the father’s death—such as any alterations in roles, the double roles of the mother, and how the children perceived the loss of their father. The disadvantage emerged around the question of whether it was the right time to bring up this subject. In Rose’s written comments about that session, she said that when the therapist mentioned her father, she was suddenly reminded of the difficulties her mother faced and she was afraid of seeing her mother cry. Rose’s comment pointed out an important concern: Rose and her family came for family treatment due to anorexia nervosa; there had already been a family crisis and it would cause more sorrow for the family to explore the effects of the father’s death. Based on Rose’s comment, this seemed to be the wrong time to make this therapeutic move (discussing the death). This makes it clear that, before addressing such sensitive issues, a certain level of trust must be built. Rose found it embarrassing to answer questions about her family’s finance. As therapists and helping professionals in Hong Kong often come from the middle class, they may not know the shame and difficulties faced by poor families. Therefore, a more empathetic attitude is encouraged. For example, when the therapist wishes to address or assess a family’s financial status, verbal consent should be sought first, such as “Would you be willing to share with me some details about your family’s financial status? The issue of family income is certainly a private matter, and if you feel it is beyond the realm of family treatment, please do not feel obligated to discuss it with me.” Not only should the therapist ask for verbal consent; s/he should also look for non-verbal cues such as facial expression and tone of voice, to help determine whether they are ready and willing to talk about the subject, or reluctant to do so. Finally, it is perhaps best not to broach such sensitive subjects at the beginning of treatment, but rather to wait until trust can be built between the family and the therapist.

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CONCLUSION Family treatment should advocate the importance of preserving our own culture, knowledge, family characteristics and social specificity. To question the insistence on the universality of every family’s experience is the first step. It is now time to consider calls for indigenous knowledge that can evolve into a socio/cultural-specific framework, in order to provide the greatest benefits to the afflicted families that the practice of family therapy serves.

SECOND AUTHOR’S BACKGROUND Joyce, L. C. Ma PhD, Clinical member and approved supervisor, AAMFT, Professor Department of Social Work The Chinese University of Hong Kong E-mail: [email protected]

ACKNOWLEDGMENTS We want to thank the patient with anorexia nervosa and her family for sharing their stories with me. Finally, my doctoral study is sponsored in part by a research grant supported by the Research Grants Council (CUHK: 4090/99H).

REFERENCES American Psychiatric Association. (1994). Practice Guideline for eating disorders. Washington, D. C.: Author. Bordo, S. (1989). The body and the reproduction of femininity: A feminist appropriation of Foucault. London: Rutgers University Press. Burnett. P. C. and Fanshawe, J. P. (1997). Measuring school-related stressors in adolescents. Journal of Youth and Adolescence, 26(4), 415-428. Chan, C. Y. Z. and Ma, L. C. J. (2002). Family themes of food refusal: Disciplining the body and punishing the family. Health Care for Women International. 23 (1), 48-58. Hepworth, J. (1999). The social construction of anorexia nervosa. London: Sage Publications. Locke, L. D. and McCollum, E. E. (2001). Clients’ views of live supervision and satisfaction with therapy. Journal of Marital and Family Therapy, 27(1), 129-133. Minuchin, S., Baker, B. L., Rosman, B. L., Liebman, R., Milman, L. and Todd, T. C. (1975). A conceptual model of psychosomatic illness in children: Family organization and family therapy. Archives of General Psychiatry, 32, 1031-1038. Minuchin, S., Rosman, B. and Baker, L. (1978). Psychosomatic families: Anorexia nervosa in context. USA: Harvard University Press.

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Morries. K. and Shepherd, C. (2000). Quality social work with children and families. Child and Family Social Work, 5 (2), 169-176. Pinsof, W. M. and Wynne, L. C. (2000). Toward progress research: Closing the gap between family therapy practice and research. Journal of Marital and Family Therapy, 26(1), 1-8. Rastogi, M. and Wampler, K. S. (1999). Adult daughters’ perceptions of the mother-daughter relationship: A cross-cultural comparison. Family Relations, 48(3), 327-336. Reimers, S. and Treacher, A. (1995). User-friendliness and theories of family therapy- The contribution of second-order thinking and feminism. In S. Reimers and A. Treacher (eds) Introducing User Friendly Family Therapy. London: Routledge, pp. 180-196. Stolk, Y. and Perlesz, A. J. (1990). Do better trainees make worse family therapists? A follow-up study of client families. Family Process, 26, 45-58. Wilson, K. and Ryan, V. (2001) Helping parents by working their children in individual child therapy. Child and Social Work, 6 (3), 209-217.

INDEX A Aboriginal, 97 absorption, 179, 194 accessibility, 38, 84, 104, 199 accident victims, 36, 43 accidents, ix, xii, 36, 123, 124, 126, 127, 128, 130 accuracy, 17, 197 achievement, 42, 80, 84, 85, 102, 107 acid, 179, 183, 186, 192, 193, 194, 196, 200, 201 activation, 178 acupuncture, 174, 176, 181 acute, xvi, 73, 116, 124, 139, 179, 188, 189, 194 acute promyelocytic leukemia, 189 adaptability, 100 additives, 12 adducts, 189 administration, 73, 139, 149, 179, 182, 196, 201, 204, 206 administrative, 70 administrators, 66, 68, 70 adolescence, 39, 78, 86, 102, 213, 223 adolescent boys, 217 adolescents, xi, 48, 55, 64, 73, 76, 77, 78, 79, 80, 81, 83, 84, 85, 86, 87, 129, 204, 225 adult, 37, 87, 93, 120, 196, 197 adult learning, 120 adult population, 93 adulthood, 65, 79, 85, 87, 213, 223 adults, 49, 55, 56, 78, 129, 179, 181, 182, 186, 191, 192, 194, 195, 196, 198, 200, 201, 202, 203, 204, 220 advertisement, 177 advertisements, 18, 41, 70, 104 advertising, 38 aetiology, 64 affective disorder, 160 African American, 58, 74, 76

African Americans, 76 afternoon, 83, 117, 196, 220 age, x, xvii, 4, 18, 35, 36, 37, 43, 49, 57, 58, 59, 60, 65, 66, 70, 72, 81, 84, 103, 104, 119, 178, 193, 194, 198, 201, 203, 204, 212, 216, 225 ageing, 52 agent, 6, 7, 24, 174 agents, 18, 31, 149, 188 aging, 57, 192, 193, 198, 199 aging population, 198 aid, xviii, 115, 166, 169, 195 AIDS, 168 air, 35, 43, 126, 156 airways, 194 alcohol, 58, 59, 60, 64, 100, 126, 136 alcohol abuse, 100 alcoholism, 49, 197 alkaloids, 182 allergic reaction, 27 alpha, 200 alpha-linolenic acid, 200 alternative, xiii, 158, 173 alternative medicine, xiii, 173 Alzheimer’s disease, 180, 202 ambulance, xviii, 169 amendments, 198 American Diabetes Association, 79 American Heart Association, 79 American Psychiatric Association, 209, 225 amine, 174 amputation, 168 anabolic, 201 anaesthesia, 124, 132 anemia, 168 anger, 217 angiotensin II, 189 animals, 12, 13, 28, 139, 145, 146, 180 anorexia, ix, xiv, 209, 210, 211, 212, 213, 214, 217, 221, 224, 225

228

Index

anorexia nervosa, ix, xiv, 209, 210, 211, 212, 213, 214, 217, 221, 224, 225 antagonists, 204 anthropometry, 197 antibiotics, 28, 170 anti-cancer, 174, 188 antigenic shift, 139 antioxidant, 65, 75 antiviral, 143, 145, 149 antiviral drugs, 143, 145 anxiety, 49, 100, 171 apoptosis, 187, 189 apples, 71 application, ix, 1, 2, 82, 114, 121, 168, 220 arachidonic acid, 186 argument, 157, 172, 215 artery, 167, 204 arthritis, 49, 58, 168, 179, 188 ascorbic, 194 ascorbic acid, 194 Asia, 74, 79, 111, 174, 182, 192, 204 Asian, 44, 100, 109, 111, 200, 207 assessment, x, xi, xii, xvii, 39, 40, 41, 42, 47, 48, 50, 51, 52, 53, 63, 67, 68, 70, 81, 82, 89, 91, 92, 94, 97, 99, 104, 108, 132, 147, 172, 202, 216, 224 assignment, 94 assumptions, 165, 215 asthma, 60, 61 atherosclerosis, 197 atmosphere, 104, 156, 178, 205, 215 attacks, 103, 164 attitudes, 20, 39, 90, 94, 97, 102, 105, 174, 187 attractiveness, 95 Australia, 45, 65, 90, 109, 110, 115 authority, 21, 56, 101, 126, 130, 154 autism, 153 autonomy, xi, 50, 77, 78, 84, 85, 102, 213, 214 availability, xi, 27, 73, 89, 90, 91, 92, 94, 95, 96 avian flu, 124 avian influenza, xiii, 12, 28, 137, 138, 139, 140, 143, 144, 149, 150 Avian influenza, xii, 137, 138, 151 avoidance, 16 awareness, x, xi, xiv, 35, 36, 37, 38, 41, 48, 63, 65, 72, 78, 79, 90, 94, 95, 101, 103, 105, 124, 129, 165, 182, 183, 191, 195, 198, 199

