The RGC Public Policy Research Funding Scheme (Round 2)

1. Traditional Chinese Medicine in Hong Kong: Utilization Patterns and its Role in the Future Healthcare System The RGC Public Policy Research Funding Scheme (Round 2) Principal Investigator: Prof. Sian Griffiths Director, School of Public Health and Primary Care Faculty of Medicine The Chinese University of Hong Kong Postgraduate student trained: Vincent Chung BCM BSc PhD, Registered Chinese Medicine Practitioner

2. Developing Traditional, Complementary and Alternative Medicine (TCAM) International Perspective from the World Health Organization (WHO): Two major milestones: The WHO Traditional Medicine Strategy 2002-5 The WHO Congress of Traditional Medicine 2008

3. WHO and TCAM Development (1) The WHO Traditional Medicine Strategy 2002-5 specified the goals of • 1) increasing governmental support for TCAM amongst member states; • 2) promoting the integration of TCAM into member states’ national healthcare systems • In a WHO survey published in 2005: • 51 out of 96 responding member states were planning a national policy for TM/CAM, • while the remaining states have already formulated policies

4. The Beijing Declaration for Developing TCAM, 2008 1. formulate national policies, regulations and standards… ensure appropriate, safe and effective use of traditional medicine 3. establish systems for the qualification, accreditation or licensing of traditional medicine practitioners. • policy context, • professional attitudes and training, • patients’ choice, and • financing of access and service development. 4. communication between conventional and traditional medicine providers should be strengthened 2. integrating traditional medicine into their national health system

5. Development of TCAM in Health System Policy: Context and Regulation Profession: Evolving Inter-professional Relationship between TCAM and WM Patient: TCAM use and public health Development of TCAM in Health System Price: Investment for equity and service reorganization Health Services Research Framework for Analyzing the Development of TCAM: Policy, Profession, Patient and Price (4P)

6. Development of TM/CAM in Health System Policy: Context and Regulation Profession: Evolving Inter-professional Relationship between TCAM and WM Patient: TCAM use and public health Development of TCAM in Health System Price: Investment for equity and service reorganization Health Services Research Framework for Analyzing the Development of TM/CAM: Policy, Profession, Patient and Price (4P) TM/CAM - traditional medicine/complimentary and alternative medicine

7. Traditional Chinese Medicine (TCM) in Hong Kong: Policy Development since 1997 • Basic Law of Hong Kong SAR, Article 138 • 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.

8. TCM in Hong Kong: Overview • After handover: • The professional role of TCM is explicitly stated in the constitutional law • The government repeatedly announce their commitment in developing TCM Sick leave and health condition assessment certificates issued by registered TCM practitioners is recognized by law 1997 1999 2006 2009 Before handover: Neither regulated or promoted – allopathic western medicine (WM) has dominated the public healthcare system • Establishment of the Chinese Medicine Council of Hong Kong (CMCHK) • New entrants must complete 5 year formal undergraduate training and passing the licensing exam • 14 TCM clinics established under tripartite management of NGO, University and the Hospital Authority Griffiths S, Chung V. (2009). Development and regulation of traditional Chinese medicine practitioners in Hong Kong. Perspective in Public Health. 2009, 129, 64.

9. 3 Major Achievements • 1. Formal regulation and registration of TCM practitioners • Chinese Medicine Council of Hong Kong (CMCHK) • Chinese Medicine Ordinance. • 2. Introduction of TCM services into the public healthcare system • Established 14 out of 18 planned TCM outpatient clinic. Private hospital with TCM service proposed. • 3. Professional education in TCM • Establishment of full time undergraduate training in TCM • Compulsory Continuing Medical Education (CME) program for all registered TCM practitioners • Policy Address 1997 • Policy Address 2001 • Policy Address 2005 • Policy Address 2009

10. Development of TM/CAM in Health System Policy: Context and Regulation Profession: Evolving Inter-professional Relationship between TCAM and WM Patient: TCAM use and public health Development of TCAM in Health System Price: Investment for equity and service reorganization Health Services Research Framework for Analyzing the Development of TM/CAM: Policy, Profession, Patient and Price (4P) TM/CAM - traditional medicine/complimentary and alternative medicine

11. Choice for TCM and integrative TCM-WM in the HK population • An understanding of who, how and why patients are choosing TCM may offer valuable insights for policy making. • Data on the characteristics of TCM users in the population may be used to answer policy questions in all three domains of public health – health services, health protection, and health promotion (Griffiths, Jewell, & Donnelly, 2005). Griffiths S, Jewell T, Donnelly P. Public health in practice: the three domains of public health. Public Health 2005; 119: 907-913.