B bachelor’s degree, 109, 147, 165, 185, 199 bacteria, 12, 27 baking, 28 bananas, 71

barrier, xii, 99 barriers, 54, 57, 113, 114, 117, 118, 132, 158 basic needs, 7 battered women, 104 behavior, 92, 123, 125, 126, 128, 129, 130, 201 behavioral change, 20, 36, 42, 43, 116, 155 behavioural disorders, 58 behaviours, 48, 53, 85, 87, 98, 107 Beijing, 181, 188, 189 beliefs, 20, 50, 90, 97, 104, 157, 188, 201, 207, 210 benefits, x, 20, 35, 36, 38, 39, 41, 43, 65, 114, 115, 158, 184, 196, 197, 198, 211, 225 benzodiazepine, 181 bereavement, 197 beverages, 71, 197 bias, 4 binding, 150 biotin, 201 birds, xii, 137, 138, 139, 143, 145, 148, 149 birth, xv, xvi, 3 bladder, 169 blame, 216 blaming, 210, 214, 216 blood, 75, 124, 168, 179, 192, 206, 207 blood clot, 206 blood glucose, 179 blood plasma, 180 blood pressure, 75, 168 blood vessels, 192 BMI, xiv, 77, 81, 82, 84, 197, 209, 211, 221 body fluid, xv, xviii, xix body image, 210 body mass index, 194, 199, 200, 203, 204 body size, 64 body temperature, 215 body weight, 64, 81, 82, 201 bone density, 194 bone loss, 188 bone mass, x, 192 bone mass density, x bottom-up, 37 bowel, 81, 82 boys, 83 bradycardia, 168 brain, 73, 207 Brazil, 203 breakfast, 66 breast cancer, 186, 188 breathing, xvi, 53, 64, 75 Britain, 161, 174 bronchodilator, 174 brothers, 156 Buddhism, 101

Index buildings, 67 buses, xii, 123, 124, 125, 130 by-products, 146

C cache, 87 caffeine, 60 calcium, 192, 193, 196 calorie, 199, 203 CAM, xiii, 173, 174, 178, 184, 185 Cambodia, 138 campaigns, xi, 18, 42, 77, 130, 195 Canada, 64, 65, 90, 159, 174, 177, 195 cancer, 43, 71, 74, 77, 81, 116, 121, 160, 174, 187, 188, 196, 200, 207, 211 cancer care, 121 cancer cells, 187, 189 cancer treatment, 174, 188 car accidents, 19 carbohydrates, 192, 196 carbon, 35, 43 carbon dioxide, 35, 43 cardiovascular disease, 64, 75, 77, 195 cardiovascular system, 168 caregiver, 102, 110, 193, 199 caregivers, 48, 50, 51, 52, 53, 54, 200, 202, 203, 204 caregiving, 102, 204 Caribbean, 172 carotene, 196 carpopedal spasm, 194 case study, ix, 117, 131, 154, 158 cast, 210, 212 casting, 221 catabolism, 201 catheter, xix Caucasian, 64 CDC, 139 cell, 189 Census, 49, 55, 67, 74, 191, 200 Centers for Disease Control, 79, 86, 151, 159 central obesity, xi, 63, 65, 66, 67, 68, 70, 72, 73 cereals, 28 cerebrovascular, 49 cerebrovascular disease, 49 certificate, 42, 114, 121 channels, 93, 114, 117, 118, 126 check-ups, 67 cheese, 27 cheilosis, 192 chemicals, 175, 183 chemotherapy, 189 chicken, 28, 140

229

chickens, 137, 138, 140 child abuse, 103 childcare, 220 childhood, 39, 55, 57, 78 childless, 103 children, xvii, 36, 37, 41, 43, 48, 64, 72, 75, 76, 78, 84, 85, 100, 101, 102, 103, 104, 147, 154, 211, 212, 213, 214, 215, 218, 219, 220, 224, 225, 226 China, xii, 23, 99, 100, 137, 141, 144, 145, 146, 150, 156, 174, 176, 177, 178, 180, 181, 182, 185, 188, 189, 200, 206, 211 Chinese medicine, ix, 173, 176, 177, 178, 186, 187, 188, 189 Chinese women, xii, 99, 110 cholesterol, 182, 186, 192, 193, 195, 196 CHP, 21, 39, 42, 91, 92, 141, 143, 145, 147 chronic disease, xi, 63, 64, 65, 67, 68, 71, 76, 77, 81, 85, 164 chronic diseases, xi, 63, 64, 65, 67, 68, 71, 76, 77, 81, 164 chronically ill, 73 cigarette smoking, 64 circulation, 64 cisplatin, 189 citizens, 2, 79, 124, 171 citizenship, 154 Citrus aurantium, 183 civil society, 54 civilian, 67 class size, 166 classes, xiii, 36, 43, 82, 103, 116, 125, 147, 163, 164, 165, 167 classical, 210 classroom, 41, 164, 169 classrooms, 39, 164 clients, x, 47, 50, 51, 52, 53, 54, 58, 73, 95, 115, 202 clinical assessment, xvi clinical trial, 180 clinical trials, 180 clinics, 70, 71, 72, 146, 148, 176, 184 Clostridium botulinum, 2 closure, 145, 147 cluster analysis, 186 CNN, 159 coagulation, 193 coffee, 116 cognition, 72 cognitive function, 55, 194 coherence, 68, 170 cohesion, 100, 106, 107, 116 cohesiveness, 218

230

Index

collaboration, xi, xii, 36, 39, 49, 51, 52, 54, 63, 66, 67, 70, 73, 80, 81, 85, 91, 93, 94, 95, 99, 103, 104, 119, 120, 179, 180 collectivism, 210 colon, 65, 71 colon cancer, 65 colorectal cancer, 64, 74, 188 coma, 206 commerce, 67 communication, ix, xii, xiii, 50, 52, 53, 72, 93, 94, 99, 101, 104, 105, 106, 108, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 131, 140, 150, 153, 154, 155, 156, 157, 158, 159, 161, 164, 171, 172, 180, 207, 213, 216, 224 communication processes, 113, 114, 117 communication skills, ix, xii, xiii, 72, 101, 104, 105, 106, 113, 114, 115, 116, 118, 119, 120, 121, 122, 153, 155, 158, 159, 164, 171, 172 communication strategies, 114 Communist Party, 206 communities, 37, 45, 56, 65, 97, 126, 129, 146, 164 community, ix, x, xi, xii, xiii, xv, 18, 36, 37, 38, 39, 40, 42, 44, 47, 48, 49, 50, 51, 52, 53, 54, 56, 63, 66, 67, 68, 71, 72, 73, 80, 84, 91, 92, 93, 99, 100, 103, 104, 105, 106, 107, 108, 110, 123, 125, 126, 130, 132, 137, 138, 139, 143, 146, 147, 149, 177, 178, 180, 181, 192, 194, 195 community service, 80 community support, 100 compassion, xviii compatibility, 180 competency, 50 competition, 42, 83, 85, 107, 108 compliance, 39, 197 complications, 179, 201 components, xi, 52, 89, 94, 175 composition, 201 Comprehensive Social Security Assistance, 49, 100, 198 concentration, 50, 136, 194 conceptual model, 225 confidence, 19, 115, 116, 128, 147, 181, 215 confidentiality, 5, 33, 51, 83 conflict, 100, 101, 102, 103, 113, 154, 155, 157, 222 conflict resolution, 103 conformity, 8 confrontation, 179 Confucianism, 101, 102, 111 confusion, 203, 210 conjunctivitis, 139 consciousness, 215 consent, 3, 5, 33, 51, 106, 170, 224 consolidation, 91

constipation, 81 constraints, xvii, 218 consultants, 161 consumers, 1, 23, 182 consumption, xi, 63, 64, 65, 68, 70, 73, 147, 182, 196, 199 contamination, 12, 18, 20 contingency, 138, 140, 143, 147, 151 continuity, 78 contracture, xvi control, xiii, 20, 36, 49, 50, 67, 68, 72, 74, 75, 78, 80, 84, 91, 103, 115, 125, 134, 137, 144, 145, 146, 148, 149, 150, 171, 173, 176, 177, 178, 180, 183, 185, 217, 222, 223 control group, 180 conversion, 174 convulsion, 169 cooking, 7, 18, 20, 25, 31, 70, 71, 72, 82, 83, 92 cooling, 157 Copenhagen, 76 copper, 193 coronary artery disease, 204 coronary heart disease, 182, 196, 200 corporations, 129 correlation, 155 cost-effective, 197 costs, 109, 197, 198 cough, 139, 170 counseling, xvii, 146 couples, 103, 104, 160 course content, 163 covering, 198 CRC, 185, 187 creativity, 51 crime, 19, 26, 108 crisis intervention, 103, 132 crisis management, ix, xii, 123, 124, 125, 126, 127, 129, 130, 131, 132, 137, 140, 141, 143, 144 critical thinking, 164 cross-cultural, 226 cross-cultural comparison, 226 cross-sectional, 40, 200 Crotalaria, 175 crying, 213, 222 CSR, 151 cues, 224 cultivation, 182 cultural beliefs, 210 cultural influence, 174 culture, 2, 50, 65, 66, 68, 72, 73, 85, 94, 100, 101, 102, 104, 106, 154, 158, 174, 182, 184, 210, 224, 225 curriculum, 82, 84, 116, 180