12. Five major research questions How do Chinese populations perceive TCM’s role in contemporary healthcare? Who uses TCM in Hong Kong? How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals? Does TCM have a role in tackling the challenges of increasing NCD prevalence in our aging population? 5) What are the policy implications of these findings?

13. VIEWS ON TRADITIONAL CHINESE MEDICINE AMONGST CHINESE POPULATIONS:A SYSTEMATIC REVIEW OF QUALITATIVE AND QUANTITATIVE STUDIES Question 1: How do Chinese populations perceive TCM’s role in contemporary healthcare? Patient Education and Counseling, 2009, Under Review

14. Method and Literature Flow Potentially relevant studies identified electronically and screened for retrieval (n=1423) Relevant studies retrieved from library search (n=3) Studies excluded (n=1405) Relevant studies included in this review (n=18+3= 21) Quantitative survey (n=13) Qualitative studies (n=6) Mixed method studies (n=2) Study location: Mainland China (n=0) Taiwan (n=1) Hong Kong (n=10) Overseas (n=2) Study location: Mainland China (n=1) Taiwan (n=0) Hong Kong (n=2) Overseas(n=3) Study location: Mainland China (n=0) Taiwan (n=0) Hong Kong (n=1) Overseas (n=1) • We searched 5 electronic databases (MEDLINE, EMBASE, AMED, PsychINFO, and British Nursing Index) • Since their inception till Jan 2009 for qualitative studies and quantitative surveys that investigated Chinese people’s views on TCM • No Limit on the location of the study populations (China, Taiwan, Hong Kong, Macao or overseas)

15. Data analysis Mills et al. Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators . PLoS Med 2006. Garcia et al. Women’s View of Pregnancy Ultrasound; A Systematic Review. Birth 2002 29(4) 225-50. Lucas et al . A Systematic Review of Lay Views about Infant Size and Growth. Arch Dis Child 2007 92 120-7 Harden et al. Applying systematic review methods to studies of people's views: an example from public health research . JECH 2004 58(9) 794-800 • The methodological quality of all included studies was assessed independently by two reviewers (VCH Chung and CH Lau) using the criteria proposed by Mills et al (Mills, E.J. 2006). • Findings of all included studies were extracted independently by two investigators. We employed a qualitative approach for data synthesis, which involved three main steps of: (1) classifying studies, (2) comparing and contrasting findings, and (3) thematic analysis (Harden, A. 2004; Lucas, P. 2007; Garcia, J. 2002). • Analysis of the extracted data generated 4 major themes: • (1) cultural grounding, faith and lay construction of TCM knowledge; • (2) perceived strength and weakness of TCM; • (3) perceived complementarity of TCM and WM; • (4) choice for integrated TCM-WM treatment.

16. Summary of Findings • Lay applications of ancient Chinese philosophies and TCM theories like Yin-Yang and Qi-Blood are commonly used to explain aetiology, interpret symptoms and to provide rationale for self care practices. • It is perceived that TCM is a lay form of healthcare in which recommendations from family and friends, instead of healthcare professionals, are of crucial value. • The perceived advantage of integrating TCM and WM is mainly confined to the improvement of physical health outcomes and “holism” would be achieved when the side effects of WM are minimized whilst the tonic effects of TCM is maximized.

17. Analysis of the thematic household survey datasets 2002 and 2005 Datasets to answer the following questions 2. Who uses TCM in Hong Kong? 3. Does TCM have a role in tackling the problem of chronic non-communicable disease on our aging population? 4. How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals?

18. Thematic HouseholdSurvey 2002 & 2005 • Commissioned by the Census and Statistic Department, Hong Kong SAR Government • Conducted between May – July, 2002 and Nov 2005 – Mar 2006 • Covered the entire land based population of HK, including both non-institutional and institutional residents • Survey data were collected through the use of structured questionnaire via face to face interviews during personal visit by trained enumerator • Covering BOTH non-institutional and institutional residents, • 29,561 non-institutional (response rate: 97.2%, 2002) • 2,111 institutional (response rate: 78.4%, 2002) • 33,263 non-institutional (response rate: 79.2%, 2005) • 3,461 institutional (response rate: 93.7%, 2005) • Representing 6,504,255 (2002)/ 6,750,652 (2005) persons after applying population weight

19. 61.7% Financing Context: Western care is tax funded with wide accessibility TCM is mostly private, require out of pocket payment Have you EVER consulted a Chinese Medicine (CM) practitioner? >=15 yrs, Hong Kong Thematic Household Survey, 2005 (N=36,724)

20. DEMOGRAPHIC AND HEALTH RELATED CHARACTERISTICS OF TRADITIONAL CHINESE MEDICINE USERS IN HONG KONG Question 2: Who uses TCM in Hong Kong? Vincent Chung, Eric Wong, Jean Woo, Sui Vi Lo, Sian Griffiths (2007). Use of Traditional Chinese Medicine in Hong Kong Special Administrative Region of China. Journal of Alternative and Complementary Medicine, 13(3), 361-367.