Index customers, 145 cycles, 70, 209 cycling, x, 36, 37, 38, 40, 43, 45, 46 cyclists, 36, 41 cyclosporine, 180 cystoscopy, 170 cytochrome, 180, 182

D daily living, xviii, 36, 37, 80, 102 dairy, 196 dandelion, 179 danger, 3 data analysis, 13 data collection, 5, 39, 53 database, 93 death, 7, 8, 18, 64, 73, 123, 136, 139, 147, 202, 212, 215, 224 death rate, 202 deaths, xi, xvi, 24, 30, 64, 68, 77, 148, 187 decision makers, 140 decision making, xviii, 80 decisions, xvii, 39, 53, 70, 103, 155 defects, 124, 126, 127 defense, 75 deficiency, 180, 192, 193, 194, 200, 202 deficit, 90, 167 deficits, 198 definition, 117, 118 delivery, 93, 119, 121, 122, 140, 144, 145, 146, 163 dementia, 65, 180, 196 Denmark, 46, 76, 88, 98, 112, 121 density, x, 182, 193, 194 dental caries, 194 dentistry, 181 dentures, 194 Department of Agriculture, 79, 88 Department of Education, 111 Department of Justice, 111, 125, 131 depressed, 100 depression, 49, 58, 60, 61, 192, 197, 199, 200, 203 deprivation, 55 destruction, 128 detachment, 167 detection, 200 diabetes, 64, 65, 74, 77, 164, 192, 195, 196 diabetes mellitus, 74, 164 diagnostic criteria, 58, 209 diarrhea, 139 diet, ix, xi, xviii, 26, 63, 64, 65, 66, 67, 70, 71, 72, 73, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 87, 89,

231

90, 91, 92, 93, 94, 95, 96, 97, 188, 192, 193, 194, 196, 200, 201, 202, 204 dietary, 64, 66, 71, 72, 73, 74, 75, 77, 85, 90, 186, 192, 193, 194, 195, 196, 197, 204 dietary habits, 85 dietary intake, 192, 193, 194 dieting, 216 diets, 64, 90, 201 differentiation, 210, 219 digestion, 194 dilation, 194 dioxins, 28 direct observation, 39 disability, 64, 124, 195 disabled, 199 disappointment, xix disaster, xii, 123, 124, 132 discharges, 148 discipline, 17 discounts, 67, 72 discretionary, 78 discretionary spending, 78 diseases, xi, xvi, xix, 8, 18, 19, 20, 39, 64, 73, 77, 79, 80, 81, 166, 180, 193, 194, 195, 196 disinfection, 143 disorder, 57, 147, 203, 209, 221 disposable income, 198 distraction, 125 distress, 139, 204, 210 distribution, ix, 1, 3, 4, 5, 7, 16, 18, 32, 176, 177 diving, 170 division, 51, 130 divorce, 103, 154, 155, 159 dizziness, 168 DNA, 189 doctor-patient, xix doctors, xiv, xv, xvi, xvii, 19, 148, 155, 160, 189, 206, 207 domestic violence, xii, 99, 100, 101, 103, 104, 105, 106, 107, 108, 172 donor, xix dosage, 182, 183 download, 45, 150 draft, 177 drainage, 142, 144 dream, 220 drinking, 156, 210 drowning, xviii drug abuse, 104 drug interaction, 187 drug therapy, 194 drug use, 126, 136

232

Index

drugs, 59, 139, 143, 168, 173, 174, 175, 177, 179, 180, 186, 189, 194 dual identities, 184 duplication, 103, 130 duration, x, 139, 169 duties, xvii, 101, 206 dyes, 2 dysmenorrhea, 178

E E. coli, 1 earnings, 223 ears, xiii, 160, 163, 170 earth, 174 East Asia, 174, 182, 192 eating, xi, 13, 16, 28, 63, 65, 66, 67, 68, 70, 71, 72, 73, 77, 78, 79, 80, 82, 84, 85, 87, 90, 92, 95, 96, 210, 213, 216, 217, 219, 221, 222, 223, 225 eating disorders, 210, 225 economic change, 37, 72, 99 economic development, 164 economic stability, 154 economic status, 48, 50 eczema, 180 edema, 168, 197 education, 21, 22, 32, 33, 41, 42, 44, 46, 70, 74, 88, 93, 96, 98, 109, 111, 112, 115, 120, 128, 129, 130, 131, 147, 159, 165, 166, 171, 172, 205 educational background, 3, 4 educational system, 216 educators, 57, 80, 84, 97, 163, 167, 195 egg, 38, 41 elderly, ix, x, xiii, 18, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 78, 101, 102, 110, 129, 143, 148, 189, 191, 192, 193, 194, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204 elderly population, 49, 191, 195, 201, 203 elders, 202 electrolytes, 179 email, ix, 1, 3, 4, 5, 18, 32, 33 Emergency Department, xvi, xviii emergency management, 126 emergency preparedness, 126, 132 emotion, xiv emotional, xvii, 53, 87, 102, 161, 193 emotional distress, xvii, 87, 161 emotions, 207 empathy, 105 employees, 140, 156, 164 employers, 129 empowered, 36, 50, 114

empowerment, 36, 37, 38, 53, 54, 67, 71, 72, 87, 91, 97, 103, 105, 119 encouragement, 92, 93, 95, 102, 108, 218, 220 end-of-life care, 171 endotoxemia, 188 endurance, 75 energy, 77, 93, 119, 192, 193, 196 England, 116, 203 enrollment, 165 enthusiasm, 70 environment, x, xi, xii, xviii, 35, 36, 37, 38, 40, 41, 48, 52, 63, 64, 65, 68, 71, 72, 73, 74, 79, 80, 90, 91, 92, 95, 96, 104, 105, 113, 114, 115, 119, 125, 126, 157, 164, 181 environmental conditions, 55 environmental standards, 147 enzymes, 180 Ephedra, 174 epidemic, 150, 166 epidemics, 149 epidemiology, 74 epilepsy, 169, 194 equality, 211 equity, 37, 38, 44, 46, 57, 66, 75, 80, 85, 88, 91, 98, 103, 105 ERIC, 111 estates, 143 estradiol, 182 ethics, xix, 92, 182 Europe, 65, 76, 174, 193, 196 European Commission, 3, 5, 19, 21 European Union, 3, 177 evening, 67, 196 exclusion, 200 execution, 147 exercise, 35, 53, 65, 66, 73, 75, 107, 164 exertion, 189 expenditures, 105 external validity, 4 extraction, 133 extrapolation, 184 eyes, xv, 179, 188, 189, 212

F face validity, 4 facial expression, 156, 224 facilitators, 40, 54, 57, 83 factor analysis, 74 failure, xv, 102, 126 faith, 19, 178, 207 familial, 74

Index family, vii, ix, xii, xiv, xv, xvii, xviii, 48, 50, 51, 52, 53, 54, 57, 96, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 141, 143, 145, 153, 154, 155, 156, 157, 159, 167, 168, 193, 199, 202, 203, 204, 209, 210, 211, 212, 213, 215, 216, 217, 218, 219, 220, 221, 223, 224, 225, 226 Family caregivers, 200 family conflict, 108 family environment, 212 family income, 224 family interactions, 213, 216, 221 family members, ix, xiv, xviii, 100, 101, 102, 104, 105, 107, 109, 141, 143, 145, 167, 199, 209, 210, 213, 214, 217, 221 family relationships, 103, 211, 217, 219 family studies, vii family support, 50, 57 family therapy, xiv, 209, 210, 211, 225, 226 family units, 102 family violence, 105, 108, 153, 159 FAO, 64, 76 farms, 140, 141, 144, 145, 148 fast food, 64, 77, 78 fat, 64, 65, 90, 193, 196, 211, 222, 223 fatalities, xii, 123, 130 fatigue, 65, 168, 193 fax, 150 FDA, 23, 177 fear, xvii, 100, 209, 216 February, 21, 83, 219 fee, 70, 80, 122, 218 feedback, 42, 53, 70, 71, 95, 107, 117, 118, 119, 157, 160, 163, 167, 172 feeding, 196, 199 feelings, 42, 51, 70, 84, 153, 167, 212, 213, 214, 216, 217 fees, 66, 82 feet, 70, 216, 221 females, xiii, 13, 182, 191, 193 femininity, 225 feminism, 226 feminist, 210, 225 femoral neck, 202 femur, 199 fever, 139, 170, 179 fiber, xviii, 90 fibrosis, 180, 186 fighters, xviii filial piety, 102 film, ix, 104, 106, 205, 206, 207 films, xiv, 205, 207 finance, 67, 72, 224 financial support, 40, 102, 198, 223

233

Finland, 56, 97 fire, xviii, 174 first aid, 115, 169 fish, 1, 23, 28, 137 fitness, 182 flood, xviii, xix flooding, 124, 131 focus group, 66 focusing, 79, 91, 155, 219 folic acid, 196, 201 food, ix, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 30, 31, 32, 33, 64, 66, 67, 70, 72, 73, 75, 77, 78, 79, 81, 82, 83, 84, 90, 91, 92, 93, 94, 95, 97, 106, 141, 145, 146, 147, 156, 177, 182, 183, 184, 185, 186, 192, 194, 198, 199, 200, 201, 202, 216, 221, 225 food additives, 12 Food and Drug Administration, 23, 177 Food and Drug Administration (FDA), 177 food industry, 183 food intake, 194, 221 food poisoning, 6, 7, 8, 21, 22, 23, 24, 25, 30, 31, 33 food safety, ix, 1, 2, 3, 4, 5, 6, 7, 8, 12, 13, 15, 16, 17, 18, 19, 20, 21, 23, 25, 27, 32, 33 food stamp, 201 formal education, ix, 1 Foucault, 225 Fox, 196, 201 fracture, 168, 202 fractures, 193, 194, 196, 200 fragmentation, 103 France, 49, 56 freedom, 212 friction, 158 friendship, 57 fruits, xi, 63, 64, 65, 66, 67, 68, 70, 71, 72, 73, 78, 79, 86, 90, 94, 174, 195, 196, 197 frustration, 100 frying, 28 fulfillment, 37, 198, 213 funding, xii, 38, 54, 67, 78, 82, 85, 86, 99, 108 fundraising, 105, 108 funds, 54, 67, 72 furniture, 219 fusion, 1 futures, 224

G gait, 35, 43 gambling, 104 games, 38, 39, 41, 79, 113, 117, 119

234

Index

gastrointestinal, 8 geese, 138 gender, 3, 4, 14, 20, 81, 96 gene, 75 gene expression, 75 general knowledge, 164 general practitioner, 171 general practitioners, 171 generalizability, 4, 17 generation, 18, 101, 102, 164 Geneva, 45, 46, 58, 88, 98, 110, 112, 121, 189 geriatric, 196 Germany, 49 gift, 154 Ginkgo biloba, 183 ginseng, 183 GIP, 151 girls, 56, 83 globalization, 163 glucose, 179 goals, 71, 153, 157, 215, 216 goal-setting, 196 God, xv, xix, 207 gold, 174 Good Manufacturing Practice, 177 government, xi, xii, xiv, 17, 18, 37, 40, 42, 54, 67, 70, 72, 73, 78, 79, 84, 85, 90, 94, 99, 100, 103, 104, 105, 106, 108, 116, 125, 126, 130, 140, 141, 143, 145, 147, 149, 176, 191, 198, 206 government policy, 106 grades, 36, 216 grafting, 168 grains, 196 grandparents, 154 granulocyte, 180 green tea, 71 groups, 4, 7, 8, 13, 16, 17, 18, 19, 20, 28, 56, 65, 72, 75, 83, 84, 103, 105, 107, 116, 143, 149, 155, 166, 167, 178, 180, 197, 198, 203 growth, xii, xiii, 99, 160, 173, 177, 178, 184, 185, 187, 188 growth factor, 178, 188 growth inhibition, 187 Guangdong, 148, 187 guidance, xii, 99, 102, 103, 196 guidelines, 38, 44, 71, 83, 102, 106, 110, 117, 118, 132, 146, 149, 177 guilty, xvii, 213

H H5N1, vi, ix, xii, 137, 138, 139, 140, 147, 148, 150, 151, 164

handling, xii, 20, 28, 123, 124, 128 hands, 192, 213, 216, 219 hanging, 106 harm, ix, xii, 5, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 111, 159 harmony, ix, xii, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 111, 159 Harvard, 225 hazards, 126 headache, 108, 170 healing, xviii health care, ix, xi, xii, xiii, xiv, xviii, xix, xx, 39, 45, 46, 48, 50, 56, 57, 63, 65, 66, 73, 78, 86, 87, 88, 89, 91, 96, 98, 99, 109, 113, 115, 119, 120, 121, 123, 164, 165, 173, 174, 176, 177, 178, 180, 181, 182, 183, 184, 185, 186, 187, 188, 191, 193, 196, 197, 198, 209 health care professionals, ix, xi, xiv, xix, xx, 89, 165, 209 health care sector, xiii, xiv, 173, 182, 184, 191 health care system, 39, 109, 123, 174, 177, 178, 188, 193 health education, 6, 7, 21, 25, 32, 40, 67, 70, 73, 80, 97, 101, 108, 120, 131 health effects, 183, 196 health information, 70, 82, 91, 103 health problems, 8, 19, 194 health services, xii, 48, 49, 58, 67, 99, 176, 195 health status, x, 47, 49, 78, 79, 80, 81, 144, 146, 195, 202 healthcare, vii, 48, 49, 67, 72, 95, 103, 123, 131, 149, 174 hearing, 158, 167 hearing loss, 167 heart, 35, 43, 56, 64, 65, 97, 168, 179, 182, 187, 194, 196, 200, 206, 222 Heart, 74, 75, 79, 120, 167, 175, 201, 204, 206, 208 heart disease, 64, 65, 182, 187, 196 heart failure, 194 heat, 181, 182 heating, 28 height, xiv, xviii, 41, 81, 197, 209 helmets, 40, 41, 44 helplessness, xvii, 217 hematuria, 169 heme, 182, 188 heme oxygenase, 182 hemodialysis, 203 hemoglobin, 168 hemophilia, 179 herbal, xiii, 173, 174, 176, 177, 178, 179, 181, 182, 183, 184, 185, 186, 188, 189, 206, 208

Index herbal medicine, xiii, 173, 174, 176, 177, 178, 181, 182, 184, 185, 186, 188, 189, 206 herbs, xvi, 174, 175, 176, 178, 179, 180, 182, 183 high blood pressure, 192 high fat, 78 high risk, 52, 147, 204 high school, 211 high tech, 80 higher quality, 198 higher-income, 198, 201 high-risk, xiii, 137, 139, 147 hip, 193, 199, 201 hip fracture, 199, 201 holistic, 79, 158 homework, 212 homicide, 100 hopelessness, xvii hormones, 28 hospital, xi, xv, xvi, xvii, xviii, 51, 70, 73, 78, 86, 90, 91, 92, 93, 94, 95, 96, 114, 115, 116, 120, 145, 148, 161, 179, 187, 194, 202, 206, 207 hospital care, xvi hospitalization, xvi, xviii, 7, 18, 30 hospitalizations, 30 hospitalized, 168, 179, 200 hospitals, 24, 54, 90, 114, 116, 146, 148, 164, 180 host, 139 household, 3, 49 housing, 49, 56, 57, 67, 104, 211 HSC, 44 human, x, xii, xiv, xix, 41, 51, 55, 130, 137, 138, 139, 140, 141, 143, 144, 147, 149, 150, 151, 164, 179, 187, 189, 204, 207 human brain, 41 human capital, 164 human exposure, 147 humans, xiii, 137, 139, 140, 147, 178 husband, xii, 100, 212, 214, 215 hygiene, x, 8, 12, 18, 19, 25, 31, 47, 48, 49, 53, 54, 143, 147, 149, 164 hyperlipidemia, 188 hypersensitivity, 187 hypertension, 64, 65, 167, 195 hypertensive, 174 hypoventilation, 168

I ICD, 58 identification, 70, 92 identity, 185, 210 idiopathic, 179, 189 images, ix, xv, 52

235

imagination, 168 immigrants, xii, 64, 99, 100, 108, 200 immigration, 149 immune function, 180 immunity, 139, 202 immunization, 55 immunosuppression, 193 impairments, 193 implementation, x, xii, xviii, 4, 20, 21, 47, 48, 51, 52, 56, 81, 89, 91, 92, 97, 99, 105 in vivo, 178, 180 incentives, 52, 195 incidence, 179, 193, 196, 200 income, 43, 56, 100, 104, 178, 198, 201, 212, 218, 219, 224 incompatibility, 180 incurable, 180 independence, xi, 77, 78, 192, 223 indication, 116 indicators, 4, 129, 202, 203 indices, 203 indigenous, 225 indigenous knowledge, 225 individual action, 91 individual development, 103 Indonesia, 138 induction, 180 industry, 147, 183, 205 inequality, 48, 180, 200 infarction, 167, 186 infection, xii, xv, xvii, 8, 21, 115, 137, 138, 139, 140, 143, 145, 148, 149, 151, 167, 168, 170, 179, 189 infections, 139, 180, 192, 194 infectious, 148, 164 infectious disease, 148, 164 infectious diseases, 148, 164 inflammatory, 187 inflation, 72 influenza, xiii, 12, 28, 137, 138, 139, 140, 141, 143, 144, 148, 149, 150, 151 influenza a, 150 information sharing, 51, 131 Information System, 136 information technology, 163 informed consent, 51 inhalation, xvi inhibition, 187 inhibitors, 139, 187 inhibitory, 178 inhibitory effect, 178 injection, 179 injunction, 104, 106

236

Index

injuries, 36, 40, 43, 123, 130 injury, 44, 124, 169 insecurity, 202 insertion, xvii insight, 156, 158 insomnia, x, 47, 48, 49, 53, 55, 56, 57, 59, 193 inspection, 177 inspections, 147 institutionalization, x, 47, 49 institutions, xiii, 163, 180, 191, 192, 194, 197, 217 instruction, 107, 138 instruments, 82 insulin, 193 integration, 147, 180, 184 integrity, 41 intellectual development, 164 intensive care unit, 148 intentions, xix, 214 interaction, 38, 50, 155, 216, 224 interactions, 36, 38, 51, 53, 187, 213, 216, 221 interference, 197 internal validity, 4 internet, 4 Internet, 70, 93, 95, 146 interpersonal communication, 52, 93, 113, 114, 116, 117, 118, 120, 122, 155 interpersonal relations, 154 interpersonal relationships, 154 intervention, 20, 48, 71, 72, 73, 97, 103, 108, 132, 155, 164, 171, 179, 180, 197, 199, 200, 201, 202, 203, 210, 211, 224 interview, x, xi, 3, 4, 18, 47, 50, 51, 52, 53, 70, 81, 89, 91, 92, 93, 94, 95, 105, 106, 212 interviews, xi, xii, 3, 17, 39, 41, 50, 51, 63, 66, 71, 81, 82, 84, 92, 95, 99 intraperitoneal, 182 intravenous, xvii, 179 investment, 37, 80, 147 IPV, 110 Iran, 177 Ireland, 21 iron, 193 irrigation, 167 Islamic, 177 island, 21 isolation, 148, 150, 197 Israel, 48, 49, 56, 91, 96, 97 Italy, 49