21. Who are using TCM in Hong Kong?

22. Summary Points • Compared to the pre-1997 studies, three novel findings were noted. • Firstly, respondents from the higher socioeconomic class emerged as a new class of TCM users. • Secondly, there was low TCM utilization rate among the institutionalized elderly. • Lastly, older respondents were less like to be covered by TCM insurance. • Policy Implications: Better understanding of • 1. TCM accessibility among the elderly and • 2. Possible financing opportunities for community TCM services warrant further research.

23. COMPARING THE OUTPATIENT CONSULTATION EXPERINCES AMONGST WM AND TCM USERS Question 3: How do patients perceive the quality of communication in their outpatient encounters with TCM and WM professionals? Vincent Chung, Lau Chun Hong, Eric Wong, Eng Kiong Yeoh, Sian Griffiths (2009). Perceived Quality of Communication amongst Outpatients in Western and Traditional Chinese Medicine Clinics in a Chinese Population. Health Policy, 90, 66-72.

24. CAHPS 2.0 core component

25. Are patients satisfied with communication quality in outpaients encounters? Patients are generally satisfied…?

27. Summary Points • Users of WM public services were more likely to be dissatisfied with all evaluated aspects. • The observed differences highlight the dissatisfaction with public WM services, which are mainly accessed by less affluent patients. • Compared to users of private WM services, multivariate analysis showed that TCM patients were more likely to rate their clinicians highly for listening skills but low for respect. • Further studies to better understand the reasons for dissatisfaction and the possible policy and organizational solutions are warranted. • The need in improving communication skill training in TCM higher education, especially in privacy protection, should be further studied.

28. INTERRELATIONSHIP BETWEEN AGE, CHRONIC DISEASE STATUS AND CHOICE FOR TCM AND WM Question 4: Does TCM have a role in tackling the challenges of increasing NCD prevalence in our aging population? Vincent Chung, Lau Chun Hong , Eng Kiong Yeoh, Sian Griffiths. Age, Chronic Disease Status and the Choice for Western and Chinese Medicine in a Chinese Population. BMC Health Service Research, In press.

29. (1) Double consulting of WM and TCM professionals is popular >=15 yrs, Hong Kong Thematic Household Survey, 2005 (N=36,724) Visited WM practitioner only: 80.23% Visited a healthcare professional in the past 12 months: (n=18,087) Visited both WM & TCM practitioners: 16.60% “double consulters” Visited TCM practitioners only: 3.17%

30. Probability of health service utilization type by age and NCD status (2) Age, NCD and Choice for WM and TCM services Probability of utilization Using WM only, with NCD • Curves for using WM only and double consulting forms a hyperbola, with vertex located at the middle aged • Middle aged chronic disease patient are more probable to double consult, approaching a 7(WM): 3 (double) ratio Using both WM and TCM, with NCD Age

31. Summary Points

32. Findings from previous parts of presentation showed that government initiative in TCM development have led to increasing patient choice for integrative TCM-WM care. However, corresponding inter-professional care between WM Doctors (WMD) and TCM Practitioners (TCMP) has not been facilitated.

33. Patient Choice and Need for Inter-professional Collaborations • The preservation of continuity, coordination and comprehensiveness in a pluralistic primary care system poses a challenge to policy makers. • Fostering inter-professional collaboration between TCMP and WMDmay improve quality of care, • but the current segregation of TCM and WM provisions in the Hong Kong health system implies that significant financial investments on education and service re-organization will be a prerequisite for better joint up working (e.g. sharing of electronic health records). Greenhalgh, 2007 Bell et al., 2002; Boon, Verhoef, O'Hara, & Findlay, 2004, Snyderman & Weil, 2002

34. Misalignment in Patients’ Preference for Integrated TCM-WM and Professional Segregation between WMD and TCMP under the Hong Kong Policy Context Policy Context: Professionalization of TCMP and renewal of national identity Colonial legacy of WM dominance Profession: Lack of Inter-professional collaboration between WMD & TCMP Development of TM/CAM in Health System Patient: Preference in using both TCM and WM Misalignment Price

35. Developing a policy framework for integration of traditional Chinese and allopathic medicine in Hong Kong using Delphi techniqueSupported by RGC Public Policy Research Funding Scheme (Round 4)In Progress

36. Thank You Website: http://www.sphpc.cuhk.edu.hk Email address: info_sphpc@cuhk.edu.hk