J JAMA, 186 Japanese, 206

job satisfaction, 114, 115 jobs, 218 joints, 35, 43 judge, 220 jurisdictions, 154 justice, 37, 66, 73 justification, 172

K Kampo medicine, 185 kernel, 174 kidney, 179, 189 killing, 100 kindergarten, 143, 211, 219, 220, 223

L labeling, 72 labour, 51, 130 land, xv, xvi, xviii, xix language, 3 large-scale, 3, 4 Latino, 110 law, 100, 101, 102, 104, 105, 106 laws, 103, 126, 131 LDL, 196 leadership, 52, 54, 95, 115, 119, 121, 124, 132, 206, 217, 224 learners, 85 learning, 38, 42, 48, 95, 106, 115, 116, 117, 118, 120, 163, 164, 165, 171, 172, 217 learning culture, 164 learning environment, 42, 116, 119, 164 learning outcomes, 164 legislation, 37, 66, 124, 126, 131, 145, 189 legumes, 192, 196 leisure, 37, 64, 212 leisure time, 64 lending, 40 lens, ix lesbian, 160 lesions, xvi, xvii, 181, 182 leukemia, 189 leukemia cells, 189 license fee, 66, 70 licenses, 140 licensing, 176, 198 life expectancy, xiii, 191, 195 life experiences, 56 life style, 90

Index lifestyle, x, 49, 52, 64, 71, 72, 73, 78, 80, 85, 98, 100, 105 lifestyles, 53, 164, 182, 195, 198 life-threatening, 181, 182 limitation, xi, xii, 63, 95, 99 limitations, 43, 48, 82, 165, 170, 180, 197, 210 linkage, 105 links, xiv, 97, 209 linolenic acid, 196 lipids, 201 lipoprotein, 196, 201 lipoproteins, 201 listening, xiii, 115, 117, 118, 153, 155, 158, 159, 216 liver, 174, 179, 182 Livestock, 141 living environment, 37, 49, 107, 213 local authorities, 19 local government, xiv, 18, 191, 198 London, 44, 45, 46, 55, 56, 57, 74, 75, 86, 87, 88, 97, 98, 109, 110, 111, 116, 120, 159, 201, 225, 226 longitudinal studies, 64 longitudinal study, 71 loss of control, 125 love, xv, xix, 154, 207, 210, 212 lover, 207 low tech, 80 low-density, 196, 201 low-density lipoprotein, 196, 201 low-income, 100, 212, 219 lung, 49, 174, 179, 189 lung cancer, 189 lung disease, 49 lungs, xvi, 140 lying, 169 lymph, 168 lymphoma, 64

M Macao, 148, 207 Macau, 205 machines, xv mad cow disease, 27 magnesium, 196 Mainland China, 141, 145 mainstream, 56, 176, 178 maintenance, xiii, 37, 40, 41, 73, 111, 191, 192, 195, 196, 198 males, xiii, 13, 20, 73, 90, 93, 182, 191 malnutrition, xiii, 191, 192, 193, 194, 196, 197, 198, 200, 201 management, ix, x, xii, xiii, xiv, xvii, 47, 48, 54, 56, 90, 95, 100, 103, 120, 121, 123, 124, 125, 126,

237

127, 128, 129, 130, 131, 132, 137, 140, 141, 143, 144, 149, 181, 182, 191, 192, 195, 197, 215 man-made, 124, 130 manners, 114 manpower, 4, 95, 108, 143, 147 manslaughter, 207 manufacturer, 177 mapping, 48 marital quality, 155 marital status, 3 market, 106, 138, 139, 141, 142, 143, 144, 145, 146, 174, 183 markets, 18, 137, 138, 139, 140, 141, 143, 144, 145, 147, 150 marriage, ix, xiii, 100, 103, 153, 154, 155, 156, 158, 159, 160 marriages, xiii, 153 married couples, 160 Marshall Islands, 87, 97 mask, 108 mass media, ix, 41, 46, 52, 80, 88, 93 Massachusetts, 159, 182, 187 maternal, 156, 172 matrix, 193 meals, 59, 66, 196, 218 measurement, 4, 67, 71, 72, 197 measures, 32, 37, 124, 126, 140, 141, 143, 144, 145, 146, 147, 148, 159, 178, 195 meat, 12, 66, 137, 196 media, ix, 16, 19, 41, 46, 52, 80, 88, 93, 104, 146, 167, 170 median, 139 mediators, 82 medical care, 164 medical student, xx, 171, 187 Medicare, 202 medication, 196, 204 medications, 149, 198 medicinal plants, 174, 183 medicine, ix, xiii, xvi, xix, 55, 57, 165, 172, 173, 174, 176, 177, 178, 179, 180, 181, 182, 183, 184, 185, 186, 187, 188, 189, 196, 205, 206 meditation, 53 Mediterranean, 196, 200, 201, 204 membership, 70, 72 memory, xv, 207 men, ix, x, 49, 64, 65, 66, 67, 68, 70, 72, 75, 193 menopause, 49 menstrual cycle, 209 menstruation, 49, 221 mental disorder, 153, 209 mental health, vii, 48 mental illness, 100

238

Index

mentor, 55 mercury, 28 messages, 3, 18, 21, 52, 66, 129 metabolic, 64, 73, 188, 204 metabolic disorder, 188 metabolic syndrome, 64, 73 metabolism, 186, 192 metropolitan area, 67, 201 Mexican, 56 Mexico, 88, 112 Microbes, 208 microcosm, 179 micronutrients, 192 microsomes, 182 microsurgery, 170 middle class, 224 middle-aged, ix, x, xi, xvi, 63, 64, 65, 66, 67, 68, 72, 73, 74, 75, 168 midlife, 70, 75 migrant, 105 migration, 188 migratory properties, 178 Millennium, 96 Mini Nutritional Assessment, 197, 201 minority, 13, 54, 65, 72 minors, 129 misconception, 2 missions, ix misunderstanding, 113, 119, 155, 158, 214 MNA, 197 mobile phone, 70 modalities, 177 models, 56, 84, 87, 90, 105, 124, 130, 180, 182 modernism, 103 modernization, xiii, 173, 174, 177, 184 money, 4, 78, 155, 156, 198, 218 mood, 213 moral training, 101 morality, 102 morbidity, 196 morning, xvii, 48, 105, 106, 117, 168, 220 mortality, 139, 182, 196, 200 mortality rate, 139, 182 mortality risk, 196 motivation, 73, 91, 164, 171 motives, 96 motorcycles, 126 mouse, 23 mouth, 160, 169, 194 movement, 46, 88 multidimensional, 43 multidisciplinary, 37 murder, 207

murmur, 167 muscle, xvi, xviii, 139, 178, 188, 189, 194 muscle atrophy, xvi, xviii muscle cells, 178, 188, 189 muscle relaxation, 194 muscles, 35, 43, 197 musculoskeletal, 64 music, xv, 171 mutation, 139, 147 mutations, 150 mutual respect, 181 myocardial infarction, 75, 168, 182, 196, 201

N NAD, 189 narratives, xiv, 209 nation, 72, 84 National Academy of Sciences, 150 national culture, 26 National People’s Congress, 176 nationality, 25 natural, 37, 53, 126, 132, 164, 177 natural disasters, 164 natural environment, 37 nausea, 139 neck, xix, 199 negative emotions, 155 negative influences, 197 negative outcomes, 43 neglect, 20 negligence, 135 negotiation, 39 neighbourhoods, 50, 52 nephrotic syndrome, 179, 189 nerves, 192 nervous system, 169 network, 3, 4, 18, 100, 107, 124, 148, 198 networking, 163 neuraminidase, 139 New Orleans, 187 New York, 57, 58, 111, 120, 122, 160 New Zealand, 126, 131 Newton, 203 NGOs, 36, 38, 40, 100, 103, 104, 105, 106, 107 niacin, 192, 201, 202 Niacin, 192 nicotinamide, 192 Nicotine, 111 nicotinic acid, 192 NOAA, 198 noise, 53, 60, 157, 219 non-institutionalized, 192, 194, 202

Index nonverbal, 115 non-violent, 108 normal, xviii, xix, 48, 141, 168, 192, 194, 214, 215, 216, 221 normal aging, 192 norms, 2, 20 North America, 174 nurse, x, xvii, 40, 43, 47, 51, 52, 86, 93, 94, 95, 96, 97, 109, 116, 120, 168, 169 nurses, ix, xi, xii, xvi, xvii, 40, 80, 81, 83, 84, 89, 90, 91, 92, 93, 94, 95, 96, 97, 113, 114, 115, 116, 117, 118, 119, 120, 121, 181, 205 nursing, vii, xii, xiii, 40, 45, 55, 57, 87, 89, 92, 93, 94, 95, 96, 98, 109, 113, 114, 115, 116, 120, 121, 178, 187, 191, 199, 203, 204 nursing care, xiii, 114, 115, 191 nursing home, 199, 203, 204 nutrient, 90, 92, 193, 198, 201, 202 nutrients, 192, 194, 196, 198 nutrition, xiv, 66, 70, 72, 73, 76, 79, 84, 87, 97, 191, 192, 195, 196, 198, 199, 200, 201, 203, 204 nutrition education, 203

O obedience, 100 obese, 65, 68, 72, 77, 81, 85, 197 obesity, xi, 63, 64, 65, 66, 67, 68, 70, 72, 73, 76, 77, 79, 81, 87, 97, 195 obligations, 101, 103 observations, ix, xiii, xiv, xvii, 41, 51, 168, 170, 173, 176, 196, 209, 210 obstructive lung disease, 49 occupational, xviii, 72, 73, 129, 130, 131 occupational groups, 72 occupational health, 131 occupational therapy, 73 octopus, 88 offal, 140 offenders, 103 oil, 90, 197, 202 oils, 192 old age, 198, 201 older adults, 55, 56, 179, 191, 192, 195, 196, 198, 200, 201, 202, 203, 204 older people, ix, xiii, 57, 102, 199 olfactory, 194 olive, 197 olive oil, 197 omega-3, 196 oncology, 43, 160 online, 150, 151 opposition, 130

239

optimization, 131 oral, 179, 181, 182, 188, 194, 196, 202, 203 oral health, 181, 182, 188, 203 oral health problems, 181 organ, 126 organic, 27 organizational development, 131 organoleptic, 20 Oseltamivir, 139 osteocalcin, 193 osteomalacia, 194 osteoporosis, x, 192, 193, 195, 196, 200, 202, 203 otitis media, 170 outpatient, 148 outpatients, 178 ovarian cancer, 189 ovariectomized, 188 ovariectomized rat, 188 ovariectomy, 182 overeating, 222, 223 overtime, xvii, 67 overweight, 79, 81 ownership, 51, 54, 211 oxygen, xviii oysters, 1

P Pacific, 74, 151, 200 pain, xiv, xvii, 168, 169, 170, 206, 207, 210 palpitations, 168 pandemic, 139, 140, 143, 147, 149, 150, 151 parent involvement, 41 parent-child, 38, 102, 221 parents, xv, xvi, xix, 36, 38, 39, 40, 41, 42, 72, 80, 81, 83, 84, 101, 102, 103, 105, 110, 154, 155, 156, 157, 158, 210, 212, 226 parotid, 194 participant observation, 81 particles, 196, 201 partnership, x, xi, 47, 48, 49, 51, 54, 63, 67, 70, 72, 79, 80, 85, 89, 90, 91, 93, 94, 95, 105, 115, 119, 167, 196, 211, 217 partnerships, 57, 91, 96, 97, 103 passive, 217 paternal, 217 pathogenic, 138, 150, 180 pathology, 200 pathways, xviii patient-centered, 116, 120, 171 patients, xii, xiv, xvi, xvii, xix, 43, 92, 93, 96, 113, 114, 115, 116, 117, 118, 119, 145, 148, 155, 160,

240

Index

161, 164, 170, 174, 179, 181, 185, 194, 196, 201, 202, 203, 204, 205, 206, 209, 210 PDGF, 178 pedestrians, 125, 169 peer, 4, 93, 117, 196 peer group, 4 peer support, 93 peers, 78, 84, 212 pellagra, 192 penalty, 126 perception, ix, 1, 2, 3, 4, 17, 19, 20, 21, 23, 32, 33, 76, 108, 194, 195 perceptions, 151, 215, 226 Perilla frutescens, 183 periodontal, 181, 186, 194 periodontal disease, 186, 194 peristalsis, 194 personal communication, 104 personal control, 19, 20 personal hygiene, 19, 25, 31, 143 personal identity, 210 personality, 156 pesticide, 1 pesticides, 12, 22 P-glycoprotein, 180 phagocytic, 180 pharmaceutical, 52 pharmaceuticals, 174, 180 pharmacopoeia, 173 Philadelphia, 44, 55, 56, 57, 87, 120, 121, 132 philosophy, 101 phone, x, 47, 51, 53, 67, 70, 94 physical activity, 36, 40, 64, 65, 71, 74, 75, 78 physical exercise, 39, 53, 59 physical health, 90, 100, 193, 194 physicians, 155 Physicians, 111, 202 physiological, 192, 194, 197, 221 physiotherapy, xvi, 131 pig, 154 pigs, 139 pilot study, 4 planning, x, xii, 39, 45, 47, 48, 50, 51, 55, 66, 67, 75, 81, 89, 91, 92, 93, 97, 103, 105, 107, 120, 131, 140, 150, 151, 198, 203, 211, 217 plants, 28, 174, 183 plaque, 197 plasma, 180, 182, 186, 194, 201 platelet, 178, 188 platforms, 174 play, xiii, xv, 38, 101, 102, 107, 117, 163, 165, 167, 168, 169, 170, 171, 194, 197, 210, 215 pleasure, 7, 19

pneumonia, 139, 148, 188 poison, 182 poisoning, 6, 7, 8, 21, 22, 23, 24, 25, 30, 31, 33 police, xviii, 37, 38, 40, 41, 45, 105, 133 policy making, 73 political aspects, 140 politics, 206 pollutants, 12 pollution, 7, 19, 26 polygamy, 154 polyunsaturated fat, 193 polyunsaturated fatty acid, 193 polyunsaturated fatty acids, 193 poor, 65, 79, 81, 95, 110, 115, 116, 158, 194, 198, 210, 211, 212, 215, 217, 219, 223, 224 poor health, 217 population, xiii, 4, 13, 17, 19, 20, 39, 43, 44, 48, 49, 57, 66, 67, 74, 75, 77, 78, 79, 86, 93, 96, 97, 101, 109, 124, 145, 164, 174, 177, 178, 181, 191, 192, 193, 195, 196, 197, 198, 199, 200, 201, 202, 203, 204 population group, 20 pork, 1 Portugal, 49 positive attitudes, 178 positive correlation, 193 positive reinforcement, 71 postsecondary education, 172 post-translational, 193 poultry, ix, xii, 137, 138, 139, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 150 poverty, 50, 100, 194, 197, 198 power, 101, 102, 119, 130 pragmatic, 211 prediction, 197 prednisone, 179 preference, 27, 85, 153 pregnancy, 49 premature death, 65 preparedness, 126, 131, 140, 143, 151 preschool, 219 preservatives, 27 pressure, 44, 75, 168, 192, 214, 218, 220 prevention, xii, 39, 44, 56, 64, 67, 73, 76, 80, 84, 87, 101, 105, 106, 123, 124, 125, 126, 127, 144, 149, 164, 182, 188, 189, 195, 200 preventive, 32, 40, 65, 124, 125, 141, 143, 146, 182, 187, 195 prices, 94, 95 primary care, 120 primary school, ix, x, xi, 5, 35, 77, 78, 147, 220 printing, 68, 70 privacy, 51

Index private, 54, 67, 130, 146, 148, 149, 178, 198, 224 private sector, 54, 146, 148, 149, 198 proactive, 38 probability, 19 problem solving, 164 problem-solving, 41, 108, 211 problem-solving skills, 211 problem-solving strategies, 108 procreation, 154 production, 207 professional duties, xvii professional qualifications, 184 professions, xiv, 164, 191, 198, 207 progesterone, 182 prognosis, xvii, 213 program, ix, x, xi, xii, 6, 7, 20, 25, 35, 36, 38, 39, 40, 41, 42, 43, 47, 48, 50, 51, 52, 53, 54, 55, 56, 58, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 77, 78, 79, 80, 81, 82, 83, 84, 85, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99, 101, 103, 104, 105, 106, 107, 108, 129, 130, 140, 172, 201 proliferation, 178, 189 promotion campaigns, xi, 77, 126 promyelocytic, 189 property, 126 proposition, 38 prostate, 73 prostate cancer, 73 protection, 40, 67, 101, 104, 106, 124 protective clothing, 143 protein, xviii, 78, 90, 193, 196, 199 proteins, 178, 193 protocol, 149, 210 prototype, 201 psoriasis, 167 psychiatric illness, 58 psychological distress, xvii psychological health, 73, 90, 155, 193 psychological problems, 64 psychological stress, 65 psychologist, x, xvii, 47, 51, 53 psychosomatic, 225 Psychosomatic, 57, 225 public awareness, x, xiv, 37, 41, 191, 195, 199 public education, 144 public health, 17, 18, 19, 22, 44, 46, 55, 75, 86, 88, 124, 151, 183, 188, 192 public housing, 57, 211 public policy, 49, 66, 104 public resources, xii, 99 public sector, 148 public welfare, 211 publishers, 97

241

pupils, xi, 77, 78, 85

Q quail, 138 qualifications, 195, 206 qualitative research, vii, 124 quality of life, 38, 49, 54, 65, 192, 195, 196, 199, 203 quantitative research, 32 quarantine, 140, 145 Quebec, 201 questionnaire, 2, 3, 4, 5, 23, 32, 33, 42, 52, 53, 68, 71, 81, 82, 84, 104, 105, 106, 107, 118 questionnaires, ix, x, xi, xii, 1, 3, 4, 5, 18, 32, 39, 47, 52, 63, 81, 82, 85, 99, 107

R race, 79, 184 radio, 70, 104, 146 rail, 126 random, 17, 166, 181 random assignment, 166 Random sampling, 142 range, vii, 8, 12, 27, 126, 210 rat, 180, 182, 189 rats, 182 reaction rate, 179 reading, 52 reality, 156, 164, 218 recall, 170, 207 recalling, 215 receptors, 150 recognition, xi, xiv, 77, 133, 175, 176, 177, 180, 184, 185, 191, 195, 198 reconstruction, 125 recovery, 114, 123, 124, 128, 131, 132, 147, 194, 209, 210, 213, 219, 221 recreational, 39, 148 recycling, 105, 106 red light, 126 reflection, 119 reforms, 198 refuge, 104 regeneration, xviii registered nurses, 81, 92, 114 registered nurses (RNs), 114 regular, x, 59, 60, 61, 64, 65, 67, 71, 93, 125, 211 regulation, 102, 189 regulations, 37, 126, 176, 177, 184, 186 regulatory framework, 176

242

Index

rehabilitate, 128 rehabilitation, xviii rehearsing, xix reinforcement, 71, 106 relationship, xix, 64, 92, 100, 101, 102, 103, 104, 107, 115, 154, 155, 156, 157, 199, 204, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 221, 223, 226 relationships, x, xiv, 35, 38, 43, 100, 101, 103, 105, 120, 154, 156, 207, 210, 211, 217, 219, 221 relatives, xii, xviii, 3, 4, 108, 113, 114, 115, 116, 117, 118, 128, 156, 158 relaxation, x, 47, 48, 53, 194 reliability, 4, 17, 53, 85, 170 remission, 179 renal, xvi, xvii renal failure, xvi, xvii repair, 128 reproduction, 225 reputation, 128 residential, 36, 148, 197 residues, 1, 12, 28 resistance, 139 resolution, 103, 157, 158 resources, xii, xvii, 4, 18, 21, 38, 41, 54, 71, 72, 79, 91, 92, 93, 96, 99, 105, 106, 128, 130, 143, 144, 146, 151, 154, 164, 219 respiratory, 124, 139, 168, 179, 215 respiratory rate, 215 restaurant, 23, 74, 90, 141, 155 restaurants, xi, 28, 63, 66, 67, 70, 71, 72, 73, 96 restenosis, 178 restructuring, 224 retail, 142, 148 retention, 167, 169 retirement, 198 rewards, 42, 67, 70 riboflavin, 192, 201 rice, 216 rickets, 194 risk, ix, x, xiii, 1, 2, 3, 4, 7, 12, 17, 19, 20, 21, 28, 32, 47, 49, 52, 64, 65, 71, 73, 74, 75, 77, 78, 100, 124, 130, 137, 138, 139, 140, 147, 150, 180, 193, 196, 197, 198, 201, 204, 205 risk assessment, 180 risk factors, 2, 12, 20, 64, 72, 74, 75, 100, 201 risk perception, ix, 1, 2, 3, 4, 17, 19, 20, 32 risks, ix, 1, 3, 7, 8, 10, 11, 12, 16, 17, 19, 26, 50, 124, 191, 193, 195, 196, 197, 198, 199 road safety, 38, 41, 42, 123, 125, 126, 127, 128, 129, 130, 131, 132 role-playing, xiii, 163, 164, 165, 168, 170 rural, 180

S sadness, 212 safeguard, 19, 20 safety, ix, 1, 2, 3, 4, 13, 16, 17, 18, 19, 20, 22, 23, 27, 32, 35, 36, 37, 38, 39, 40, 41, 42, 46, 57, 97, 112, 119, 123, 125, 126, 127, 128, 129, 130, 131, 132, 177, 179, 180, 183, 184, 189 Salen, 200, 201 saline, xvii salmonella, 27 Salmonella, 2, 23, 24, 31 salt, 64, 90 Salvia miltiorrhiza, 175 sample, 4, 17, 49, 181 sampling, ix, 1, 3, 4, 17, 32, 142, 143, 144, 146 SARS, 164, 166, 179, 187, 189, 207 satellite, 100 satisfaction, 70, 84, 95, 114, 115, 118, 160, 161, 225 saturated fat, 193, 196 saturated fatty acids, 196 savings, 109 scholarship, 17 school, ix, x, xi, 3, 4, 5, 18, 23, 35, 36, 37, 39, 40, 41, 42, 44, 48, 56, 77, 78, 79, 81, 82, 83, 84, 85, 86, 90, 114, 129, 130, 143, 145, 147, 171, 178, 211, 212, 220, 225 scientific understanding, 180, 184 scores, 52, 58 seafood, 154 search, 87 searching, 85 Seattle, 185 secondary schools, 3, 4, 78, 85 secretion, 194 security, 123, 140, 195, 198, 199 sedentary, 64, 65, 66, 68 seizure, 194 selecting, 92, 140, 165 selenium, 196 self-awareness, 36 self-care, xviii self-confidence, 106, 113, 119 self-control, 216 self-efficacy, 20, 85 self-employed, 51 self-empowerment, 50 self-esteem, 50, 100, 102 self-help, 38 self-image, xvii self-management, 144 self-report, x, 47, 49, 52 senior citizens, 203

Index sensitivity, xvii separation, 137 septic shock, 182, 188 serum, 180, 182, 194, 196 serum albumin, 194 services, ix, xi, xii, xiii, 36, 39, 43, 48, 49, 50, 58, 63, 67, 92, 99, 100, 103, 104, 105, 106, 107, 108, 145, 146, 176, 180, 191, 195, 200, 211, 219 severe acute respiratory syndrome, 124, 179 severity, xviii, 109, 124, 139 sewage, 143 sex, 154, 159 SFDA, 23 shame, 100, 224 shape, xix, 43, 80, 209 shares, 220 sharing, 51, 70, 104, 105, 107, 108, 116, 131, 155, 225 shock, 182, 188 shortage, xvii, 85 shortness of breath, 168 shoulder, 40 shy, 100, 108, 211 sibling, 210, 215, 216, 221 siblings, 211, 213, 215 side effects, 189 signaling, 178 signals, 41, 42, 126, 136 signs, xvi, xvii, 126, 136, 139, 215 similarity, 206 sine, 178 Singapore, 73, 79, 84, 110 sites, 66 skills, ix, x, xii, xiii, 40, 41, 43, 47, 48, 49, 53, 60, 61, 67, 72, 73, 80, 90, 91, 95, 100, 101, 104, 105, 106, 107, 113, 114, 115, 116, 117, 118, 119, 120, 121, 122, 153, 154, 155, 158, 159, 160, 161, 163, 164, 171, 172, 211, 215, 218 skills training, 115, 116 skin, xvi, xvii, xviii, 79, 81, 192 sleep, ix, x, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 64, 65, 75, 200 sleep deprivation, 55 sleep disorders, 55, 56 sleep disturbance, 48, 55 sleep habits, 53 sleeping pills, 58, 60, 61 smiles, 157 smoke, 58 smoking, 64, 104, 187 smooth muscle, 178, 188, 189 smooth muscle cells, 178, 188, 189 smoothness, 82

243

SMS, 3, 145 social acceptance, 178 social activities, 212 social assistance, 198 social awareness, 195 social capital, 85 social change, 45, 56, 103 social class, 103 social construct, 225 social context, 197, 198, 210 social development, 38 social environment, xiv, 66, 70, 173, 174, 177, 191, 195 social factors, 48, 68, 104, 194, 197 social group, 50 social isolation, 197 social justice, 37, 66, 73 social life, 219 social network, 100 social order, 102 social problems, xii, 99, 100 social relations, 105 social relationships, 105 social responsibility, 37, 73, 91 social security, 198 social services, 103, 104, 219 social status, 180 social support, xviii, 38, 49, 50, 53, 64, 108 social support network, xviii social systems, 100 social welfare, xii, 99, 103, 193, 195, 198, 199 social work, vii, x, xiii, xvi, xvii, 40, 47, 51, 103, 104, 105, 106, 163, 165, 171, 202, 203, 206, 226 social workers, 40, 103, 104, 105, 106 sociocultural, 76 socioeconomic, 104 sociological, 45, 56, 97 sodium, 179 software, 125 soil, xvi solidarity, 99, 101 sounds, 169, 220 South Asia, 44 sovereignty, 174, 176 Spain, 49 species, xv, 147 specificity, 225 speed, 136 speed limit, 136 spelling, 106 sphincter, 194 spinach, 1, 22 spine, 193

244

Index

spleen, 179 sponsor, 93, 94 sports, 56, 90, 97 spouse, 70, 99, 103 sputum, xvi St. Louis, 57, 87, 98 stability, 154, 185 stages, x, xiii, 38, 44, 47, 53, 173, 177, 179, 189 stakeholder, 37 stakeholders, 1, 19, 64, 71, 155 standards, 114, 125, 127, 147, 177, 198 Staphylococcus aureus, 7, 18, 24, 31 stars, 52 starvation, 221 statistics, 3, 18, 40, 46, 55, 74, 130, 138, 191 status epilepticus, 194 statutes, 184 statutory, 125, 127, 176, 178 stigma, 198 stigmatization, 100 stimulant, 174, 182 stock, 143 stockpile, 145 stomatology, 181 strain, 210 strains, 140 strategies, xvii, 19, 20, 37, 45, 55, 64, 67, 70, 72, 73, 75, 85, 92, 97, 104, 108, 113, 114, 116, 132, 149, 192, 195, 196, 198 strength, 75, 194, 210, 212, 220 stress, xii, 35, 43, 48, 53, 56, 58, 65, 90, 97, 100, 103, 113, 114, 115, 154, 155, 161, 202, 217, 218, 222 stressors, 203, 225 stroke, 64, 73 structuring, 37 student group, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 18, 20 students, ix, x, xi, 3, 4, 5, 6, 8, 12, 13, 32, 35, 36, 37, 38, 39, 40, 41, 42, 43, 77, 78, 79, 80, 81, 82, 83, 84, 85, 89, 90, 98, 116, 121, 160, 164, 165, 166, 167, 168, 169, 170, 171, 178, 181, 187, 218 students’ understanding, 42, 169 subjective, xiv, 170, 194, 209 subjective experience, xiv, 209 substances, 28 suffering, ix, xiv, xv, xvi, 103, 170, 174, 179, 194, 209 sugar, 90, 192 suicidal, 100 sulphur, 186 summer, 40, 41, 42, 171, 218 supervision, 225

supervisor, 206, 225 supplements, 196, 202 suppliers, 83 supply, 50, 79, 141 support staff, 115 surgeons, 181 surgery, 124, 170 Surgery, 109, 185 surgical, 205, 208 surprise, 210 surveillance, 143, 144, 145, 146, 148 survival, xviii, 139 survivors, 124 susceptibility, 192 sustainability, xi, 54, 63, 73, 77, 84, 85, 129 swallowing, 194 Switzerland, 132 symbolic, 177 sympathy, 212 symptom, 55, 139, 210 symptoms, 47, 49, 139, 179, 181, 182, 188, 192, 194, 210, 213, 221, 224 synthesis, 193

T tachycardia, 168, 182, 188 Taiwan, 98, 111 talent, 220 Taoism, 101 target population, 39, 48, 50, 66, 109 targets, 72, 84 taste, 7, 19, 68, 90, 95, 194 taxis, xii, 123, 124 Taxol, 175, 188 taxpayers, 109 tea, 53, 155 teachers, xviii, 3, 36, 38, 39, 40, 41, 42, 46, 81, 82, 83, 167 teaching, xiii, 40, 41, 73, 86, 106, 120, 130, 163, 164, 165, 166, 167, 168, 171, 206 teaching quality, 130 team members, x, xii, xviii, 40, 47, 51, 52, 53, 54, 80, 82, 83, 89, 93, 94, 95, 105, 106, 115 teenagers, 220 teens, 44 teeth, 194 telecommunications, 126 telephone, xii, 3, 4, 39, 42, 48, 99, 104, 105, 106, 126, 181, 198 television, ix, xiv, 52, 70, 205, 212 temperament, 78, 80, 85, 220 temperature, 119, 215

Index tension, 210 territory, 4, 124, 176 terrorism, 19, 26 terrorist, 164 terrorist attack, 164 tertiary education, 13, 20 testosterone, 73 Thai, 124 Thailand, 132, 138, 177 therapeutic interventions, 216 therapeutic relationship, 120, 211 therapeutics, 177 therapists, 224, 226 therapy, 174, 179, 180, 181, 188, 196, 225, 226 thiamine, 201 thinking, 8, 9, 10, 11, 25, 26, 90, 220, 226 Thomson, 109 threat, xiii, 123, 137, 147 threatening, 1 thresholds, 194 throat, 139 thrombosis, 197 tibia, 182 time frame, 93 tissue, xviii, 192 title, 32, 33, 74, 223 tobacco, 60, 171 tomato, 2, 23 top-down, 81 total cholesterol, 196 tourist, 147 toxicity, 183 trade, 176, 177, 183 traditional medicines, 185, 189 traditionalism, 103 traffic, xii, 37, 40, 46, 123, 124, 125, 126, 127, 128, 129, 130, 131, 134, 136 traffic flow, 125, 131 trainees, 226 training, 38, 40, 42, 53, 75, 95, 101, 104, 106, 107, 114, 115, 119, 128, 129, 130, 140, 160, 172, 176, 180, 197 transfusion, 168 transgenesis, 172 transition, 174, 185, 213, 223 translation, 4, 17 transmission, 101, 138, 139, 143, 144, 145, 147 transmits, 101 transplant, 179, 189 transport, 132, 138, 141, 143, 144, 146 transportation, ix, xii, 39, 123, 124, 130, 131, 141, 163, 218 travel, 43

245

trial, 199, 204 triglyceride, 192 trust, 19, 28, 94, 103, 115, 158, 178, 181, 217, 224 trusts, 184 tsunami, 124, 132 tsunamis, 164 tuberculosis, 120 tutoring, 218, 219 two-way, 115

U ulcer, 168 uncertainty, 73, 183, 219 undergraduate, xiii, 116, 163, 166, 171 undergraduate education, xiii, 163, 171 undergraduates, xiii, 116, 163, 165, 167, 171 undernutrition, 192, 193, 194, 199, 203 unemployment, xii, 99, 100, 147 unhappiness, 210 UNICEF, 103 United Kingdom, 49, 174, 176 United Nations, 64 United States, 36, 47, 49, 79, 84, 88, 99, 159, 161, 193, 195, 198, 200 universality, 225 universities, 114, 116, 176 university education, 217 upload, 46 urbanisation, 64 urbanization, 37, 103 urinary, xiii, xvii, 163, 169, 170 urinary retention, 169 urinary tract infection, 170 urine, 169, 170 urologist, 169 urology, 169 USSR, 46, 88, 98, 112, 121

V vaccination, 138, 140, 149 vaccine, 149 validity, 4 values, ix, 8, 50, 51, 90, 101, 102, 104, 157, 181, 182, 207, 210 variables, x, 35, 43, 164, 199, 204 vegetable oil, 192 vegetables, xi, 1, 22, 28, 63, 64, 65, 66, 67, 68, 70, 71, 72, 73, 75, 78, 79, 86, 90, 137, 192, 195, 196, 197 vehicles, 124, 125, 130, 133, 141, 144, 146

246

Index

ventilation, 53, 59, 60, 142, 144 ventricular tachycardia, 182 venue, 122, 213 Vermont, 46 victims, xii, xviii, xix, 6, 18, 36, 43, 99, 100, 103, 123, 128, 202 videotape, 170 Vietnam, 138 village, 42 violence, xii, 99, 100, 101, 103, 104, 105, 106, 108, 110 violent, 100, 103 virology, 141, 146 virulence, 138 virus, xii, 5, 137, 138, 139, 140, 147, 148, 150 viruses, 12, 24, 28, 31, 33, 138, 139, 150 viscera, 179 vision, 174 visual acuity, 194 vitamin A, 73, 192 vitamin B1, 201 vitamin B12, 201 vitamin D, 194, 203 Vitamin D, 203 vitamin D deficiency, 194, 203 vitamin E, 196 vitamin K, 192, 194, 200, 204 vitamin supplementation, xviii vitamins, 65, 193, 194, 196, 203 vocational, 100 voice, 209, 219, 224 voluntary organizations, 105 Volunteers, 70, 106 vomiting, 139 vulnerability, 123, 193

welfare, 12, 13, 28, 95, 198, 200 wellbeing, 155, 199 well-being, 36, 39, 43, 57, 101, 104, 123 wellness, 38, 45, 56, 58, 97 Western countries, 65, 174, 176, 193 Western culture, 158 Western-style, 77 wholesale, 138, 141, 143, 144, 145, 146 wild animals, 145 windows, 59 winning, 83, 158 wisdom, ix, 67, 71, 72 withdrawal, 5 witnesses, 156 women, 20, 56, 57, 65, 66, 72, 99, 100, 103, 104, 108, 111, 112, 172, 188, 193, 196, 199, 201, 216 wood, 174 word of mouth, 70 work environment, 91 workers, ix, xi, xii, 17, 51, 63, 65, 66, 67, 68, 70, 71, 72, 73, 90, 95, 137, 138, 139, 140, 143, 145, 147, 149, 150, 181, 197, 219 working hours, 66 workload, xvii, 66, 154 workplace, 68, 89, 90, 91, 97, 115, 118, 119, 155 work-related stress, 115 World Bank, 87 World Health Organization (WHO), xiii, 36, 37, 38, 39, 45, 46, 48, 49, 50, 51, 58, 64, 66, 76, 77, 78, 79, 80, 81, 84, 88, 89, 90, 91, 93, 98, 100, 103, 104, 105, 107, 110, 112, 119, 121, 123, 124, 126, 129, 132, 137, 138, 139, 140, 144, 145, 148, 150, 151, 173, 174, 176, 189 worm, xv, xix worry, 8, 11, 12, 16, 20, 213 writing, vii, 52, 147

W X waistline, 81, 82 waking, 48, 58 Wales, 78, 86, 109 walking, 169 war, 95, 113, 116, 194 warning letters, 37 water, xviii, 138, 174 waterfowl, 138 wealth, 50 web, 74 weeping, xvii weight control, 71 weight gain, 87, 209, 216, 219 weight loss, 75, 197, 209

xerostomia, 194, 202, 203

Y yang, 185 yield, 224 yin, 185

Z zoonotic, 137